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The Effectiveness of External Ankle Supports in the Prevention of Inversion Ankle Sprains among Elite and Recreational Players

JBI Database of Systematic Reviews and Implementation Reports: Volume 5 - Issue 10 - p 1–12
doi: 10.11124/jbisrir-2007-776
Systematic Review Protocol
Free

Evidence Synthesis Group conducting review

Philippines Allied Health Evidence Synthesis Group

University of Santo Tomas, Manila, Philippines

Affiliated with the Centre for Allied Health Evidence (CAHE)

University of South Australia

City East Campus

Adelaide

SA 5000

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Evidence Synthesis Group conducting the review

Name: Philippines Allied Health Evidence Synthesis Group affiliated with the Centre for Allied Health Evidence, University of South Australia, Adelaide

Contact for review

Telephone: Ms Janine Margarita R. Dizon

Telephone (+632) 786–1611 loc 8454 - 8455 or 4035–4036

Facsimile (+632) 740–9713

Email: jrdizon@mnl.ust.edu.ph or jmrdizon@yahoo.com

Primary reviewer

Name: Janine Margarita R. Dizon

Telephone (+632) 786–1611 loc 8454 - 8455 or 4035–4036

Facsimile (+632) 740–9713

Email: jrdizon@mnl.ust.edu.ph

Secondary reviewer

Name: Ms Josephine Joy Reyes

Telephone (+632) 4786–1611 loc 8454 - 8455

Facsimile (+632) 740–9713

Email: jbreyes@mnl.ust.edu.ph

Commencement date 31st of October 2006

Expected completion date 30th June 2007

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Background and rationale for assessment

Lateral ankle sprains are one of the most common types of injuries that occur during recreational and elite sporting activities. Several epidemiological studies have shown that about 10–28% of all sports injuries are ankle sprains, resulting in the longest absence from athletic activity compared to other types of sports injuries.1 Because of this, different interventions such as exercises, ankle taping techniques, ankles braces and orthoses have been identified to prevent the incidence and recurrence of ankle sprains. Other methods of prevention of ankle ligament injuries include the use of modified footwear and associated supports and adapted training regimens and injury awareness.

External support (taping/orthosis) is the most common preventive method among athletes, and many studies especially laboratory investigations and some clinical trials have been conducted on its effectiveness. According to Verhagen et al, exercises & external ankle supports are the most common interventions in the prevention of ankle sprains. One possible rationale is that the use of ankle tape or a brace increases the kinesthetic awareness of ankle positioning and increases support to the ankle joint by limiting hindfoot motion, specifically inversion2

Hume and Gerrard3 examined the literature regarding the effectiveness of external bracing in reducing ankle sprains. They reported that little information was available delineating the precise mechanisms through which ankle supports reduce ankle injury. Conventionally, the ability of a brace to restrict ankle motion has been the presumed predominant mechanism of action. In their study, rigid and semi-rigid braces were found to be more effective in limiting ankle motion than taping, which was found to lose much of its restrictive support after 20 minutes of exercise. Other mechanisms of effect were postulated for taping such as enhancing the proprioceptive function of the injured ankle. External supports were not found to improve athletic performance, and in some situations were found to impair athletic performance. Hume and Gerrard3 have recommended that where there is a clear history of recurrent ankle injury, the use of an external support should be encouraged. Barrett and Bilisko4 also reviewed the relevant literature and found that although biomechanical studies have demonstrated that high-top shoes improve mechanical ankle stability, clinical studies regarding their effectiveness in reducing ankle sprains were inconclusive.

In this review, the researchers would like to focus on the effectiveness of external ankle supports such as ankle orthoses and ankle taping in preventing the occurrence and recurrence of ankle sprains among elite and recreational players. It has been noted that in some situations, external supports impair performance among athletes. It is therefore necessary to determine whether such preventive measures are effective in preventing and reducing ankle sprains.

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Objectives

The objective of this review is to establish best practice in relation to external ankle supports in preventing occurrence and recurrence of ankle sprains among elite and recreational players

The specific review questions to be addressed are:

  • What is the effectiveness of any external ankle support in preventing the occurrence of ankle sprain in recreational and elite athletes?
  • What is the effectiveness of any external ankle support in preventing the recurrence of ankle sprain in recreational and elite athletes?
  • The general objective of this study is to investigate evidence for the effectiveness of external ankle supports in preventing ankle sprains from occurring in the first place, and where sprains have occurred previously, preventing their recurrence, among elite and recreational players.
  • This study also aims to identify which of the external ankle supports have a higher level of evidence for their use.
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Research questions

  • What is the evidence of effectiveness of any external ankle support for elite and recreational players, in preventing ankle sprains from occurring at all, or preventing their recurrence?
  • Where there are two or more types of external ankle supports fount to be effective, which has the highest level of evidence?
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Criteria for considering studies for this review

Types of studies

To determine evidence of the effectiveness of external ankle supports in preventing ankle sprains in elite and recreational players, randomized controlled clinical trials (RCTs) are the study design of choice. Clinical controlled trials (CCTs) and quasi experimental trials will be considered in the absence of RCTs.

