Chronic ankle instability (CAI), a pathological condition characterized by repetitive bouts of the ankle giving way, commonly develops following a lateral ankle sprain injury. Individuals with CAI have been shown to exhibit deficits in postural control and alterations in movement dynamics, which have been suggested to be contributing factors to the recurrent injury paradigm. The purpose of this investigation was to conduct a comprehensive biomechanical analyses to examine the influence of CAI on postural control and movement dynamics during a single leg squat, side-cut task, and single leg landing on an inverted surface. Fifteen participants with CAI and fifteen participants without CAI completed the study following a between-subjects design, with limb serving as the repeated measure during the single leg squat. Each participant completed a single leg squat, side-cut task, and unexpected and expected single leg landings on a tilted surface. Results from the single leg squat and single leg landings on the tilted surface were analyzed using a 2 x 2 mixed-model ANOVA, while results from the side-cut task were analyzed using an independent samples t-test. Statistical significance was considered for all dependent variables when p < 0.05. Individuals with CAI demonstrated impaired postural control, as indicated by reduced time-to-boundary, during the single leg squat compared to controls. Altered ankle joint kinetics and increased sagittal plane hip joint stiffness were observed in the CAI group compared to controls. With regards to the single leg landings on the inverted surface, during the unexpected landing condition the CAI group displayed altered neuromuscular control and ankle kinematics. However, when the landing on the inverted surface as expected, the CAI group exhibited similar motor control strategies to the control group. Findings from this study indicate CAI alters postural control and movement dynamics during functional and dynamic movements, which may be used by researchers and clinicians to develop rehabilitation protocols to restore maladaptive movement patterns in individuals that develop CAI.

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1 Abstract Title Ankle sprain, conservative versus operational treatment: A literature review Aim The main purpose of this thesis is to assess and review the efficacy of main types of conservative and surgical interventions applied on ankle sprain injuries, as also the factors that influence the clinical outcomes in patients undergoing the selected treatment procedures. Method This thesis is a literary research, reviewing articles from relevant journals and books. Information and data sources were retrieved from English, released between 1980 and 2016, using electronic databases and reference lists of articles. The following databases were searched for the highest possible amount of relevant articles, with an attempt to reduce publication and/or selection bias: PubMed, EMBASE, CINAHL, The Cochrane Library (Cochrane Database of Systematic Reviews), Web of science and Medline. Preliminary searches began at the inception of the project, and the full search was concluded in October 10th , 2016. A restriction for the type of publication (meta-analysis, systematic review, clinical trials, comparative trials, practice guidelines and case studies) was applied when allowed by the databases research tools. Results The analysis of the reviewed studies resulted that conservative treatment approaches is the main...

Ankle sprains are one of the most common type of sports injury. They occur most frequently when the foot is in a supine or inverted position. Recovery from an ankle sprain can take from one and up to 26 weeks depending on the severity of the injury. During that period the individual will be unable to participate in any meaningful sports activity and as such it is important to be able to prevent the occurrence of such injuries. Prevention of ankle sprain injuries would require a better understanding of the risk factors of this injury. Several studies attempted to assess such risk actors by inducing foot inversion or supination however the platforms used in these studies were shown to be limited. Hence the main aim of this project is to develop a system that can be used to assess the effect of sudden foot and ankle inversion/supination on the musculoskeletal system of dynamic subjects (e.g. walking, running, jumping, etc.). For this purpose a three degrees of freedom (DOF) rotating platform has been designed, manufactured and installed in the Institute of Motion Analysis and Research (IMAR) Sports Laboratory. The platform rotates around 3 different axes allowing inversion or supination of the foot and ankle of dynamic subjects. The degree of rotation around each axis can easily be set by the researcher/operator. A strain gauge was used to detect foot strike to the platform. As a safety measure laser emitter/receivers check that the entire foot is on the footplate before the platform rotates. Optical encoders provide essential feedback of rotation angles, speed and acceleration. The necessary software and user interface for controlling the platform were also written and tested. The platform was synchronised with a bilateral four-channel EMG (electromyography) system and a 12 camera Vicon® MX-13 system thus allowing measurement of muscle activity and kinematic data during the supination of the foot. A set of software modules were written to allow automated management and processing of the data generated by the new system. The new system was then implemented in a study to validate it and to assess the role of shoes in ankle sprains. In this study, subjects would walk in three different foot conditions: barefoot, and with two different types of sports shoes, along the walkway of the Sports Laboratory where the platform was fitted. When a subject steps on the embedded platform, it rotates causing the subject's foot to supinate. At the same time, the EMG data from the peroneus longus, tibialis anterior, and lateral gastrocnemius muscles are recorded, along with the kinematics of the subject's whole body. The obtained results demonstrated the validity of the newly developed system. Data from the validation study also revealed increased muscle activity following induced foot supination in shod conditions compared to barefoot. Muscle activity of the rotating platform step was found to be significantly higher than the steps before and after. The platform rotation was also found to have an observable effect on body kinematics. The newly developed system is hoped to help provide a better understanding of the risk factors of ankle sprain injury and how to prevent this injury. The system can be used to help improve the design of current footwear and identify which footwear provides better protection against ankle sprain injury. The system can also be used to assess the effectiveness of different ankle injury rehabilitation schemes and different training programs that aim to reduce ankle sprain injuries. The new system can be utilised to identify individuals who are at risk of sustaining an ankle sprain injury. The system can also be utilised in studies outside the scope of ankle sprain injuries.

