Comparative Analysis of Land-Based vs. Water-Based Balance Training on Quality of Life and Physical and Psychological Deficits in Athletes with Chronic Ankle Instability: A Randomized Controlled Trial Assessing the Influence of Exercise Environment

doi:10.21203/rs.3.rs-4991597/v1

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Research Article

Comparative Analysis of Land-Based vs. Water-Based Balance Training on Quality of Life and Physical and Psychological Deficits in Athletes with Chronic Ankle Instability: A Randomized Controlled Trial Assessing the Influence of Exercise Environment

https://doi.org/10.21203/rs.3.rs-4991597/v1

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Background

Aquatic training is recognized for its effective and gentle rehabilitation benefits, yet its effects on athletes with chronic ankle instability (CAI) is not well-studied. This research aims to compare the effects of water-based (WBBE) and land-based (LBBE) balance training on functional performance, dynamic balance, fear of reinjury, and quality of life in athletes with CAI, hypothesizing that aquatic training will lead to greater improvements.

Methods

Forty-one athletes with CAI were randomly assigned to either the WBBE group (n = 21) or the LBBE group (n = 20). Both groups participated in an identical balance training program consisting of 24 sessions over 8 weeks, each lasting 30–45 minutes. Functional ankle instability was assessed using the Cumberland Ankle Instability Tool (CAIT), kinesiophobia with the Tampa Scale for Kinesiophobia (TSK-17), and quality of life with the Short Form-36 Health Survey (SF-36). Dynamic postural control was measured with the Y Balance Test (YBT), and functional performance was evaluated through the Figure-8 hop (F8H) and the single-limb side-hop (SLSH) tests. Perceived treatment effects were assessed using the Global Rating of Change (GROC). Data were analyzed using mixed-design ANOVA (P ≤ 0.05).

Results

The statistical analysis of the study revealed no significant time × group interaction effects for CAIT scores, kinesiophobia scores, the Psychological Quality of Life (QoL) Component, or SEBT scores (p > 0.05). The LBBE group showed significant improvements in functional tasks, specifically in F8H and SLSH scores, compared to the WBBE group (p < 0.05), while the WBBE group had better outcomes in overall Quality of Life and the Physical QoL Component than the LBBE group (p < 0.05).

Conclusion

Both land-based and water-based balance exercises offer unique benefits for rehabilitating athletes with CAI, with land-based exercises improving functional performance and water-based exercises enhancing overall and physical Quality of Life. A flexible, individualized rehabilitation program that incorporates both modalities can optimize recovery and address specific needs like Quality of Life and functional performance, despite no significant differences in ankle stability, kinesiophobia, psychological QoL, and dynamic balance between the two approaches.

Trial registration

Clinical Trials: UMIN000051746

Aquatic Training

Functional Performance

Postural Control

Kinesiophobia

Postural Balance

Approximately 40% of individuals who suffer an initial lateral ankle sprain develop chronic ankle instability (CAI), characterized by recurring instability, sensory deficits, joint laxity, pain, swelling, and impaired function(1). The factors leading to CAI are complex and may include mechanoreceptor damage, impaired motor perception(2), balance disorder(3) and fear of movement(4). Functionally, athletes with CAI experience impaired postural control, which hinders athletic performance and often leads to prolonged absences from training and competition(5, 6). These athletes struggle with activities necessitating rapid changes in direction, jumping, and landing, heightening their susceptibility to additional injuries(5, 7, 8). The recurrent nature of CAI can severely limit physical activity and daily activities for years, significantly decreasing the quality of life(9–11). Moreover, the psychological burden of fearing re-injury can erode confidence and competitiveness(4). Therefore, managing CAI in athletes is vital not only for preserving their physical well-being and performance but also for sustaining their long-term athletic careers.

Conservative interventions, including numerous rehabilitation programs focusing on balance training, strength training, and multi-exercise programs, are typically the first line of defense against CAI(12, 13). Among these, balance training has shown substantial efficacy in enhancing treatment outcomes. Such exercises stimulate the ankle ligaments and joint capsule, improving motor sensory input and activating gamma motor neurons, thereby aiding motor perception in individuals with CAI(14, 15).

