Do exercise therapies restore the deficits of joint position sense in patients

Key points

1. 01Chronic ankle instability (CAI) involves a poor sense of ankle position (joint position sense, JPS), which raises the risk of re-spraining.
2. 02This review pooled 7 studies comparing exercise therapy against non-training controls using the joint position reproduction (JPR) test.
3. 03Exercise improved passive JPS in inversion (weighted mean difference about 1.54 degrees) and eversion (about 1.80 degrees) versus controls.
4. 04Exercise did NOT significantly improve active JPS in inversion or eversion, even though active JPS is where CAI patients are most impaired.
5. 05The authors conclude exercise programs likely improve already-intact JPS rather than restoring the genuine deficits of CAI, suggesting longer, active-JPS-focused programs are needed.

How it was conducted

Design

Systematic review and meta-analysis (PRISMA, prospectively registered, INPLASY202110032)

Search

Seven databases (PubMed, Embase, Cochrane, CINAHL, Web of Science, SPORTDiscus, Scopus) from inception to February 2022

Included studies

7 studies of patients with chronic ankle instability; mean age ranged from 19.6 to 40.6 years

Comparison

Exercise therapy versus non-training controls, change in absolute error on the joint position reproduction (JPR) test

Outcome

Weighted mean difference (WMD) in JPS change with 95% confidence interval, random-effects model, subgrouped by JPR type (active/passive) and ankle direction

Quality

PEDro scale (score of 6 or higher considered good quality) and International Ankle Consortium criteria

What they found

• Passive JPS improved significantly in inversion (weighted mean difference approximately 1.54 degrees) favoring exercise therapy over non-training controls.
• Passive JPS improved significantly in eversion (weighted mean difference approximately 1.80 degrees) favoring exercise therapy.
• A significant positive effect on passive JPS in dorsiflexion was found across four pooled studies, but heterogeneity was high (I-squared = 90.2%).
• No significant effect on passive JPS was observed in plantar flexion across four studies.
• Active JPS showed no significant effect in inversion (three studies) or eversion (two studies) when exercise therapy was compared with non-training controls.

Limitations

• Few studies were pooled in each analysis (7 total, fewer than 10 per pool), so publication bias could not be formally assessed.
• Heterogeneity was high in some analyses (for example I-squared = 90.2% for passive dorsiflexion), and CAI criteria and training content varied across studies.
• No study could blind participants or therapists, and only 2 of 7 reported concealed allocation and blinded assessors; most did not fully meet the standardized CAI severity criteria.
• The significant result for passive JPS in dorsiflexion was unstable in sensitivity analysis, becoming non-significant when single studies were removed.

Why it matters

For patients

Exercise therapy can help your passive ankle position sense, but do not assume it fully fixes the instability problem; ask your clinician about programs that specifically train active control.

For clinicians

Standard balance and strengthening programs improve passive JPS in inversion and eversion but appear not to restore the active JPS deficits central to CAI, so consider longer, active-JPS-targeted protocols.

For readers

This review highlights that a treatment can show measurable benefit on one outcome while still missing the specific deficit that defines the disorder.