Effect Of Manual Therapy And Active Stretching For Individuals With Chronic Ankle Instability

Objectives: Chronic ankle instability(CAI)is the most common issue after ankle sprain,which can lead to recurrent ankle sprains and lower extremity motor dysfunction.However,the mechanism of lower extremity motion control still has not been clear.Meanwhile,manual therapy(MT)is one of the commonly used conservative treatment for individuals with CAI,of which efficacy has not yet been widely determined.Accordingly,on the one hand,this study aims to explore the correlation between the balance performance and the ankle proprioception on CAI patients,in order to clarify the role of proprioception in the lower limb balance ability of CAI patients.On another hand,to deliver evidence-based evidence for the conservative treatment in clinical practice,this research tried to determine the efficacy of MT for individuals with CAI though meta-analysis,as well as to explore potential difference of immediate effect between MT and active stretching.As for that,the research was divided into two sub-studies,study 1 and study 2,respectively.In the Study1Purpose: Can manual therapy improve functional outcomes for individuals with chronic ankle instability Design: Systematic review with meta-analysis of randomized controlled trials.Participants: Individuals with chronic ankle instability.Intervention: Manual therapy is defined as an intervention that involves joint mobilization,and mobilization with movement.Outcome measure: The primary outcome is patient-reported function(PRF)questionnaires scores,the secondary outcomes are ankle dorsiflexion range of motion(DFROM)and balance control.Results: Four studies were included(n=208,mean age=24.4)in the meta-analysis,with moderate to high quality on the PEDro scale(range 6 to 8).For patient-reported function(PRF)questionnaires,one study reported no significant improvement produced by one-session manual therapy on visual analog scale(VAS),two studies reported significant improvement after six-session manual therapy measured by foot and ankle ability measures sports subscale(FAAMS)and Cumberland ankle instability tool(CAIT),respectively.For DFROM,there was no significantly greater effect for the treatment group compared to the control group in either the weight-bearing lunge test(3 studies,n=147,SMD=1.24(95%CI-0.87 to 3.36),I2 =96%)or non-weight-bearing inclinometer test(2 studies,n=47,I2=43%,MD=3.41degrees(95%CI-0.26 to 7.09)).However,after six sessions of manual therapy,a positive effect on DFROM was found on WBLT(2 studies,n=80,SMD=2.39,(95% CI 0.55,to 4.23),I2 =93%).For the SEBT,overall star excursion balance test(SEBT)score after one-session manual therapy showed no significant difference with those receiving no treatment or sham intervention(3 studies,n=137,MD=2.05,95% CI(-0.96,5.05),I2=75%),while qualitative analysis of 2 included studies showed significant improvement both on the SEBT score and single limb balance test(SLBT).Summary : Six sessions rather than one session of manual therapy improves ankle functional performance for individuals with CAI.Further research is needed to determine how long this effect of manual therapy on ankle function lasts.In the study 2Purpose: To investigate the factors affecting the lower extremity motor function of individuals with CAI,and to explore the benefits of manual therapy for CAI on the lower limb balance control and proprioception.Methods: A total of 38 subjects with unilateral or bilateral chronical ankle instability were enrolled,including 20 males and 18 females,after collecting human morphological parameters from all participants and Cumberland ankleinstability tool(CAIT),as well as the frequency of sprain within recent 1 year,the functional assessment of the ankle joint was performed on the lower limbs of the subjects who met the inclusion criteria,including the weight-bearing lunge test(WBLT),and Star excursion balance test(SEBT),which includes three sub-direction tests,namely Anterior(SEBTA),Posteromedial(SEBTPM)and Posterolateral(SEBTPL)respectively.The movement extent discrimination assessment(AMEDA),which was used to assess ankle proprioception.All participants then were randomly divided into three groups and intervened,including the mobilization with movement group(MWM)(n=14)and lunge exercise group(LE)(n=12),as well as a control group(Control)(n=12).After the intervention,the evaluators collected the functional indexes of the ankle joints of the CAI patients after the intervention.The statistical analysis method used Pearson's correlation coefficient analysis to analyze the relationship among the functional tests of the lower extremities.The repeated measures analysis of variance(RMANOVA)was used to compare the differences among three groups on the WBLT,SEBT and AMEDA test changes before and after the intervention.Results: Pearson's correlation analysis showed a strong correlation in the three sub-directions of the SEBT test(r A-PM=0.593,r PM-PL=0.651,r PL-A=0.662,all p < 0.001);the WBLT test and SEBTA have weak correlation(r=0.330,p<0.05);however,there was no significant correlation between AMEDA and SEBT in each sub-direction(p>0.05).In addition,CAIT was no significant correlated among SEBT,WBLT and AMEDA(p> 0.05).RMANOVA showed that there were no significant main effects(F=0.61,p>0.05)in the total performance of SEBT(F=3.67,p>0.05)and AMEDA before and after intervention in the three groups of CAI subjects.In the WBLT test,RMANOVA showed significant main effects(F = 4.50,p = 0.04,?2 = 0.11),but there was no significant interaction among groups(F = 2.87,p > 0.05).Summary: There was a significant correlation between ankle dorsiflexion and lower limb balance test,but no significant correlation was found between the two groups in the test of proprioception and balance ability;neither single treatment through manual therapy or active stretch was enough to improve the functional outcomes for CAI patients.Conclusion:(1)As one of the commonly used CAI self-assessment and diagnostic tools,CAIT scale may not have the ability to quantitatively evaluate the severity of lower limb function impairment in CAI patients.(2)The lower limb balance function of CAI patients and proprioception test using AMEDA method were no significant correlated,indicating that the proprioceptive ability could not be directly translated into the performance of lower limb motor function.(3)Manual therapy is effective for improving the lower limb motor function of patients with CAI.This effect needs to be manifested by multiple treatment effects;(4)on single session,active stretching technique does not show significant effect for individuals with CAI.(5)Due to the lack of targeted testing tools for lower limb motor function tests,the mechanism of manual therapy for improving the performance of lower limb balance function still needs further exploration.