Introduction: Ankle injuries are among the most prevalent acute musculoskeletal injuries, and are a significant burden on any health system. The interaction of the physiotherapist with the patient and their mutual understanding of impairments, function and recovery are important to achieving a satisfactory return to work and leisure activities. To date, little attention has focused on this interaction. There is a need for further exploration of differences and associations between outcome questionnaires that investigate similar domains of pain and function, and whether scores from such outcome measures are related to the patient’s perception of function and recovery. Of further interest is whether there are relationships between impairment measures and perceived function, and how actual performance of tasks might influence the patients understanding of their capabilities. To provide a more complete picture of these relationships, a ‘mixed methods’ approach using qualitative research methods within a quantitative study was thought to be most appropriate. The overall aim of this thesis was to utilise this research approach to investigate patients’ perceptions of their recovery and elucidate factors important to both therapists and patients that ultimately might enhance their understanding of recovery from an ankle injury. Literature reviews: Three literature reviews were undertaken. Firstly a review of systematic reviews investigating ankle sprains identified a wide variety of management strategies. There was a lack of strong evidence to support any particular management strategy. Hence clinicians are likely to have difficulty setting appropriate rehabilitation plans. Secondly a critical review identified a number of different outcome questionnaires that were utilised to gauge recovery level; however, justification for their selection was often lacking. This review also identified that little emphasis was placed on understanding the patients’ perception of their injury and the rehabilitation process. A final critical review investigated impairment and performance measures and identified four specific areas that were focused upon by clinicians during the treatment of ankle sprains: joint position sense, postural control, strength and performance during function. However, only weak evidence was found for there being a deficit in joint position sense, postural control and strength in the injured limb following an ankle sprain, and inconclusive evidence of deficits in physical performance of tasks related to function. Methods: Forty participants with an acute sprained ankle were recruited along with their treating physiotherapist. The participants completed a Global questionnaire, the Lower Limb Task Questionnaire (LLTQ) and the Short Form -36 (SF-36) Questionnaire at the initial visit, at discharge and at a six week follow up visit where they also undertook impairment testing involving, joint position sense, postural control and strength along with a functional performance test and selected functional activities. Ten participants were purposefully selected to undertake semi-structured interviews. The treating physiotherapists completed global questionnaires at the initial visit and at time of discharge. An interpretive hermeneutic approach was undertaken to examine the participants’ perceptions. Results: There were equal numbers of males and female participants and the average age of participants was 30.5 years. The relationship between questionnaires for the domains of pain and function varied between low and high degrees of association. The global limitations scores between the participants and physiotherapists were similar at the initial visit, whereas on discharge the participants had a significantly lower score (p<0.05) compared to the physiotherapists. With respect to impairment testing, there was a significant difference (p<0.05) between the uninjured limb compared to the injured limb for the joint position sense and performance agility hop test. All other comparisons of impairments were not significant (p>0.05). There was no association between questionnaire scores and impairment measures (p>0.05). Additionally there were no significant associations between previous injury and questionnaire scores and impairment measures. Finally in relation to the performance of specific functional tests there was a significant difference (p<0.05) between the six week follow up LLTQ score and the score following actual performance of the test. The findings of the participants’ interviews identified three key concerns. Firstly, that participants have a limited understanding of questionnaires, and secondly, that there is a difference in understanding of ‘recovery’ between the therapist and the patient at time of discharge. Thirdly, there was dissociation between outcome measures and the patient’s perception of their own recovery. Conclusions: This study revealed a lack of understanding and effective communication concerning physiotherapy practice in relation to ankle sprains. It was apparent that questionnaires purporting to measure similar constructs are at times dissimilar in scores and are not related strongly. Care needs to be taken in selecting and interpreting outcome measures particularly in relation to questionnaires. It was also apparent that caution should be exercised when considering the influence of impairment measures upon function. Physiotherapists should be aware that patients may perceive a lack of confidence in their level of function at the time of discharge. As a result physiotherapists need to incorporate strategies to improve patient confidence in their management plan.

