The effects of thoracic mobility versus lumbopelvic stabilization exercises on lower extremity flexibility,dynamic balance and proprioception in patients with chronic ankle instability

Abstract

BACKGROUND:

Chronic ankle instability (CAI) presents neuromuscular control and functional performance difficulties. Although ankle-focused rehabilitation is widely practised, the relative effects of exercises targeting thoracic mobility and lumbopelvic stabilization in addressing CAI have not been thoroughly investigated.

OBJECTIVE:

The study aims to compare the effects of thoracic mobility and lumbopelvic stabilization exercises in patients with CAI.

METHODS:

The study was designed as a prospective randomized controlled clinical trial. A total of 30 participants (mean age $=$ 31.93 $\pm$ 7.31; 21F/9M) who scored 27 points or on the Cumberland ankle instability tool voluntarily were enrolled in the study. The participants were randomly divided into two groups. In addition to the rehabilitation protocols, each participant was given a home exercise program, including ankle-strengthening exercises (3 times a week). The first group trained with thoracic mobility (TM), while the second group did lumbopelvic stabilization (LS) exercises under supervision twice a week for eight weeks. Participants’ pre and post-treatment assessments spanned an 8-week rehabilitation period, during which ankle and hip joint range of motion measurements were obtained using an electronic goniometer. Additionally, dynamic balance was assessed through the Y balance test, while ankle proprioception was evaluated using joint position sense measurements. The flexibility was assessed with an active straight leg raise test.

RESULTS:

Y balance, CAIT, and active straight leg raise test scores were improved in the eighth week in the thoracic mobility group ( $p<$ 0.05), while only active straight leg raise test and CAIT scores were significantly different in the lumbopelvic stabilization group ( $p<$ 0.05) according to intra group variables. In comparing the post-treatment scores between the groups, the thoracic mobility group had superior results in the joint position sense test for the right side of the hip and plantarflexion. (hip; TM: 70.71 $\pm$ 6.80, LS: 68.76 $\pm$ 5.50, plantarflexion; TM: 44.24 $\pm$ 7.28, LS: 38.30 $\pm$ 5.08).

CONCLUSION:

The findings suggest that while both interventions are effective in addressing various aspects of ankle instability, the thoracic mobility exercises may offer additional benefits, particularly in enhancing joint position sense, thereby providing valuable insights for the optimization of rehabilitation protocols for individuals with chronic ankle instability.

Keywords

Balance chronic ankle instability flexibility lumbopelvic stabilization thoracic mobility proprioception

1. Introduction

Chronic ankle instability (CAI) is associated with laxity and mechanical instability after repeated lateral ankle sprains. Acute ankle sprains are among the most frequent musculoskeletal injuries, with up to 70% of those who deal with an acute ankle sprain developing persistent physical disability, including CAI [1]. It frequently occurs in professional athletes as well as in sedentary individuals. People with CAI suffer from loss of balance, problems in weight bearing, gait problems, strenuous activities, and walking on uneven surfaces and experience repetitive injuries [2, 3, 4]. Furthermore, decreased range of motion (ROM), loss of strength, proprioceptive and neuromuscular deficits, and altered gait patterns can be seen in people with chronic ankle problems [5].

There are two main treatment options for CAI: surgical and non-surgical treatment. Conservative treatment methods frequently used in the treatment of CAI can be listed as electrotherapy, manual therapy, bracing, taping and exercise therapy [6, 7, 8]. Electrotherapy agents used for CAI therapy are Transcutaneous Electrical Nerve Stimulation (TENS), Neuromuscular Electrical Stimulation (NMES), and Ultrasound (US) [9, 10]. The most commonly used conservative treatment methods in people with CAI are highly recommended for patients with chronic ankle instability, at least over the first two-month period, as follows. In the acute stage, PRICE (Protection, Rest, Ice, Compression, Elevation) protocol, NMES [10] TENS application and brace use have been applied to reduce pain and oedema. Bracing and taping methods fail to support chronically unstable ankles [7, 10]. Although there are several non-surgical options for CAI treatment in the literature, exercise therapy is the critical strategy of the treatment protocols. The methods frequently used in exercise therapy are strengthening, neuromuscular, balance, proprioceptive, functional, gait, plyometric and agility exercises [11, 12].

