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00005768-200906000-0001800005768_2009_41_1287_wikstrom_capabilities_6miscellaneous-article< 174_0_29_5 >Medicine & Science in Sports & Exercise©2009The American College of Sports MedicineVolume 41(6)June 2009pp 1287-1295Balance Capabilities after Lateral Ankle Trauma and Intervention: A Meta-analysis[APPLIED SCIENCES]WIKSTROM, ERIK A.1; NAIK, SAGAR2; LODHA, NEHA2; CAURAUGH, JAMES H.21Biodynamics Research Laboratory, Kinesiology Department, University of North Carolina at Charlotte, Charlotte, NC; and 2Applied Physiology and Kinesiology Department, University of Florida, Gainesville, FLAddress for correspondence: Erik A. Wikstrom, Ph.D., ATC, Department of Kinesiology, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223; E-mail: ewikstrom@uncc.edu.Submitted for publication July 2008.Accepted for publication November 2008.ABSTRACTDespite the high incidence of lateral ankle sprains, the issue about whether postural control is impaired after acute or chronic injury is still unresolved. In addition, the literature is unclear if balance training, a commonly prescribed intervention, improves postural control after a history of lateral ankle trauma.Purpose: To conduct a meta-analysis on studies reporting the effects of lateral ankle trauma on postural control and how balance training affects postural control after acute and chronic lateral ankle trauma cumulatively and separately as moderating variables.Methods: Thirty-seven postural control studies qualified for inclusion in the meta-analysis. Twenty-five studies investigated postural control independent of an intervention, and 15 studies administered balance-training interventions. Separate analyses on the two types of studies calculated Hedges' g individual effect sizes (ES). Further, we explored moderating variables for both the postural stability and the intervention studies.Results: A significant cumulative effect size (ES) indicated that postural stability is impaired after a history of ankle injury (ES = 0.492, P < 0.0001). Moderator analysis revealed that both acute and chronic lateral ankle trauma negatively affected balance: a) acute: ES = 0.419, P < 0.0001, and b chronic, ES = 0.570, P < 0.0001. A third meta-analysis showed that balance training improves postural control (ES = −0.857, P < 0.0001). In addition, moderator variables indicated large ES for both types of ankle trauma.Conclusions: Postural control impairments are present in patients with a history of lateral ankle trauma. However, clinicians should exercise caution when using the uninjured contralateral limb as a reference of normal postural control. In addition, balance training improves postural control scores after both acute and lateral ankle trauma. However, further research should determine the optimal dosage, intensity, type of training, and a risk reduction/preventative effect associated with balance training after both acute and chronic ankle trauma.Lateral ankle sprains are the most common lower extremity injury in collegiate athletics (5,37) and occur at an estimated incidence of 25,000 a day in the United States (5) and have greater than 70% recurrent rate (22). In addition, up to 75% of the people who sprain their ankle will develop chronic residual symptoms that are defined as chronic ankle instability (CAI) (22). These statistics are inherent in the multiple investigations characterizing the effects of both acute ankle injury and CAI on numerous measures of the sensorimotor control system (36,56). Moreover, multiple investigations have characterized reductions in injury rates after completing various sensorimotor training programs (15,36,48).One of the most commonly examined sensorimotor outcome measures is single leg postural control. Impaired postural control is associated with an increased risk of ankle injury (78,82) and is an hypothesized potential mechanism of CAI (77,79). Due to this strong association, balance and coordination training are common components of intervention programs used by allied health care practitioners to treat patients with a history of both acute ankle trauma and CAI. Despite the common implementation of balance training, the literature reveals no consensus regarding the clinical evidence that postural control is impaired after an acute ankle sprain or the development of CAI (50). However, one systematic review provides strong evidence that postural control is impaired after an acute ankle sprain when the injured limb is compared with a healthy reference group (50). The lack of consensus is most likely due to a) the myriad of postural control methods and measures used, making direct comparison of the existing literature difficult (61), and b) the potential for bilateral impairments in postural control after a lateral ankle sprain (50).Moreover, evidence is accumulating that implicates various sensorimotor training programs in reducing the