Aquatic-based exercise training has emerged as a promising rehabilitation method due to its unique properties, including buoyancy and hydrostatic pressure, which offer significant advantages over land-based exercises. Buoyancy reduces joint impact, facilitates resistance training, and provides a supportive, nearly weightless environment(16).Hydrostatic pressure enhances joint stability and uniformly resists muscle groups, promoting functional training(1). The aquatic environment also necessitates constant muscle engagement for stabilization, leading to improvements in both strength and balance(16). Additionally, water provides superior sensory feedback, and the controlled environment can alleviate the fear of re-injury, often present during rehabilitation(17, 18).Many patients experience fear of re-injury(4), which can hinder the beneficial effects of rehabilitation(19); however, the aquatic environment can mitigate these fears by providing greater safety. For these reasons, the aquatic environment may be more effective than the land environment for balance training.

Despite the recognized benefits of aquatic training in various musculoskeletal conditions(18, 20, 21), its application in treating CAI remains under-researched. For instance, studies have shown that aquatic exercises can improve mobility, muscle strength, and proprioception in patients with knee osteoarthritis(20) and those recovering from ACL reconstruction(18). However, the specific impact of aquatic training on CAI, particularly in athletes, has not been thoroughly investigated. Therefore, this study aims to compare the effects of land- and water-based balance training programs on functional performance, dynamic balance, fear of reinjury, and quality of life in athletes with CAI. We hypothesize that incorporating an aquatic environment into balance training will significantly enhance these outcomes compared to land-based exercises.

Study design

This study was a single-blinded randomized clinical trial that examined the impact of an 8-week intervention period on performance, balance, and quality of life in participants assigned to either water-based balance exercises (WBBE) or land-based balance exercises (LBBE) groups, with assessments conducted before and after the intervention.

Participants

Based on a previous study indicating a Cohen's d of 0.38 for the Cumberland Ankle Instability Tool (22), a sample size calculation using G*Power software (v.3.1.9.2) determined that 40 participants were needed for a repeated measures analysis of variance with an alpha of 0.05 and power of 0.90. Anticipating a 15% dropout rate as recommended by the International Ankle Consortium(7), 46 participants were enrolled between June 2018 and August 2018 through presentations at local community, public, and university clubs in (blinded).

The study included athletes aged 18 to 55 who had suffered a significant ankle sprain with inflammatory symptoms (e.g., pain and swelling) that led to at least one day of sports time loss within the 12 months before enrollment. Eligible participants had to report at least two episodes of ankle instability (e.g., giving way and recurrent sprains) for more than three months before enrollment and score 24 or below on the CAIT. Exclusion criteria involved positive ligamentous laxity confirmed by physiotherapist-administered anterior drawer and Talar tilt tests, as well as a history of fractures or surgery in either lower extremity within 3 months before enrollment. Other exclusions encompassed participants with muscular, joint, or neurological conditions affecting lower limb function, those currently in ankle rehabilitation programs, and athletes with visual, vestibular, or cognitive deficits, aligning with recommendations from the International Ankle Consortium (7).

Randomization

After baseline testing, participants were randomly assigned to either the WBBE or LBBE group using a closed envelope technique with a 1:1 allocation ratio, while ensuring gender balance through block randomization with block sizes of 2 and 4. These block sizes were chosen to effectively balance small sample sizes and minimize predictability in assignments. To maintain strict allocation concealment, group assignments were kept hidden from investigators, laboratory specialists, and data analysts using sequentially numbered, opaque, tamper-evident sealed envelopes. An independent administrator, uninvolved in other aspects of the study, managed the envelopes, which were only opened after participants completed all baseline assessments, thus preserving the integrity of the study's randomization process.

Baseline measurements

Functional ankle instability was evaluated using the CAIT, a nine-item questionnaire that measures ankle instability during both sports and daily activities. CAIT scores range from 0 to 30, with lower scores indicating greater severity of ankle instability. In this study, a score below 24 was used as the threshold for identifying ankle instability (23).

Kinesiophobia, or fear of movement, was assessed with the Tampa Scale for Kinesiophobia (TSK-17), a 17-item scale where each item is rated on a 4-point Likert scale from “strongly disagree” to “strongly agree.” The total score ranges from 17 to 68, with higher scores reflecting greater levels of kinesiophobia(24).

Quality of life was measured using the Short Form-36 Health Survey (SF-36), which assesses eight health domains split into physical and mental components. The physical component includes physical functioning (10 items), role limitations due to physical problems (4 items), bodily pain (2 items), and general health perception (5 items). The mental component covers vitality (4 items), social functioning (2 items), role limitations due to emotional problems (3 items), and mental health (5 items). The total score ranges from 0 to 100, with higher scores indicating better health status (25).

