Effect of ultrasound-guided percutaneous neuromodulation in ankle instability: a case study

Abstract Background and Aims Ankle proprioception can be tested in many ways. Some studies have found improvements in individuals with chronic ankle instability after receiving treatment and training proprioceptive acuity and speed. Currently, there is a scarcity of evidence concerning percutaneous neuromodulation. The first findings were reported in the post-surgical stage after total knee arthroplasty and in neural improvements and symptoms in patients with hyperactive bladder. Aim To evaluate the effectiveness of percutaneous neuromodulation on the tibial nerve for the improvement of various proprioception parameters in patients with chronic ankle instability. Material and Methods Five men (age: 24.8 ± 4.9 years; height: 1.78 ± 0.08 m; weight: 86 ± 9.8 kg) with chronic ankle instability, who regularly practiced sports activities participated in the present study. People who had undergone an injury in the previous three months were excluded from the speed. Currently, there is a scarcity of evidence concerning test before and immediately after percutaneous neuromodulation. A single leg balance test was performed with eyes open and closed, maintaining the single-legged position on a force plate during 30 seconds (Accupower; AMTI, Watertown, MA) registering 1000 Hz. The displacement of the center of pressure (DOT) was determined based on the distances of its antero-posterior axes (DOT_AP) and medio-lateral (DOT_ML). Furthermore, the amplitudes of anteroposterior and mediolateral displacement were evaluated (ACPap and ACPml). The posterior tibial nerve was stimulated under ultrasound guidance using a 100 Vpp current, with a pulse width of 250 μs and a repetition frequency of 2 to 10 Hz. The process was performed on three occasions during 30 seconds, with an intensity that was acknowledged by the patient but which did not go beyond a score of 3 in the visual analog scale (VAS). The means and standard deviations were calculated for all variables. The effect size was calculated establishing the confidence interval at 90% and the probability of the change being significant was qualitatively calculated. Results A decrease was found in the ACPap (Pre-test eyes open: 5.42 ± 0.62 and eyes closed: 15.99 ± 0.60; Post-test eyes open 4.05 ± 0.36 and eyes closed 10.33 ± 0.49) after the neuromodulation intervention on the tibial nerve. This was a significant change and a “possible” effect size was found in the closed eyes condition (-0.54; ± 0.72), according to Hopkins. For the remaining variables, no significant differences were observed. Conclusions A decreased displacement of the center of mass was found in the antero-posterior axis after performing the neuromodulation technique on the tibial nerve in patients with chronic ankle instability.

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Balance Training and Center-of-Pressure Location in Participants With Chronic Ankle Instability

Journal of Athletic Training ◽

10.4085/1062-6050-49.3.94 ◽

2015 ◽

Vol 50 (4) ◽

pp. 343-349 ◽

Cited By ~ 17

Author(s):

Abby Mettler ◽

Lisa Chinn ◽

Susan A. Saliba ◽

Patrick O. McKeon ◽

Jay Hertel

Keyword(s):

