Efficacy of Dual Task Training on Ankle Stability in Chronic Ankle Sprain

DOI: https://doi.org/10.21203/rs.3.rs-1907495/v1

Abstract

Background

Ankle sprain are among the common injuries in the physically active population. Majority of those who suffer ankle sprains have residual symptoms including pain, episodes of giving way, compromised proprioception and neuromuscular control, and re-injury leading to chronic ankle instability.

Objective

The objective of the present study was to find the effect of dual task training on ankle stability in chronic ankle sprain.

Method

A total of 42 participants with chronic ankle sprain were randomly allocated in 2 groups which contains 21 participants in each group. Group A received Dual Task Training with conventional treatment and Group B received Conventional Treatment only. Both group received treatment for 3 days a week for 4 weeks. All participants were assessed pre intervention (baseline) and post intervention (end of 4th week) for pain via NPRS, static balance via single leg stance test, dynamic balance via functional reach test, ankle muscle strength via Micro FET2 dynamometer, ROM assessed via goniometer, proprioception via degree of foot position sense.

Result

Statistical analysis showed significant improvement (P < 0.05) in Pain, Muscle strength and ROM within the groups as well as between the groups. With reference to static balance with one’s eyes open and eyes closed, dynamic balance and proprioception showed significant difference within Group A as well as between the groups (p < 0.05).

Conclusion

This study found that dual task training effectively improves pain, static balance, dynamic balance, muscle strength, ankle ROM and proprioception.

Introduction

Ankle sprain is the most common injury, which has the greatest recurrence rate of all lower extremity musculoskeletal ailments. Ankle sprains restrict their ability to run, leap, kick, and change directions, among other activities. A sprain can be caused by a ligament damage, but it can also be caused by capsular, tendonous, or muscular injuries. The most frequent musculoskeletal injury among physically active people is lateral ankle sprains. 70% of college-aged students and 60% of athletes in high school and college had experienced at least one ankle sprain (Andrea K. Chomistek et al.; 2018).Furthermore, at least 7% of people with ankle sprain had additional repetitive symptoms, including re-injuries and functional anomalies. Re-injury of ankle sprain triggers chronic ankle instability (CAI), which acts as a cause for recurrent sprains in 55–72% of the cases. These patients with re injuries complained of residual symptoms for 6 to 18 months (Sung-Bum Ju et al.; 2017).

Recurring sprains can cause mechanical or functional deficiencies that result in proprioceptive loss, degenerative joint changes, chronic pain, and chronic ankle instability. Whether or not they are athletes, those with a history of ankle instability are more likely to suffer from ankle injuries, muscle imbalances, and joint degeneration (Gabriela Souza de Vasconcelos et al; 2018). Chronic ankle instability is defined as continuous instability and recurring sprains following an acute lateral ankle sprain that can last for years, resulting in limited physical activity, disability, and posttraumatic osteoarthritis (Cynthia J.Wright et al.; 2020).

Proprioception is the neurological process by which the body receives sensory information from its surroundings and integrates it to produce a muscular response. Balancing on a single leg with the eyes closed, balancing on a wobble board or ankle disc, and balancing on a single leg while executing a task such as catching or tossing a ball are all examples of proprioceptive training for the ankle joint. These types of activities can help the sensorimotor system adjust to changes in the environment and hence protect the body from damage (Matthew J. Rivera et al.; 2017).

Resistance training, often known as strength training, is primarily intended to improve the ankle muscles (Emily A. Hall et al; 2018).Strength training is important for a quick recovery and as a preventative strategy against recurring ankle issues. Many clinicians categorize chronic pain based on how long it has been since the first injury: usually 3 to 6 months. Chronic pain is thought to be a source of alterations in brain systems as well as a warning to avoid physical injury or sickness (Saeed Al Adal et al.; 2020).

Dual task training consists of a primary task and an additional secondary task. The two jobs could be completed as a single task with different and separate objectives. People practice both activities at the same time in a dual task intervention. Dual-task performance necessitates the simultaneous execution of two tasks (i.e., Task A and Task B). Single-task performance, in which the individual only has to complete one task at a time, is typically contrasted with this sort of performance. The brain is encouraged, compelled, and at times outright forced to process motor activities in one of four procedural memory centers: the basal ganglia, cerebellum, supplementary motor region, and premotor cortex(Kwang-Il Kwak et al.; 2016).