The Global Rating of Change (GROC) was used to gauge participants' perceived treatment effects. This 15-point scale ranges from "totally worse" to "totally better," with "no change" in the middle. Higher ratings signify improvement, while lower ratings indicate a decline in health (26).

Dynamic postural control was assessed using the Y Balance Test. Participants stood on their injured leg at the center of a grid formed by three tape measures extending at 120° angles. They maintained a one-legged stance with eyes open and hands on hips while extending their non-stance leg to reach the furthest point along each tape measure. Reach distances were standardized based on leg length, measured from hip to ankle. Three trials were conducted in each direction with a 10-second break between trials, and the best result was used for analysis(14).

Functional performance was evaluated using the Figure-8 hop test (F8H) and the single-limb side-hop (SLSH) test. The F8H required participants to hop on their injured leg as quickly as possible through a figure-8 course marked by cones over a 5-meter distance, with total time recorded using a handheld stopwatch. The shortest time was used for the analysis (5). In the SLSH, participants performed 10 lateral hops on their injured leg over a 30-cm distance as quickly as possible(27).

Interventions

Both the aquatic and land groups participated in a balance training program designed to be identical for both groups. This program was adapted from established balance protocols that have been shown to effectively reduce the incidence of ankle sprains, alleviate residual complaints, and improve postural control (14, 15, 22, 28). The included exercises and progression scheme are presented in Table 1, with a more detailed description available in Supplemental File 1. The program required participants to complete 24 sessions over 8 weeks, each lasting 30–45 minutes. Sessions began with a 5-minute warm-up (jogging and jumping jacks) and included stretching exercises. Almost all exercises were performed unilaterally (tested ankle), and progression consisted of variation in arm position, visual control and surface material(14, 28). At the start of the training, participants were briefed on the exercises and given an instruction booklet with detailed guidelines to ensure proper execution of the exercises. For the aquatic training group, exercises were conducted in a pool that accommodated participants of varying heights. The subjects in the WBBE group performed exercises without shoes, while those in the LBBE group wore athletic shoes. Based on participant feedback, exercises were individually adapted for increasing difficulty. If a participant struggled with an exercise and touched the ground three or more times, they repeated the previous level until they succeeded. One investigator supervised both training sessions, and a lifeguard was present during the aquatic sessions for safety. Participants were required to keep a diary to document their compliance and any comments. Participants who missed fewer than 5 sessions (20% of the total) completed the final assessment again following the interventions.

Table 1

Balance program exercise
Group A: Single-Leg Stance Exercise	Group E: Single-Leg Hop Exercise
• Firm Surface, Eyes open, arms extended outward • Firm Surface, Eyes open, arms crossed over chest • Firm Surface, Eyes closed, arms extended outward • Firm Surface, Eyes closed, arms crossed over chest • Foam pad, Eyes open, arms extended outward • Foam pad, Eyes open, arms crossed over chest • Foam pad, Eyes closed, arms extended outward • Foam pad, Eyes closed, arms crossed over chest	• Firm Surface, Eyes open, arms extended outward, 50 cm distance forward • Firm Surface, Eyes open, hands on the pelvis, 50 cm distance forward • Firm Surface, Eyes open, arms extended outward, 30 cm distance sideways Firm Surface, Eyes open, hands on the pelvis, 30 cm distance sideways
Group B: Crossed-Leg Sway Exercise	Group F: Single-Leg Tuck Jump Exercises
• Firm Surface, Eyes open, arms extended outward • Firm Surface, Eyes open, hands on hips • Firm Surface, Eyes closed, arms extended outward • Firm Surface, Eyes closed, hands on hips • Foam pad, Eyes open, arms extended outward • Foam pad, Eyes open, hands on hips • Foam pad, Eyes closed, arms extended outward • Foam pad, Eyes closed, hands on hips	• Firm Surface, Eyes open, arms extended outward
	Group G: Throw/Catch a Ball Exercises
	• Firm Surface, Eyes open, Unilateral • Foam Pad, Eyes open, Unilateral
Group C: Single-Leg Squat Exercise	Group H: Modified Y Balance Exercise
• Firm Surface, Eyes open, arms extended outward • Firm Surface, Eyes open, hands on hips • Firm Surface, Eyes closed, arms extended outward • Firm Surface, Eyes closed, hands on hips • Foam pad, Eyes open, arms extended outward • Foam pad, Eyes open, hands on hips • Foam pad, Eyes closed, arms extended outward • Foam pad, Eyes closed, hands on hips	• Firm Surface, Eyes open, arms extended outward, in all directions • Firm Surface, Eyes open, hands on the pelvis, in all directions • Foam Pad, Eyes open, arms extended outward, in all directions • Foam Pad, Eyes open, hands on the pelvis, in all directions
Group D: Heel Raise Exercise	Group I: 3-Way Single-leg Romanian Deadlift Exercises
• Firm Surface, Eyes open, bilateral • Foam pad, Eyes open, bilateral • Firm Surface, Eyes open, unilateral • Foam pad, Eyes open, unilateral	• Firm Surface, Eyes open, arms extended outward, in all directions