Training Program ◽

Center Of Pressure ◽

Ankle Instability ◽

Force Plate ◽

Balance Training ◽

Chronic Ankle Instability ◽

Eyes Closed ◽

Balance Task ◽

Eyes Open ◽

Data Points

Context Chronic ankle instability (CAI) occurs in some people after a lateral ankle sprain and often results in residual feelings of instability and episodes of the ankle's giving way. Compared with healthy people, patients with CAI demonstrated poor postural control and used a more anteriorly and laterally positioned center of pressure (COP) during a single-limb static-balance task on a force plate. Balance training is an effective means of altering traditional COP measures; however, whether the overall location of the COP distribution under the foot also changes is unknown. Objective To determine if the spatial locations of COP data points in participants with CAI change after a 4-week balance-training program. Design Randomized controlled trial. Setting Laboratory. Patients or Other Participants Thirty-one persons with self-reported CAI. Intervention(s) Participants were randomly assigned to a 4-week balance-training program or no balance training. Main Outcome Measure(s) We collected a total of 500 COP data points while participants balanced using a single limb on a force plate during a 10-second trial. The location of each COP data point relative to the geometric center of the foot was determined, and the frequency count in 4 sections (anteromedial, anterolateral, posteromedial, posterolateral) was analyzed for differences between groups. Results Overall, COP position in the balance-training group shifted from being more anterior to less anterior in both eyes-open trials (before trial = 319.1 ± 165.4, after trial = 160.5 ± 149.5; P = .006) and eyes-closed trials (before trial = 387.9 ± 123.8, after trial = 189.4 ± 102.9; P < .001). The COP for the group that did not perform balance training remained the same in the eyes-open trials (before trial = 214.1 ± 193.3, after trial = 230.0 ± 176.3; P = .54) and eyes-closed trials (before trial = 326.9 ± 134.3, after trial = 338.2 ± 126.1; P = .69). Conclusions In participants with CAI, the balance-training program shifted the COP location from anterolateral to posterolateral. The program may have repaired some of the damaged sensorimotor system pathways, resulting in a more optimally functioning and less constrained system.

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Balance Performance With and Without Visual Information: A Comparison of Elite Players With Chronic Ankle Instability

Journal of Exercise Science and Medicine ◽

10.32598/jesm.11.2.8 ◽

2019 ◽

Vol 11 (2) ◽

pp. 125-132

Author(s):

Zahra Raeisi ◽

◽

Ali Yalfani ◽

Keyword(s):

Visual Information ◽

Center Of Pressure ◽

Ankle Instability ◽

Chronic Ankle Instability ◽

Balance Performance ◽

Balance Test ◽

Eyes Closed ◽

Significant Difference ◽

Volleyball Players ◽

Eyes Open

Introduction: This research was conducted to determine whether professional athletes with Chronic Ankle Instability (CAI) exhibit differences in maintaining balance under conditions of with and without visual information Materials and Methods: Forty-five elite players with CAI were classified into soccer, volleyball, and basketball groups (n=15 each). All participants performed a static single-leg balance test in conditions wherein visual information was provided and withheld. Also, their center of pressure (CoP) oscillation parameters was measured. The data were examined through an analysis of variance (ANOVA) and the Tukey test. Results: A significant difference was found between the soccer and volleyball players (P=0.034) in anteroposterior CoP displacement. Furthermore, there was a significant difference between soccer compared with volleyball (P=0.001) and basketball (P=0.02) groups regarding mediolateral sway and sway area (P=0.003 and P=0.03, respectively) when they performed the test with their eyes open. A significant difference occurred between the soccer and volleyball players concerning anteroposterior and mediolateral sway (P=0.002 and P=0.04, respectively) and sway area (P=0.004) when they performed the test with their eyes closed. Conclusion: Given the necessity of maintaining a good balance in sports, volleyball coaches should design practices that reduce players’ reliance on visual information. These practices should strengthen their proprioceptive abilities through an increased challenge to their proprioceptive senses.

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Differential Ability of Selected Postural-Control Measures in the Prediction of Chronic Ankle Instability Status

Journal of Athletic Training ◽

10.4085/1062-6050-46.3.257 ◽

2011 ◽

Vol 46 (3) ◽

pp. 257-262 ◽

Cited By ~ 35

Author(s):

Danielle Knapp ◽

Sae Yong Lee ◽

Lisa Chinn ◽

Susan A. Saliba ◽

Jay Hertel

Keyword(s):

