Transcript The effects of exercise on non-accident related chronic ankle

Exercise Treatment of Non-Accident
Related Chronic Ankle Instability in
Ehlers-Danlos Syndrome
Alberto Friedmann, MS
American College of Sport Medicine
Ankle Injuries in Sport:
• Common
• Debilitating
• Poorly Rehabilitated
• Reocurring
• Functional Instability
Chronic instability is not limited to injuries:
Genetic and neuromuscular disorders result in instability without trauma.
Hereditary Disorders of Connective Tissue (HDCT)
• Ehlers-Danlos Syndrome
• Marfan’s Syndrome
• Osteogenesis Imperfecta
• Benign Hypermobility Syndrome (Mild EDS
Hypermobility – Type III)
Hereditary Disorders of Connective Tissue:
•Result of defective collagen (glue)
•Elastin and collagen are weak
•Tissue is frail and lax
•Fibrillins are weak and tear
Up to 70% show the same symptoms as those with frequent ankle sprains.
“Hypermobility is defined as an abnormally increased range of joint motion
due to excessive laxity of the constraining soft tissues” (Everman, 1998).
Clinical Maneuver
Unable to perform
(0 points)
Able to Perform
(1 Point)
Apposition of Thumb to Forearm
Right
Left
0
0
1
1
Extension of fifth finger beyond 90 degrees
Right
Left
0
0
1
1
Extension of elbow beyond 10 degrees
Right
Left
0
0
1
1
Extension of knee beyond 10 degrees
Right
Left
0
0
1
1
Forward flexion of trunk, legs straight, palms
touching the floor
0
1
Total Beighton Score (0-9)
Functional Ankle Instability
Inability to use the ankle for daily activity:
• Walking
• Standing
• Bathing
• Getting out of a chair
• Basic balancing
Functional instability of the ankle is the most common residual
disabilities after an acute ankle sprain.
Ankle Rehabilitative Therapies
• Strengthening (pronation)
• Balance
• Proprioception
• Caused by nerve-fiber damage
• Traditionally low in hypermobile subjects
“Recent studies have demonstrated reduced proprioceptive sensation in
the joints of subjects who have hypermobility syndrome. Such findings
have led to speculation that impaired sensory feedback contributes to
excessive joint trauma in effected individuals” (Everman, 1998).
Most common trauma:
•Talofibular Joint
•Calcaneofibular Joint
Other trauma – often seen in hypermobile subjects:
• Talocrural Joint
• Talocalcaneal Joint
• Talocaneonavicular Joint
• Calcaneocuboid Joint
Traditional rehabilitation therapies:
• Balance Boards
• Theraband resistance
• Open and Closed Kinetic Chain
• Peroneal reaction treatment
• Joint proprioception treatment
Traditional means of rehabilitaion:
• Resistance training
• Reactive Neuromuscular training
• Proprioceptive training
Study purpose was to determine the effects of exercise on nonaccident-related chronic ankle instability, particularly in subjects who
have Ehlers-Danlos Syndrome or Benign Hypermobility Syndrome.
The study looked at multi-range stability in the talocrural,
talocalcaneal, talocaneonavicular and calcaneocuboid joints .
Hindfoot
Talocrural
Tibiofibular
Talocalcanear (Subtalar)
Midfoot
Talocalcaneonavicular
Cuneonavicular
Cuboideonavicular
Intercuneiform
Cuneocuboid
Calcaneocuboid
Participants:
• Direct Observation
• Volunteers
• Hypermobility Syndrome
• Five or higher on Beighton’s Scale
• 18-older
• No recent ankle trauma
• No severe ankle trauma
Procedures:
• Eight-Week Exercise Program
• Three days of exercise per week
• Traditional Rehabilitation Therapies
• Resistance Training
• Reactive Neuromuscular
• Proprioception/Balance
• Active stabilization exercises
Measures:
•Range of Motion
•Functional Strength
•Stability
•Proprioception
•Neurological Reflex
•Study start, after four weeks, study
end (total of three measures)
Range of Motion:
• Standard Goniometer
• Anatomical Neutral
• Dorsiflexion – 200
• Plantar Flexion – 500
• Inversion – 50
• Eversion - 50
Monthly Training Regimen
Exercise
Mon.
Tue.
Wed.
Friday
Resistance Training
X
Reactive Neuromuscular Training
X
X
Proprioception Exercises
X
X
Active Stabilization Exercises
X
Thur.
X
X
Sat.
Sun.
Resistance Exercises
• Leg Press
• Calf Raise
• Knee Extensor
• Knee Flexor
• Two sets of 12 repetitions at 60% max.
• Resistance increased by 10% at week four
• Third set added at week seven
Reactive Neuromuscular Training
Used resistance tubing:
• Uniplanar Anterior Weight Shift
• Uniplanar Posterior Weight Shift
• Uniplanar Medial Weight Shift
• Uniplanar Lateral Weight Shift
Proprioceptive Exercises
One-foot standing balance
One-foot standing balance with hip flexion
One-foot standing balance using weights in diagonal pattern
One-foot standing balance while playing catch
Exercises on balance board
Active Stabilization Exercises
Used a step-stool measuring 16” x 16” x 8” (40.6cm x 40.6cm x 20.3cm
• Forward step-up on stool
• Lateral step-up on stool
• Two-foot hop-up on stool
• Two-foot lateral hop-up on stool
• One-foot hop-up on stool
• One-foot lateral hop-up on stool
• Two-foot jump-over stool
• Two-foot lateral jump-over stool
• One-foot jump-over stool
• One-foot lateral jump-over stool
Functionality
Plantar Flexion
Dorsiflexion
Inversion
Eversion
Measured on a scale 0-15:
• 0 Non functional
• 0-4 Functionally Poor
• 5-9 Functionally Fair
• 10-15 Functional
Functionality