The primary purpose of all these conservative treatment methods is to reduce pain and oedema, prevent unnecessary surgery, decrease the incidence of recurrent ankle sprains, increase functionality, and help patients return to their daily lives [13]. One systematic review conducted by Mollà Casanova et al. investigated the effectiveness of balance exercises on functionality, ankle instability and dynamic balance compared to regular and strength exercises. They found that balance exercise improved functionality, ankle instability, and dynamic balance outcomes. However, compared to strength training, the effectiveness of balance exercise was only more significant regarding the functionality outcome [14]. The systemic review study by Xue et al. investigated the effectiveness of exercise therapy on restoring joint position sense (JPS) in patients with CAI compared to non-training controls. Existing exercise therapies in the literature (muscle strengthening, balance, coordination, and vibration) may have a positive effect on passive JPS during inversion and eversion but do not restore the active JPS deficits of injured ankles in patients with CAI when compared with non-training controls [15]. In a systematic review by Kosik et al., therapeutic interventions (balance training, resistive training, joint mobilization, orthotics, and static stretching) were investigated for their efficacy on self-reported function during activities of daily living or physical activity. This research found that balance exercises were more effective than all other methods [16]. McCann et al. [17] mentioned that they discovered links between weakened isometric hip adductor and abductor muscles and chronic ankle and foot conditions, including recurring ankle sprains. Additionally, a recent finding highlighted reduced isometric hip abduction strength in the affected limb compared to the non-involved limb in individuals with chronic ankle instability. According to their results, chronic ankle instability can cause decreased isometric hip strength significantly through decreased lumbopelvic stability and influence dynamic postural control performance. Additionally, they suggested that CAI rehabilitation strategies should consider hip muscular strengthening with lumbopelvic stabilization to facilitate improvements in dynamic postural control. Some studies also researched the effect of lumbopelvic stabilization on CAI; one found that lumbopelvic stabilization exercises not only help reduce pain and enhance hip joint function but are also a practical approach for adults with functional ankle instability [18].

Nowadays, exercise-based treatment methods have shifted to a holistic perspective. In this holistic view, the body should be composed of kinetic chains. Considering the kinetic chains, the information received from the ground is transferred from the bottom up, including the core region; therefore, an injury in the lower segments may predispose to another injury in the upper segments [19]. Every precaution to manage lower extremity risk factors should be taken in the previous chain layers. Holistic methods comprehending chronic lower limb injuries take into account all motion segments. (e.g., the hip and knee in ankle and foot pathologies). For instance, evidence of abnormal hip and knee kinematics during dynamic tasks in people with CAI implies that the hip and knee muscles may be involved in this disorder [20]. Additionally, a systematic study reported that people experiencing chronic ankle instability exhibit weaknesses in ankle inversion and eversion strength. Furthermore, their findings further indicated variations in hip and knee strength between individuals with CAI and those without. They suggested that the rehabilitation of CAI individuals should consider assessing these components of the kinetic chain [21]. According to these literature findings, a limited number of studies investigated the effectiveness of rehabilitation protocols by taking the kinetic chain into account in the management of CAI. These studies mentioned that the thoracic vertebrae are crucial in providing strength to the arms and legs, serving as an optimal functional segment that demands a balance of stability and mobility. Additionally, lumbopelvic motor control is associated with worsening balance and physical performance [22, 23]. In people with CAI, postural and balance problems arise when there is a weakness in lumbopelvic stabilization and thoracic mobility. Additionally, individuals require more effort to sustain a neutral position and posture. The failure to do so results in individuals getting tired earlier and the injury frequency increases [22]. However, there is a lack of comprehensive investigation into rehabilitation protocols systematically considering the kinetic chain in managing CAI. While a singular study evaluated the effectiveness of exercise protocols focusing on the lumbopelvic region within the kinetic chain, a critical gap exists in extending this approach to a broader understanding of the interconnected components in CAI [23]. By addressing this gap in the literature, our research seeks to contribute valuable insights to optimizing holistic rehabilitation strategies for individuals grappling with the complexities of chronic ankle instability. To the best of our knowledge, there are no studies published involving the lumbar and thoracic region that compare the effectiveness of lumbopelvic stabilization and thoracic mobilization exercises with resistive exercises and compare the results in people with CAI. This study aims to compare the effectiveness of exercises given for the lumbopelvic and thoracic regions.

2. Methods

2.1 Participants

A total of 30 patients, 21 women and 9 men, aged 20–45 years (mean age $=$ 31.93 $\pm$ 7.31; BMI: 22.22 $\pm$ 3.05) volunteered to take part in this prospective randomized controlled clinical trial. All participants were right dominant. To assess the severity of ankle instability we used the Cumberland Ankle Instability Tool (CAIT) with a maximal score of 27 [5]. Using the G*Power program, at least $n=$ 15 individuals were required for each group based on an effect size d is 1.077, power of 0.80, and $\alpha$ of 0.05, which is based on the intergroup CAIT measurement differences of similar studies [24].

Inclusion criteria of the study were determined as follows: (refrain from ‘bulleting’; refrain from using ‘being’ and ‘having’) Being 20-45-year-old, having at least two previous lateral ankle sprains of the same ankle, having at least one episode of “giving way” within the previous six months,

•
Having persistent symptoms during functional activities and being free of symptoms from any previous lower limb injuries, no other lower extremity injuries.

The exclusion criteria of the study were determined as follows,

•
Having any systemic illness (e.g. rheumatoid arthritis, diabetes Mellitus), lower extremity and spine surgery history related to fractures or disorders,
•
Having received steroid injections within the previous six months,
•
Undergoing physiotherapy before the intervention,
•
Being pregnant or the existence of a tumour.

