Chronic ankle instability (CAI) is a common condition after lateral ankle sprain. CAI is characterized by mechanical and/or functional instability, or recurrent episodes of "giving way," persisting for at least 12 months after the initial injury, and is associated with limitations in activity and participation. In amateur athletes, CAI may be overlooked or undertreated, although sport-specific activities require rapid integration of visual, vestibular, somatosensory, and cognitive information. Postural stabilization training is commonly used to improve balance and neuromuscular control in individuals with CAI. However, individuals with CAI may show increased reliance on visual information and altered visual-vestibular sensory reweighting during postural control tasks. The vestibulo-ocular reflex (VOR) contributes to gaze stability and visual clarity during head movements and may also be related to neurocognitive processes such as attention and processing speed. This study is designed as a randomized controlled, prospective, parallel-group, pretest-posttest design trial to investigate whether VOR exercises added to postural stabilization training improve dynamic balance, functional instability, and neurocognitive performance in amateur athletes with CAI.
Chronic ankle instability (CAI) is a common condition after lateral ankle sprain. CAI is characterized by mechanical and/or functional instability, or recurrent episodes of "giving way," persisting for at least 12 months after the initial injury, and is associated with limitations in activity and participation. In amateur athletes, CAI may be overlooked or undertreated, although sport-specific activities require rapid integration of visual, vestibular, somatosensory, and cognitive information. CAI has been explained through various theories, including poor neuromuscular control, reduced muscle strength, decreased kinesthetic awareness, deficits in postural stability, and functional and mechanical instability \[10\]. However, contemporary models emphasize that CAI cannot be explained solely by peripheral or mechanical changes; rather, it represents a multidimensional condition in which the interaction between the perception of sensory input, central processing of this information, and generation of an appropriate motor response is impaired \[10,12\]. Accordingly, in addition to peripheral adaptations, these alterations may also affect neurocognitive functions, and it has been reported that neurocognitive abilities such as attention, inhibitory control, and visual memory may be impaired in individuals with CAI. Current evidence suggests that lower neurocognitive performance may be associated with impaired neuromuscular control and coordination in musculoskeletal injuries. Although this relationship has been more clearly described in anterior cruciate ligament injuries, it has been examined to a more limited extent in ankle injuries. Postural stabilization training is commonly used to improve balance and neuromuscular control in individuals with CAI. However, individuals with CAI may show increased reliance on visual information and altered visual-vestibular sensory reweighting during postural control tasks. The vestibulo-ocular reflex (VOR) contributes to gaze stability and visual clarity during head movements and may also be related to neurocognitive processes such as attention and processing speed. This study is designed as a randomized controlled, prospective, parallel-group, pretest-posttest trial to investigate the effects of vestibulo-ocular reflex (VOR) exercises added to postural stabilization training on dynamic balance, functional ankle instability, and neurocognitive performance in amateur athletes with chronic ankle instability (CAI). Dynamic balance will be assessed using the Y-Balance Test, while functional ankle instability will be evaluated using the Turkish version of the Cumberland Ankle Instability Tool. Neurocognitive performance will be assessed through single-leg balance and figure-of-eight performance under cognitive load, hopping performance under visual constraint, selective attention, and inhibitory control measures. Approximately 56 participants with CAI will be randomly allocated to either a Postural Stabilization Training Group or a Postural Stabilization Training plus Vestibulo-Ocular Reflex Exercises Group. Both groups will participate in a six-week intervention program conducted three days per week. Each session will last approximately 45 minutes, including 40 minutes of exercise and 5 minutes of ankle mobilization. Outcome measures will be assessed at baseline, immediately after the six-week intervention, and at a four-week follow-up.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
56
Participants in this group will receive ankle joint mobilization followed by a structured postural stabilization training program. The program will include single-leg stance progression, hop stabilization tasks, and number-sequence hop tasks. Exercises will be progressed according to the participant's ability to complete each task without errors. Ankle joint mobilization will include talocrural anteroposterior mobilization and distal fibular mobilization with movement, applied before the exercise session for approximately 5 minutes. The total session will last approximately 45 minutes and will be performed 3 times per week for 6 weeks.
Participants in this group will receive the same ankle joint mobilization and postural stabilization training program as the Postural Stabilization Training Group. In addition, vestibulo-ocular reflex (VOR) exercises involving fixation on a visual target during head movements will be implemented. VOR exercises will be structured to progressively increase postural demands and will include sitting, standing, walking, and single-leg stance positions. The total session will last approximately 45 minutes and will be performed 3 times per week for 6 weeks.