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Types of participants

This review will include any study involving any adult (18 years old and above) elite or recreational players (elite players in the national training pool, those competing in national or state events or those playing recreationally). Participants should not have or have incurred an ankle sprain that occurred as a result of participation in the sport. Studies reporting on players with existing musculoskeletal injuries other than ankle sprains, or post-operative cases will be excluded from the review.

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Types of interventions

External ankle supports are described as any type of ankle tape, brace or orthosis which is applied to the ankle with the aim of preventing ankle sprains.

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Outcome measures

Prevalence, incidence, count data of ankle sprains that occurred as a result in participation in the sport

Incidence of adverse effects resulting from the use of the external ankle support.

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Search strategy for identification of studies

Language

Both published and unpublished English language studies will be sought. Assessment for inclusion of foreign language publications will be based on the English language extract, and if considered appropriate, an English translation of the study will be sought.

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Bibliographic databases and Key words

The following keywords will be used to search for studies to be included in this review (concept 1 AND concept 2 AND concept 3):

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Databases will be searched for all the years available as indicated below. Studies identified during the database searches will be assessed for relevance from a review of the title, abstract and descriptors of the study. A full text report will be obtained for all studies deemed to be relevant. The databases that will be searched include:

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Unpublished literature

To minimize publication bias, unpublished studies will also be identified using Dissertations Abstracts International and Proceedings First.

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Hand searching

The reference lists of all publications of included trials will be searched for additional trials. Hand searching of relevant conference proceedings will also be included.

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Content experts

Content experts in Australia and the Philippines will be contacted in order to obtain additional references, unpublished trials and ongoing trials.

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Methods of the review

Validity Assessment

Level of evidence

The evidence of the retrieved studies will be assessed using the JBI levels of evidence (Table 1)

Table 1

Table 1

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Assessment of methodological quality

Two independent reviewers will critically appraise each study. A third reviewer will be consulted if there is disagreement between reviewers. The ‘JBI Critical Appraisal of Evidence Effectiveness’ will be used to critically appraise each study (Appendix 1). The JBI tool consists of eleven items, each requiring a dichotomous yes/no, unclear and N/A response, with a yes response being allocated one point, and a no/unclear response being allocated zero points. Studies scoring six or above on the JBI critical appraisal tool will be categorized as good quality.

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Data extraction

Data will be extracted independently by two reviewers using the ‘JBI data extraction tool’ (Appendix 2). A third reviewer (Professor Karen Grimmer-Somers) will be asked to adjudicate if the initial reviewers disagree. Data to be collected will include type of design; details of randomisation (if used), study population, intervention, control, outcomes, and quality and result of study analysis. When necessary, we will attempt to contact the researchers of a study to obtain missing information.

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Data synthesis

Data will be summarised statistically if they are sufficiently similar and if they are of adequate quality. If two or more studies are comparable in terms of extract dose and formulation, patient demographics, and disease activity, data will be pooled in a meta-analysis using Review Manager (Revman) software. Weighted mean differences and 95% confidence intervals (CI) will be calculated for continuous data to analyse the size of the effects of the interventions. For dichotomous data, the effect sizes will be expressed in terms of relative risks and 95% CI.

Statistical heterogeneity between trials will be assessed using chi-square analysis. In the presence of significant heterogeneity (p < 0.05), a random effects meta-analysis will be used. Causes of heterogeneity will be explored by conducting subgroup and sensitivity analyses. If the statistical pooling of results is inappropriate, the findings will be summarised in narrative form.

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Data storage

For tracking purposes, all articles obtained for the review will be recorded on a data storage form (Appendix 3), which will provide details about the article's authors, title and source, which database the article was retrieved from, and the location where the article is being stored.

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Potential conflict of interest

None declared

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References

1. Papadopoulos ES, Nicolopoulos C, Anderson EG, Curran M and Athanasopoulos S, The role of ankle bracing in injury prevention, athletic performance and neuromuscular control: A review of the literature. The Foot 2005. 15:1-6
2. Verhagen EALM, van Mechelen W, de Vente W, The Effect of Preventive Measures on the Incidence of Ankle Sprains. Clinical Journal of Sport Medicine, 10:291-296.
3. Hume, PA, Gerrard, PF. Effectiveness of external ankle support. Bracing and taping in rugby union. Sports Med. 1998. 25(5):285-312.
4. Barrett and, Bilisko T. The role of shoes in the prevention of ankle sprains. Sports Med 1995; 20:277-280.
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APPENDIX 1

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APPENDIX 2

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APPENDIX 3

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© 2007 by Lippincott Williams & Wilkins, Inc.