All participants who voluntarily participated in the study according to the inclusion criteria were informed about the study plan and signed the informed consent form. The participants provided written informed consent, which had been approved by the ethical committee at the Faculty of Health Sciences of Yeditepe University (IRB study protocol: 92, 24.11.2022).
2.2 Study protocol and design

All subjects who volunteered to participate in the study filled out demographic information (age, gender, limb dominancy, existing chronic disease, previous surgical condition and injuries, exercise behaviours) and consent forms. Participants were randomly divided into two groups. This randomization was computer-based and was done via https://www.randomizer.org [25].

The first group (TM) was designated the thoracic mobility group and referred to as TM. The second group (LS) was designated the lumbopelvic stabilization group and referred to as LS. The first group received home and thoracic mobility exercises: thoracic extension on a foam roller, side lying thoracic rotation, quadruped thoracic rotation, and squats with extension and rotation. The second group received home and lumbopelvic stabilization exercises: bridge with alternate leg, single leg bridge, four-point kneeling with arm and leg extension, side plank on the front arm with the knee flexed (right, left), sitting on a Swiss ball and hip flexion. All protocols were conducted twice weekly for eight weeks (16 sessions in total) and performed by a physical therapist.

The same home exercises were given to both groups, including ankle-strengthening exercises with resistance bands. Before starting the rehabilitation protocols, the Y balance test, Active Straight Leg Raise Test and Joint Position Sense test were assessed for each participant. Participants were evaluated via pre-treatment and post-treatment (8 weeks) rehabilitation protocols, and the results were recorded. Measurements were made with an electronic goniometer for a range of ankle, knee and hip joint motions. Moreover, the Y balance test assessed dynamic balance, while joint position sense was used for ankle proprioception.

2.3 Outcome measures

Participants were evaluated pre and post-treatment. The Cumberland Ankle Instability Tool was used to determine the instability levels of the participants. Measurements were made with an electronic goniometer for the range of motion of the ankle and hip joints. The Y balance test was used for assessing dynamic balance, and joint position sense was used for ankle proprioception.

2.4 Cumberland ankle instability tool (CAIT)

Hiller et al. [5] developed the Cumberland Ankle Instability Tool (CAIT), demonstrating high content validity and reliability. The questionnaire’s main advantage is that it only has nine items with scores ranging from 0 to 30, with lower scores indicating worse stability. The test’s cutoff score of less than 27 indicates chronic ankle instability. Because it has multiple answer options, the instrument’s precision is increased. The CAIT uses a numeric value to assess the severity of instability and can be completed for both the left and right ankles, allowing assessment of both ankles separately [26].

2.5 Y balance test

The Y Balance Test is reliable and valid, assessing dynamic balance through reaching in 3 directions. The participants reach with one foot in anterior, posteromedial, and posterolateral directions as far as possible while standing on the other foot in the centre. The angles between the posterolateral and the posteromedial should be 90 degrees. The participants are instructed to put their hands on their pelvis and be barefoot while conducting the test. They were asked to reach three times in each direction, and these values were averaged for data analysis. The test was considered invalid if the person could not return from the reached point, lifted their hands from their pelvis, or lost their balance [27].

Figure 1.

Thoracic extension with foam roller.

Figure 2.

Sidelying thoracic rotation.

Figure 3.

Quadruped thoracic rotation before and after.

2.6 Active straight leg raise test (ASLR)

Participants in the ASLR test were told to voluntarily elevate their right leg off the table as far as they could while maintaining a straight knee. Hip flexion was used to raise the right leg so that the heel was above the table and kept there for around 5 seconds. A goniometer was used to measure and record the participant’s hip flexion angle while they were in this position [28].

2.7 Joint position sense test (JPS)

The joint position sense test (JPS) is clinically the most applied test for assessing the proprioception of the limbs. The JPS can be defined as the awareness of the actual position of the extremity. Often, JPS can be used in many joints in the body such as knee, elbow, ankle, hip and spine [29].

During this test, while the participant is lying on their back with eyes open, the related joint is passively brought to the specified angle and held in this position for 5 seconds. This process is repeated three times. After waiting 30 seconds, the participant is asked to move it to the position closest to this angle. This angle is measured and recorded with a goniometer. A joint position sense test will be performed for the hip, knee and ankle to measure the proprioception of the lower extremity. Determined angles for joints: hip flexion angle as 75^∘, knee flexion angle as 50^∘ ankle dorsiflexion as 10^∘ plantarflexion as 40^∘.

Figure 4.

Squat with extension and rotation.

Figure 5.

Bridge with alternate leg.

Figure 6.

Single leg bridge.

2.8 Rehabilitation protocols

Rehabilitation protocol sessions took 50 minutes twice a week for eight weeks and were completed under the supervision of a physiotherapist.