(Table 1 about here)

Statistical analyses

The researchers employed SPSS statistical software version 22 (IBM, Armonk, New York) for data analysis, presenting results using mean with standard deviation, frequency with percentages, and mean differences with 95% confidence intervals. Normality and variance homogeneity were assessed using the Shapiro-Wilk test and Levene's test, respectively. To evaluate the effects of LBBE versus WBBE on dependent variables, separate 2 × 2 mixed-model ANOVAs were conducted, with groups (land-based and water-based exercises) and time (baseline and posttest) as factors. Post hoc tests were conducted as needed, maintaining a significance level of 0.05 for all analyses.

A total of 46 athletes with CAI participated in the study, with 23 assigned to the WBBE group and 23 to the LBBE group (Table 2). Five participants were excluded due to missing more than three training sessions, illness, or family issues—two from the WBBE group and three from the LBBE group. Both groups demonstrated high adherence rates, with an overall attendance of 98% (approximately 99% for the WBBE group and 97% for the LBBE group). Ultimately, 41 participants completed the study and were included in the final statistical analysis.

Table 2

Demographics and Clinical Characteristics of Participants by Groups
Variables	WBBE Group (n = 22)	LBBE Group (n = 21)	t-value	p-value
Gender (men/ women)	12 / 10	11 / 10	-	-
Age (years)	32.9 ± 9.6	29.7 ± 8.9	1.1	0.3
Weight (kg)	78.9 ± 18.4	79.5 ± 10.9	0.13	0.9
Height (cm)	174.9 ± 8.2	176.0 ± 8.6	0.6	0.5
Body Mass Index (kg/m²)	25.6 ± 4.8	25.7 ± 4.5	0.1	0.9
Affected Side (left/right/bilateral)	5 / 14 / 3	4 / 15 / 2	-	-
Target Side (dominant/nondominant)	16 / 6	14 / 7	-	-
Injury History (months)	8.2 ± 1.7	8.8 ± 2.0	1.00	0.30
Time Since First Sprain (years)	1.7 ± 1.1	1.9 ± 1.1	0.46	0.65
Time Since Last Sprain (months)	6.2 ± 2.2	6.9 ± 2.5	0.84	0.40
Data are presented as mean ± standard deviation (mean ± SD) or frequency.

(table 2 about here)

The repeated-measures ANOVA did not reveal significant time × group interaction effects for CAIT scores (p < 0.05), indicating that the WBBE group did not improve CAIT scores more than the LBBE group at the post-test. Over the 8-week study period, CAIT scores increased by 27.94% in the WBBE group and 26.25% in the LBBE group (Table 3, Fig. 1).

Similarly, no significant time × group interaction effect was found for kinesiophobia scores (p < 0.05), suggesting that the WBBE group did not show greater reductions in kinesiophobia than the LBBE group at the post-test. During the study period, kinesiophobia scores decreased by 13% in the WBBE group and 8.6% in the LBBE group (Table 3, Fig. 1).

The study did find significant time × group interaction effects for overall Quality of Life (QoL) (p = 0.001) and the Physical QoL Component (p = 0.01), but not for the Psychological QoL Component (p = 0.06). The WBBE group demonstrated the greatest improvements in overall QoL and the Physical QoL Component, though it did not have a significant advantage in the Psychological QoL Component compared to the LBBE group. Specifically, the LBBE group saw a 9.76% increase in overall QoL, with a 6.43% improvement in the Physical QoL Component and 13.04% in the Psychological QoL Component. In contrast, the WBBE group exhibited greater increases: an 18.21% improvement in overall QoL, 17.37% in the Physical QoL Component, and 18.97% in the Psychological QoL Component (Table 3, Fig. 1).