recurrence of ankle injuries (15,36,47,48). Although the underlying mechanism of why these programs are effective is still not completely understood, the restoration of "proper" or "normal" postural control has been hypothesized (3,21,47,81). Although the restoration of "normal" postural control has been postulated, no consensus exists regarding the clinical evidence that balance training restores "normal" postural control to patients with either an acute lateral ankle sprain or CAI (51). Most likely, this lack of consensus is due to a) the myriad of multiple balance training programs, b) the varying lengths of programs, and c) the multiple postural control measures used in the existing literature (51,61). Thus, to date, reviews and systematic reviews have attempted to summarize the postural control literature because it relates to lateral ankle sprains and CAI and have had limited success in drawing decisive conclusions about the impairment and the restoration of "normal" postural control (50,51,61).A comprehensive meta-analysis provides a quantitative solution to the concerns that emerged from previous studies and systematic reviews. Indeed, determining an overall effect size (ES) in an area of study is convincing evidence considering the frequency of meta-analyses reported in evidence-based medicine. A cumulative assessment of the evidence found in our meta-analyses would provide a valuable source of information. Indeed, health care practitioners would be able to use such an informative comprehensive and quantitative review to make better clinical decisions regarding acute lateral ankle sprains, CAI, and balance training. Therefore, the purposes of this meta-analysis were to answer the following clinical questions: a) Does a history of either acute ankle injury or CAI result in impairments of postural control? and b) Does balance and coordination training improve postural control in individuals with a short or long history of ankle trauma?METHODSubjects: study selection and inclusion/exclusion criteriaConducting an exhaustive search for ankle stability and balance-training studies began with two computerized databases (1980-2008): a) PubMed and b) Cochrane Database of Systematic Reviews. Six key words dictated our search: ankle sprain, ankle instability, ankle injuries/trauma, balance training, postural control, and rehabilitation. Additional search techniques included examining reference lists of retrieved articles.Our search identified 51 potential articles on stability after ankle injury and balance training (1,2,4,6-8,12-14,16-21,23-25,27,28,30-33,36,38,40-42,44-46,49-53,55,57-60,62,68-72,76,77,79). Further review confirmed what articles met inclusion criteria for answering our research questions about a history of ankle trauma, postural control, and balance training. Only studies assessing static postural control measures in patients with a history of lateral ankle trauma were included. We only included studies that used static measures for two reasons: a) to compare our results with previous systematic reviews and b) because studies assessing dynamic postural control are as of yet not common in the ankle trauma literature. Furthermore, all studies needed to address at least one of the two questions stated above.Consistent with conventional meta-analysis techniques, 14 studies were excluded from our list of 51 articles for the following reasons: a) 7 review articles (2,16,30,44,50,51,60); b) 1 case study (45); and c) 6 insufficient data (18-20,24,38,42). The 37 remaining studies examined postural control after ankle injury and/or used various types of balance-training protocols during ankle injury recovery as an intervention for improving/restoring postural control.Table 1 shows the specific details about each study. The authors unanimously agreed on the 37 postural control articles as well as balance-training studies included in the meta-analysis. Data were extracted by two authors and separately confirmed by two other authors.TABLE 1. Characteristics of the ankle injury studies in the present meta-analyses.Establishing outcome measuresSpecific outcome measures varied across acute/chronic ankle injuries and rehabilitation conditions. To avoid bias in our meta-analysis, only one outcome measure per study, a common postural control measure, was selected and the results of each measure were standardized. For our primary question concerning postural control after acute or chronic injuries (trauma), the three most frequent outcome measures were a) center of pressure excursion, b) reach distance during a star excursion balance test, and c) postural sway. However, the direction of the change in postural control measures, either an increase or a decrease, directly impacts postural stability interpretations. Indeed, two different situations indicate an increase in postural control deficit: a) a positive value (sign) on the center of pressure excursion and