Postural Control ◽

Center Of Pressure ◽

Ankle Instability ◽

Force Plate ◽

Chronic Ankle Instability ◽

Control Measures ◽

Likelihood Ratios ◽

Absolute Minimum ◽

Persistent Symptoms ◽

Eyes Closed

Context: Chronic ankle instability (CAI) is a term used to identify a condition associated with recurrent ankle sprains and persistent symptoms. Balance deficits, evaluated using center-of-pressure (COP) force-plate measurements, have been shown to occur in people with CAI. Objective: To determine the differential abilities of selected force-plate postural-control measures to assess CAI. Design: Case-control study. Setting: Laboratory. Patients or Other Participants: A total of 63 individuals with CAI (30 men, 33 women: age = 22.3 ± 3.7 years, height = 169.8 ± 9.6 cm, mass = 70.7 ± 14.3 kg) and 46 healthy controls (22 men, 24 women: age = 21.2 ± 4.1 years, height = 173.3 ± 9.2 cm, mass = 69.2 ± 13.2 kg) volunteered. Intervention(s): Participants performed 3 10-second trials of quiet, single-limb stance on a force plate under 2 conditions: eyes open and eyes closed. Main Outcome Measure(s): Measures of COP area, COP velocity, COP SD, COP range of excursion, percentage of COP range used, time-to-boundary absolute minimum, time-to-boundary mean of the minima, and time-to-boundary SD of the minima were calculated. All measures with the exception of COP area were calculated in both the mediolateral (ML) and anteroposterior directions. For each measure, a receiver operator curve analysis was created, and the corresponding area under the curve was tested. The optimal diagnostic threshold value for each measure was determined, and the corresponding positive and negative likelihood ratios were calculated. Results: Three eyes-closed, single-limb force-plate measures (COP ML SD, ML percentage of COP range used, and time-to-boundary absolute minimum) predicted CAI status. However, all 3 measures had positive likelihood ratios associated with only small shifts in the probability of a patient with a positive test having CAI and negative likelihood ratios associated with very small shifts in the probability of a patient with a negative test not having CAI. Conclusions: No single force-plate measure was very effective in predicting if an individual had CAI or not.

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Rehabilitation for Chronic Ankle Instability With or Without Destabilization Devices: A Randomized Controlled Trial

Journal of Athletic Training ◽

10.4085/1062-6050-51.3.09 ◽

2016 ◽

Vol 51 (3) ◽

pp. 233-251 ◽

Cited By ~ 35

Author(s):

Luke Donovan ◽

Joseph M. Hart ◽

Susan A. Saliba ◽

Joseph Park ◽

Mark Anthony Feger ◽

...

Keyword(s):

Center Of Pressure ◽

Ankle Instability ◽

Controlled Trial ◽

Neuromuscular Control ◽

Chronic Ankle Instability ◽

Rehabilitation Program ◽

Balance Test ◽

Randomized Controlled ◽

Eyes Closed ◽

Lower Extremity Muscle

Individuals with chronic ankle instability (CAI) have deficits in neuromuscular control and altered movement patterns. Ankle-destabilization devices have been shown to increase lower extremity muscle activity during functional tasks and may be useful tools for improving common deficits and self-reported function.Context: To determine whether a 4-week rehabilitation program that includes destabilization devices has greater effects on self-reported function, range of motion (ROM), strength, and balance than rehabilitation without devices in patients with CAI.Objective: Randomized controlled clinical trial.Design: Laboratory.Setting: A total of 26 patients with CAI (7 men, 19 women; age = 21.34 ± 3.06 years, height = 168.96 ± 8.77 cm, mass = 70.73 ± 13.86 kg).Patients or Other Participants: Patients completed baseline measures and were randomized into no-device and device groups. Both groups completed 4 weeks of supervised, impairment-based progressive rehabilitation with or without devices and then repeated baseline measures.Intervention(s): We assessed self-reported function using the Foot and Ankle Ability Measure. Ankle ROM was measured with an inclinometer. Ankle strength was assessed using a handheld dynamometer during maximal voluntary isometric contractions. Balance was measured using a composite score of 3 reach directions from the Star Excursion Balance Test and a force plate to calculate center of pressure during eyes-open and eyes-closed single-limb balance. We compared each dependent variable using a 2 × 2 (group × time) analysis of variance and post hoc tests as appropriate and set an a priori α level at .05. The Hedges g effect sizes and associated 95% confidence intervals were calculated.Main Outcome Measure(s): We observed no differences between the no-device and device groups for any measure. However, both groups had large improvements in self-reported function and ankle strength.Results: Incorporating destabilization devices into rehabilitation did not improve ankle function more effectively than traditional rehabilitation tools because both interventions resulted in similar improvements. Impairment-based progressive rehabilitation improved clinical outcomes associated with CAI.Conclusions:

