The authors concluded that balance and co-ordination training can be used to prevent or treat acute ankle sprains. There was insufficient evidence about effects on chronic ankle instability. The evidence appeared to support the authors’ conclusions, but incomplete reporting of review methods and study quality made it difficult to comment on the strength of the evidence underpinning the authors’ conclusions.

To evaluate the effects of balance and co-ordination training on the prevention of ankle sprains and the treatment of acute ankle sprains and chronic ankle instability.

PubMed and CINAHL were searched from 1966 through October 2006. Search terms were reported. In addition, reference lists of identified studies were screened.

Studies that evaluated balance and co-ordination training for prevention or treatment of ankle sprains, acute ankle sprains or chronic ankle instability were eligible for inclusion. Studies had to report sufficient data for the calculation of effect sizes for instrumented postural control measures in the modified Romberg position on a stable force plate or calculation of relative risk reduction (RRR) and numbers needed to treat (NNT) to prevent incident or recurrence ankle sprains.

Where reported, most studies evaluated interventions involving balance, rocker and wobble boards or ankle disk training. Some studies included a control/sham group. Participants included elite athletes, school- and community-based volleyball, soccer and basketball players, males and females and people with and without a history of ankle injury. Where reported, some training sessions were supervised and others were not. Duration of follow-up ranged from none to one year. Where reported, intervention durations and frequencies varied.

The authors stated neither how papers were selected for the review nor how many reviewers performed the selection.

Study validity was assessed using the 10-point PEDro scale. The two authors reached agreement on these quality scores.

Relative risk reductions and numbers needed to treat with 95% confidence intervals (CI) were calculated for the preventative and treatment effects of interventions. Effect sizes (Cohen’s d) with 95% CIs were calculated for: instrumented postural control measures and self-reported function scores for intervention versus control groups; pre- and post-training measures; and for involved versus uninvolved limbs in patients with unilateral acute ankle injuries. Effect sizes were classified as described by Cohen as weak (<0.4), moderate (0.41 to 0.7) and strong (>0.7). The authors did not state how many reviewers performed the data extraction.

The studies were grouped by intervention aim (prevention, treatment of acute injuries and treatment of chronic injuries) and combined in a narrative synthesis. The quality of evidence was graded using the Strength of Recommendation Taxonomy (SORT) system.

Six RCTs (n=2,086) and five prospective cohort studies (n=908) were included in the review. Sample sizes ranged from 10 to 1,127. PEDro scores ranged from 4 to 8.

Prevention of lateral ankle sprains (two RCTs, n=1,892 and one prospective cohort, n=814, but this may be an overestimate as it was unclear whether the same or different participants were included in the different year groups): Both RCTs reported that the intervention was associated with a significant reduction in the risk of ankle sprain in patients with a past history of ankle sprain, but there was no significant reduction in the risk of injury in patients with no past-history of ankle sprain. Relative risk reductions ranged from 20 per cent to 60 per cent. Numbers needed to treat ranged from 12 to 44. The prospective cohort reported a significant reduction in injury risk in year two of training, but not in year one.

Balance and co-ordination training for the treatment of acute ankle sprains (two RCTs, n=119 and one prospective cohort, n=48): One RCT and the cohort study reported no significant difference in postural control measures between trained and untrained groups. Three of four effect sizes from one RCT showed no significant difference in postural control measures between injured trained limbs and uninjured limbs.

Treatment of chronic ankle instability (two RCTs, n=75 and three prospective cohort studies, n=46): None of the studies provided sufficient data to permit calculation of relative risk reductions or numbers needed to treat. Studies reported mixed results for the effects of training versus no training on chronic ankle instability; results for some measures were significant and results for others were not significant.

Effect sizes were reported in the review. Many crossed zero. Thus, there may be uncertainly regarding the reliability of the reported findings.

Balance and co-ordination training can be used to prevent or treat acute ankle sprains in athletes, particularly those with ankle sprains. There was insufficient evidence about effects on chronic ankle instability.

The review question was clearly stated. Inclusion criteria were specified for participants, interventions and outcomes. Criteria for study design were broad. Several relevant sources were searched, but no attempts to minimise publication and language bias were reported. Appropriate methods were used to minimise reviewer error and bias during the assessment of validity, but without descriptions of the methods used to select studies and extract data it was not possible to tell whether efforts were made to reduce reviewer errors and bias. Validity was assessed, but only the composite score was presented. This made it difficult to comment independently on the reliability of the evidence presented. In view of the diversity among studies, a narrative synthesis was appropriate. However, the synthesis was not always clear and easy to interpret. It would have been helpful to provide information on the forest plots, effect sizes and confidence intervals. In addition, results from individual studies were not discussed in relation to study quality. The evidence appeared to support the authors’ conclusions, but incomplete reporting of review methods and study quality made it difficult to comment on the strength of the evidence underpinning the conclusions.

Practice: The authors recommended balance and co-ordination training to prevent ankle sprains, especially in people with a history of ankle sprains.

Research: The authors stated that there was a need for larger well-designed prospective studies to confirm the review findings about the positive effects of balance and co-ordination training in the prevention of lateral ankle sprains. More high-quality larger RCTs were required to evaluate the optimal length and intensity of balance training programmes for the treatment of acute ankle sprains. Research was also required to evaluate the risk of recurrent injury in patients with chronic ankle instability who had undergone balance and co-ordination training; studies could try novel non-linear measures that may be sensitive enough to detect improvements in postural control after balance training using the Star Excursion Test.

Not stated.

McKeon PO, Hertel J. Systematic review of postural control and lateral ankle instability, part 1: can deficits be detected with instrumental testing? J Athl Train 2008;43(3):293-304.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.