After four weeks:




Overall increase in functional strength
Decrease in pain
Decrease in joint popping
After eight weeks:



All participants fully functional in all tests
Virtual elimination of pain
Elimination of joint popping
Quality of Life
Functional Strength
Less = lower exercise = atrophy = less functionality
More = more exercise = hypertrophy = more functionality =
Independence= Higher Quality of Life
Quality of Life
Pain
More = depression = unwillingness to exercise = atrophy = more pain
Less = Better outlook = social activities = social exercise = Less
medication = Higher Quality of Life
Quality of Life
Proprioception
Less = Poor balance = unwillingness to exercise = Higher risk of injury =
Nerve fiber damage = Decreased proprioception
More = Better balance = feeling of ability = exercise adherence = lower
risk of injury = Increased independence = Higher quality of life
Change in Range of Motion, Active
R Plnt
R Dors
R Invert
R Evert
L Plnt
L Dorsa
L Invert
L Evert
20
10
0
-10
-20
-30
-40
-50
-60
-70
-1
-2
-3
-4
-5
Change in Range of Motion, Passive
10
0
-10
-20
-30
-40
-50
-60
-70
R Plnt P
R Dors P
R Invert P
R Evert P
L Plnt P
L Dorsa P
L Invert P
L Evert P
Overall Change in Range of Motion
0
-5
-10
-15
-20
-25
-30
Part. 1
Part. 2
Part. 3
Part. 4
Part. 5
1-5 Mean
Reduction in ROM
Overall decrease in both passive and active indicates:
Hypertrophy in tendons and ligaments as well as
muscle tissue.
Hypermobile joints can be strengthened and stabilized before
laxity leads to injury.
Proper, supervised exercise is of benefit to this population
Inversion Changes
Inversion injuries:
• Common
• Reoccur
• Difficult to rehabilitate
Participants showed:
Decreased Range of Motion
Decreased Pain and Joint Popping
Increased Balance and Proprioception
Increased Daily Functioning
Implications
Rehabilitation of other joints for this special population
Shoulder Capsule
Hip Socket
Interphalangeal Joints
Metacarpophalangeal Joints
Implications
EDS patients, and possibly patients with other
hypermobility syndromes, could be treated in multiple
joints prior to disruptive injuries or the need for surgery
due to joint hyperlaxity.
Injury and surgery is more damaging and dangerous for
this population than the average person.
Implications
Study participants showed primary gains during the
initial four weeks of study intervention
Primary increases in range of motion occurred during
the final four weeks of study intervention
Therefore, it is possible that a four-week intervention
followed by maintenance would be as, if not more,
successful
Future Research
Studies involving a larger population and studies
involving multiple-joint treatments
Long-term effects of exercise on children with Hereditary
Disorders of Connective Tissue
Four-week versus Eight-week programs
Animal studies involving muscle, tendon and ligament
tensile strength, elasticity and plasticity