title: Extrinsic visual feedback and additional cognitive/physical demands affect single-limb balance control in individuals with ankle instability.
abstract: OBJECTIVE
  To investigate the impact of extrinsic visual feedback and additional cognitive/physical demands on single-limb balance in individuals with ankle instability.
  
  
  METHODS
  Sixteen subjects with ankle instability participated in the study. Ankle instability was identified using the Cumberland Ankle Instability Tool (CAIT). The subject's unstable ankle was examined using the Athletic Single Leg Stability Test of the Biodex Balance System with 4 different protocols: (1) default setting with extrinsic visual feedback from the monitor; (2) no extrinsic visual feedback; (3) no extrinsic visual feedback with cognitive demands; and (4) no extrinsic visual feedback with physical demands. For the protocol with added cognitive demands, subjects were asked to continue subtracting 7 from a given number while performing the same test without extrinsic visual feedback. For the protocol with added physical demands, subjects were asked to pass and catch a basketball to and from the examiner while performing the same modified test.
  
  
  RESULTS
  The subject's single-limb postural control varied significantly among different testing protocols (F = 103;P= 0.000). Subjects' postural control was the worst with added physical demands and the best with the default condition with extrinsic visual feedback. Pairwise comparison shows subjects performed significantly worse in all modified protocols (P< 0.01 in all comparisons) compared to the default protocol. Results from all 4 protocols are significantly different from each other (P< 0.01) except for the comparison between the "no extrinsic visual feedback" and "no extrinsic visual feedback with cognitive demands" protocols. Comparing conditions without extrinsic visual feedback, adding a cognitive demand did not significantly compromise single-limb balance control but adding a physical demand did. Scores from the default protocol are significantly correlated with the results from all 3 modified protocols: No extrinsic visual feedback (r = 0.782;P= 0.000); no extrinsic visual feedback with cognitive demands (r = 0.569;P= 0.022); no extrinsic visual feedback with physical demands (r = 0.683;P= 0.004). However, the CAIT score is not significantly correlated with the single-limb balance control from any of the 4 protocols: Default with extrinsic visual feedback (r = -0.210;P= 0.434); no extrinsic visual feedback (r = -0.450;P= 0.081); no extrinsic visual feedback with cognitive demands (r = -0.406;P= 0.118); no extrinsic visual feedback with physical demands (r = -0.351;P= 0.182).
  
  
  CONCLUSIONS
  Single-limb balance control is worse without extrinsic visual feedback and/or with cognitive/physical demands. The balance test may not be a valid tool to examine ankle instability.
authors.affiliation: You-jou Hung, Jacob Miller, Department of Physical Therapy, Angelo State University, San Angelo, TX 76909, United States.
authors.forename: You-Jou
authors.initials: YJ
authors.lastname: Hung
authors.affiliation: You-jou Hung, Jacob Miller, Department of Physical Therapy, Angelo State University, San Angelo, TX 76909, United States.
authors.forename: Jacob
authors.initials: J
authors.lastname: Miller
keywords: Ankle; Balance; Instability; Motor control; Rehabilitation