Physical Therapy Program
Learning Activity for Database Searching
Rehabilitation Research I
Literature Scavenger Hunt Submission Form
Read through Chapter 31 in your text. Develop a PICO research question. Write the question below and indicate each of the elements here:
Is balance-training an effective intervention for improving balance deficits as measured by the Star Excursion Balance Test (SEBT) in patients with chronic ankle instability?
P: Chronic ankle instability
I: balance-training program
C: no balance training
O: balance deficits
Database Dates Search Terms Limiters Number of sources
PubMed Last 10 years chronic ankle instability OR CAI AND balanc* (in title/abstract) NOT vibrat* (in title) NOT drug* Species: HumansLanguage: English Article type: RCT, clinical study, clinical trial, comparative study 32
CINAHL 2008to 2018 chronic ankle instability OR CAI (in abstract) AND balance (in title) NOT hip Language: English 38
Cochrane 2008 to 2018 chronic ankle instability OR CAI only dates (2008 to 2018) 3
PEDro 2008 to 2018 chronic ankle instability OR CAI AND balance Body part: foot or ankle 20
Table 1. Search Results
Choose one of the articles in your Pub Med results. Find the article that provides the highest level of evidence but not a meta-analysis or systematic review. Identify the study design and level of evidence (use center for evidence based medicine ratings). In one sentence, describe the clinical implications for PT practice.
Linens et al4 investigated the efficacy of Wobble Board rehabilitation on balance impairments for patients with chronic ankle instability. Study design: Prospective randomized controlled trialLevel of evidence: 1b
Using CINAHL, identify one article that represents the highest level of evidence that was NOT also indexed in PubMed (there is some overlap) and was not a systematic review or meta-analysis. Identify the study design and level of evidence. In one sentence, describe the clinical implications for PT practice.
McKeon et al6 investigates the efficacy of balance training on static and dynamic postural control and function in patients with chronic ankle disability. Study design: Randomized controlled trialLevel of Evidence: 1b
3. Identify an article from PEDro. Choose a summary of a RCT that has received a ‘PEDro Score.’ List the PEDro score. Briefly identify some of the strengths and weaknesses that contributed to the score. Cruz-Diaz et al7 investigated the efficacy of a 6-week balance-training program on athletes with chronic ankle instability. This article received a PEDro score of 7/10. Some of the strengths that contributed to the score include random and concealed allocation, baseline comparability, and blind subjects, while some of the weaknesses that contributed include non-blinded therapists, and no intention-to-treat analysis.
4. Identify a systematic review or meta-analysis in the Cochrane database (not a clinical trial). In one sentence each, identify the types of participants, the types of studies, and the types of interventions for the included studies. In one sentence, describe the clinical implications for PT practice.
The types of participants in this systematic review included skeletally mature adults with chronic ankle instability which is defined as symptoms of CAI, “giving way”, or repeated sprains lasting for at least 6 months, and the trials that were excluded from the study were those whose participants were children, and adults with congenital or degenerative conditions. Studies that were included in the review were randomized or quasi-randomized controlled trials that compared surgical treatment to some other treatment or no treatment for chronic ankle instability. Any form of treatment for CAI was included, such as surgical treatment, post-surgical rehabilitation, neuromuscular exercise programs, and ankle brace/tape supports. De Vries et al3 investigated 10 peer-reviewed studies to compare the efficacies of surgical treatment, post-surgical rehabilitation, and neuromuscular exercise programs in the treatment of patients with chronic ankle instability.
