Chinese Journal of Tissue Engineering Research ›› 2023, Vol. 27 ›› Issue (18): 2943-2952.doi: 10.12307/2023.341
Proprioception characteristics of functional ankle instability: a meta-analysis
Wu Yihan1, Wei Qiaoye2, Pang Yu1, Liu Zhongqiang1
- 1School of Physical Education, Southwest Medical University, Luzhou 646000, Sichuan Province, China; 2Department of Rehabilitation Medicine, People’s Hospital of Wulong District of Chongqing, Chongqing 408500, China
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Received:2022-04-21Accepted:2022-06-13Online:2023-06-28Published:2022-09-19 -
Contact:Liu Zhongqiang, MD, Associate professor, Master’s supervisor, School of Physical Education, Southwest Medical University, Luzhou 646000, Sichuan Province, China -
About author:Wu Yihan, Master candidate, School of Physical Education, Southwest Medical University, Luzhou 646000, Sichuan Province, China -
Supported by:The Joint Funds Project of Luzhou-Southwest Medical University, No. 2015LZCYD-R11(1/7) (to PY); Scientific Research Project of Sichuan Provincial Department of Education in 2018, No. 18SB0811 (to LZQ)
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Wu Yihan, Wei Qiaoye, Pang Yu, Liu Zhongqiang. Proprioception characteristics of functional ankle instability: a meta-analysis[J]. Chinese Journal of Tissue Engineering Research, 2023, 27(18): 2943-2952.
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2.1 文献筛选流程及结果 根据制定的纳入与排除标准分别检索6个数据库，初步检索共获得相关文献3 850篇，随后使用EndNote X9.2软件对所检索到的重复文献进行剔除，共剔除重复文献1 129篇，对剩余文献的题目与摘要阅读后获得文献111篇，阅读全文后最终纳入26篇观察性研究[12-13，24-47]，共包括547例功能性踝关节不稳患者。文献筛选流程及结果见图2。"
2.2 纳入文献基本特征 共纳入26项观察性研究[12-13，24-47]，其中有5篇文献测试了单侧功能性踝关节不稳患者与对侧肢体的内翻运动觉[25-27，39，43]。有19篇文献测试了单侧功能性踝关节不稳患者的关节位置觉[12-13，24，28，30-32，34-35，37，39-47]，其中包含与对侧肢体和健康对照组相比在内翻、外翻、跖屈、背屈4个方向的测试，并根据主动与被动位置再现进行亚组分析。有8篇文献测试了单侧功能性踝关节不稳患者在冠状面运动的力觉[12，29，33，36，38，40，43，47]，并根据内翻与外翻方向进行亚组分析，具体见表1。"
2.3 纳入文献的质量评价结果 对纳入的26项研究进行质量评价与风险评估[12-13，24-47]，其中队列研究和病例-对照研究根据纽卡斯尔-渥太华量表评定后显示，2项队列研究评分为6分[29，35]，2项队列研究评分为8分[37，43]，4项病例-对照研究为7分[31，36，40，45]，2项病例-对照研究为8分[38-39]，结果显示均为中到高质量文献。另外16项横断面研究根据美国医疗保健研究和质量机构推荐的11项检查表评定后显示均为中等质量文献[12-13，24-28，30，32-34，41-42，44，46-47]，具体评估结果见表2。"