postural sway and b) a negative value on the star excursion balance test, time to boundary, and limits of stability. Consequently, ourdata were entered into the meta-analysis program with the same sign in relation to an increase in postural control deficit.Two predominant outcome measures in the balance-training studies were postural sway and center of pressure excursion. Our second research question determined the effect of balance-training intervention contributions to postural control performances with acute or chronic ankle injury/trauma. Both analyses were consistent with conventional meta-analytic techniques (29,34,64,65).Data synthesis and analysisAccording to Rosenthal (64), two functions are inherent in a meta-analysis: a) synthesis and b) analysis. First, the synthesis function includes describing the relevant properties of the collection of studies including ES as a whole. Second, the analysis function involves calculating a weighted ES in a collection of common studies and identifying moderator variables that may explain the standardized mean differences (65,66).In line with conventional meta-analysis purists, we computed Hedges adjusted g for individual ES of the studies that investigated postural stability after ankle injury as well as balance-training intervention. Computing Hedges adjusted g is a robust and conventional meta-analysis technique for determining individual ES and incorporating the adjusted pooled variance (64-67,75). Further, we selected a random-effects model for our meta-analysis to ensure consistency in examining heterogeneity of the 25 postural control studies and 15 ankle rehabilitation studies (34,35,74). Indeed, the ES were weighted by the inverse variances to avoid inflated ES and to derive the overall corrected mean ES (29,34,64,65,74). Further, weighting ES by an inverse of the variances reduces the potential bias from studies with disparities in sample size. This technique is conventional and highly recommended by meta-analysis experts (34,64).Measuring the contribution of moderator variables on individual ES is the third standardized meta-analytic technique recommended (29,74). Given that most participants in our balance after ankle injury and balance-training studies are categorized as either acute or chronic trauma, we explored the possibility that individual ES varied depending on these two specific conditions.Measuring heterogeneityAdditional meta-analytic techniques included computing a heterogeneity test known as I2. This technique measures the degree of inconsistency across studies in a meta-analysis (29,64,65). Moreover, I2 evaluates the consistency of evidence beyond a statistical chance occurrence, represents heterogeneity as a percentage, and displays increased heterogeneity as larger values (low = 25%; moderate = 50%; high = 75%). Ideally, this magnitude of variability test will produce low values so that we are confident that the selected studies are similar.Fail-safe analysisClassic fail-safe N analysis determines the stability of meta-analytic results by calculating the number of nonsignificant studies required to nullify an overall effect (63). The technique uses the probability value of the overall (pooled) ES to compute the number of studies required to negate the effect.Given that only published studies on postural stability after ankle injury and balance training were included in the present meta-analysis, we conducted a classic fail-safe analysis to determine whether there was publication bias (29,64,74). Typically, positive ES are reported in published studies, so we are trying to avoid any potential bias in our data.Quality assessmentFurther, consistent with recommendations by Higgins and Green (34), we evaluated the quality of each study (39,54). Three quality assessment criteria included a) randomization (i.e., subject and treatment assignments), b) double blinding (i.e., knowledge of balance-training treatments), and c) dropouts or withdrawals (34). Tables 2A and B display the quality assessment values of our postural stability and rehabilitation/intervention studies in addition to the type of experimental design.TABLE 2. Quality assessments for each study included in the meta-analyses.RESULTSPostural Control Deficit and Ankle Trauma (Acute and Chronic) Meta-AnalysisMean ESA random-effects model meta-analysis of the 25 postural control studies indicated a significant overall Hedges' g mean effect size (ES) of 0.492 (SE = 0.048; P<0.0001) with a 95% confidence interval of 0.397 to 0.587. This ES is a medium, positive effect (e.g., small = 0.20, medium = 0.50, and large = 0.80) that indicates a postural control deficit (11,64,65). Individual-weighted ES ranged from 0.128 to 1.905. Moreover, the combined effect on postural stability across two types of comparisons a) between the injured leg and the sound leg (control) in the same participants and b) between an injured group and a control group