The ANOVA also did not reveal significant interaction effects for the YBT composite score (p = 0.16) or its reach components: anterior (p = 0.14), posteromedial (PM) (p = 0.12), and posterolateral (PL) (p = 0.7). These results suggest that the WBBE group did not achieve significantly greater improvements in dynamic balance compared to the LBBE group. The LBBE group increased their composite score by 9.2%, with specific gains of 4.7% in the anterior, 11.1% in the PM, and 10.2% in the PL reaches. In comparison, the WBBE group’s reach distances increased by 7.4% for the composite score, 3.0% for the anterior, 8.2% for the PM, and 9.9% for the PL reach (Table 3, Fig. 1).

However, the study did find a significant improvement in the Lateral Hopping score (p = 0.04) and figure-of-8 hop score (p = 0.02) for the WBBE group compared to the LBBE group. Over the 8 weeks, the LBBE group showed greater improvements in both tests, with time scores decreasing by 10.8% in Lateral Hopping and 10.4% in the figure-of-8 hop, compared to smaller reductions of 7.4% and 7.8% in the WBBE group, respectively. These reductions indicate time improvements in both groups from the pre-test to the post-test (Table 3, Fig. 1).

Table 3

Repeated Measure ANOVA Results for Ankle Instability, Fear of Movement, Functional Performance, and Dynamic Postural Control
Variables	Time	WBBE group (n = 22)	LBBE group (n = 21)	Between-group difference Mean (95%CI)	Group effects		Time effects		Group × Time effects
Variables	Time	WBBE group (n = 22)	LBBE group (n = 21)	Between-group difference Mean (95%CI)	F	p	f	p	f	P
Functional ankle instability (0 to 30)	Pretest	18.2 ± 3.5	16.9 ± 4.8	1.3 (-1.4 to 3.9)	0.67	0.42	81.1	< 0.001	0.33	0.57
Functional ankle instability (0 to 30)	Postets	23.3 ± 3.0	21.4 ± 4.5	1.9 (-0.5 to 4.3)	0.67	0.42	81.1	< 0.001	0.33	0.57
Fear of movement (17 to 68)	Pretest	36.1 ± 3.0	35.9 ± 3.5	0.3 (-1.7 to 2.4)	0.61	0.4	68.5	< 0.001	1.4	0.2
Fear of movement (17 to 68)	Postets	29.3 ± 3.9	30.8 ± 3.1	-1.5 (-3.7 to 0.8)	0.61	0.4	68.5	< 0.001	1.4	0.2
Quality of life
Physical component score (0-100)	Pretest	63.9 ± 13.9	66.4 ± 14.4	-2.5 (-11.5 to 6.4)	0.05	0.8	45.6	< 0.001	9.0	0.01*
Physical component score (0-100)	Postets	75.0 ± 12.5	70.7 ± 12.7	4.3 (-3.7 to 12.3)	0.05	0.8	45.6	< 0.001	9.0	0.01*
Mental component score (0-100)	Pretest	66.9 ± 10.8	67.1 ± 12.7	-0.2 (-7.6 to 7.3)	3.0	0.6	116.1	< 0.001	3.9	0.06
Mental component score (0-100)	Postets	79.6 ± 9.2	75.9 ± 9.3	3.8 (-2.1 to 9.7)	3.0	0.6	116.1	< 0.001	3.9	0.06
Total score (0-100)	Pretest	65.4 ± 9.4	66.8 ± 10.2	-1.4 (-7.5 to 4.8)	0.3	0.6	140.0	< 0.001	12.0	< 0.001*
Total score (0-100)	Postets	77.3 ± 8.5	73.3 ± 7.7	4.1 (-1.1 to 9.2)	0.3	0.6	140.0	< 0.001	12.0	< 0.001*
Functional performance
Figure-of-8 hop (S)	Pretest	16.6 ± 3.1	16.3 ± 2.6	0.4 (-1.4 to 2.2)	0.5	0.5	268.2	< 0.001	5.9	0.02*
Figure-of-8 hop (S)	Postets	15.4 ± 2.8	14.6 ± 2.4	0.8 (-0.8 to 2.5)	0.5	0.5	268.2	< 0.001	5.9	0.02*
Lateral Hopping (S)	Pretest	16.9 ± 3.0	17.1 ± 2.9	-0.26 (-2.1 to 1.6)	0.02	0.9	107.2	< 0.001	4.2	0.04*
Lateral Hopping (S)	Postets	15.6 ± 2.7	15.3 ± 2.6	0.34 (-1.3 to 2.0)	0.02	0.9	107.2	< 0.001	4.2	0.04*
Dynamic postural control
Anterior reach (% LL)	Pretest	67.2 ± 6.6	65.9 ± 6.5	0.7 (-3.5 to 4.9)	0.06	0.8	93.9	< 0.001	2.3	0.14
Anterior reach (% LL)	Postets	70.3 ± 6.9	70.8 ± 7.6	-0.6 (-5.1 to 3.9)	0.06	0.8	93.9	< 0.001	2.3	0.14
PM reach (% LL)	Pretest	97.5 ± 7.2	96.3 ± 5.6	1.2 (-2.9 to 5.3)	0.05	0.8	109.0	< 0.001	2.1	0.12
PM reach (% LL)	Postets	105.6 ± 5.5	107.0 ± 6.4	-1.4 (-5.0 to 2.4)	0.05	0.8	109.0	< 0.001	2.1	0.12
PL reach (% LL)	Pretest	89.3 ± 5.7	92.6 ± 8.4	-3.3 (-8.4 to 0.3)	3.0	0.09	160.1	< 0.001	0.20	0.6
PL reach (% LL)	Postets	98.1 ± 6.8	102.1 ± 7.0	-4.0 (-8.4 to 1.8)	3.0	0.09	160.1	< 0.001	0.20	0.6
Composite score (%LL)	Pretest	84.5 ± 4.6	84.9 ± 3.6	-3.3 (-7.9 to 1.3)	1.0	0.3	319.2	< 0.001	3.4	0.07
Composite score (%LL)	Postets	90.8 ± 4.5	92.7 ± 3.5	-4.0 (-8.4 to 0.4)	1.0	0.3	319.2	< 0.001	3.4	0.07
Data are presented as mean ± standard deviation (mean ± SD) or frequency. Abbreviations; WBBE; water-based balance exercises, LBBE; land-based balance exercises. *Significant between group changes, #significant within-group changes.