In people with Chronic Ankle Sprain, there have been a number of therapies aimed at reducing symptoms, improving function, and reducing recurring sprains. Balance training devices, such as unstable balance platforms, are prescribed in proprioceptive rehabilitation programmes to address proprioceptive deficiencies and restore functional stability of the ankle joint (Susan. Rozzi et al.; 1999). Balance training in the weight-bearing posture may be an effective way to reestablish neuromuscular control and hence improve functional ability. To rehabilitate ankle instability, therapeutic therapies such as ankle strength training, proprioceptive training, balance training, imagination exercise, isokinetic exercise, and ankle structure support have been adopted, as well as the effect of ankle instability (M. Spencer Cain et al.; 2020).

Therefore, this study was conducted on chronic ankle sprain patient to see the effect of dual task training on ankle stability. The dual task training performed with balance training and resistance training to see the effect on muscle strength, pain, balance- static and dynamic, ankle range of motion and proprioception were evaluated in patients with chronic ankle sprain.

Materials And Methods

This was a Pre-test Post-test Experimental design which was done with chronic ankle sprain patients at Physiotherapy Out-patient Department of SGT Medical College and Hospital, Gurugram, Haryana. The proposal of the study was submitted for ethical approval to the ethical committee and the study has been cleared by Institutional Ethical Committee (IEC) of SGT University under the following SGTU/FPHY/2022/13 (Regn. No.200311013).

Sample size

A sample size of 42 was calculated through G -Power Software.

Effect size d = 0.8, α err prob = 0.05, power (1-β err prob = 0.80)

Inclusion and Exclusion criteria:

The inclusion criteria was both both male and female having chronic ankle sprain age group 18 to 30 years, frequent giving way incidents, history of more than one lateral ankle sprain, duration with more than 3 months and strength with minimum grade 3 were included in the study and the participants having any history of lower extremity injury/surgery, fracture, head injury, vestibular or balance disorders or bilateral injuries were excluded from the study.

Outcome measures:

1. Pain

2. Balance – Static and Dynamic

3. Proprioception

4. Muscle Strength

5. Ankle Range of Motion

Measurement of proprioception

Degree of foot position sense was used to record proprioception in the ankle. Foot position sense was recorded by placing the ankle joint on non-affected side in some degrees of dorsiflexion or plantarflexion and asking participants to match the position with the affected ankle with their eyes closed. Angle of difference in the position of ankles was noted in degrees (Ahmad H. Alghadir et al.; 2020).

Measurement of balance

Static Balance

Single leg balance test. In this test, the participants stand on a single leg without shoes or socks, with the opposite knee bent without touching the weight bearing leg. Participants’ hands were place on both hips to prevent using their arms for balance (Fig. 2). Then measure the length of time each participant could maintain their balance. The test was performed three times with the participants’ eyes open, and then three times with eyes closed and an average of three trials was record in seconds for the study. At least 5 min of rest was permitted between each trial to avoid participant fatigue (Khalid A Alahmari et al.; 2020).

Dynamic Balance

Functional Reach test in this test, the participant enters a standing position on a line mark on the floor. An inch tape was attached to a wall at about the shoulder height of the Participant. The participant was instructed to stand close to wall without touching it while facing the inch tape with shoulder flexion at 90° and hand fisted (Fig. 3). The therapist records the starting position at the knuckle of the third metacarpal head on the ruler, then instruct the Participant to reach as far forward as possible along the length of the tape without moving the feet. At this time, the therapist once again records the location of the knuckle of the third metacarpal. Participants were required not to lean against the wall at any time during the test. If they did lose balance, the therapist will stop the test. The study determines scores by assessing the difference between the start and end positions, it conducted three trials with one minute of rest between each and record the average for all the participants in centimeters (Khalid A Alahmari et al.; 2020).