2.4 Meta分析的结果 2.4.1 两组内翻运动觉差异 共纳入5篇文献[24，26-27，39，43]。异质性分析结果显示：I2=45%，P=0.06，纳入研究的异质性较低。采用固定效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者相较于对照组(对侧肢体、健康人群)存在内翻运动觉缺陷(SMD=0.53，95%CI：0.36-0.71，P < 0.000 01)。按对照来源进行亚组分析显示，单侧功能性踝关节不稳患者与对侧肢体相比存在内翻运动觉缺陷(SMD=0.42，95%CI：0.16-0.69，P=0.001)，与健康人群相比存在内翻运动觉缺陷(SMD=0.62，95%CI：0.39-0.86，P < 0.000 01)，见图3。"
2.4.2 两组关节位置觉差异 功能性踝关节不稳与对侧肢体比较：共5篇观察踝关节内翻的文献[30-32，39，43]，异质性分析结果显示：I2=92%，P < 0.000 01，纳入研究的异质性较大，进行敏感性分析调查异质性来源，当剔除HANCI等[39]后汇总的异质性显示，I2=64%，P < 0.000 7，这提示HANCI等[39]可能是较大异质性的来源。采用随机效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者相比于对侧肢体存在内翻关节位置觉(主动与被动复制)的缺陷(SMD=1.60，95%CI：0.77-2.43，P=0.000 2)。按主被动复制进行亚组分析显示，主动复制条件下，单侧功能性踝关节不稳患者相比于对侧肢体存在内翻关节位置觉的缺陷(SMD=2.25，95%CI：0.47-4.02，P=0.01)，被动复制条件下，单侧功能性踝关节不稳患者相比于对侧肢体存在内翻关节位置觉的缺陷(SMD=1.25，95%CI：0.29-2.21，P=0.01)，见图4。"
共纳入16篇观察踝关节内翻的文献[12-13，24，28，31-32，34-35，37，40-43，45-47]。异质性分析结果显示：I2=86%，P < 0.000 01，纳入研究的异质性较大，进行敏感性分析调查异质性来源，当剔除梁炳寅等[42]文献后被动内翻复制的异质性显示，I2=0%，P=0.17，这提示梁炳寅等[42]文献可能是被动内翻位置觉较大异质性的来源。采用随机效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者相比于健康人群存在内翻关节位置觉的缺陷(SMD=0.66，95%CI：0.25-1.07，P=0.002)。按主被动进行亚组分析显示，主动复制条件下，单侧功能性踝关节不稳患者相比于健康人群存在内翻关节位置觉的缺陷(SMD=0.80，95%CI：0.11-1.48，P=0.02)，被动复制条件下，单侧功能性踝关节不稳患者相比于健康人群存在内翻关节位置觉的缺陷(SMD=0.55，95%CI：0.04-1.05，P=0.03)，见图5。 "
共纳入有7篇文献观察了踝关节外翻[12-13，28，40-41，45-46]。异质性分析结果显示：I2=97%，P < 0.000 01，纳入研究的异质性较大，进行主被动亚组分析显示主动外翻位置觉可能是较大异质性的来源(I2=91%，P < 0.000 01)。采用随机效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者与健康人群相比不存在外翻关节位置觉的差异(SMD=1.81，95%CI：0.02-3.60，P=0.05)。按主被动进行亚组分析显示，主动复制条件下，单侧功能性踝关节不稳患者与健康人群相比存在外翻关节位置觉缺陷(SMD=3.68，95%CI：1.85-5.52，P < 0.000 1)，被动复制条件下，健康人群相比于单侧功能性踝关节不稳患者存在外翻关节位置觉缺陷(SMD=-0.61，95%CI：-1.19至-0.02，P=0.04)，见图6。 "
共纳入11篇文献观察了踝关节跖屈[12-13，28，34-35，40-41，44-47]。异质性分析结果显示：I2=94%，P < 0.000 01，纳入研究的异质性较大，进行敏感性分析调查异质性来源，当剔除后CHANG等[46]被动跖屈复制的异质性显示，I2=19%，P=0.29，这提示CHANG等[46]可能是被动跖屈位置觉较大异质性的来源。采用随机效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者与健康人群相比不存在跖屈关节位置觉的差异(SMD=0.80，95%CI：-0.19-1.79，P=0.11)。按主被动进行亚组分析显示，主动复制条件下，单侧功能性踝关节不稳患者与健康人群相比不存在跖屈关节位置觉的差异(SMD=1.05，95%CI：-0.56-2.65，P=0.20)，被动复制条件下，单侧功能性踝关节不稳患者与健康人群相比不存在跖屈关节位置觉的差异(SMD=0.32，95%CI：-0.28-0.91，P=0.29)，见图7。 "