(Table 3 about here) (Fig. 1 about here)

The study found that athletes with CAI experienced significant improvements in ankle stability, fear of movement, quality of life, dynamic balance, and functional performance following either WBBE or LBBE). The moderate to large effect sizes from the pretest to the posttest indicate that both interventions led to clinically meaningful changes. Although no significant differences were observed between WBBE and LBBE regarding ankle stability, fear of movement, psychological QoL, or dynamic balance, the LBBE group demonstrated notable improvements in functional performance tests such as the Figure-of-8 hop and lateral hopping, while the WBBE group showed better outcomes in overall and physical QoL. This suggests that both modalities are effective but may offer distinct advantages for different outcomes.

Contrary to our study's findings, Sadaak, AbdElMageed (29) reported that a four-week aquatic therapy program significantly outperformed traditional physiotherapy for elite athletes with Grade III ankle sprains, leading to faster recovery, improved pain management, enhanced dynamic balance, and better overall athletic performance. Athletes in the aquatic therapy group returned to sports nearly three weeks earlier than those undergoing land-based exercises, indicating a shift towards functional, exercise-based rehabilitation over conventional immobilization. In contrast, Kim, Kim (30) found that both aquatic and land-based exercises produced similar reductions in pain and improvements in static and dynamic stability for elite athletes with Grade I or II ankle sprains. This lack of significant difference supports our observation that while each exercise type has distinct advantages, neither consistently surpasses the other across all outcomes. These studies underscore that the relative effectiveness of aquatic versus land-based exercises can vary based on injury type, severity, and specific outcomes measured. For instance, Roth, Miller (21) noted that both land-based and water-based exercises are effective for static and dynamic balance in healthy individuals. Our study aligns with this by showing that each exercise environment offers unique benefits specific to different aspects of physical and functional performance.

Performing balance exercises in water and on land offers unique advantages due to the distinct properties of each environment, resulting in different impacts on quality of life and functional performance for individuals with ankle instability. Water-based exercises use buoyancy to reduce joint stress, making movements easier and enhancing comfort while also promoting muscle strengthening and proprioceptive training with minimal injury risk. This low-impact setting leads to improved physical health and higher scores in both overall and physical quality of life. Conversely, land-based exercises provide greater specificity and variability by closely mimicking real-life movements, thereby enhancing skills related to hopping and lateral movements crucial for daily activities and sports. Consequently, while water-based exercises mainly improve quality of life, land-based training more effectively boosts functional performance.

