Investigation of dynamic postural control in athletes with and without chronic ankle instability accompanied by high and low levels of kinesiophobia during jump landing: A cross-sectional study

doi:10.21203/rs.3.rs-4046541/v1

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Research Article

Investigation of dynamic postural control in athletes with and without chronic ankle instability accompanied by high and low levels of kinesiophobia during jump landing: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-4046541/v1

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Background

Individuals with chronic ankle instability (CAI) commonly experience pain, swelling, giving way, and postural instability. It has been observed that they exhibit a certain level of fear of movement, which impacts their postural stability. The degree of fear of movement can be assessed using the Tampa Scale of Kinesiophobia (TSK), ranging from low to high levels. Dysfunction in postural control can be influenced by this fear of movement. In the present study, researchers compared the dynamic postural control characteristics during jump landing between CAI athletes with low and high levels of kinesiophobia and healthy controls.

Methods

Sixty participants with CAI were divided into three groups: CAI subjects with low kinesiophobia, CAI subjects with high kinesiophobia (determined by a cutoff of 38 in TSK score), and healthy controls. The participants performed a single-leg jump landing on a force plate, either on the side of the unstable ankle for CAI subjects or on the matching ankle for healthy controls. Time to stabilization (TTS), center of pressure displacement (COP), velocity of COP displacement in anterior-posterior (AP) and medial-lateral (ML) directions, as well as the total direction, were calculated for further analysis as outcome measures. Statistical analysis was conducted using one-way analysis of variance, with a significance level set at 0.05 for each analysis.

Results

The study's results revealed that the time to stability in the AP and total direction exhibited the most significant difference between the high kinesiophobia group and the healthy control groups (P = 0.019, P = 0.00 respectively). Additionally, CAI subjects with high kinesiophobia demonstrated a significant increase in the standard deviation of COP velocity in the AP direction (P = 0.002), a significant decrease in COP velocity variability in the ML direction (P = 0.002), and a significant increase in COP displacement variability in the ML direction compared to healthy controls (P = 0.006).

Conclusions

Individuals with high fear of re-injury may perceive the jumping landing task as threatening, requiring more time to land and regain stability. This fear can limit the variability of velocity in the ML direction, leading to reduced control over the AP direction due to constraints on controlling degrees of freedom.

Kinesiophobia

Chronic Ankle Instability

Jump Landing Task

Dynamic Postural Control

Ankle instability is commonly caused by lateral ankle sprains, which are a common injury among sportsmen (1). It's estimated to impact around 70% of those who have experienced an ankle sprain (2). Two primary forms of ankle instability exist: mechanical ankle instability, associated with hypermobility, and functional ankle instability. Both types are connected to chronic ankle instability (CAI) (3, 4). Individuals with CAI, particularly athletes, commonly report sensations of their ankles giving way (3, 4).

Physical impairment, delayed reaction movements, and diminished muscle power and postural control can all contribute to CAI (5–7). Studies have revealed that patients with chronic ankle instability (CAI) display variances in postural control, as evidenced by center of pressure (COP) displacement during functional tasks (8, 9). Additionally, psychological factors following an injury may contribute to further physical impairment among CAI patients (10–12).This includes elevated dread of re-injury, also referred to as kinesiophobia or fear of movement, which is a common psychological response to injury (13).

The fear of movement is reported as a maladaptive emotional response to an overwhelming fear of injury, which can result in avoidance behaviors, including changing postural control (14). The fear of movement is reported as a maladaptive emotional response to an overwhelming fear of injury, which can result in avoidance behaviors, including changing postural control (15). The fear of movement is reported as a maladaptive emotional response to an overwhelming fear of injury, which can result in avoidance behaviors, including changing postural control (16).

Athletes' functional performance is impacted by kinesiophobia as judged by the Tampa Scale of Kinesiophobia (TSK) (17), Additionally, it reduces the efficacy of therapeutic therapies(13, 18–20). Those who are afraid of a new injury may be more vulnerable to physical impairments, lower self-reporting abilities, and less postural control (21, 22). There is proof that the brain areas responsible for emotion and postural regulation are connected neuronally (23–25). Efferent projections from the limbic and amygdala structures, which are crucial for processing emotions like fear, connect to brain regions related to postural control (25). Consequently, psychological factors, such as stress, anxiety, and fear, can increase the likelihood of impaired postural control in a person Consequently, psychological factors, such as stress, anxiety, and fear, can increase the likelihood of impaired postural control in a person (26).

