Perceptual-Interdependence Framework In Ankle Rehabilitation

Original Editor - Ewa Jaraczewska based on the course by Helene Simpson

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson  

Introduction[edit | edit source]

The current approach to rehabilitation for ankle sprains does not reflect the progress made in research on chronic ankle instability (CAI).[1] This progress revolves around a biopsychosocial model of function, disability, and health, integration of perception and the dynamics of skills acquisition.[2] Inadequate approaches in ankle rehabilitation,[2] lack of consensus on the management of sprains,[3] and a misunderstanding of the severity of this type of injury[1] are some factors that impact recovery and outcomes in rehabilitation post-ankle injury. According to Lin et al.,[4] 46% of individuals with a history of ankle sprain develop chronic ankle instability.

CAI causes multiple physical complications outside the ankle joint. It can affect an individual's range of motion, balance, movement pattern, proprioception, and muscle strength.[4] These impairments can limit a person's activity and participation and are associated with perceptual-interdependence alterations.[2] It has, therefore, become essential to base the model of ankle rehabilitation on the perceptual-interdependence framework to successfully improve a patient's function, reduce disability, and prevent complications associated with CAI.[2]

Biopsychosocial Model of Health

Biopsychosocial Model of Functioning[edit | edit source]

George Engel is the father of the biopsychosocial model, which has been described in the literature as a biopsychosocial model of illness,[5] biopsychosocial model of disability,[2] or a biopsychosocial model of functioning.[6] It is an approach to illness, disability or functioning in which mind, body, and social environment are all integrated and influence the outcome.[7] The biopsychosocial model was developed in response to a biomedical model which failed to recognise the social, psychological and behavioural dimensions of illness.[5]

The biopsychosocial model does not replace the biomedical model. Instead, it completes it. In addition to the disease (bio), it adds behaviour (psycho) and environment (social) to build a complete model of healthcare.[5] This model is focused on persons with life experiences and expectations who have acquired an illness which has not separated them from the physical environment in which they live, work and function, and which influences their choices and decisions. For example, according to the biopsychosocial model in chronic pain conditions, the pain originates from the nociceptive or neuropathic physiologic stimulus and is regulated by the patient's psychological and socioeconomic situation.[8] The following strategies must be incorporated to successfully manage it:[8]

  • Empowering the patient to manage pain
  • Improving pain-coping resources
  • Reducing disability
  • Incorporating self-regulatory, behavioural, and cognitive techniques

There are many benefits to using the biopsychosocial model:

  • According to Smith et al.,[9] it leads to person-centred care
  • Weiner et al.[10] state that it improves patient outcomes
  • Buchbinder et al.[11] suggest that using the biopsychosocial model is a way to address social attitudes. Changes in social attitudes might positively affect illness in patients
  • Kamer et al.[12] show its effectiveness in the management of chronic low back pain.
ICF model

International Classification of Functioning (ICF)[edit | edit source]

The biopsychosocial model became the basis for the International Classification of Functioning (ICF) introduced by the World Health Organization (WHO). According to this classification system, the disease or illness must be recognised and managed based on the assessment of the biological, psychological, and social factors.[5]

In the biomedical model, when looking at a person with a sprained ankle, one thinks about range of motion, strength, or gait impairments. This picture could describe any person with a sprained ankle. In the biopsychological model, this individual lives on the second floor without an elevator and his need to negotiate stairs will be different from another patient who lives on the ground floor and has no steps. A physiotherapist will be expected to further assess this person's family support and access to other health resources when, for example, a brace or walking device are prescribed. In the biopsychosocial approach, every person is unique when it comes to their needs and wants.

Perceptual-Interdependence[edit | edit source]

In 1965, a new model of ankle rehabilitation was introduced thanks to the work of Freeman and his colleagues,[1] and Nagi.[13] In the 1965 paper by Freeman et al.,[14] the term "functional instability of the foot" was used to describe a patient's perception of the ankle which "gives away".[2] It offered a framework for the treatment of the ankle that included coordination exercises and started a paradigm shift in the treatment of ankle injury.

Nagi proposed the term "active pathology", which defines the body's defensive and coping mechanisms and leads to impairments. The consequence of these mechanisms is the presence of impairments even when the injury is healed.[2] According to Nagi, impairments cause functional limitations which affect a person's ability to fulfil their personal and social roles. He further stated that these limitations are affected by the patient's perception of the injury, which is the end effect of the reactions and expectations of this person's stakeholders (family, friends, coworkers, neighbours, etc). Based on Nagi's concept, the disability must be recognised in the context of the individual's perception and the perception of the society to which they belong.[2]

"In the biopsychosocial model (.....) disability was the culmination of actual and perceived impairments and functional limitations due to the perceptions of the patient and society".[2]

Perceptual-Interdependence Framework Post-Ankle Sprain Rehabilitation[edit | edit source]

The current model for chronic ankle instability recognises that pathomechanics, sensation and a patient's behaviour have neurologic consequences and influence this person's perception and action. However, current treatment protocols do not always use this model to generate optimal outcomes following an ankle sprain.[2]

In a new rehabilitation paradigm, cell, tissue, body, self and society are interdependent.