The CAIT is specifically designed to assess the subjective symptoms of CAI. (23) Given that CAI lacks an objective criterion standard test, such as a positive MRI, patient-reported questionnaires like the CAIT are crucial for accurately quantifying the severity and impact of this condition on individuals. (3, 23) The International Ankle Consortium endorses the CAIT for use in (CAI) research, where it serves as an inclusion criterion, a descriptive tool, and a patient-reported outcome measure(7). A score increase of ≥ 3 points on the CAIT has been established as the minimum threshold for clinically meaningful improvement. (31) In our study, the LBBE group showed a 27.94% improvement (5.1 points), and the WBBE group exhibited a 26.25% improvement (4.5 points), both exceeding this threshold. These improvements are comparable to those reported in previous studies, such as a 5.1-point increase after 6 weeks of strength training and a 4.2-point increase following a 6-week balance training program. (32) Similarly, Cain, Ban (33) reported a 4.42-point increase in CAIT scores for participants undergoing resistance band training and a 5.8-point increase for those using a BAPS board training program.

Kinesiophobia, an exaggerated fear of movement and anticipation of pain, can significantly impair an athlete's strength, postural control, and movement patterns, increasing the risk of re-injury. (34) This condition is especially prevalent in individuals with CAI, who tend to exhibit higher levels of kinesiophobia than healthy individuals, negatively impacting their muscles, proprioception, and postural control. (24) In our study, both LBBE and WBBE groups showed significant within-group reductions in kinesiophobia, with scores decreasing by 18.9% in the WBBE group and 14.2% in the LBBE group. The minimal detectable change (MDC) for TSK-17 in individuals with musculoskeletal pain is 13%,(34) meaning that any reduction beyond this threshold reflects a meaningful decrease in kinesiophobia for the study participants. Consistent with our study, other research has demonstrated that six weeks of strength and balance training can effectively reduce TSK scores by 7.8% and 15.8%, respectively. (32) Although there was no significant difference between the two groups in reducing kinesiophobia, the results suggest that both types of balance training are effective. This highlights the importance of balance training, particularly in enhancing balance, in mitigating the fear of movement associated with FAI.

CAI is associated with reduced health-related quality of life (HRQOL), as evidenced by lower scores on the Short Form-36 (SF-36)(9, 10). Using multidimensional HRQOL tools like the SF-36 helps clinicians better incorporate patient perspectives into rehabilitation and outcome evaluations.(11) Specifically, in our study, the LBBE group saw a 9.76% increase in overall QoL, with a 6.43% improvement in the Physical QoL Component and 13.04% in the Psychological QoL Component. In contrast, the WBBE group exhibited greater increases: an 18.21% improvement in overall QoL, 17.37% in the Physical QoL Component, and 18.97% in the Psychological QoL Component.

Functional performance tests are dynamic evaluations used to assess overall lower body function, incorporating key components such as muscular strength, neuromuscular coordination, and joint stability, all of which can be impacted by joint injuries.(5, 8) These tests, including hopping tasks, are cost-effective, easy to administer, and valuable for tracking patient progress in both clinical and field settings.(8) Over 8 weeks, the LBBE group demonstrated greater improvements compared to the WBBE group, with reductions of 10.8% (1.85 seconds) in Lateral Hopping time and 10.4% (1.69 seconds) in Figure-of-8 Hop time, versus 7.4% (1.25 seconds) and 7.8% (1.26 seconds) reductions in the WBBE group, respectively. Both intervention groups exceeded the proposed MDC scores for the side-hop (0.97 seconds) and Figure-of-8 hop tests (0.98 seconds) (33). Previous studies also highlight the effectiveness of such training (32, 33). Park, Oh (32) reported that 6 weeks of strength and balance training reduced Lateral Hopping time by up to 1.3 seconds and Figure-of-8 hop test time by up to 1.0 seconds, while another study (27) found that 4 weeks of Resistance Band training resulted in reductions of 1.13 seconds in Lateral Hopping time and 0.77 seconds in Figure-of-8 hop test time (33).