are readily apparent in the Forest plot of the individual ES (Fig. 1).FIGURE 1. Forest plot of the 25 individual ES analyzed in the postural stability studies. The order from top to bottom matches the alphabetical list in Table 3A. The numbers on the far right correspond to the reference numbers for studies included in the analysis, and the diamond labeled at the bottom of the plot represents the overall ES.TABLE 3. Summary statistics for the 25 studies included in the postural control deficit meta-analysis.Moderating variable analysisOur initial meta-analysis indicated postural control impairments in patients with a history of lateral ankle trauma. However, more imporantly, what is the cumulative effect of postural control when considering the histories of ankle trauma as moderating variables? Thus, acute and chronic injuries were analyzed as moderating variables in the 25 postural control studies.This second meta-analysis on moderating variables used a random-effects model and revealed a medium, significant cumulative effect of 0.494 (SE = 0.052; P < 0.0001) with lower and upper limits for the 95% confidence interval of0.393 to 0.596. The number of subjects for each type ofankle trauma study is as follows: acute = 230 and chronic= 324. Additional analysis of the studies focused oneach type of ankle injury history revealed a similar pattern. The acute ankle sprain studies (N = 10) indicated a medium effect with an ES = 0.419 (SE = 0.073; P < 0.0001), with a confidence interval of 0.275 to 0.563. Similarly, the CAI studies (N = 15) indicated a cumulative effect = 0.570 (SE= 0.074; P < 0.0001), and the 95% confidence interval for the chronic studies was 0.426 to 0.714.Measuring heterogeneityVariability calculations on the combined studies revealed an I2 = 8%. This indicates that the moderating variables have a relatively high amount of consistency in the studies (35).Fail-safe analysisThe fail-safe analysis determined that 707 null effect findings were necessary to lower the cumulative ES to an insignificant level. Specifically, 707 null studies are required to reduce our cumulative effect to a point that various types of ankle trauma would not affect postural control.Quality assessmentAs shown in Table 3A, the 25 postural control studies displayed a relatively low quality. Few studies described the randomization procedure used nor conducted single/double blind experiments.Postural Control Deficit and Balance-Training Intervention Meta-AnalysisMean ESA random-effects meta-analysis of the 15 postural control and balance-training intervention studies revealed a large significant cumulative Hedges' g effect = −0.857 (SE = 0.097; P < 0.0001), with a 95% confidence interval of −1.047 to −0.667 (11,64,65). Individual-weighted ES ranged from −1.848 to −0.42. The overall ES shown in the Forest plot clearly demonstrates postural control differentiation according to rehabilitation treatments (Fig. 2).FIGURE 2-Forest plot of the 15 individual ES analyzed in the balance-training intervention studies. The order from top to bottom matches the alphabetical list in Table 3B. The numbers on the far left correspond to the reference numbers for studies included in the analysis, and the diamond labeled at the bottom of the plot represents the overall ES.Moderating variable analysisAgain, a potential moderating variable is whether the subjects represented acute or chronic ankle traumas. Analysis of the type of ankle injury history as a moderating variable on postural stability in rehabilitation studies indicated a large significant overall effect = −0.865 (SE = 0.099; P < 0.0001) with lower and upper limits for the 95% confidence interval of −1.059 to −0.671. Separate analyses of the acute (N = 110) and chronic (N = 165) histories revealed two significant cumulative ES: a) acute, ES = −0.824 (SE = 0.198; P < 0.0001), with lower and upper confidence interval limits = −1.212 to −0.437; and b) chronic, ES = −0.879 (SE = 0.115; P < 0.0001), with lower and upper confidence interval limits = −1.103 to −0.654.Measuring heterogeneityVariability calculations on the 4 acute and 11 chronic ankle trauma postural control studies revealed an I2 = 36%. This indicates a low level of heterogeneity in the balance-training intervention studies.Fail-safe analysisThe fail-safe analysis calculated the number of studies required to lower the cumulative effect to an insignificant level. Specifically, 494 null studies are necessary to reduce the effect of various rehabilitation interventions on postural stability for participants who experienced acute and chronic ankle injuries.Quality assessmentAs with the postural control studies, the 15 balance-training interventions and ankle trauma studies demonstrated a relatively low quality. Although 10 (67%) of the studies described randomization procedures, only 1 (7%) conducted a single or double blind experiment.DISCUSSIONPostural control deficit after later