Cell-Tissue[edit | edit source]

An example of cell-tissue connection is mechanotransduction, which defines a cell's ability to convert mechanical stimuli into biochemical signals. This ability results in intracellular changes, including cell proliferation and differentiation. Constant interaction between the cell and the extracellular matrix (ECM) occurs during tissue development and as a result of tissue ageing or tissue injury. In the case of tissue injury, the changes in the ECM can lead to tissue stiffness. A treatment protocol focusing on limiting joint immobilisation can decrease tissue stiffness.[15]

Goals: pain reduction, restoring the integrity of damaged structures, inflammation control.

Tissue-Body[edit | edit source]

A tissue-body connection can be defined by the perception of the body tissue in relation to body movement.[2] In ankle rehabilitation, it combines appropriate loading, which initiates mechanotransduction, with sensory information received from the skin, joint and surrounding muscles through joint mobilisation, plantar massage, stretching and progressive resistive exercises.[2]

Goals: improve range of motion, increase strength, facilitate neuromuscular control, and improve gait mechanics.

Body-Self[edit | edit source]

Self-efficacy, control, and resiliency achieved through the integration of body parts with cognitive and emotional perception characterise a body-self connection.[2] In the treatment post-ankle injury, it is achieved by early coordination training. This training progresses from simple to complex tasks, and is performed in a predictable environment first before moving into an unpredictable environment.[2]

Goal: return to sport-specific or daily living-specific activities.

Self-Society[edit | edit source]

The self-society connection is defined as a self-perception in the context of others. It is measured by an individual's integration into society and the roles they fulfil there. Prognostic timelines, expectations, and progressions in return to full activities are issues which must be addressed in the rehabilitation programme after an ankle injury.[2]

Goal: return to sports participation, return to participation in activities of daily living.

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 Simpson H. Paradigm Shift in Rehabilitation of the Ankle. Physiopedia Course, 2022.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 McKeon PO, Donovan L. A Perceptual Framework for Conservative Treatment and Rehabilitation of Ankle Sprains: An Evidence-Based Paradigm Shift. J Athl Train. 2019 Jun;54(6):628-638.
  3. Wever GS, McCollum GA. The management of acute lateral ankle sprains: a survey of South African surgeons and best evidence available. SA Orthopaedic Journal, 2018;17: 35-39.
  4. 4.0 4.1 Lin CI, Houtenbos S, Lu YH, Mayer F, Wippert P-A. The epidemiology of chronic ankle instability with perceived ankle instability- a systematic review. J Foot Ankle Res 2021; 14(41).
  5. 5.0 5.1 5.2 5.3 Wade DT, Halligan PW. The biopsychosocial model of illness: a model whose time has come. Clin Rehabil. 2017 Aug;31(8):995-1004.
  6. Rojas M, Barrios M, Gómez-Benito J, Mikheenkova N, Mosolov S. Functioning Problems in Persons with Schizophrenia in the Russian Context. Int J Environ Res Public Health. 2021 Sep 29;18(19):10276.
  7. Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care. 2018 May-Jun;7(3):497-500.
  8. 8.0 8.1 Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007 Jul;133(4):581-624.
  9. Smith RC, Fortin AH, Dwamena F, Frankel RM. An evidence-based patient-centred method makes the biopsychosocial model scientific. Patient Educ Couns. 2013 Jun;91(3):265-70.
  10. Weiner SJ, Schwartz A, Sharma G, Binns-Calvey A, Ashley N, Kelly B, Dayal A, Patel S, Weaver FM, Harris I. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013 Apr 16;158(8):573-9.
  11. Buchbinder R, Jolley D, Wyatt M. Population-based intervention to change back pain beliefs and disability: three-part evaluation. BMJ. 2001 Jun 23;322(7301):1516-20.
  12. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev. 2014 Sep 2;(9):CD000963.
  13. Nagi SZ. Some conceptual issues in disability and rehabilitation. In: Sussman M, editor. Sociology and Rehabilitation. Washington, DC: American Sociological Society; 1965. p. 100.
  14. Freeman MA. Treatment of ruptures of the lateral ligament of the ankle. J Bone Joint Surg Br. 1965 Nov;47(4):661-8
  15. Huber AK, Patel N, Pagani CA, Marini S, Padmanabhan KR, Matera DL, Said M, Hwang C, Hsu GC, Poli AA, Strong AL, Visser ND, Greenstein JA, Nelson R, Li S, Longaker MT, Tang Y, Weiss SJ, Baker BM, James AW, Levi B. Immobilization after injury alters extracellular matrix and stem cell fate. J Clin Invest. 2020 Oct 1;130(10):5444-5460.