Measurement of Muscle Strength

Tibialis Anterior

Participants was in supine position. The dynamometer was positioned against the dorsal and medial surface of the foot. After instruction, each participant was asked to dorsiflex and inversion of the ankle joint as hard as possible for 2–3 s. The Therapist measured the muscle strength three times on the same day, and a 2s rest was given between each trial (H. Gapeyeva et al.; 2015). Figure 4

Peroneus longus

Participants were in supine position. The dynamometer was positioned against the plantar surface of the foot. After instruction, each participant was asked to plantarflex and eversion of the ankle joint as hard as possible for 2–3 s. The Therapist measured the muscle strength three times on the same day, and a 2s rest was given between each trial (H. Gapeyeva et al.; 2015). Figure 5

Study Protocol

Procedure

Participants were randomly selected using random sampling. Whole procedure was explained to the Participants and prior the treatment written consent was taken from the participants. The study was conducted in Physiotherapy OPD of SGT University hospital. The participants who fulfilled the inclusion and exclusion criteria were included in the study. All the participants included in the study underwent basic assessment and assigned randomly into 2 groups named as Group A (Dual Task Training + Conventional Therapy) and Group B (Conventional Therapy). The baseline measurement was evaluated. All the groups followed the protocol and data was collected at the baseline and at the end of 4th week after intervention.

Group A: Dual Task Training

The dual task training with balance training on wobble board. Participants have to catch thrown ball during the balance training. In the Double task training, the first week standing on two feet, the second week standing with left and right weight shift (Fig. 6), the third week, standing with front and back weight shift and in the fourth week standing on one leg on ground (Fig. 7). Double-task training was conducted in which the participant received a ball thrown from a distance of 5 m. The ball received one time with the right hand, then with the left hand, and then with both hands. Participants trained for 4 weeks, 3 days a week. Duration for training 20 minutes/day (Kwang-Il Kwak et al.; 2016).

The dual task training with strength training involved the use of an elastic theraband. Inversion, Eversion, Dorsiflexion and Plantar flexion was performed together to strengthen the surrounding ankle. Double-task training with resistance was conducted in which the participant received a ball thrown from a distance of 5 m (Fig. 8). The ball received one time with the right hand, then with the left hand, and then with both hands. Participants were instructed to perform each exercise for 2 sets (10 repetitions per set). Participants trained for 4 weeks, 3 days a week. Duration for training 20 minutes/day (Khalid A Alahmari et al.; 2020).

Group B

Conventional Therapy: Hot pack for 10 minutes, Ankle active Range of Motion Exercises (2 sets 10 repetitions per set), Ankle circles - clockwise 10 circles and counterclockwise 10 circles (2 sets), Ankle Isometrics (2 sets 10 repetitions 5 sec hold), Heels raise (3 sets 10 repetitions), One leg standing with eyes open and closed (2 sets 10 repetitions 5 sec hold) for 3 days/week for 4 weeks (Carl G. Mattacola et al.; 2002).  

Table 3.2 Ankle Balance and Strength Training Protocol

STATISTICAL ANALYSIS

Statistical analysis of 42 patient’s Pain, Balance, Muscle Strength, Ankle ROM, and Proprioception was performed using Software IBM SPSS 26 for Windows Version. Data was entered into an excel spreadsheet, tabulated and statistical analysis was performed for this purpose. All of the variables, mean and standard deviation were determined. Tables and graphs were used to display the data’s properties. At p˂0.05, the results were considered statistically significant.Paired Sample T-Test was used to analyze inter-group differences for the variables Pain, Balance, Muscle Strength, Ankle ROM and Proprioception at baseline and the end of the 4th week.Independent Sample T-Test was used at baseline and end of the 4th week to analyze and compare the intra-group differences for the variables Pain, Balance, Muscle Strength, Ankle ROM, and Proprioception.

Results

Comparison of Pain, Ankle ROM and Muscle strength

Statistical analysis of 4-week interventional study revealed that both the interventions i.e., dual task training and conventional therapy were effective in reducing pain, improving ankle ROM and muscle strength within the groups (p < 0.05) and in between the groups (p < 0.05).

Comparison of static and dynamic balance

Within group A showed significant difference in static (eyes open and closed) and dynamic balance (p < 0.05) whereas within group B showed insignificant difference in static and dynamic balance (p < 0.05).There was significant difference between the group in static (eyes open and closed) and dynamic balance (p < 0.05).

Comparison of proprioception

It showed significant difference within group A and between the groups (p < 0.05).