Disertacijoje įvertinta 144 sportininkų, patyrusių ūmią čiurnos raiščių traumą, čiurnos funkciją atspindinčių rodiklių kaita reabilitacijos eigoje. Greta įprastinių čiurnos funkciją atspindinčių rodiklių, tokių kaip čiurnos skausmas, patinimas, subjektyviai vertinama čiurnos funkcija, šiame darbe taip pat buvo vertinama čiurnos izometrinė eversijos ir inversijos jėga. Kadangi izometriniai jėgų matavimai buvo atliekami ūmiuoju čiurnos raiščių pažeidimo periodu, tai buvo vertinamas ir šių matavimų poveikis čiurnos funkcinei būklei. Darbe taip pat buvo vertinamas ir palyginamas įprastinės ir paspartintos kineziterapijos programos efektyvumas, nustatomos atskirų rodiklių, atspindinčių čiurnos funkcinę būklę, tarpusavio sąsajos ir jų reikšmė prognozuojant čiurnos funkcijos atsigavimą. Darbe įrodyta, kad taikant paspartintos kineziterapijos programą, atsižvelgiant į reabilitacijos eigoje įvertintus izometrinės eversijos ir inversijos jėgų rodiklius, galima pasiekti didesnį reabilitacijos efektyvumą. Taip pat nustatyta, kad izometrinės jėgos matavimai neturi įtakos čiurnos funkcinei būklei, o šių matavimų metu gauti duomenys objektyviai atspindi reabilitacijos eigą ir pagal tai galima dalinai prognozuoti čiurnos funkcijos atsigavimą. / In the dissertation, an analysis of ankle‘s function indicators as well as their changes during the rehabilitation of 144 sportsmen after acute ankle sprain was performed. In addition to conventional indicators of ankle function (lower extremity scale score, pain, and swelling) in this study the indicators of isometric ankle eversion and inversion strength were assessed. Since the isometric strength measurements were performed during acute stage after ankle sprain, the impact of these measurements to functional status of the ankle and recovery course was evaluated. Additionally, in this study the efficacy of standard and accelerated home-based exercise program were assessed and intercorrelations of ankle function indicators and their predictive value for ankle recovery were established. It was shown, that isometric measurements of eversion and inversion strength do not influence ankle‘s functional state and course of rehabilitation among sportsmen after acute ankle sprain. Accelerated home-based exercise program based on isometric testing had a trend of better improvement of ankle function. It was also found that the isometric eversion and inversion strength measurement does not affect the functional state of the ankle, and the data obtained during these measurements objectively reflects the course of rehabilitation and can predict the recovery of ankle function.