Reset Fizyoterapi
Istanbul, Turkey (Türkiye)
RECRUITINGY Balance Test
The Y-Balance Test will be used to assess dynamic postural control. Participants will perform the test barefoot, standing on the test limb with hands on the hips, and will reach in the anterior, posteromedial, and posterolateral directions with the free limb. Invalid trials, including loss of balance, movement of the stance foot, or removal of the hands from the hips, will be repeated. Reach distances will be recorded in centimeters, normalized to limb length, and a composite score will be calculated.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Cumberland Ankle Instability Tool
The Cumberland Ankle Instability Tool is a 9-item questionnaire used to evaluate perceived ankle instability and functional limitations. The total score ranges from 0 to 30, with lower scores indicating greater ankle instability. A score of 24 or lower is considered consistent with functional ankle instability
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Single-Leg Stance + Number / Word Sequence Task
This task will assess static balance under cognitive load. Participants will stand on the affected limb on a foam pad and perform a backward number or word sequence task. In the first 10 seconds, the researcher will read six random items; participants must repeat them in reverse order within the next 10 seconds while maintaining balance. Each trial will last 20 seconds. Postural errors include removing hands from the hips, touching the ground with the non-stance foot, moving or hopping on the stance foot, hip flexion or abduction \>30°, limb contact, loss of balance, or failure to maintain the position for \>5 seconds. Each error scores 1 point, up to 10 per trial. One cognitive error is recorded for incorrect order, incomplete recall, or no response within 10 seconds. The total score is the sum of postural and cognitive errors; higher scores indicate poorer performance. After one practice trial, three trials will be recorded, and the mean total error score will be used for analysis.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Side Hop Test + Pinhole Glasses
This test will assess hopping performance under visual constraint. Participants will stand on the affected limb and hop laterally and medially over two parallel lines placed 30 cm apart. Before testing, they will complete 3-4 submaximal practice repetitions without visual constraint. During testing, participants will wear pinhole glasses and complete the task as quickly as possible. One repetition is defined as hopping from the outside of one line to the outside of the opposite line and back to the starting side. The time required to complete 10 round-trip hops will be recorded in seconds. Two trials will be performed with a 60-second rest interval, and the shortest time will be used for analysis. A trial will be repeated if the contralateral limb touches the ground, the participant steps on a line, double-limb contact occurs, or the hopping sequence is interrupted.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Figure-of-Eight Hop Test + Backward Counting Task
The Figure-of-Eight Hop Test with backward counting will assess hopping performance under cognitive load. Participants will hop on the affected limb around two cones placed 5 m apart, completing the figure-of-eight pattern twice as quickly as possible. Before testing, they will walk through the course and complete one submaximal hopping trial without the cognitive task. During testing, participants will count backward by sevens from a number between 200 and 250; numbers ending in 7 or 0 will be excluded. They will perform both tasks simultaneously without prioritizing either. After a cognitive error, the researcher will provide the correct response and the participant will continue. A trial will be repeated after contralateral foot contact, double-limb contact, cone contact or displacement, course deviation, pattern disruption, or balance loss. Two trials will be performed with 60-s rest. The shortest completion time and number of correct cognitive responses will be recorded.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Stroop Test
This test will assess selective attention and inhibitory control and will be administered in a seated position after a brief practice trial. Participants will complete three conditions: color naming, word reading, and incongruent color-word naming. In the incongruent condition, they will name the ink color while inhibiting the tendency to read the word; this condition will serve as the primary measure of inhibitory control and interference resolution. Completion time will be recorded in seconds for each condition. Errors and spontaneous corrections will also be recorded for the incongruent condition. Interference resistance will be calculated as incongruent ink-color naming time minus word reading time. Outcomes will include color naming time, word reading time, incongruent condition time, interference resistance time, errors, and spontaneous corrections.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Foot and Ankle Ability Measure (FAAM)
The Foot and Ankle Ability Measure Turkish Version (FAAM-T) will be used to evaluate postural stability and foot/ankle-related functional ability following chronic ankle instability and lateral ankle sprain. The FAAM consists of 29 items and includes two subscales: the Activities of Daily Living subscale (FAAM-ADL, 21 items) and the Sports subscale (FAAM-S, 8 items). The Sports subscale is specifically designed to assess sport-related function and complex motor tasks and is widely used as a self-reported outcome measure in athletic populations. Scores are expressed as a percentage, with lower scores indicating greater sport-related functional limitation.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Weight-Bearing Lunge Test
The Weight-Bearing Lunge Test will be used to assess ankle dorsiflexion range of motion in a weight-bearing position. The maximum distance at which the knee can touch the wall without heel lift will be measured in centimeters. A dorsiflexion distance on the affected side that is ≥2.5 cm less than the unaffected side will be considered indicative of dorsiflexion limitation.
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
Dynamic Visual Acuity Test
The Dynamic Visual Acuity Test will be used to assess the functional status of the vestibulo-ocular reflex (VOR). Static visual acuity (SVA) and dynamic visual acuity (DVA) during active head movements will be measured, and the difference between these two values will be used as an indicator of VOR function. For both measurements, the smallest line that can be read with at least 50% accuracy will be recorded. The change in the SVA-DVA difference will be reported after the intervention
Time frame: baseline, 6 weeks after baseline, and 10-week after baseline
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