Group 1: Thoracic mobility rehabilitation (TM)

•
Thoracic extension on foam roller: Participants are positioned supine with semi-flexed knees. The foam roller is placed in the mid-thoracic region. Afterwards, patients were asked to perform thoracic extension without moving the lumbar spine (Fig. 1).
•
Sidelying thoracic rotation: Participants are instructed to lie on one side (both sides were performed) with support under their head. Both knees are in a flex position. Without separating or moving their lower extremities, the participants were asked to rotate their trunk with the help of their upper arm and perform thoracic rotation to the other side (Fig. 2).
•
Quadruped thoracic rotation: The participants are positioned in a four-point kneeling stance, with one hand behind the head for support. The participants did a thoracic rotation by turning their torso and head to both sides (Fig. 3).
•
Squat with extension and rotation: After reaching the lowest point of their squat, participants were asked to straighten their legs and simultaneously reach both arms upward toward the ceiling. While keeping one arm reaching upward, they rotated their torso and shoulders in the direction of the arm extended. They returned to a forward-facing position and descended to the squat position (Fig. 4).

Group 2: Lumbopelvic stabilization rehabilitation (LS)

•
Bridge with alternate leg: The participants were requested to bring their legs into tabletop position (hip and knees are at 90^∘) during the bridge exercise while keeping their pelvis neutral (Fig. 5).

Figure 7.
Four point kneeling with arm and leg extension.

Figure 8.
Side plank on front arm with knee flexed.

•
Single leg bridge: The bridge exercise is performed with one leg while the other is extended. Both limbs should be performed (Fig. 6).
•
Four-point kneeling with arm and leg extension: In the four-point kneeling position, the crossed arm and leg are extended while the neutral pelvis position is held. The trunk should be stabilized as much as possible (Fig. 7).
•
Side plank on the front arm with knee flexed (right, left): The legs are in semi-flexion while lying on one side. The elbow should be placed under the shoulder, and the head should align with the spine. The other arm can be aligned along the upper side of the body (Fig. 8).
•
Sitting on a Swiss Ball and hip flexion: During this exercise, participants are requested to sit on a Swiss ball with a neutral spine and pelvis position with stretching arms across. Without moving their pelvis, hip flexion is instructed one by one (Fig. 9).

2.9 Home exercises

Ankle strengthening exercises were given for both groups. These exercises were performed with a resistance exercise band, including all the movements of the ankle (dorsiflexion, plantarflexion, inversion and eversion). They were performed three days a week for three sets of 10 repetitions.

2.10 Statistical analysis

The Statistical Package for the Social Sciences 26.0 (SPSS) program was used for all statistical analyses. A Kolmogorov-Smirnov test was used to assess the data distribution. The analysis of the pre and post-treatment values within the groups was performed by a “Wilcoxon test”. Means of variables: arithmetic mean $\pm$ standard deviations are shown as “ $\bar{x}$ $\pm$ SD”. The differences between the groups before and after the treatment were examined by a “Mann-Whitney U test”, and the differences were revealed. The significance level was set at $p<$ 0.05.

3. Results

Twenty nine out of the 30 participnats engaged in sports. All had experienced sprains and 60% had two. Additionally, over half of the participants reported sprains in the last six months, and all had experienced a sensation of “giving way” in the foot. None none of the participants had experienced lower extremity injuries in the last six months.

Table 1
Demographic details of the participants^*

Variable ( $N=$ 30)	N	%	Mean $\pm$ Stan. deviation
Sex
Female	21	70.0
Male	9	30.0
Age			31.93 $\pm$ 7.31
BMI			22.22 $\pm$ 3.05
Doing sports
No	1	3.3
Yes	29	96.7
Type of sports
Swimming	4	13.33
Pilates	5	16.67
Walking/Running	20	66.68
Sprain History
Yes	30	100.0
Number of sprains
2	18	60.0
3	9	30.0
4	3	10.0
Sprains in the Last 6 Months
No	17	56.7
Yes	13	43.3
Sensation of “Giving way” in the foot in the Last 6 Months
Yes	30	100.0
Sensation of “Giving way” in the foot in
Right	16	53.3
Left	14	46.7
Extremity Injuries In The Last 6 Months
No	30	100.0

Figure 9.

Sitting on a swiss ball and hip flexion.

Table 2

The comparison of the pre-post treatment scores of the intragroup variables each test