Pain

Independent Sample t-Test was applied to analyzed Pain and showed significant differences between the baseline Pain (p = 1.000) and end of 4th week Pain (p = 0.028).Graphical representation of mean comparison between the group A and group B showed significant difference. (Table 1 and Graph 1)  

Table 1

Independent Sample t-Test between the group for pain

Variable

Mean ± SD

t-Value

p-Value

Group A

Group B

Pre-Pain

1.33 ± 0.96

1.33 ± 1.01

0.00

1.000

Post Pain

0.10 ± 0.30

0.67 ± 1.11

-2.27

0.028*

*Significant

Balance

Independent Sample t-Test was used to analyzed Balance between the group and showed significant differences between the baseline in Static eyes open (p = 0.778), Static eyes closed (p = 0.893), Dynamic (p = 0.681) and end of 4th week Static eyes open (p = 0.003), Static eyes closed (p = 0.022), Dynamic (p = 0.036). Graphical representation of mean comparison between the group showed significant differences. (Table 2and Graph 2). 

Table 2

Independent Sample t-Test between the group for Balance – static and dynamic.

Variable

Mean ± SD

t-Value

p-Value

Group A

Group B

Pre-Static(eyes open) (sec)

13.38 ± 3.22

13.11 ± 2.96

0.28

0.778

Post Static(eyes open) (sec)

15.60 ± 3.02

12.77 ± 2.78

3.15

0.003**

Pre-Static(eyes closed) (sec)

5.21 ± 1.89

5.14 ± 1.75

0.13

0.893

Post Static(eyes closed) (sec)

6.65 ± 1.98

5.37 ± 1.43

2.38

0.022*

Pre-Dynamic (cm)

8.88 ± 3.04

8.49 ± 3.06

0.41

0.681

Post Dynamic (cm)

9.79 ± 2.89

8.05 ± 2.23

2.17

0.036*

**Highly Significant *Significant

Ankle muscle strength

Independent Sample t-Test was used to analyzed Balance between the group and showed significant differences between the baseline in Tibialis anterior (p = 0.874), Peroneus longus (p = 0.825) and end of 4th week in Tibialis anterior (p = 0.047), Peroneus longus(p = 0.041). Graphical representation of mean comparison between the group showed significant differences. (Table 3and Graph 3). 

Table 3

Independent Sample t-Test between the group for Ankle Muscle Strength

Variable

Mean ± SD

t-Value

p-Value

Group A

Group B

PreTibialis anterior(N)

4.99 ± 1.28

5.05 ± 1.22

-0.16

0.874

Post Tibialis anterior(N)

5.61 ± 1.13

5.11 ± 0.88

2.04

0.047*

PrePeroneus longus(N)

4.88 ± 1.23

4.96 ± 1.11

-0.22

0.825

Post Peroneus longus(N)

5.50 ± 1.11

4.99 ± 1.07

2.10

0.041*

*Significant

Ankle Range of Motion

Independent Sample t-Test was used to analyzed Balance between the group and showed significant differences between the baseline in Plantarflexion (p = 0.891), Dorsiflexion (p = 0.153), Inversion (p = 0.858), Eversion (p = 0.248) and end of 4th week Plantarflexion (p = 0.044), Dorsiflexion (p = 0.020), Inversion (p = 0.042), Eversion (p = 0.043). Graphical representation of mean comparison between the group showed significant differences. (Table 4and Graph 4). 

Table 4

Independent Sample t-Test between the group for Ankle Range of motion.

Variable

(Degree)

Mean ± SD

t-Value

p-Value

Group A

Group B

Pre Plantarflexion

37.29 ± 5.58

37.05 ± 5.64

0.13

0.891

Post Plantarflexion

39.10 ± 4.94

35.71 ± 5.55

2.08

0.044*

Pre Dorsiflexion

19.86 ± 3.41

18.19 ± 3.98

1.45

0.153

Post Dorsiflexion

22.24 ± 3.14

19.86 ± 3.22

2.42

0.020*

Pre Inversion

37.57 ± 4.38

37.81 ± 4.19

-0.18

0.858

Post Inversion

38.33 ± 4.30

35.48 ± 4.50

2.10

0.042*

Pre Eversion

22.05 ± 3.76

20.48 ± 4.86

1.17

0.248

Post Eversion

23.71 ± 2.64

21.76 ± 3.37

2.08

0.043*

*Significant

Ankle Proprioception

Independent Sample t-Test was used to analyzed Balance between the group and showed significant differences between the baseline in Dorsiflexion (p = 0.897), Plantarflexion (p = 0.834) and end of 4th week Dorsiflexion (p = 0.046), Planatarflexion (p = 0.010). Graphical representation of mean comparison between the group showed significant differences. (Table 5and Graph 5). 