Individuals with CAI experience balance deficits due to a compromised sensorimotor system, which limits their ability to quickly adapt to external forces(6). This condition, though originating from a ligament injury, leads to broader systemic changes that slow the neuromuscular system's response, increasing susceptibility to instability. In our study, both intervention groups surpassed the MDC scores proposed by Cain, Ban (33) for medial (5.05%), posteromedial (6.58%), and posterolateral (7.04%) reach directions. The LBBE group achieved a 9.2% increase in the composite score, with improvements of 4.7% in the anterior reach, 11.1% in the posteromedial reach, and 10.2% in the posterolateral reach, while the WBBE group showed a 7.4% increase in the composite score, with 3% in the anterior reach, 8.2% in the posteromedial reach, and 9.9% in the posterolateral reach. In line with our study, Cain, Ban (33) reported that participants in the resistance band training group experienced substantial increases in reach distances, with 14.1% in the anterior direction, 15.2% in the posteromedial (PM) direction, and 15.2% in the posterolateral (PL) direction and the BAPS board training group showed more modest improvements, with increases of 1.0% in the anterior reach, 10.0% in the PM reach, and 9.5% in the PL reach.

Strength and limitations

When interpreting the results of this study, several limitations must be considered. The focus on athletes may limit the generalizability of the findings to the broader population with CAI. Potential confounding factors, a short follow-up duration, and reliance on self-reported outcomes could introduce measurement bias and impact result accuracy and generalizability. Future research should investigate the long-term effects of aquatic therapy on functional outcomes, such as preventing recurrent sprains, and explore the benefits of combining aquatic therapy with other interventions, like neuromuscular training. Additionally, further studies are needed to evaluate the duration of balance improvements post-training. Addressing sample size and cultural factors is crucial for enhancing the validity and applicability of study findings. Participant blinding was not feasible due to the study's design, which may have led to biased outcome assessments. Ethical concerns about withholding therapeutic interventions led to the exclusion of a control group, limiting comparisons between water-based and land-based balance exercises against rest. As a result, the effects of different exercise environments on ankle stability, fear of movement, psychological quality of life, and dynamic balance remain speculative, and no definitive conclusions can be drawn about the superiority of water-based versus land-based balance exercises compared to rest.

Practical implications

The study's findings offer valuable insights for tailoring rehabilitation strategies for CAI. Both water-based and land-based balance exercises demonstrate effectiveness in improving ankle stability, fear of movement, quality of life, and functional performance. Clinicians can use this information to design personalized rehabilitation programs that align with individual patient goals—whether it's enhancing overall quality of life or focusing on functional performance. Water-based exercises can be particularly beneficial for reducing joint stress and boosting quality of life, while land-based exercises might be more effective for improving specific functional skills. Additionally, addressing kinesiophobia through these exercise modalities can significantly support recovery and prevent re-injury. Overall, incorporating these findings into practice can help optimize rehabilitation outcomes and ensure a comprehensive approach to managing CAI.

The study concludes that both water-based and land-based balance exercises effectively enhance ankle stability, fear of movement, quality of life, dynamic balance, and functional performance in individuals with CAI. Although no significant differences were found between the two modalities regarding ankle stability, psychological QoL, or dynamic balance, each type of exercise offered distinct benefits: land-based exercises led to greater improvements in functional performance, while water-based exercises provided more substantial enhancements in overall and physical QoL. These findings indicate that either exercise type can be advantageous depending on the specific outcomes desired. The study highlights the value of a flexible, individualized rehabilitation approach and emphasizes the importance of including balance training—whether land-based or water-based—in CAI rehabilitation programs to address kinesiophobia and optimize recovery outcomes.

Acknowledgments:

The authors would like to thank all the participants who contributed to this study.

Authors’ Contributions:

AN and KA conceptualized the original idea and designed the study. KA conducted the literature review and data collection. AN handled data analysis, interpretation, and statistical analysis. KA drafted the manuscript and AN reviewed and edited it.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of Data and Materials:

The data supporting the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy concerns related to the research participants.

Competing Interests:

The authors declare no conflicts of interest regarding the research, authorship, or publication of this article.

Ethics Approval and Consent to Participate:

This study adhered to all ethical principles, ensuring that all participants provided informed consent and were fully informed about the research's purpose and procedures. Participants were assured of the confidentiality of their information and had the option to withdraw from the study at any time. They were also given the opportunity to access the research results if desired. The study received approval from the (Blinded) and was registered with the (Blinded). The authors followed the principles outlined in the Declaration of Helsinki.

Consent for Publication:

Not applicable.

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No competing interests reported.

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Comparative Analysis of Land-Based vs. Water-Based Balance Training on Quality of Life and Physical and Psychological Deficits in Athletes with Chronic Ankle Instability: A Randomized Controlled Trial Assessing the Influence of Exercise Environment

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