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Comparative Effectiveness of Plantar-Massage Techniques on Postural Control in Those With Chronic Ankle Instability

Journal of Athletic Training ◽

10.4085/1062-6050-52.4.02 ◽

2017 ◽

Vol 52 (7) ◽

pp. 629-635 ◽

Cited By ~ 8

Author(s):

Erik A. Wikstrom ◽

Kyeongtak Song ◽

Ashley Lea ◽

Nastassia Brown

Keyword(s):

Postural Control ◽

Ankle Instability ◽

Chronic Ankle Instability ◽

Balance Test ◽

Physically Active ◽

Lateral Ankle ◽

Massage Treatment ◽

Eyes Open ◽

University Setting ◽

Stimulation Of

Context: One of the major concerns after an acute lateral ankle sprain is the potential for development of chronic ankle instability (CAI). The existing research has determined that clinician-delivered plantar massage improves postural control in those with CAI. However, the effectiveness of self-administered treatments and the underlying cause of any improvements remain unclear. Objectives: To determine (1) the effectiveness of a self-administered plantar-massage treatment in those with CAI and (2) whether the postural-control improvements were due to the stimulation of the plantar cutaneous receptors. Design: Crossover study. Setting: University setting. Patients or Other Participants: A total of 20 physically active individuals (6 men and 14 women) with self-reported CAI. Intervention(s): All participants completed 3 test sessions involving 3 treatments: a clinician-delivered manual plantar massage, a patient-delivered self-massage with a ball, and a clinician-delivered sensory brush massage. Main Outcome Measure(s): Postural control was assessed using single-legged balance with eyes open and the Star Excursion Balance Test. Results: Static postural control improved (P ≤ .014) after each of the interventions. However, no changes in dynamic postural control after any of the interventions were observed (P > .05). No differences were observed between a clinician-delivered manual plantar massage and either a patient-delivered self-massage with a ball or a clinician-delivered sensory brush massage in any postural-control outcome. Conclusions: In those with CAI, single 5-minute sessions of traditional plantar massage, self-administered massage, and sensory brush massage each resulted in comparable static postural-control improvements. The results also provide empirical evidence suggesting that the mechanism for the postural-control improvements is the stimulation of the plantar cutaneous receptors.

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Alterations in Neuromuscular Control at the Knee in Individuals With Chronic Ankle Instability

Journal of Athletic Training ◽

10.4085/1062-6050-49.3.28 ◽

2014 ◽

Vol 49 (5) ◽

pp. 599-607 ◽

Cited By ~ 17

Author(s):

Masafumi Terada ◽

Brian G. Pietrosimone ◽

Phillip A. Gribble

Keyword(s):

Confidence Interval ◽

Effect Size ◽

Muscle Activation ◽

Sagittal Plane ◽

Ankle Instability ◽

Force Plate ◽

Neuromuscular Control ◽

Chronic Ankle Instability ◽

Electromyographic Activity ◽

Vastus Medialis

Context: Few authors have assessed neuromuscular knee-stabilization strategies in individuals with chronic ankle instability (CAI) during functional activities. Objective: To investigate the influence of CAI on neuromuscular characteristics around the knee during a stop-jump task. Design: Case-control study. Setting: Research laboratory. Participants or Other Participants: A total of 19 participants with self-reported unilateral CAI and 19 healthy control participants volunteered for this study. Intervention(s): Participants performed double-legged, vertical stop-jump tasks onto a force plate, and we measured muscle activation around the knee of each limb. Main Outcome Measure(s): We calculated the integrated electromyography for the vastus medialis oblique, vastus lateralis, medial hamstrings, and lateral hamstrings muscles during the 100 ms before and after initial foot contacts with the force plate and normalized by the ensemble peak electromyographic value. Knee sagittal-plane kinematics were also analyzed during a stop-jump task. Results: Compared with control participants, the CAI group demonstrated greater prelanding integrated electromyographic activity of the vastus medialis oblique (CAI = 52.28 ± 11.25%·ms, control = 43.90 ± 10.13%·ms, t36 = 2.41, P = .021, effect size = 0.78, 95% confidence interval = 0.11, 1.43) and less knee-flexion angle at the point of initial foot contact (CAI = 7.81° ± 8.27°, control = 14.09° ± 8.7°, t36 = −2.28, P = .029, effect size = −0.74, 95% confidence interval = −1.38, −0.07) and at 100 ms post–initial foot contact (CAI = 51.36° ± 5.29°, control = 58.66° ± 7.66°, t36 = −3.42, P = .002, effect size = −1.11, 95% confidence interval = −1.77, −0.40). No significant results were noted for the other electromyographic measures. Conclusions: We found altered feed-forward patterns of the vastus medialis oblique and altered postlanding knee sagittal-plane kinematics in the CAI group. These observations may provide insight regarding sensorimotor characteristics that may be associated with CAI.

