Original ResearchThe effect of additional joint mobilization on neuromuscular performance in individuals with functional ankle instability
Introduction
Functional ankle instability (FAI) is a common lower extremity dysfunction following lateral ankle sprain (Freeman, Dean, & Hanham, 1965). Individuals with FAI often reported feelings of perceived ankle instability or “giving way” during walking or sport activities (Freeman et al., 1965, Hertel, 2002). Previous studies showed that individuals with FAI exhibited altered patterns of muscle activation, including peroneus longus (PL), tibialis anterior (TA), and soleus (SOL) muscles (Delahunt et al., 2006, Eils and Rosenbaum, 2001, Hopkins et al., 2009, Konradsen and Ravn, 1991, Linford et al., 2006, Lin et al., 2011, Lin and Shih, 2014, Palmieri-Smith et al., 2009, Vaes et al., 2002). Some reports demonstrated differences in balance control strategies between individuals with FAI and non-injured people, such as a more proximal control strategy and a larger postural sway during the single leg standing task in FAI population (Levin et al., 2012, Mitchell et al., 2008, VanDeun et al., 2007). These might indicate deficits in joint proprioception and neuromuscular control which might expose people with FAI to a greater risk of recurrent ankle injuries. Other researchers attributed postural control deficits to decreased ankle dorsiflexion range of motion in individuals with functional or chronic ankle instability (Basnett et al., 2013, Drewes et al., 2009, Hoch et al., 2012a, Hubbard et al., 2007).
Clinicians often use neuromuscular or balance training as the treatment intervention for FAI (Eils and Rosenbaum, 2001, Linford et al., 2006, Loudon et al., 2008, O'Driscoll and Delahunt, 2011). However, evidence for the effectiveness of neuromuscular or balance training is limited to moderate regarding muscle performance, posture stability, or self-perceived improvement (Loudon et al., 2008, O'Driscoll and Delahunt, 2011). Despite the fact that deficits in ankle dorsiflexion have been shown to influence the dynamic balance performance in those with chronically unstable ankles, not many investigators addressed this problem when examining the intervention effect of functional ankle instability. Preliminary data support the effectiveness of joint mobilization on the dynamic posture performance and ankle function in people with chronic ankle instability (Delahunt et al., 2013, Hoch et al., 2012b, Hoch and McKeon, 2011). However, these studies have only assessed the immediate effect or the effect of a short intervention period (two weeks) of joint mobilization alone. Whether or not joint mobilization combined with regular neuromuscular training would result in better neuromuscular and posture performance remains unclear.
This study is a randomized controlled trial examining the effects of four-week joint mobilization combined with neuromuscular training on function, range of motion, muscle activity and balance performance of the ankle joint in individuals with FAI.
Section snippets
Study design and participants
This was a cross-sectional study. Participants had to sign the informed consent before entry into the study. This trial was conducted from October 2014 to July 2015. Forty five participants with FAI were included in the study, and randomly assigned into three groups: the control group (CG), the training group (TG) and the mobilization with training group (MTG). This sample size was determined based on the preliminary data of our pilot study which suggested we needed at least nine participants
Results
Fig. 1 shows the flow of the study. Forty five participants with FAI were recruited and randomized into the CG (7 males 8 females, body mass index BMI = 22.2 ± 2.5), the TG (7M8F, BMI = 22.1 ± 2.6), and the MTG (10M5M, BMI = 23.3 ± 3.2) (Table 1). No significant difference was found in any of the demographic characteristics. Most participants reported more than five episodes of ankle sprain, but were unable to recall the actual number of recurrences or the timeframe of their symptoms. Two
Discussion
Insufficient ankle joint mobility has been shown to contribute to impaired balance performance in individuals with chronic ankle instability (Basnett et al., 2013, Drewes et al., 2009, Hoch et al., 2012a, Hubbard et al., 2007). Joint mobilization is a common intervention for joint mobility deficits. Nevertheless, there is a paucity of data on the clinical effects of joint mobilization for functional ankle instability. Hoch and McKeon (2011) and Delahunt et al. (2013) revealed that ankle joint
Conclusion
Through four weeks of intervention, joint mobilization combined with neuromuscular training resulted in additional benefits on self-reported ankle severity, ankle dorsiflexion mobility, and balance performance in the posterolateral direction, as compared to the training only group and control group. The effect of additional joint mobilization on general improvement, muscle activation, and the anterior and posteromedial balance tests were still uncertain. Future research should explore the
Conflict of interest statement
All authors state that they do not keep any commercial, financial or personal relationships which may lead to a conflict of interests that could inappropriately influence their work. No research grant sponsor had any involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.
Ethical approval statement
This study was approved by the Human Research Ethics Committee, National Yang-Ming University, Taiwan (YM103064).
Acknowledgements
The authors would like to thank Dr. Ya-Yun Lee for her valuable suggestions. This study was in part supported by Ministry of Science and Technology, Taiwan (MOST 104-2410-H-010-013).
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