Introduction: Ankle injuries are among the most prevalent acute musculoskeletal injuries, and are a significant burden on any health system. The interaction of the physiotherapist with the patient and their mutual understanding of impairments, function and recovery are important to achieving a satisfactory return to work and leisure activities. To date, little attention has focused on this interaction. There is a need for further exploration of differences and associations between outcome questionnaires that investigate similar domains of pain and function, and whether scores from such outcome measures are related to the patient’s perception of function and recovery. Of further interest is whether there are relationships between impairment measures and perceived function, and how actual performance of tasks might influence the patients understanding of their capabilities. To provide a more complete picture of these relationships, a ‘mixed methods’ approach using qualitative research methods within a quantitative study was thought to be most appropriate. The overall aim of this thesis was to utilise this research approach to investigate patients’ perceptions of their recovery and elucidate factors important to both therapists and patients that ultimately might enhance their understanding of recovery from an ankle injury. Literature reviews: Three literature reviews were undertaken. Firstly a review of systematic reviews investigating ankle sprains identified a wide variety of management strategies. There was a lack of strong evidence to support any particular management strategy. Hence clinicians are likely to have difficulty setting appropriate rehabilitation plans. Secondly a critical review identified a number of different outcome questionnaires that were utilised to gauge recovery level; however, justification for their selection was often lacking. This review also identified that little emphasis was placed on understanding the patients’ perception of their injury and the rehabilitation process. A final critical review investigated impairment and performance measures and identified four specific areas that were focused upon by clinicians during the treatment of ankle sprains: joint position sense, postural control, strength and performance during function. However, only weak evidence was found for there being a deficit in joint position sense, postural control and strength in the injured limb following an ankle sprain, and inconclusive evidence of deficits in physical performance of tasks related to function. Methods: Forty participants with an acute sprained ankle were recruited along with their treating physiotherapist. The participants completed a Global questionnaire, the Lower Limb Task Questionnaire (LLTQ) and the Short Form -36 (SF-36) Questionnaire at the initial visit, at discharge and at a six week follow up visit where they also undertook impairment testing involving, joint position sense, postural control and strength along with a functional performance test and selected functional activities. Ten participants were purposefully selected to undertake semi-structured interviews. The treating physiotherapists completed global questionnaires at the initial visit and at time of discharge. An interpretive hermeneutic approach was undertaken to examine the participants’ perceptions. Results: There were equal numbers of males and female participants and the average age of participants was 30.5 years. The relationship between questionnaires for the domains of pain and function varied between low and high degrees of association. The global limitations scores between the participants and physiotherapists were similar at the initial visit, whereas on discharge the participants had a significantly lower score (p<0.05) compared to the physiotherapists. With respect to impairment testing, there was a significant difference (p<0.05) between the uninjured limb compared to the injured limb for the joint position sense and performance agility hop test. All other comparisons of impairments were not significant (p>0.05). There was no association between questionnaire scores and impairment measures (p>0.05). Additionally there were no significant associations between previous injury and questionnaire scores and impairment measures. Finally in relation to the performance of specific functional tests there was a significant difference (p<0.05) between the six week follow up LLTQ score and the score following actual performance of the test. The findings of the participants’ interviews identified three key concerns. Firstly, that participants have a limited understanding of questionnaires, and secondly, that there is a difference in understanding of ‘recovery’ between the therapist and the patient at time of discharge. Thirdly, there was dissociation between outcome measures and the patient’s perception of their own recovery. Conclusions: This study revealed a lack of understanding and effective communication concerning physiotherapy practice in relation to ankle sprains. It was apparent that questionnaires purporting to measure similar constructs are at times dissimilar in scores and are not related strongly. Care needs to be taken in selecting and interpreting outcome measures particularly in relation to questionnaires. It was also apparent that caution should be exercised when considering the influence of impairment measures upon function. Physiotherapists should be aware that patients may perceive a lack of confidence in their level of function at the time of discharge. As a result physiotherapists need to incorporate strategies to improve patient confidence in their management plan.