Journal Article Introduction
Chronic ankle instability is a common condition that is characterized by recurrent ankle sprains. This can limit a patient’s independence and affect their ability to perform activities of daily living. There have been many treatment options identified not only to treat chronic ankle instabilities but also to prevent recurrent re-injuring. The incident rate of ankle instabilities resulting from ankle sprain is 2.15 for 1000 persons in the United States. Males between eighteen and twenty-four years of age and females over thirteen years of age are at highest risk of chronic ankle instability.1 A chronic ankle instability is an underreported condition where as much as 55% of population who sustain an ankle injury does not seek out healthcare providers for evaluation or treatment. Despite the fact that many incidents of ankle instabilities have been underreported, this condition still has the highest level of incidence among self-reported musculoskeletal conditions. Among all emergency room visits in the United States, over 3 millions are associated with chronic ankle instability.2 Physical therapy plays a major role in the treatment of this commonly occuring musculoskeletal condition. Among common treatment interventions are neuromuscular training, bracing and balance training. De Vries et al explains that the most common initial intervention for a patient with chronic ankle instability is neuromuscular training that may or may not be paired with ankle joint bracing.3 If these interventions do not show improvement, oftentimes surgery is recommended if the ligaments surrounding the joint are torn or elongated.3 Many clinicians treat patients with CAI without targeting specific modifiable deficits, such as poor balance and impaired sensorimotor function, while evidence of balance-training programs that target these deficits demonstrates improvement in CAI.4 One particular test of balance, the Star Excursion Balance Test (SEBT), detects deficits by challenging subjects’ proprioception and postural control, by having the patient balance on one leg while reaching as far as they can with the other leg.5 A few studies attempt to pinpoint specific balance exercises that improve CAI while implementing the SEBT pre- and post-intervention. One of these exercises involves the Wobble Board, where, in brief, subjects would balance with one leg on a circular board and then rotate the board clockwise and counterclockwise for a certain period of time.4 Different populations have also been studied, such as athletes with CAI, where one study showed that after a 6-week balance-training intervention with usual training versus an only usual training group, there were significant differences in SEBT scores between the groups.7 A study by McKeon et al focused on the postural control deficits of patients with CAI by looking at the amount of time it takes for a subject to make a postural correction to maintain stability, using a time-to-boundary test.6 The participants of the study were randomly allocated to balance training or control group. The goal of the balance training group was to work on postural control by focusing mainly on balancing activities performed on stable and unstable surfaces which included dynamic stabilization following perturbation, single leg stance, dynamic reaching at different angles and landing from a hop for 4 week period whereas control group maintained the same level of activity as they did before enrolling in the study. The results this study showed that TTB and SEBT measures improved, demonstrating improvement in static and dynamic postural control.6References
Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJJ. The epidemiology of ankle sprains in the united states. JBJS. 2010;92(13). https://journals.lww.com/jbjsjournal/Fulltext/2010/10060/The_Epidemiology_of_Ankle_Sprains_in_the_United.3.aspx.
Gribble PA, Delahunt E, Bleakley C, et al.Selection criteria for patients with chronic ankle instability in controlled research: A position statement of the international ankle consortium. J Orthop Sports Phys Ther. 2013;43(8):585-591. https://doi.org/10.2519/jospt.2013.0303. doi: 10.2519/jospt.2013.0303.
de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. Cochrane Database of Systematic Reviews. 2011(8). https://doi.org//10.1002/14651858.CD004124.pub3. doi: 10.1002/14651858.CD004124.pub3.
Linens SW, Ross SE, Arnold BL. Wobble board rehabilitation for improving balance in ankles with chronic instability. Clinical Journal of Sport Medicine. 2016;26(1). https://journals.lww.com/cjsportsmed/Fulltext/2016/01000/Wobble_Board_Rehabilitation_for_Improving_Balance.11.aspx.
Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simplifying the star excursion balance test: analyses of subjects with and without chronic ankle instability. J Orthop Sports Phys Ther. 2006;36:131–137. https://doi.org/10.2519/jospt.2006.36.3.131. doi: 10.2519/jospt.2006.36.3.131.
McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Medicine & Science in Sports & Exercise. 2008;40(10). https://journals.lww.com/acsm-msse/Fulltext/2008/10000/Balance_Training_Improves_Function_and_Postural.14.aspx.
Cruz-Diaz D, Lomas-Vega R, Osuna-Pérez MC, Contreras FH, Martínez-Amat A. Effects of 6 weeks of balance training on chronic ankle instability in athletes: A randomized controlled trial. Int J Sports Med. 2015;36(09):754-760. doi: 10.1055/s-0034-1398645.