Author ORCID Identifier

Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Health Sciences


Rehabilitation Sciences

First Advisor

Dr. Arthur J. Nitz

Second Advisor

Dr. Matthew C. Hoch


Ankle sprains are generally considered innocuous injuries; however, as many as 74% of patients will develop chronic symptoms. 1-3 Chronic ankle instability (CAI) is defined by a history of ankle sprain accompanied by ongoing bouts of giving way, residual ankle sprain symptoms, and a decrease in patient-perceived function. As understanding of sensorimotor deficits in individuals with CAI have advanced, treatment strategies have evolved to include a robust focus on balance training to mitigate dynamic and static postural control impairments exhibited in individuals with CAI. A problem arises as these improvements have not been conclusively linked to a decrease in CAI. Additionally, acknowledging the need for improved feed-forward postural control and the associated deficits in peripheral mechanoreceptors, treatments that directly affect peripheral receptors are lacking in current practices. Dry needling (DN) is a neurophysiological treatment tool that directly affects the neurophysiology of muscle, thereby likely affecting local muscle spindle receptors and feed forward postural control mechanisms. Currently, the effect of DN in the lower extremity on clinical and neurophysiologic components of balance is unknown.

The long-term goal of this line of research is to improve health outcomes for individuals suffering a lateral ankle sprain. The first step toward this aim is understanding the neurophysiologic and sensorimotor effects of DN in both healthy individuals and those with CAI. Secondly, the appropriate dosage of DN treatment is currently unknown. Finally, identifying patient factors that may predict success with this treatment is clinically relevant and currently lacking. We hypothesized that 1) individuals with CAI would demonstrate larger immediate improvements in postural control compared to healthy controls 2) weekly, cumulative DN would demonstrate greater improvements in postural control and proprioception when compared to a single treatment and 3) baseline patient factors exist that predict individuals with CAI that will respond to DN treatment.

The results of our first study illustrated that individuals with CAI indeed do have larger immediate improvements in postural control than healthy controls after a single DN treatment. While both groups demonstrated within group improvements in static and dynamic balance, individuals with CAI demonstrated greater improvements in dynamic balance measured with the Star Excursion Balance Test (SEBT). In our second study, weekly DN treatment produced immediate, but not greater improvements with cumulative treatments in dynamic postural control and inversion kinesthesia sense. However, cumulative treatments did produce improvements in eversion kinesthesia sense and static postural control in the mediolateral direction with eyes open, but with small to moderate effect sizes. In our final study, the Global Rating of Change (GROC) scale, a patient-oriented measure of overall improvement in symptoms, and the reach distance in the posteromedial direction of the SEBT as a clinician-oriented measure, were separately used to predict responders to DN treatment. Using the GROC, treatment expectation was found to be the single best predictor of treatment response. However, if the posteromedial direction of the SEBT was used to determine responders to DN treatment, both treatment expectation and a score ≥23.5 on the Identification of Functional Ankle Instability scale were found to be predictive of positive treatment response.

In conclusion, DN individuals with CAI has demonstrated immediate improvement in dynamic postural control and proprioception, more than healthy controls. However, this improvement is not significantly augmented by subsequent treatments. Finally, baseline patient factors exist to predict responders to DN treatments. Factors predicting response to treatment differ based on patient or clinician-oriented determinants of treatment response to DN. These results are of an exploratory nature and thus should be interpreted with caution. Additional research is necessary to further elucidate aspects of this work, specifically response to various dosages to DN treatment, patient response when combining DN treatment with other rehabilitation treatments, baseline predictive factors and mechanistic explanations for improvements in postural control.

Digital Object Identifier (DOI)

Funding Information

Rehabilitation Sciences Doctoral Program Pilot Funding April 2018

Retired Army Medical Specialist Corps Endowment Fund April 2018