The purpose of the study is to investigate dynamic core stability training versus cognitive training on balance, functional performance, postural control, ankle instability scores, ankle dorsiflexion range of motion, and mental workload in chronic ankle instability
History of chronic lateral ankle sprain and/or recurrent sprain and/or "feelings of instability or giving way" for 6 months or more before the study, with at least 2 episodes.
Patients are between 18 and 30 years old. 3- Body mass index less than 30
None
Parallel
strengthening exercises
Other interventionStretch the gastrocnemius and soleus muscles for 30 seconds with 3 repetitions. Strengthen all ankle muscles using TheraBand resistance for various movements (dorsiflexion, plantar flexion, inversion, and eversion) and combined movements for 3 sets of 10 repetitions, three sessions weekly for two months. The training program includes progression from seated to standing for stretching and single-limb for bipedal calf raises.
Balance training
Other interventionChallenging disc training, utilized in balance studies, begins with participants standing with slightly bent knees. The dynamic balance training comprises 9 protocols focused on tracking a moving red circular target zone using a green point cursor that represents the center of pressure. Participants shift their body weight in various directions with visual feedback on a computer screen. Over 8 weeks, participants complete 16 sessions, each lasting 20 seconds with 7 seconds of rest in between. The time spent correctly tracking the target is measured and analyzed across all protocols.
Functional core training
Other interventionParticipants will receive functional core motor control (stabilization) exercise and the traditional program (consisting of stretching protocol, strengthening of all ankle muscles, and balance activities) 3 sessions per week for 2 months.
Spinal motor control (stabilization) exercises
Other interventionThe training program consists of three phases: 1. \*\*Cognitive Phase (Weeks 1-2):\*\* Focuses on isolating the transversus abdominis and multifidus muscles using a biofeedback pressure device. Exercises involve isometric contractions with 10-second holds, repeated four times daily. 2. \*\*Associative Phase (Weeks 3-4):\*\* Introduces less stable exercises (e.g., quadruped and standing positions) aimed at enhancing spine neutrality. 3. \*\*Automatic Phase (Weeks 5-8):\*\* Involves dynamic movements that integrate spine control with extremity movements. Key exercises include lunges with a medicine ball, squats, and various plank variations, emphasizing co-contraction of core muscles for stability during movements.
Cognitive training
Other interventionBalance training is combined with a cognitive task involving a backward digit span test, where participants must recall and repeat sequences of numbers in reverse order, testing working memory. This test includes three difficulty levels (3-, 4-, and 5-digit sequences) performed over 35 seconds. Participants will either recall digits while maintaining static stability or after squatting upon hearing a number, with a focus on accuracy within 5 seconds. Performance is measured by the percentage of correctly recalled digits, and error scoring will be documented via video recording for each posture task.
assessment of change of pain
Ankle pain will be evaluated using the Arabic version of the Cumberland Ankle Instability Tool, which consists of questions that the patient must answer to reflect their condition. The scoring ranges from 0 to 30, with 0 indicating severe instability and 30 indicating normal stability. A score below 24 suggests Chronic Ankle Instability as defined by the International Ankle Consortium
assessment of ankle instability
Ankle instability will be evaluated using the Arabic version of the Cumberland Ankle Instability Tool, which consists of questions that the patient must answer to reflect their condition. The scoring ranges from 0 to 30, with 0 indicating severe instability and 30 indicating normal stability. A score below 24 suggests Chronic Ankle Instability as defined by the International Ankle Consortium
assessment of foot function
Participants will complete a 29-item questionnaire consisting of the Foot and Ankle Ability Measure, which includes a 21-item Activities of Daily Living (ADL) Subscale and an 8-item Sports Subscale. Each item is rated on a 5-point Likert scale from 0 (unable to perform) to 4 (no difficulty), yielding a potential score of 0 to 84 for the ADL subscale and 0 to 32 for the Sports subscale. The total score is calculated by subtracting the raw score from the maximum possible score, dividing by the maximum score, and multiplying by 100 to determine the percentage of maximum ability achieved.
assessment of functional performance
The side-hop test involves participants hopping laterally on one limb over a distance of 30 cm for 10 repetitions, with a stopwatch recording the fastest time. Trials are invalidated if the contralateral foot touches the ground. After 1-3 practice trials, 3 test trials are conducted, and the average time is used for analysis (Kamonseki et al., 2018). Additionally, the figure of the hop test requires participants to hop twice around a 5-m cone-marked course as fast as possible, with penalties for footfall or course deviations, and timing recorded to the nearest 0.01 seconds.
assessment of postural control
The modified star test grid features three lines emanating from a center point, oriented as anterior, posteromedial, and posterolateral. Participants stand at the center with feet together and perform single-limb squats, reaching towards maximum points along each direction line with the swinging limb. The participant must lightly touch the line with the distal part of the reaching foot without shifting their weight to it or resting on it. They must then return the limb to the center while maintaining balance on the stance limb. Any heavy contact, resting, or shifting during the trial invalidates it. Maximum reach distances are measured with a tape measure.
assessment of balance
The "Self-check" mode provides two measurement options for Static Balance Testing and alternative assessments using an Electronic Balance Board. Participants stand with feet shoulder-width apart (\~30 cm) and are monitored via a computer screen displaying a target zone of five concentric circles. The test includes a 15-second adaptation phase followed by a 20-second measurement period, during which stability is assessed based on how long a tracking ball remains within the inner circle. Scores range from 1 (Excellent Stability) to 5 (Bad Stability), with lower scores indicating better performance. Additionally, dynamic tasks require participants to track a target point on-screen, measuring time in the target for scoring. After the tests, scores for each foot and the overall percentage difference are displayed, with values below 10% indicating good body balance.
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