ankle traumaThis comprehensive meta-analysis clearly indicates that postural control deficits are present in those with a history of lateral ankle trauma. These postural control deficit results of 25 studies provide a representative sample of ankle injury severity and gender. Specifically, the meta-analyses indicated that both moderating variables support postural control impairments present in acute lateral ankle sprains and CAI.A previous systematic review by McKeon and Hertel (50) demonstrated postural control deficits in patients with an acute lateral ankle sprain when compared with a healthy control group. However, the authors were unable to determine whether side-to-side deficits existed, most likely due to a bilateral impairment in postural control. The current meta-analysis determined if postural control was impaired after lateral ankle trauma and did not conduct a separate analysis like McKeon and Hertel (50). Therefore, a bilateral impairment of postural control present in the investigations using side-to-side comparisons (i.e., injured limb relative to uninjured limb) may have affected our results. Indeed, visual inspection of Figure 1 (i.e., individual ES for each study, cumulative ES, and lower/upper confidence intervals) illustrates a more distorted result for the within-subject comparisons (injured to uninjured) relative to the between-subjects comparisons (injured to control group).The idea of a bilateral impairment suggests that central changes occur after a lateral ankle sprain in addition to the peripheral alterations traditionally noted. Central changes would alter motor control patterns (i.e., feed-forward neuromuscular control), which control both limbs, thus causing a bilateral impairment of postural control. Because the idea of central changes was first proposed, postural control impairments have been noted in both the injured and the uninjured limbs of acute ankle sprain patients relative to a control group (17,19). For example, Evans et al. (17) identified a bilateral impairment in postural control but also revealed that resolution of the impairment did not occur at the same time. Specifically, the impairment seen in the uninjured limb resolved 7 d postinjury whereas resolution of postural control deficits in the injured limb did not take place until at least 4 wk after injury. These results suggest that bilateral postural control impairments exist but the severity of the impairment is not equal. Thus, side-to-side differences may exist but are difficult to determine due to a bilateral impairment. The current findings, which demonstrate a combined impairment of postural stability across a within- and a between-group comparison does not support or refute the possibility that side-to-side differences exist. Yet, anecdotal evidence, Figure 1, and the existing literature seem to support the conclusions drawn by McKeon and Hertel (50). Specifically, bilateral alterations have been reported both at the ankle joint itself (17) and more interestingly at joints proximal to the ankle in acute lateral ankle sprains (9,10) and in patients with CAI (26,73). Future meta-analyses should attempt to determine whether a bilateral impairment in postural control exists and how much this impairment contributes to ankle instability.Postural control deficits were found in both types of patients, acute trauma as well as CAI. Moreover, these novel findings have not been identified in previous reports. Granted our findings are cumulative values of individual-weighted ES inherent in the meta-analysis technique. Unfortunately, a scarcity of knowledge exists regarding the underlying neurophysiologic mechanisms involved in acute ankle sprains and CAI. Thus, the present investigation cannot comment on the cause of the postural control impairments due to the retrospective study design.Although our findings indicate deficits in postural control, the results do not challenge previously asserted recommendations for evaluating postural control in patients with a history of lateral ankle sprain(s). Like previous investigations, the current results imply that a bilateral impairment in postural control may exist, and therefore extreme caution must be taken by the clinician when considering the use of an uninjured limb as a criterion for normal postural control (50). Using the uninjured limb as a reference may lead to inappropriate conclusions about the patient's ability to balance and therefore may result in a hasty return to play. Indeed, research indicates an association between an impaired postural control and an increased risk of sustaining a lateral ankle sprain (47,78,82). In addition, patients have an elevated risk of recurrent injury for 12 months after a lateral ankle sprain (81). Therefore, clinicians should use a healthy reference group or preferably baseline preinjury measures of postural control when evaluating a patient's postural control after an acute