	TM ( $n=$ 15)				LS ( $n=$ 15)
	Mean	SD	$Z$	$P$	Mean	SD	$Z$	$P$
Left anterior (Pre)	62.88	11.98	$-$ 2.608	0.009	69.33	8.21	$-$ 0.973	0.330
Left anterior (Post)	65.28	12.36			70.82	8.91
Left posterolateral (Pre)	58.25	9.80	$-$ 3.181	0.001	64.26	8.06	$-$ 0.063	0.950
Left posterolateral (Post)	62.06	7.32			63.96	7.30
Left posteromedial (Pre)	59.32	13.72	$-$ 2.802	0.005	59.08	8.97	$-$ 3.046	0.002
Left posteromedial (Post)	63.76	11.39			65.97	7.58
Right anterior (Pre)	63.49	8.81	$-$ 2.795	0.005	68.34	9.93	$-$ 0.284	0.776
Right anterior (Post)	65.33	8.21			68.38	10.96
Right posterolateral (Pre)	62.22	10.99	$-$ 2.471	0.013	63.99	7.17	$-$ 1.887	0.059
Right posterolateral (Post)	64.52	10.48			66.58	4.84
Right posteromedial (Pre)	57.18	8.62	$-$ 3.173	0.002	63.20	7.42	$-$ 1.363	0.173
Right posteromedial (Post)	60.92	8.78			66.58	4.84
Joint position sense hip right (Pre)	69.13	6.92	$-$ 2.017	0.044	71.09	2.14	$-$ 1.421	0.155
Joint position sense hip right (Post)	70.71	6.80			68.76	5.50
Joint position sense hip left (Pre)	68.58	8.40	$-$ 2.131	0.033	67.40	7.38	$-$ 2.557	0.011
Joint position sense hip left (Post)	70.86	5.73			70.53	5.24
Joint position sense knee right (Pre)	53.41	6.32	$-$ 2.359	0.018	50.60	5.76	$-$ 1.321	0.186
Joint position sense knee right (Post)	55.92	6.77			52.05	4.33
Joint position sense knee left (Pre)	56.04	7.02	$-$ 0.597	0.551	56.65	7.51	$-$ 1.005	0.315
Joint position sense knee left (Post)	56.73	5.77			59.10	6.91
Joint position sense dorsiflexion R. (Pre)	17.54	11.94	$-$ 2.841	0.004	13.07	3.28	$-$ 0.565	0.572
Joint position sense dorsiflexion R. (Post)	14.87	9.21			12.60	1.74
Joint position sense dorsiflexion L. (Pre)	15.80	5.81	$-$ 2.103	0.035	15.20	3.68	$-$ 2.948	0.003
Joint position sense dorsiflexion L. (Post)	14.22	4.04			13.38	2.49
Joint position sense plantarflexion R. (Pre)	38.64	6.97	$-$ 0.028	0.977	43.83	8.36	$-$ 0.094	0.925
Joint position sense plantarflexion R. (Post)	38.30	5.08			44.24	7.28
Joint position sense plantarflexion L. (Pre)	40.74	8.83	$-$ 0.596	0.551	41.82	7.51	$-$ 0.227	0.820
Joint position sense plantarflexion L. (Post)	40.92	6.25			41.45	4.53
ASLR right (Pre)	77.09	13.38	$-$ 3.423	0.001	68.38	8.38	$-$ 3.011	0.003
ASLR right (Post)	80.86	11.82			74.32	7.58
ASLR left (Pre)	77.36	10.35	$-$ 3.414	0.001	71.98	8.29	$-$ 1.790	0.073
ASLR left (Post)	80.30	10.14			75.28	6.93
CAIT right (Pre)	21.86	6.06	$-$ 3.198	0.001	23.33	6.83	$-$ 2.965	0.003
CAIT right (Post)	24.46	6.19			24.86	5.65
CAIT left (Pre)	24.53	4.94	$-$ 2.585	0.010	20.93	8.17	$-$ 2.816	0.005
CAIT left (Post)	25.73	3.82			22.66	6.66

In comparing the pre and post-treatment scores of the Y Balance Test, there was a significant difference in all directions (left anterior, left posterolateral, left posteromedial, right anterior, right posterolateral and right posteromedial) in the TM group ( $p<$ 0.05, Table 2). On the other hand, in the LS group only the left posteromedial test revealed a significant difference ( $p<$ 0.05), while there was no difference between the other directions ( $p>$ 0.05). The pre-test score (59.08 $\pm$ 8.97) of the left posteromedial test was lower than the post-test score (65.97 $\pm$ 7.58, Table 2). In the LS group, no significant differences were indicated for any of the directions except the left stance posteromedial direction ( $p<$ 0.05, Table 2).

Table 3

The comparison of the post treatment scores interrater variables for each test value^*