Table 5

Independent Sample t-Test between the group for Proprioception.

Variable

(Degree)

Mean ± SD

t-Value

p-Value

Group A

Group B

Pre Dorsiflexion

1.81 ± 1.20

1.86 ± 1.15

-0.13

0.897

Post Dorsiflexion

0.86 ± 0.85

1.71 ± 1.70

-2.05

0.046*

Pre Plantarflexion

3.43 ± 1.43

3.33 ± 1.49

0.21

0.834

Post Plantarflexion

1.24 ± 0.94

2.43 ± 1.74

-2.74

0.010*

*Significant

Discussion

Ankle sprains are highly prevalent traumatic injury that affects physically active people more frequently. Recurrent injury prevention and ensuring safe participation in sports and activities of daily living (ADL) are the main objectives of rehabilitation activities.

This research was done to see the effect of dual task training on ankle stability in chronic ankle sprain. After interpreting the results of our present study, we found that 4 weeks of dual task training combined with balance and strength training significantly decreased pain and improved balance, muscle strength, ankle range of motion and proprioception outcomes in subjects suffering from chronic ankle sprain. The results suggest that the balance training protocol with wobble board and strength training protocol with therabands simultaneously performing dual activity (such as catching the ball) increased ankle stability among participants aged 18 to 30 years.

Participants with a chronic ankle sprain experienced a mild pain, which was common during physical activity and did not differ between genders. Pain was present in participants with chronic ankle sprain, with the level of pain reported to be 3 (out of 10 on the numerical analogue scale). The majority of chronic ankle sprain participants in the present study experienced pain during moderate to strenuous physical activity as opposed to everyday activities when they had ankle pain. This could be as a result of most participants being younger adults (Saeed Al Adal et al.; 2019).

There was significant decrease in NPRS in both the intervention group after 4 weeks of treatment. The reduction in pain intensity in both groups is attributed to hypoalgesic effect which is explained by the inhibitory Golgi tendon reflex, activated during the isometric contraction that in turn leads to the reflex relaxation of the muscle (Vaegter et al.; 2014). They concluded that high intensity isometric contraction of muscles produced a larger local exercise induced hypoalgesia compared to low intensity contraction (Vaegter et al.; 2014). Consequently, it has been argued that increase in strength could be a physiological mechanism underpinning decreased pain (Larsson et al.; 2015). Dual task training and conventional therapy decreased pain in chronic ankle sprain patients.

Another outcome measure i.e. balance both static and dynamic shows significant difference in the experimental group (p < 0.05). Present study was supported by (HaifangWang et al.; 2021) that showed significant improvement in both static and dynamic balance by giving balance and resistance training.Chronic ankle sprain showed deficits in both static and dynamic balance after the ankle injury. This shows that even when the acute phase's symptoms have already subsided, deficiencies still exist as a result of the development of numerous long-term variables (Ahmad H. Alghadir et al.; 2020). Dual task training with balance and strengthening exercises improves static and dynamic balance to our current study and statistically significant (p < 0.05). Balance and strengthening exercises has been shown to have central effects on the sensorimotor system that leads to development of balance and posture control deficits. Static balance improvement shows that ankle strength is an important factor influencing the somatosensory regulation during standing position and balance through its effects on muscle and tendon receptors of the foot and ankle that include the plantar cutaneous receptors (Jam et al .;2006). Dynamic balance development was mainly due to the combination of neural factors and increase in concentric and eccentric muscle activity in subjects with chronic ankle sprain (Moritani et al.; 1979).