Previous studies have shown a correlation between postural stability tests and fear of mobility in CAI individuals (27). Psychological influences, including fear, can also affect physical function (28). According to Alshahrani et al., postural sway in CAI patients is linked to higher kinesiophobia (29). Conversely, research has shown a correlation between physical exercise and the intensity of kinesiophobia (28, 30). It appears that kinesiophobia's effects on people with CAI have drawn a lot of attention (27–29). Psychological influences, including fear, can also affect physical function (28). According to Alshahrani et al., postural sway in CAI patients is linked to higher kinesiophobia (29). Conversely, research has shown a correlation between physical exercise and the intensity of kinesiophobia (28, 30). It appears that kinesiophobia's effects on people with CAI have drawn a lot of attention (27–29). A significant body of research has demonstrated a connection between kinesiophobia, pain severity, functional impairment, and quality of life in this regard (28, 31, 32). The greater pain intensity, functional disability, and quality of life were all substantially correlated with baseline kinesiophobia scores (28, 31). This study aimed to investigate the effect of kinesiophobia levels on the postural control parameters in athletes with and without chronic ankle instability during jump landing. It was conducted, because there are few studies that look into the effects of fear of movement on postural stability in CAI subjects(27, 29), and no studies that look into the levels of kinesiophobia on postural stability of CAI subjects. It was hypothesized that individuals with CAI who experience kinesiophobia, regardless of severity, will exhibit increased postural sway and velocity of displacement.

Study design

This case–control study was performed in the physiotherapy department of the *****laboratory. The study was approved by the Human Research Ethics Committee of the *****by number *****.

Participants

Sample size

Using the G*Power program (version 3.1.9.4) and pilot data collected from seven athletes in each group, the sample size was computed taking into account the TTS during the jump landing task. Power of 0.90, α = 0.05, and effect size f of 0.6 were determined based on a prior analysis. 48 subjects was determined to be the sample size. With a 10% attrition rate, a sample size of 60 people (20 in each group) was taken into account.

Participants

Sixty subjects, 20 controls, and 40 CAI (Table 1) were divided into three groups: healthy control, CAI with high kinesiophobia, and CAI with low kinesiophobia based on TSK score cutoff point 38 (33). Inclusion criteria were: nonprofessional athletes, who had more than 6 hours of sports activities at level one (jumping movements, rotation with Change of direction such as basketball, handball, and football) or level two (intensity of jumping movements and change to level one is less like volleyball, racquet sports, martial arts, and gymnastics) in club per week (34). The participants had at least one ankle sprain in the last 12 months that required protected weight bearing or immobilization for at least 3 days (35). score < 90% on the daily living sub-scale and score < 80% on the sports sub-scale of the Foot and Ankle Measure(FAAM) (36).Exclusion criteria included participants experiencing pain and discomfort during the trial, severe visual impairment and balance disorders (eg labyrinthitis or benign paroxysmal positional vertigo), any other condition known to affect balance; previous fractures of the lower limb, and surgery in the lower extremity (8, 37), history of neurologic conditions(38, 39), Pain and swelling of the ankle during the last 3 month (36). The control group had no experience of lateral ankle sprains. Enrolled participants read and signed the written informed consent, before study participation.

Outcome measures

Questionnaires

FAAM and TSK questionnaire were completed by CAI athletes. The healthy controls only competed in the TSK. The FAAM is a 29-element questionnaire split into two sub-scales: Daily Living Activities (ADL) with 21 elements and SPORTS with 8 elements. Each element is rated on a 5-point Likert scale representing various levels of difficulty (no difficulty at all, slight difficulty, moderate difficulty, extreme difficulty, and inability to do so). The ADL and SPORTS subscales have an overall score of 84 and 32, respectively. Scores are converted into percentages with higher scores indicating a higher level of functional status for each subscale. The FAAM also includes three other overall functional status ranges. There are two scales for each FAAM subscale that require subjects to rate their current level of function during activity daily living (ADL) and SPORTS tasks at 100% level with 0% indicating an inability to carry out any task and 100% indicating the level of performance before injury. Another scale asked subjects to assess their current level of global function, with responses classified as normal, near normal, abnormal, and severely abnormal (36).

TSK is a 17-point instrument designed for measuring the pain-related fear of the new jury/motion. All items are graded on a 4-point (1–4) Likert scale from Strongly Disagree to Strongly Agree. The TSK score varies between 17 and 80, with higher scores indicating a higher degree of fear associated with motion/re-identification pain. The cutoff point of Tampa Scale of Kinesophobia was 38 (40).

