The Effect of Balance and Combined Exercises on Pain and Functional Characteris- tics of Female Athletes With Chronic Ankle Instability

* Corresponding Author: Fatemeh Haataamee, MSc. Address: Department of Corrective Exercise and Sport Injury, Faculty of Physical Education and Sport Sciences, Tehran South Branch, Islamic Azad University, Tehran, Iran. Tel: +98 (919) 1028415 E-Mail: fatemeh.haataamee@gmail.com 1. Department of Corrective Exercise and Sport Injury, Faculty of Physical Education and Sport Sciences, Tehran South Branch, Islamic Azad University, Tehran, Iran. 2. Sport Biomechanics & Sport Injuries Department, Faculty of Physical Education and Sport Sciences, Kharazmi University, Tehran, Iran. *Fatemeh Haataamee1 , Seyed Sadrodin Shojaodin2


Introduction
n ankle joint is among the joints with the most sports injuries [1,2]. A lateral ankle sprain is one of the most common inju-A ries that occur during exercise and performing daily living activities [3,4]. These injuries occur more frequently in football, futsal, basketball, volleyball, and sports requiring quick body direction change [1]. Studies have suggested that muscle weakness, followed by increased ankle joint laxity and sensory-motor deficits as a result of a sprain, is associated with deficits in balance, postural control, and function [3]. Balance training, Pilates, core body stabilization, as well as aquatic and preoperative exercises, are recommended to improve the performance of individuals with chronic ankle instability. We aimed to compare to types of balance and combined exercises (neuromuscular and stabilization exercises) on reducing pain and improving the range of motion and function of people with chronic ankle instability. Suggesting such effective exercises to therapists and sports coaches might reduce treatment costs and time, and the odds of recurrence of ankle ligament injury.

Participants and Methods
The study population consisted of all female athletes with chronic ankle instability participating in regional competitions in Tehran City, Iran. In total, 30 subjects aged 15-20 years were selected using a purposive sampling technique and based on the study inclusion criteria. They were divided into three groups of balance exercise, combined exercise, and controls. The Visual Analog Scale (VAS) was used for measuring pain. Side hop test, 8 hop test, single-leg triple hop test, and single-leg hop test were applied to evaluate the functional characteristics of study subjects [17]. The side hop test is used to measure the power, velocity, balance, and rotational stability of the lower extremity with an emphasis on standing on one leg [20].
The balance group performed their exercises for 6 weeks, 3 sessions per week. These exercises included a single-leg stance with eyes open, a single-leg stance with eyes open while another leg was swinging, a single-leg squat with eyes open (30°-45°), and a single-leg stance with eyes open while conducting active training (dribbling, hitting, etc.). The study subjects repetitively performed the exercises for 30 seconds with 2-min recovery between each set [23]. The combined exercise group received the neuromuscular exercise adapted from Clark and Burden plus stabilization exercises for 6 weeks, 3 sessions per week [26].

Results
The 2-way Analysis of Covariance (ANCOVA) and Tukey's posthoc test results are reported in Tables 1 and 2, respectively. The ANCOVA results revealed significant differences in the study variables between the groups. Furthermore, based on Tukey's posthoc test results, there was a significant difference between groups under side hop test, single-leg triple hop test, ankle dorsiflexion and plantarflexion (expect between the control and balance groups) (P>0.05). In terms of pain, the difference was only significant between the control and balance groups as well as between the control and combined exercise groups.

Discussion
The obtained results suggested that training protocols applied in our study significantly impacted pain, function, and the range of motion indices in female athletes with chronic ankle instability; the combined exercises had more effect on these variables. In terms of pain, our results were consistent with those of Sahranavard et al. [30] and Yafani et al. [31]. Regarding the variable of function, our results were in agreement with those of Mohammadi et al. [11], Ashoury et al. [32], and Cain et al. [16], but against the findings of Haugen et al. [33]. The possible reason for this discrepancy may be the exercise program type.
Applying therapeutic modalities, like exercise therapy, indirectly reduces pain by improving muscle strength, proprioception, and motor control [36]. This is because exercise therapy reduces tissue sensitivity to pain. In a shorter time, therapeutic exercises could increase the muscle strength through neural mechanisms, such as increased motor unit recalling, modification of messages transmitted to motor neurons, and the alteration of agonist-antagonist muscle activity.

Conclusion
Combined exercises demonstrated higher effects on pain reduction in female athletes with chronic ankle instability, compared to balance exercise. Their effect was also higher under functional tests. Both methods improved the range of motion (dorsiflexion and plantar flexion). The effect of balance exercises was more significant on plantar flexion, while combined exercises had a higher effect on dorsiflexion. It is suggested that sports therapists and coaches use exercises that address different aspects of treatment plans in ankle sprain rehabilitation programs.

Compliance with ethical guidelines
All participants were informed of the study objectives and methods, and informed consent was obtained from them. They were assured of the confidentiality of their information and were free to leave the study at any time.

Funding
This study was extracted from a master thesis approved by the Department of Sport Injury and Corrective Exercise at University of Guilan. We received no financial support from any organization.

Conflicts of interest
The authors declare no conflict of interest.