ankle sprain or the development of CAI (50). In addition, changes proximal to the ankle joint suggest that the traditional rehabilitation protocols that focus solely on the ankle are not sufficient to restore postural or neuromuscular control after an acute lateral ankle sprain or in a patient with CAI (9,10,26,73).Balance-training intervention after later ankle traumaGiven that localized intervention protocols appear to be insufficient at restoring neuromuscular control and because a bilateral impairment may exist, global coordination/training programs are recommended for both the injured and the uninjured limbs of patients with a lateral ankle sprain (3,71). The current findings support these recommendations as postural control scores improved in patients with both an acute lateral ankle sprain and a CAI. Previously, a systematic review indicated that although the point measures implied improvement in postural control after balance training, too many of the resulting confidence intervals crossed zero, resulting in an inconclusive finding (51). On the other hand, our significant cumulative postural control and rehabilitation findings based on individual-weighted ES overcame the multiple measurement techniques and numerous variations of balance-training programs. These results suggest that the restoration of "normal" postural control has been restored and may be the causal mechanism for the reduction of recurrent ankle injuries after the completion of a balance-training program.Although postural control improved across all conditions (acute and CAI), our study design, like previous systematic reviews, was unable to determine the exact treatment dosage necessary to see improvements and more importantly see a reduction in the number of recurrent injuries (51). For example, postural control improvements have been reported in patients with acute ankle sprains after just 3 d of balance training (41,70). However, postural control improvements have been reported in patients with CAI after 4(28) and 6 (76) wk of global coordination/balance training. The rapid improvements seen after acute injury are extremely exciting, but Bahr et al. (3) reports that the longer a balance-training program is implemented, the greater preventative effects accrue from the program. Most of the above studies were prospective, meaning that the baseline measures represent the postural control deficit that existed before the intervention. However, none of these investigations collected preinjury postural control measures. Therefore, we are confident that balance training improves postural control after lateral ankle trauma, but we cannot be certain that balance training restored preinjury levels of postural control.Ultimately, the exact dosage, the type of exercise, and the level of intensity will most likely be determined by several variables, including, but not limited to, injury severity, concomitant injuries, demands of the activity/sport and position played, experience with balance training, motor ability levels, and physical conditioning. Regardless of the balance-training parameters, the current findings support the position that patients with a history of lateral ankle trauma complete a balance/coordination training program for three reasons. First, balance-training programs improve postural control, a measure associated with an increased risk of sustaining a lateral ankle sprain (47,78,82). Second, these programs reduce the recurrence of ankle injuries (15,36,47,48), which is the primary symptom of CAI, and finally, the development of CAI compromises the talar articular surface (43) and is a common cause of posttraumatic osteoarthritis (80).CONCLUSIONSPostural control impairments are present in patients with both a short and a long history of lateral ankle sprains. However, we urge caution when using the uninjured limb as a reference for "normal postural control" because bilateral deficits may mask postural control impairments. Balance/coordination training programs improve the postural control scores of patients with an acute lateral ankle sprain and with CAI. Further research needs to determine the optimal dosage, intensity, and type of training needed to maximize postural control improvements and to reduce recurrent ankle injuries as well as to evaluate a risk reduction/ preventative effect associate with balance training after both acute and chronic ankle trauma. In addition, future meta-analyses should investigate the presence of a bilateral impairment in postural control and/or other sensorimotor control measures after an acute lateral ankle sprain and the development of CAI.The only external funding that partially supported this work was an AHA grant to JHC.The authors of this investigation do not have any professional relationships with companies or manufacturers who may benefit from the results of the present study. 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