COP measures

A force plate ( Bertec Corporation, Columbus, and U.S.A) was used to collect postural stability data: To study the postural stability indices, two variables of COP displacement and COP velocity in the AP and ML directions (COP x, COP y), and TTS in AP, vertical, and total directions were used. The values in the COP were available in millimeters and the sampling frequency of the device was 1000 Hz. Athletes have utilized these factors extensively to determine the dimensions of postural instability since they reflect spatiotemporal components of postural control (41–43).

Procedures

Subjects stood behind the force plate at a distance equal to half the length of their lower legs. The subjects should perform three two-foot landing jumps, which should be as much as 50% of their maximum vertical jump height that was determined before the start of the test. Subjects could swing their arms while jumping, touching markers, and then land on the unstable ankle or the matched ankle of healthy controls. Subjects were familiarized with the test conditions before starting the test (42, 44, 45). A successful jump is defined as staying on the sole on the force plate and maintaining the balance as quickly as possible up to 10 seconds after the landing. The test was repeated three times and 30 seconds rest was considered between the trials. The test must be deleted or repeated if the subject leaves the force plate, lands on the undefined leg, accompanied by an additional jump, if there was a lot of swing in the hands, trunk, and opposite leg, which causes the subject's leg to lift off the force plate(46).

Dynamic postural control parameters were: total time to stability (TTS), vertical time to stability (V-TTS), anterior-posterior time to stability (AP-TTS), velocity anterior-posterior standard deviation(V_AP_SD), distance anterior-posterior standard deviation (D_AP_SD), velocity medial-lateral standard deviation(V_ML_SD) and distance medial-lateral standard deviation (D_ML_SD). AP _TTS V_AP_SD and D_AP_SD normalized the length of the soles of the participants' feet (mm). V_ML_SD and D_ML_SD have normalized the width of the soles of the participants' feet (mm).

Data processing:

Three postural activities were analyzed using their average values. At 100 Hz, force plate data were recorded, and at 1000 Hz. The force plate (40×60, Bertec), model number 4060-08, is used for data capture. A 4 fourth-order (2 × 2 order) Butterworth low-pass filter with a 10 Hz cutoff frequency was used to bi-directionally filter the raw data. Data processing was done using MATLAB software (MATLAB R2018, The Mathworks, Inc., Natick, RI, USA). TTS in the vertical, AP, and total directions were the main results (32). To calculate TTS, the following variables were used: vertical ground reaction force (GRF), AP force, and total force vector (which includes all three forces in three dimensions). 500 millisecond time intervals were used to divide the whole test period; these intervals are represented in the diagram as windows. For every time interval, the GRF peak and trough values were determined, and the force change was computed. As the stable zone, an unbounded third-order polynomial is used. For every direction of the GRF, an unconstrained third-order polynomial was fitted to the GRF peak-corrected data. From the polynomial to the highest point of the GRF of the chosen interval, a horizontal line is drawn. TT (45) was used to compute the moment at which the polynomial intersects the line. COP metrics were secondary outcomes.

Statistical Analysis

The normality of the data was verified using the Shapiro– Wilk test and the homogeneity of variance by the Levene’s test. As all of the variables followed a normal distribution, a parametric one-way analysis of variance (ANOVA) was performed. All of the variances were detected equally. In case of significant findings, post hoc analysis was carried out; Tukey's test was performed for pairwise comparisons for equal variances. The α level was set at 0.05 for each analysis.

Demographic characteristics are presented in Table 1. There were no significant differences between the groups related to age, height, weight, and Body Mass Index (BMI) of the subjects.

Table 1- Demographic and descriptive information between three groups

ANOVA test for demographic data, N=number, SD= Standard deviation

Dynamic stability parameters

TTS parameters

Table 2 summarizes the results of the ANOVA. ANOVA results showed that there was a statistically significant difference between Total _TTS and AP _TTS between groups. Pairwise comparisons (post-doc), which were performed with Tukey's test showed that Total _TTS (P = 0/015) and AP _TTS (P = 0/00 in the high kinesiophobia group were more than other groups.