共纳入7篇文献观察了踝关节背屈[12-13，28，40-41，45-46]。异质性分析结果显示，I2=90%，P < 0.000 01，纳入研究的异质性较大，进行敏感性分析调查异质性来源，当剔除后KIM等[12]主动背屈复制的异质性显示，I2=40%，P=0.17，这提示KIM等[12]可能是主动复制较大异质性的来源。采用随机效应模型进行Meta分析结果显示：单侧功能性踝关节不稳患者与健康人群相比不存在背屈关节位置觉差异(SMD=0.86，95%CI：-0.01-1.74，P=0.05)。按主被动进行亚组分析显示，主动复制条件下，单侧功能性踝关节不稳患者与健康人群相比不存在背屈关节位置觉差异(SMD=0.99，95%CI：-0.28-2.25，P=0.13)，被动复制条件下，单侧功能性踝关节不稳患者与健康人群相比不存在背屈关节位置觉差异(SMD=0.53，95%CI：-0.36-1.443，P=0.25)，见图8。 "
2.4.3 两组力觉差异 共纳入8篇文献观察了力觉[12，29，33，36，38，40，43，47]。异质性分析结果显示：I2=88%，P < 0.000 01，纳入研究的异质性较大，进行敏感性分析调查异质性来源，当剔除KIM等[12]后外翻力觉的异质性显示，I2=46%，P=0.10，这提示KIM等[12]可能是外翻力觉较大异质性的来源。采用随机效应模型Meta分析结果显示：单侧功能性踝关节不稳患者相比于健康人群存在冠状面运动的力觉缺陷(SMD=1.35，95%CI：0.85-1.85，P < 0.000 01)。按内外翻进行亚组分析显示，在内翻方向，单侧功能性踝关节不稳患者相比于健康人群存在力觉缺陷(SMD=1.12，95%CI：0.41-1.83，P=0.002)，在外翻方向，单侧功能性踝关节不稳患者相比于健康人群存在力觉缺陷(SMD=1.51，95%CI：0.80-2.22，P < 0.000 1)，见图9。"
2.5 敏感性分析结果 对每篇纳入的文献进行逐一剔除，再将剩余文献的效应量进行合并。敏感性分析结果显示，在内翻关节位置觉的Meta分析中，当剔除KIM等[12]后效应量由(SMD=0.86，95%CI：-0.01-1.74，P=0.05)变为(SMD=0.48，95%CI：0.09-0.88，P=0.02)，当剔除YOU等[28]后效应量由(SMD=0.86，95%CI：-0.01-1.74，P=0.05)变为(SMD=1.04，95%CI：0.10-1.97，P=0.03)，其余文献剔除后均未见明显改变。 2.6 发表偏倚分析 根据《Cochrane 干预措施系统评价手册》的建议，当纳入的研究过少时，漏斗图无法真实反映可能存在的发表偏倚，因此文章仅将内翻运动觉、内翻关节位置觉(与健康人群比较)、冠状面运动的力觉进行偏倚漏斗图分析。结果显示，在内翻运动觉方面，通过观察发现有1篇文献存在较大的偏倚风险[39]，剔除后所有研究均分布于漏斗图内，分析发现相比于其他研究，文献HANCI等[39]中的角速度较慢，仅为0.1 (°)/s，因此测试出最小运动检测阈值也较小，可能因角速度的不同而产生发表偏倚，见图10。"
内翻关节位置觉漏斗图不对称，通过观察发现有6篇文献存在较大的偏倚风险[12，32，40-42，47]，在剔除后所有研究均分布于漏斗图内且更接近于中心线，通过分析发现其中的5篇文献将目标角度设定为在一定范围内的随机角度或包含2个运动平面的角度[12，32，40-41，47]，如跖屈10°，内翻10°，因此可能因角度的随机化而导致出现偏倚，另1篇文献的受试者为医院门诊的病例[42]，而其他研究的受试者多为在校学生，虽然均符合功能性踝关节不稳的纳入标准，但是可能因纳入的人群差异而出现发表偏倚，见图11。 "
冠状面运动的力觉漏斗图不对称，通过观察发现有3篇文献存在较大的偏倚风险[12，29，33]，在剔除后所有研究均分布于漏斗图内，通过分析发现ARNOLD等[29]是在开链条件下进行力觉测试，而其他研究均在闭链条件下进行，DOCHERTY等[33]对受试者进行了10次重复力觉测试，相比于其他研究中常采用的3次重复，可能因肌肉疲劳而影响测试结果。这表明不同研究会因测试方法的细节不同而出现偏倚风险，见图12。 "
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