	TM ( $n=$ 15) Mean $\pm$ SD	LS ( $n=$ 15) Mean $\pm$ SD	Mann whitney U	$P$
Left anterior (Post)	65.28 $\pm$ 12.36	70.82 $\pm$ 8.91	77.50	0.146
Left posterolateral (Post)	62.06 $\pm$ 7.32	63.96 $\pm$ 7.30	94.50	0.454
Left posteromedial (Post)	63.76 $\pm$ 11.39	65.97 $\pm$ 7.58	92.00	0.394
Right anterior (Post)	65.33 $\pm$ 8.21	68.38 $\pm$ 10.96	92.50	0.406
Right posteromedial (Post)	64.52 $\pm$ 10.48	66.58 $\pm$ 4.84	74.50	0.114
Right posterolateral (Post)	60.92 $\pm$ 8.78	60.88 $\pm$ 6.97	110.00	0.917
Single leg raise test R. (Post)	80.86 $\pm$ 11.82	74.32 $\pm$ 7.58	69.50	0.074
Single leg raise test L. (Post)	80.30 $\pm$ 10,14	75.28 $\pm$ 6.93	87.50	0.299
CAIT test R. (Post)	24.46 $\pm$ 6.19	24.86 $\pm$ 5.65	102.00	0.660
CAIT test L. (Post)	25.73 $\pm$ 3.82	22.66 $\pm$ 6.66	84.00	0.225
JPS hip right (Post)	70.71 $\pm$ 6.80	68.76 $\pm$ 5.50	59.50	0.028
JPS hip left (Post)	70.86 $\pm$ 5.73	70.53 $\pm$ 5.24	100.00	0.604
JPS knee right (Post)	55.92 $\pm$ 6.77	52.05 $\pm$ 4.33	72.50	0.096
JPS knee left (Post)	56.73 $\pm$ 5.77	59.10 $\pm$ 6.91	88.00	0.309
JPS dorsiflexion R. (Post)	14.87 $\pm$ 9.21	12.60 $\pm$ 1.74	89.50	0.337
JPS dorsiflexion L. (Post)	14.22 $\pm$ 4.04	13.38 $\pm$ 2.49	106.50	0.803
JPS plantarflexion R. (Post)	44.24 $\pm$ 7.28	38.30 $\pm$ 5.08	48.50	0.008
JPS plantarflexion L. (Post)	40.92 $\pm$ 6.25	41.45 $\pm$ 4.53	111.50	0.967

According to intragroup variables, the JPS test showed a significant difference in the TM group’s right knee, in both hip and dorsiflexion angles ( $p<$ 0.05, Table 2). The LS group had significant differences in the left hip and dorsiflexion angle. ( $p<$ 0.05, Table 2). According to intergroup variables, there was a significant difference between the study groups for the JPS hip right test and the JPS plantarflexion test ( $p<$ 0.05, Table 3). At the same time, there was no significant difference between the study groups for the other parameters ( $p>$ 0.05, Table 3). The hip right post-test value (70.71 $\pm$ 6.80) of the TM group was higher than that of the LS group (68.76 $\pm$ 5.50), while the plantarflexion right post-test value (38.30 $\pm$ 5.08) of the TM group was lower than that of the LS group (44.24 $\pm$ 7.28) ( $p<$ 0.05, Table 3).

A comparison of the Active Straight Leg Raise (ASLR) pre and post-test scores of the participants revealed a statistically significant difference between the groups in the single leg raise test right and left tests ( $p<$ 0.05). According to the results, in the TM group, the pre-test score (77.09 $\pm$ 13.38 for right, 77.36 $\pm$ 10.35 for left) was lower than the post-test score (80.86 $\pm$ 11.82 for right, 80.30 $\pm$ 10.14 for left, Table 2). ASLR test results were significantly different in both groups except for the left leg in the LS group ( $p>$ 0.05, Table 2).

According to intragroup variables, pre and post-treatment scores showed that the TM and LS groups have statistically significant values in the CAIT test for every extremity ( $p<$ 0.05, Table 2). In the TM group, the pre-test score (21.86 $\pm$ 6.06 for the right, 24.53 $\pm$ 4.94 for the left) was lower than the post-test score (24.46 $\pm$ 6.19 for the right, 25.73 $\pm$ 3.82 for the left, Table 2).

4. Discussion

This study aimed to investigate the effectiveness of two distinct rehabilitation protocols, lumbopelvic stabilization and thoracic mobility, combined with ankle-strengthening exercises in treating Chronic Ankle Instability (CAI). The primary focus was assessing improved balance, posture, and proprioception among individuals with CAI. Our findings indicate that both intervention approaches, lumbopelvic stabilization and thoracic mobility, demonstrated suitability in treating CAI, contributing to enhanced balance, posture, and proprioception. Notably, the results suggest that thoracic mobility exercises offer additional advantages, particularly in improving proprioception, as evidenced by a notable impact in the right plantarflexion and hip JPS test. These outcomes emphasize the potential preference for thoracic mobility exercises in comprehensive CAI rehabilitation strategies.

Ankle injuries are conditions that seriously affect athletes and the general population. Although people’s initial symptoms resolve quickly, they may experience ongoing and long-lasting symptoms such as pain and instability. Continued repetitive lateral ankle sprains are called chronic ankle instability (CAI) [30]. CAI is characterized by recurrent incidents or sensations that the ankle is “giving way,” as well as ongoing symptoms. These signs may include discomfort, a reduction in strength, a reduction in the ankle’s range of motion (ROM), and a lack of self-reported function – Also, persistent ankle sprains last longer than a year after the first injury [31]. According to the literature, individuals with CAI experience strength loss, proprioceptive, balance, neuromuscular, and functionality deficits and effective exercise methods are used to address these problems. Nevertheless, the effectiveness of lumbopelvic and thoracic mobility exercises in individuals with CAI has not been investigated [2, 14, 15, 16].