Table 2

Mean. ± Standard Deviation of dependent variables between three groups
Time to stability	Healthy group (Mean ± SD)	Low kinesiophobia group (Mean ±_SD)	High kinesiophobia group (Mean ±_SD)	P-value
Total _TTS	2/63 ± 0/90	2/89 ± 0/79	3/40 ± 0/84	0/019*
Vertical _TTS	2/64 ± 0/97	2/81 ± 0/81	3/31 ± 0/91	0/059
AP _TTS	0/02 ± 0/002	0/01 ± 0/002	0/03 ± 0/003	0/00*
Postural sways
V_AP_SD	0/15 ± 0/13	0/23 ± 0/84	/30 ± 0/13	0/002*
D_AP_SD	11/04 ± 2/95	11/99 ± 3/52	12/75 ± 3/10	0/247
V_ML_SD	0/60 ± 0/19	0/63 ± 0/18	0/43 ± 0/16	0/002*
D_ML_SD	0/10 ± 0/29	0/12 ± 0/04	0/14 ± 0/04	0/006*
*=Significant, Results of Tukey's test for Post Hoc comparison between groups. P < 0/05 significant finding. SD = Standard deviation, D = distance, V = velocity, ML = Medial-lateral, AP = Anterior-Posterior, TTS = time to stability)

Static Stability Parameters:

COP:

Results of one-way ANOVA showed that there is a statistically significant difference between V_AP_SD, V_ML_SD, and D_ML_SD. Tukey’s post hoc pairwise comparisons showed V_AP_SD (P = 0/001), V_ML_SD (P = 0/014), and D_ML_SD (P = 0/004) have the most differences between the healthy group and the high kinesiophobia group. V_AP_SD, D_ML_SD, were more in the high kinesiophobia group compare to the other groups. V_ML_SD was lower in the high kinesiophobia group than other groups.

The findings of this study partly supported our hypothesis. According to the results, CAI subjects, with only high kinesiophobia showed longer duration of TTs in AP and total directions, greater variability at velocity of COP in the AP direction, lesser variability at velocity of COP in the ML direction, and greater variability of COP displacement in the ML direction.

According to these findings, the CAI subjects with high kinesiophobia showed longer TTS in total and AP direction than healthy controls and CAI subjects with low kinesiophobia level. CAI subjects with high kinesiophobia seem to need more time to land and return to a stable posture. It seems that the central nervous system of CAI subjects with high kinesiophobia levels strengthens the possibility of falling and leads to slowing down their landing pattern (47). So, the postural threat (48) during the sudden transition from dynamic to static state of landing is lead to longer time to reach the stability era in CAI subjects with high kinesiophobia than healthy controls. Previous reports showed CAI subjects even not experiencing psychological factor have demonstrate longer TTS in AP (49, 50), vertical (50, 51) and total direction(49–51) during a unilateral jump tasks( lateral, forward jumping, and single jump task) compared to healthy controls (51–56). The findings of these investigation are in agreement with our results. Of course, our study compared the TTS between the CAI subjects with two levels of kinesiophobia and healthy controls, making it impossible to compare the findings of this study with those of other investigation.

In this study the CAI individuals with higher kinesiophobia showed greater variability of COP velocity in the AP direction and lesser variability of COP velocity in the ML direction during jump landing task. It seems that individuals with fear of re-injury might have perceived the jumping landing task as a fretful condition and limited the variation of velocity in the ML direction, while losing control over the AP direction due to constraint of controlling degree of freedom (57). Motor control variability leads to redundant degrees of freedom, which enables the central nervous system (CNS) to precisely control the task goal(57). Therefore, it enables individuals to combine risk-seeking behavior with more cautious whole-body movement in threat-ful conditions.(47).It seems that individuals with fear of re-injury might have perceived the jumping landing task as a threat-full condition and limited the variability of velocity in the ML direction, while lose control over the AP direction due to constraint of controlling degree of freedom (57). Motor control variability leads to the redundant degrees of freedom, which enables the central nervous system (CNS) to precisely control the task goal (57). Therefore, it enables individuals to combine risk-seeking behavior with more cautious whole-body movement threat-full conditions.(47). Hence, it could be possible that individuals with high kinesiophobia have selected a different landing strategy. Individuals can control the COP sway in the AP and ML direction through various strategies. Abe, Y., T. Sugaya and M. Sakamoto showed that foot positioning impacts on the COP sway in the AP and ML directions (58).The supination and pronation of the subtalar joint (58) is affected by both foot-to-head acceleration and the velocity of the COP in the ML direction. It further reported that CAI people even not experiencing psychological factors adopted a non-ankle strategy(59) more ankle dorsiflexion (60), reduced frontal movement’s peak(61), and lengthened the duration of movements (47) to control the trunk sway.