The finding of this study was that the muscle strength improvement was significant in both the groups with dual task training and conventional treatment (p < 0.05). Researchers have identified a significant relationship between ankle muscle weakness and ankle instability. According to Ryan, L. et al.; 1994 this muscle weakness may be caused from the disruption of the muscle’s nerve supply or selective inhibition of the invertor muscle’s capability to start affecting in the direction of the initial injury. Therefore, investigators designed different balance and strength training protocols for the ankle and reported that these exercises significantly improve ankle stability (Docherty et al.; 1998). Another reason is the outcome of balance training that stimulates numerous neurons and muscle fibers near the ankle. The tibialis anterior and peroneus longus are the muscles that are affected by balance training, according to previous electromyography studies (Laudner et al.; 2010).

The result of this study shows significant difference in ankle proprioception in patients with chronic ankle sprain (p < 0.05). The dorsiflexion joint position sense (JPS) and plantarflexion JPS was significantly improved with dual task training. Postural control issues result from a combination of neuromuscular control and proprioception impairments brought on by joint injury, which further restricts the joint's dynamic defence mechanism and predisposes it to repeated injury and instability (Rozzi et al.; 1999). Muscle receptors support the sensory feedback on changes in muscle length, joint position awareness, and movement speed. These receptors play a crucial role in ankle proprioception. Through stimulating the tibialis posterior, flexor hallucis longus, and flexor digitorum muscles, the sensory involvement of the tibial nerve surely contributes to the ankle joint position awareness and motor control (Taira et al.; 2003). Two different sensory processes could have caused such a change. According to Bongiovanni et al.; 1990 two mechanisms for the change: first, the stimulation of joint mechanoreceptors during exercise; and second, cerebral adaptation to primary afferent (Ia, IIa) terminals of muscle spindles.For these reasons, dual task training is a crucial component in rehabilitating participants with chronic ankle sprain.

Another outcome measure i.e. ROM measure via universal goniometer revealed that there was significant improvement in ankle ROM- dorsiflexion, plantarflexion, inversion and eversion in both the groups experimental as well as control group after 4 weeks of treatment (p < 0.05). Active ROM was present in participants there was no restrictions in movement (Ahmad H. Alghadir et al.; 2020). Resistance training has been suggested to reduce neural inbition and improve the coordination of primary and stabilizing muscles (Clark et al.; 2008). Dual task training further improved the Range of Motion of the participants. After gradual improvement in the initial symptoms most of the patients who seek medical care restored physiological ROM after the injury.

Thus, we can say that our intervention was equally effective among the subjects of chronic ankle sprain in achieving change in all the parameters. Dual task training with balance and strength training should be considered as a feasible option for management of chronic ankle sprain. With appropriate precautions and supervision under a qualified Physiotherapist, this mode of training can be very useful for every individual as it does not bear any side effects and brings along improvement in chronic ankle sprain.

Limitation of the study:

One of the limitations of the present study was a small sample size and a short duration of the intervention owing to the limited time frame for completion of the study. This current study did not conduct a follow up of all the participants after 4 weeks to see if the improvement last longer. We believe the assessment of clinical outcome measures and training protocols efficacy depends on reliable follow-up information.

Future scope of the study:

Future clinical studies can evaluate the effect of longer cross-sectional study with different lengths of training protocols with regards to improving the stability outcomes for those with CAI. Further research is necessary involving larger cohorts. Follow up will be taken in further studies. Future studies can use advance tool for balance.

Clinical Implications:

This study will help physiotherapist to use Dual task training with balance and resistance training exercises in patients with chronic ankle sprain as Rehabilitative intervention in a clinical setting.

Conclusion

4 weeks of dual task training combined with balance and strength training protocols significantly improved pain, balance both static and dynamic, muscle strength of tibialis anterior and peroneus longus, ankle range of motion of dorsiflexion, plantarflexion, inversion, and eversion and proprioception outcomes in chronic ankle sprain. Moreover, dual task training was effective in improving balance and proprioception. Including these protocols in a rehabilitation program could accelerate recovery from ankle sprains and prevent the development of chronic ankle sprain, thereby providing faster return to work.

Declarations

Funding

 No external agency or the internal agency has been involved in funding

 Conflict of Interest 

 NIL

 Contribution of Authors:

 Author 1 Designed and carried the study as principal investigator

Author 2 Selected and designed the present study and guided the principle investigator throughout and prepared the manuscript

Author 3 contributed as a co-guide to the principle investigator

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Graphs

Graphs 1-5 are available in the Supplementary Files section.