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Static Balance in Patients with Vestibular Impairments: A Preliminary Study

Scientifica ◽

10.1155/2016/6539858 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Hossein Talebi ◽

Mohammad Taghi Karimi ◽

Seyed Hamid Reza Abtahi ◽

Niloofar Fereshtenejad

Keyword(s):

Path Length ◽

Center Of Pressure ◽

Balance Control ◽

Force Plate ◽

Static Balance ◽

Eyes Closed ◽

Significant Difference ◽

Eyes Open ◽

Age Limits ◽

The Difference

Aims. Vestibular system is indicated as one of the most important sensors responsible for static and dynamic postural control. In this study, we evaluated static balance in patients with unilateral vestibular impairments.Materials and Methods. We compared static balance control using Kistler force plate platform between 10 patients with unilateral vestibular impairments and 20 normal counterparts in the same sex ratio and age limits (50±7). We evaluated excursion and velocity of center of pressure (COP) and path length in anteroposterior (AP) and mediolateral (ML) planes with eyes open and with eyes closed.Results. There was no significant difference between COP excursions in ML and AP planes between both groups with eyes open and eyes closed (pvalue > 0.05). In contrast, the difference between velocity and path length of COP in the mentioned planes was significant between both groups with eyes open and eyes closed (pvalue < 0.05).Conclusions. The present study showed the static instability and balance of patients with vestibular impairments indicated by the abnormal characteristics of body balance.

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Static Postural Stability in Chronic Ankle Instability, an Ankle Sprain and Healthy Ankles

International Journal of Sports Medicine ◽

10.1055/a-0608-4552 ◽

2018 ◽

Vol 39 (08) ◽

pp. 625-629 ◽

Cited By ~ 1

Author(s):

Yong Kwon

Keyword(s):

Postural Stability ◽

Ankle Instability ◽

Mean Amplitude ◽

Chronic Ankle Instability ◽

Medial Gastrocnemius ◽

Muscle Type ◽

Eyes Closed ◽

Ankle Muscles ◽

Eyes Open ◽

Balance Error

AbstractTo identify the single leg balance (SLB) test that discriminates among healthy, coper, and chronic ankle instability (CAI) groups and to determine effects of ankle muscles on the balance error scoring system (BESS) among the three populations. 60 subjects (20 per group) performed the SLB test with eyes open (EO) and eyes closed (EC). Normalized mean amplitude (NMA) of the tibia anterior (TA), fibularis longus (FL), and medial gastrocnemius (MG) muscles and BESS were measured while performing the SLB test. The coper group had a lower error score than the CAI group in the EC. NMA was greater in the CAI group compared to in the healthy and coper groups regardless of muscle type. NMA of the TA was less than the PL and MG regardless of the group in the EO. The CAI group demonstrated greater NMAs of the PL and MG than the healthy and coper groups in the EC. The CAI group demonstrated greater NMA of the PL and MG by compensating their ankle muscles in the EO and EC. BESS suggests that the coper group may have coping mechanisms to stabilize static postural control compared to the CAI group. The EC may be better to detect static postural instability in the CAI or coper group.