Deficits in proprioception may predispose as joint position awareness alone does not contribute to CAI and becomes a condition that may occur after injury. Proprioception can be defined as the afferent input of joint position sense and stationary position and movement awareness. It is also considered a condition of neuromuscular control. One study concluded that damage to afferent receptors in the injured ankle ligaments and joint capsule creates proprioceptive and efferent motor control deficits of sensorimotor control in individuals with ankle sprains, which would cause an increased incidence of giving way [32]. Alahmari et al. assessed the effectiveness of strengthening and proprioceptive training programs on proprioception and balance in CAI patients. Thirty-six individuals with CAI were assigned into three groups. They were then instructed to perform strength and balance workouts for six weeks. Joint position sense (JPS), static and dynamic balance (CAIT), and the lower extremity functional scale (LEFS) were all measured as part of the study. Strengthening exercises, including ankle range of motion in all four directions (dorsiflexion, plantarflexion, inversion and eversion), were performed bilaterally before progressing to dynamic resistance exercises using the resistive band. Participants started balance and postural stability exercises when they could transfer loads without pain. The plantar flexion JPS improved in all groups ( $p<$ 0.05). Static and dynamic balance development was statistically significant in all groups.

Additionally, following therapy, there were notable changes between CAIT and LEFS scores ( $p<$ 0.05) [33]. Similarly, according to our result, the joint position sense tests for hip, knee and ankle were improved at eighth-week results in both groups ( $p<$ 0.05, Table 2). Furthermore, the JPS plantar flexion (right) score was higher in the lumbopelvic stabilization group compared to the TM group ( $p<$ 0.05, Table 3). The improvement in JPS tests for hip, knee, and ankle observed in both groups in the eighth week signifies the positive impact of the intervention on proprioceptive awareness and sensorimotor control. Moreover, the significantly higher JPS plantar flexion (right) score in the LS group suggests that lumbopelvic stabilization exercises may contribute to enhanced functional outcomes in specific aspects of lower limb JPS.

Mollà-Casanova et al. conducted a randomized controlled trial with 457 volunteers and investigated the effectiveness of strength and balance exercises on individuals with CAI. The balance group included exercises such as one single leg stance, hopping, and standing on different floors; the other group did strengthening and resistive exercises. They found balance exercises are more effective regarding ankle instability and dynamic balance than classical exercise methods. However, when compared to strength training, the effectiveness of strength training was found to be high only in functionality [14]. In another study, Anguish and Sandrey conducted a 4-week single-blinded, randomized controlled trial that included two balance exercise programs. Dynamic balance and JPS test were evaluated in 18 participants with CAI. The progressive hop-to-stabilization balance (PHSB) or the traditional single-limb balance (SLB) program started and completed the study over six months. The Foot and Ankle Ability Measure (FAAM), Activities of Daily Living (ADL) subscale, FAAM-Sports subscale, Star Excursion Balance Test (SEBT), and ankle JPS (all movements) were used before and after the 4-week intervention. They found a significant main effect for all outcomes, as post-test results improved for both groups. The main effect of the group was significant only for the FAAM-Sports, with the SLB group improving more than the PHSB group. (SLB posttest $=$ 82.65 6 5.1 versus PHSB posttest $=$ 71.69 6 9.4; $p<$ 0.05) [34]. In a similar manner, our results showed that the TM group Y balance test showed significant improvements in post-test values in all directions when compared to the pre-test values ( $p<$ 0.05, Table 2). A comparison of the pre and post-test scores revealed a significant difference only in the left posteromedial direction of the Y balance test score in the LS group ( $p<$ 0.05, Table 2). On the other hand, there were no significant differences between the groups for all directions of the Y balance test score. ( $p>$ 0.05, Table 3). The noteworthy improvement in all directions of the Y balance test scores in the TM group underscores the efficacy of the thoracic mobility exercises in enhancing dynamic balance across various planes. Importantly, the absence of significant differences between the groups for all directions of the Y balance test score suggests that both interventions, while influencing specific aspects differently, contribute comparably to overall improvements in dynamic balance.

The hip joint maintains upright posture and balance [21]. In some studies, hip flexibility has been associated with dynamic performance. In a study by Tamura et al. [35], the relationship between hip flexibility and dynamic balance was evaluated. According to the results of this study, it was found that the participants had poor dynamic balance and a significant hip ROM angle while extending in the posterolateral (PL) direction. However, no relationship was found between hip flexibility and dynamic balance. Tahoon et al. evaluated 42 participants and compared their hamstring flexibility in individuals with CAI and the standard control group based on their ankle health status (CAI or the uninjured control). A digital inclinometer was used to evaluate hamstring flexibility using a passive knee extension test (PKE). The results revealed that there was a significant reduction in hamstring flexibility in the CAI group compared with the control group ( $t=$ 5.167, $p<$ 0.05) [36]. According to post-test scores of the Active Straight Leg Raise, statistically significant improvements were observed in the thoracic mobility group for both legs and the lumbopelvic stabilization group for the right leg ( $p<$ 0.05, Table 2). The observed improvement in the right leg in the lumbopelvic stabilization group suggests a targeted impact related to dominancy on unilateral leg mobility. These findings underscore the effectiveness of the interventions in promoting increased ROM and highlight their potential contributions to enhanced functional mobility.