Also, the findings of the present study showed, CAI individuals with higher kinesophobia showed greater variation at displacement of COP in ML direction. ligament injury would result in deficits of ankle proprioception in CAI subjects (62), which might lead to misinterpretation and in detection of the degree of frontal plane movements (63, 64). Inability to estimate the necessary range of motion for ankle control, disrupts the muscle activation and postural control (62). In case of postural threat situation, when an individual does not feel secure in the limits of postural stability, thereby the search for the limits of stability increase, leading to larger sway variance(65). Injured ligament might not provide precise sensory information, therefore high fearful individual might not rely on the ankle sensory information and select exploratory movements, with increased COP ML movement variability(66).

The relationship between kinesiophobia and postural sway in individuals with Chronic. CAI has been minimally explored, with only two studies (27, 29). These studies indicate a positive association between instability scores in the ML and AP directions and fear-avoidance beliefs in CAI subjects, aligning with the reported findings (27, 29). It appears that individuals with CAI may experience a cycle involving pain, muscle weakness, reduced proprioception, limited movement, and a fear of movement to mitigate the risk of movement-related harm (22, 27, 67).When performing jump landing tasks, the heightened risk of re-injury (68, 69) can trigger altered motor patterns in ankle muscles, leading to impaired ankle proprioception and postural control (29).

Limitation

This study, like other studies, has limitations. It should be noted that this study may have some limitations, such as the difficulty to generalize to the entire society and the difficulties of employing varied heights for the task of jumping-landing on one leg. Landing on the dominant or non-dominant foot can have different results. It is suggested that future studies consider the dominant leg as the same as the affected leg. Kinematic investigations should be considered as an outcome measure in synchronizing the force plane during the single-leg jump to reveal the ROM required to COP displacement. Also, EMG activity of required muscle should be investigated in future studies. It suggested future studies.

It seems that individuals with a fear of re-injury may perceive jumping and landing tasks as threatening, leading to a need for more time to land and regain stability. This fear may also limit the variability of velocity in the ML direction and result in reduced control over the AP direction due to constraints on controlling degrees of freedom. Additionally, they may feel insecure within the limits of postural stability, potentially leading to increased search for stability limits and larger sway variability. These findings suggest that athletes with kinesiophobia exhibit poorer postural control, indicating that kinesiophobia may influence the postural control techniques selected by athletes. Therefore, it appears that the degree of kinesiophobia should be considered when developing postural control exercises for athletes with CAI.

Center of Pressure (COP)

Time To Stabilization(TTS)

Chronic ankle instability (CAI)

Tempa Scale of Kinesiophobia (TSK)

Activity Daily Living (ADL)

Medial-Lateral (ML)

Anterior-Posterior (AP)

Standard Deviation (SD)

Ground reaction force (GRF)

Foot and Ankle Measure(FAAM)

Vertical time to stabilization (V-TTS)

Anterior-Posterior time to stability (AP-TTS)

Velocity anterior-posterior standard deviation (V_AP_SD)

Distance anterior-posterior standard deviation (D_AP_SD)

Velocity medial-lateral standard deviation (V_ML_SD)

Distance medial-lateral standard deviation (D_ML_SD)

Eta squared values (η_p²⁾

Ethics declarations

Ethics approval and consent to participate:

Initially, the aim of the study was explained to the participants. They were insured that their information would remain confidential. They were also informed that participation is totally voluntary, and they have the right to withdraw from the study whenever they wish. Informed consentwas obtained from each participant prior to study participation. The study was approved by the Ethics Committee at the Shahid Beheshti University of Medical Sciences (IR.SBMU.REC.1401.152) and was carried out in accordance with the principles of the Declaration of Helsinki.

Consent for publication:

Not applicable.

Competing interests:

The authors declare that they have no competing interests.

Funding:

No funding was received for conducting this study.

Author Contribution

JS, EZ, and NSS contributed to the study design and conception. JS have done data collections. YM conducted MATLAB code. EZ, MM, NSS performed the statistical analyses and interpretation of data. JS and MM wrote the original draft. SS and EZ revised the manuscript. All authors reviewed the manuscript for important intellectual content and approved the final version submitted for publication

Acknowledgements

We appreciate from physiotherapy research center in Shahid Beheshti University of Medical science and health service. Also, we appreciate from all participants and athletes participate in our study

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

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Investigation of dynamic postural control in athletes with and without chronic ankle instability accompanied by high and low levels of kinesiophobia during jump landing: A cross-sectional study

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Abstract

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Background

Methods

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Participants

Outcome measures

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COP measures

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Statistical Analysis

Results

Dynamic stability parameters

TTS parameters

Static Stability Parameters:

COP:

Discussion

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