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Effect of a 2-Week Joint-Mobilization Intervention on Single-Limb Balance and Ankle Arthrokinematics in Those With Chronic Ankle Instability

Journal of Sport Rehabilitation ◽

10.1123/jsr.2012-0125 ◽

2014 ◽

Vol 23 (1) ◽

pp. 18-26 ◽

Cited By ~ 17

Author(s):

Matthew C. Hoch ◽

David R. Mullineaux ◽

Richard D. Andreatta ◽

Robert A. English ◽

Jennifer M. Medina-McKeon ◽

...

Keyword(s):

Postural Control ◽

Outcome Measures ◽

Repeated Measures ◽

Center Of Pressure ◽

Ankle Instability ◽

Chronic Ankle Instability ◽

Talocrural Joint ◽

Joint Mobilization ◽

Multiple Treatment ◽

Eyes Open

Context:A single talocrural joint-mobilization treatment has improved spatiotemporal measures of postural control but not ankle arthrokinematics in individuals with chronic ankle instability (CAI). However, the effects of multiple treatment sessions on these aspects of function have not been investigated.Objective:To examine the effect of a 2-wk anterior-to-posterior joint-mobilization intervention on instrumented measures of single-limb-stance static postural control and ankle arthrokinematics in adults with CAI.Design:Repeated measures.Setting:Research laboratory.Participants:12 individuals with CAI (6 male, 6 female; age 27.4 ± 4.3 y, height 175.4 ± 9.78 cm, mass 78.4 ± 11.0 kg).Intervention:Subjects received 6 treatments sessions of talocrural grade II joint traction and grade III anterior-to-posterior joint mobilization over 2 wk.Main Outcome Measures:Instrumented measures of single-limb-stance static postural control (eyes open and closed) and anterior and posterior talar displacement and stiffness were assessed 1 wk before the intervention (baseline), before the first treatment (preintervention), 24–48 h after the final treatment (postintervention), and 1 wk later (1-wk follow-up). Postural control was analyzed as center-of-pressure velocity, center-of-pressure range, the mean of time-to-boundary minima, and standard deviation of time-to-boundary minima in the anteroposterior and mediolateral directions for each visual condition.Results:No significant differences were identified in any measures of postural control (P > .08) or ankle arthrokinematics (P > .21).Conclusions:The 2-wk talocrural joint-mobilization intervention did not alter instrumented measures of single-limb-stance postural control or ankle arthrokinematics. Despite the absence of change in these measures, this study continues to clarify the role of talocrural joint mobilization as a rehabilitation strategy for patients with CAI.

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Should the Minimal Intervention Principle Be Considered When Investigating Dual-Tasking Effects on Postural Control?

Brain Sciences ◽

10.3390/brainsci10010001 ◽

2019 ◽

Vol 10 (1) ◽

pp. 1 ◽

Cited By ~ 3

Author(s):

Felix Wachholz ◽

Federico Tiribello ◽

Arunee Promsri ◽

Peter Federolf

Keyword(s):

Postural Control ◽

Center Of Pressure ◽

Force Plate ◽

Principal Component ◽

Mean Velocity ◽

Dual Tasking ◽

Minimal Intervention ◽

Eyes Closed ◽

Eyes Open ◽

Postural Movement

Dual-tasking charges the sensorimotor system with performing two tasks simultaneously. Center of pressure (COP) analysis reveals the postural control that is altered during dual-tasking, but may not reveal the underlying neural mechanisms. In the current study, we hypothesized that the minimal intervention principle (MIP) provides a concept by which dual-tasking effects on the organization and prioritization of postural control can be predicted. Postural movements of 23 adolescents (age 12.7 ± 1.3; 8 females) and 15 adults (26.9 ± 2.3) were measured in a bipedal stance with eyes open, eyes closed and eyes open while performing a dual-task using a force plate and 39 reflective markers. COP data was analyzed by calculating the mean velocity, standard deviation and amplitude of displacement. Kinematic data was examined by performing a principal component analysis (PCA) and extracting postural movement components. Two variables were determined to investigate changes in amplitude (aVark) and in control (Nk) of the principal movement components. Results in aVark and in Nk agreed well with the predicted dual-tasking effects. Thus, the current study corroborates the notion that the MIP should be considered when investigating postural control under dual-tasking conditions.

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