Submitted by KARINA APARECIDA RODRIGUES null (kaarodrigues@gmail.com) on 2016-02-12T17:41:35Z No. of bitstreams: 1 A INFLUÊNCIA DA FADIGA NOS MÚSCULOS EVERSORES.pdf: 2242940 bytes, checksum: 172937512799242c5f55d9082f295349 (MD5) / Approved for entry into archive by Ana Paula Grisoto (grisotoana@reitoria.unesp.br) on 2016-02-15T11:30:53Z (GMT) No. of bitstreams: 1 rodrigues_ka_me_guara.pdf: 2242940 bytes, checksum: 172937512799242c5f55d9082f295349 (MD5) / Made available in DSpace on 2016-02-15T11:30:53Z (GMT). No. of bitstreams: 1 rodrigues_ka_me_guara.pdf: 2242940 bytes, checksum: 172937512799242c5f55d9082f295349 (MD5) Previous issue date: 2016-01-29 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A entorse do tornozelo em inversão e flexão plantar é uma das lesões mais comuns que ocorrem nas atividades de vida diária e no esporte. Embora os sintomas agudos possam se resolver rapidamente, muitos indivíduos relatam persistência de dor e instabilidade. Este tipo de lesão frequentemente acontece na fase final de um treino ou competição, e mesmo sabendo que a entorse é multifatorial, tal particularidade propicia estabelecer uma relação entre o evento da entorse e a fadiga. Diante disto, o presente estudo propõe analisar a latência e a intensidade de ativação dos músculos fibulares curto e longo em condições de fadiga, e ainda comparar indivíduos com estabilidade e instabilidade do tornozelo. Para esse fim, inicialmente foi desenvolvida uma plataforma simuladora da entorse em inversão e flexão plantar, na qual ambos os pés das voluntárias foram fixados e abaixo de onde se apoiava os pés foram acoplados transdutores de força, um de cada lado. Participaram do estudo 23 voluntárias do sexo feminino, fisicamente ativas, separadas em dois grupos: 11 fizeram parte do grupo estabilidade, não apresentavam histórico de lesão no complexo articular do tornozelo nos últimos 12 meses e outras 12 no grupo instabilidade funcional, classificadas pelo Questionário Cumberland Ankle Instability Tool. Para indução da fadiga, inicialmente foi registrada a Contração Isométrica Voluntária Máxima (CIVM) em eversão e flexão plantar. Durante a indução as voluntárias foram orientadas a manter 70% da CIVM. No momento em que a força aplicada fosse menor que 60% da CIVM o protocolo era interrompido e as voluntárias posicionadas em ortostatismo sobre a plataforma simuladora. Antes e após a fadiga foram realizadas dez simulações da entorse bilateralmente de forma randomizada e simultaneamente com o registro do sinal eletromiográfico. Assim, foi possível observar que após a fadiga não houve alteração da latência, no entanto ocorreu uma redução do nível de contração muscular, constatada pela diminuição da amplitude do sinal eletromiográfico. Ainda, não foram notadas diferenças entre os grupos estabilidade e instabilidade e verificouse maior atividade do músculo fibular curto quando comparado ao longo. Portanto, pôde-se concluir que o controle neuromuscular local ficou comprometido em situações de fadiga, devido à redução do nível de atividade dos músculos fibular longo e curto. Além disso, não foi possível observar diferença no comportamento muscular entre tornozelos estáveis e funcionalmente instáveis. / The inversion and plantar flexion ankle sprain is one of the most common injuries that occur in daily life activities and sports. Although acute symptoms can be resolved quickly, many people report persistent pain and instability. This type of injury often occurs in the final phase of a training or competition, and even though the sprain is multifactorial, such particularity provides the establishment of a relationship between the event sprain and fatigue. In this view, the present study aims to analyze the latency and activation intensity of the brevis and longus peroneus muscles in conditions of fatigue and also compare individuals with stability and instability of the ankle. For this purpose it was initially developed a simulated platform sprains in inversion and plantar flexion, in which both feet of the volunteers were fixed and below where rested his feet were coupled force transducers, one on each side. The study included 23 female volunteers, physically active, separated into two groups: 11 were part of the group stability, had no injury history in the joint complex of the ankle in the last 12 months and another 12 in functional instability group, classified by Cumberland Questionnaire Ankle Instability Tool. To induce fatigue, it was initially recorded a Contraction Isometric Maximal Voluntary (MVIC) in eversion and plantar flexion. During the induction, the participants were instructed to maintain 70% of the MVIC. At the time the force applied was below 60% of the MVIC the protocol was interrupted and the volunteers placed in standing position on the simulator platform. Before and after fatigue were held ten simulations sprain bilaterally randomly and simultaneously to record the electromyographic signal. Thus, it was observed that after the fatigue did not change the latency, but there was a reduction of muscle contraction level, evidenced by the reduction in amplitude of the electromyographic signal. Still, there were no noticeable differences between the groups stability and instability and there was a higher activity of the peroneus brevis compared to longus. Therefore, it was concluded that the local neuromuscular control was compromised in fatigue situations, due to reduced activity level of the peroneus longus and brevis muscles. Moreover, it was not possible to observe difference in muscle behavior between stable and unstable functionally ankles.