The hip and pelvis are vulnerable to sports-related injury as a force transmission link between the lower extremities and the torso [37]. Therefore, a larger perspective on the complete kinetic chain that includes the lumbopelvic area may be necessary. An athlete who displays delayed or poor neuromuscular control in the lumbopelvic region during dynamic landing tasks may be predisposed to a lower limb injury through poor stability, motion and increased forces experienced by the lower limb joints [38]. In one research, McCann studied 30 people aged between 18 and 40 in his study and divided these people into three groups equally (CAI, ankle sprain copers (COP), and healthy controls (CON)). Unilateral hip bridge, trunk flexion endurance, Biering-Sorensen, and side plank test exercises were given to these individuals to evaluate the TrA and lumbar multifidus (LM) muscles by diagnostic ultrasound imaging. FAAM-ADL and Sport FAAM-S subscales were used for self-reported evaluation of function. When we look at the results, COP had significantly greater TrA contractility than CAI and CON ( $p<$ 0.05). Although not statistically significant, a large effect size suggests that CAI had lower TrA contractility than CON. Although LM contractility did not differ between groups, TrA contractility was significantly lower in individuals with CAI [30]. Joeng et al. studied 18 participants and investigated the effect of thoracic mobilization on static and dynamic balance in people with kyphosis angles greater than 40^∘. Participants were asked to use a treadmill for 5 minutes for warm-up and cool-down periods. After the evaluation, Kaltenborn’s three-phase mobilization technique was used as a thoracic technique after pre-posttests. Results were collected in three stages: before the intervention, 3 and 6 weeks after. The results of this study showed that the angle of thoracic kyphosis decreased and body COP dynamic balance significantly ( $p<$ 0.05) improved after applying TM [22]. Our findings concluded that both groups significantly improved post-test CAIT scores right and left ( $p<$ 0.05, Table 2), with no statistical differences between groups $p>$ 0.05, Table 3). Additionally, all participants in the TM Group showed significant post-test values in all directions of Y balance scores ( $p<$ 0.05, Table 2). This finding suggests that thoracic mobility exercise not only positively affected ankle stability, as indicated by CAIT scores, but also had a broader impact on overall balance, as assessed by the Y balance test. Additionally, the lack of significant differences between groups in CAIT scores raises questions about the comparative effectiveness of these two different rehabilitation protocols, inviting further investigation into potential factors influencing the observed outcomes.

Although exercise therapy is the critical strategy in managing individuals with CAI and a wide variety of exercises (core stabilization, dynamic balance exercises, proprioception exercises, neuromuscular exercises) are found in the literature, studies involving TM and LS exercises are not available. This is the first study to investigate and compare the effectiveness of lumbopelvic stabilization and thoracic mobility exercises on CAI. The study provided has several strengths, but it also has some limitations. In our study, only right-dominant individuals were included. Future studies should examine participants with equal left and right dominant feet. While the study reached an adequate sample size based on power analysis results, a larger and more diverse sample would provide more statistical power and improve the generalizability of the results. Additionally, the intervention period lasted for eight weeks. A more extended follow-up period could help assess the sustainability of the effects over time.

5. Conclusion

Lumbopelvic stabilization and thoracic mobility with ankle-strengthening exercises are suitable to treat CAI for balance, posture, and proprioception. Furthermore, thoracic mobility exercises may be preferred over Lumbopelvic stabilization exercises, particularly in improving proprioception, with a notable impact observed in the right plantarflexion and hip JPS test.

Author contributions

CONCEPTION: ETÇ.

PERFORMANCE OF WORK: ET.

INTERPRETATION OR ANALYSIS OF DATA: ETÇ and ET.

PREPARATION OF THE MANUSCRIPT: ETÇ and ET.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: ETÇ and ET.

SUPERVISION: ETÇ.

Funding

The authors report no funding.

Footnotes

Acknowledgments

We want to thank Yekta Buse Karakurum for her help in creating the visual data for our article.

Conflict of interest

The authors have no conflicts of interest to report.

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The effects of thoracic mobility versus lumbopelvic stabilization exercises on lower extremity flexibility,dynamic balance and proprioception in patients with chronic ankle instability

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Participants

2.3 Outcome measures

2.4 Cumberland ankle instability tool (CAIT)

2.5 Y balance test

2.7 Joint position sense test (JPS)

2.10 Statistical analysis

3. Results

Table 1 Demographic details of the participants*

5. Conclusion

Author contributions

Funding

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Demographic details of the participants^*