Effect Of Stretching and Flexibility Exercises On Ankle Functional Abilities Post Ankle Fracture

Effect Of Stretching and Flexibility Exercises On Ankle Functional Abilities Post Ankle Fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect Of Stretching and Flexibility Exercises On Ankle Functional Abilities Post Ankle Fracture Naglaa Fathalla El-Sayed, Eshrak Salama Hashem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7255521/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Ankle fractures are one of the most common fractures of the lower extremity, with an incidence of 187 per 100,000 patients each year . Post ankle fracture patients reported an average 30% loss of pre injury ankle function. Function is poor due to pain and reduced joint motion, lower limb muscle strength deficits, gait abnormalities and resultant mobility limitations Aim : determine the effect of stretching and flexibility exercises on ankle functional abilities post ankle fracture . Design: Quasi experimental (one group pre and post intervention design) was utilized. Settings: The study was carried out at inpatient and outpatient Orthopedic Clinics, El- Hadra University Hospital, Alexandria -University, Egypt. Subjects: a convenience sample of 50 adult patients with ankle closed fracture, post open reduction &internal fixation were included in the study. Tools: Four tools were used for data collection. Tool I: Sociodemographic and clinical data: structured interview schedule. Tool II: Ankle mobility index. Tool III: Ankle functional ability scale and Tool IV: Ankle pain during activities assessment scale. Results: there was significant improvement of all ankle range of motion during dorsiflexion, planter flexion, inversion& eversion among the two evaluation points. There was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion& eversion superiority to post eight weeks of stretching and flexibility exercises application. There was significant improvement in the studied patients' foot and ankle ability post stretching and flexibility exercises. There was a significant decrease in pain severity at rest, during bed activities performance, at sitting position, when standing. When walking, when going up stairs &when going with superiority to eight weeks of exercises application . Conclusion: The findings of this study highlight the significant impact of stretching and flexibility exercises on improving functional outcomes in patients with ankle injuries, support the integration of such exercises into standard post-injury rehabilitation protocols to accelerate functional recovery and improve the quality of life for affected individuals. Recommendations: Future studies could further explore the comparative effects of different exercise modalities, durations, and intensities. Moreover, investigating the long-term sustainability of pain reduction and functional improvement post-intervention would be valuable in guiding ongoing rehabilitation protocols. Stretching exercises Flexibility exercises Ankle functional abilities Ankle Fracture Introduction Ankle fractures are among the most common orthopedic injuries. Most are relatively mild injuries, with good to excellent clinical outcomes expected for most patients following reduction and fixation of displaced ankle fractures [1]. Twisting lesions and falls are the most common causes of ankle fractures, followed by sports injuries. Treatments for ankle fractures ranges from conservative plaster casts to surgical fixation. Surgical treatment means reduction if the fractured parts are displaced and fixed using different devices such as metal plates, screws, tension bands or external trying to fix. These operating techniques aim at restoring anatomy and ensuring immediate stabilization, which promotes earlier mobilization [2]. Literature review Consequences of Ankle Fracture on Physical Function and Independence Post ankle fracture patients reported an average 30% loss of pre-injury ankle function. Mainly ankle function becomes poor due to pain, reduced joint motion, lower limb muscle strength deficits, gait abnormalities and subsequent mobility limitations [3] . A loss of independence and subsequent reliance on others, disturbed sleep and increased fatigue in their recovery period were considered a significant source of frustration for those patients [4]. Functional Rehabilitation for Ankle Recovery Effective rehabilitation is crucial for restoring ankle function and preventing long-term complications. The aim of functional rehabilitation is to prepare the patient for return to the pre-injury level of activity as quickly as possible without hazard on the surgical joint and functional outcome. Functional rehabilitation should include well-designed exercises that stress the tendons, ligaments, and muscles of the ankle, it should be reminded that functional exercises are to be tailored according to the individual needs of the patient [5] . The Role of Stretching and Flexibility in Ankle Rehabilitation Stretching and flexibility exercises are an essential part of ankle rehabilitation program, these exercises not only promote healing of the injured tissues but also reduce the risk of re-injury and complications associated with long-term immobility. Stretching exercises were a mainstay for decades for warm-ups before activities, maintaining the health and performance of the joints and the musculoskeletal system, reduce muscle stiffness, prevent the development of secondary complications such as contractures; facilitate optimal positioning and comfort; and reduce pain [6] . The term "flexibility" commonly apply to denote the ability to move a joint through its maximum range of motion (ROM). It involves the ability of the ankle to stretch, extend, and contract without restriction, allowing for optimal movement. Joints require movement through a full range of motion to maintain the health of cartilage and other structures within the joint (e.g. Synovium). Inflexible muscles tire more quickly, causing opposing muscle groups to work harder. Muscle fatigue can lead to muscular injuries and the inability of the muscles to protect joints from more severe injuries. Decreased flexibility may also lead to abnormal stress on structures and tissues distant from the initial site of inflexibility. The combination of stretching and flexibility work is also linked to neuromuscular benefits, such as enhanced proprioception and joint position sense [7] . Identified Gaps and Rationale for This Study : Ankle fractures represent one of the most prevalent types of fractures in the lower extremities, with an annual incidence of approximately 187 cases per 100,000 individuals [1] . This type of injury often results in prolonged functional impairments, including reduced joint mobility, pain, muscle weakness, and instability. These complications can significantly hinder an individual’s ability to walk, perform daily activities, and return to work or sports. Despite these findings, there remains a lack of researches that isolate the effects of stretching and flexibility exercises from other rehabilitation components such as strengthening and balance training. Consequently, more focused research is needed to establish standardized protocols and determine the specific contributions of these interventions in ankle fracture recovery, therefore, this study aims to examine the effect of stretching and flexibility exercises on the functional abilities of individuals who have experienced an ankle fracture, exploring their role in improving rehabilitation outcomes and long-term ankle health. Method Research design : A quasi experimental (one group pre and post intervention design) was utilized to meet the aim of the study. This design allows the researcher to measure changes in the same group of participants before and after the intervention, providing insight into the potential effectiveness of the exercise regimen. Moreover, the quasi-experimental design allowed the study to be conducted in real-world clinical settings, reflecting the actual conditions and practices of post ankle fracture patients in out at inpatient and outpatient Orthopedic Clinics. This increases the external validity of the findings to similar healthcare settings. Hypothesis Post ankle fracture patients who receive stretching and flexibility exercises exhibit higher ankle functional abilities than those patients who don’t receive it. Data collection : Meetings were arranged with eligible participants at their convenience to provide a clear explanation of the study's purpose and obtain informed consent from those willing to participate. The study was carried out on four phases: Assessment Phase : an initial assessment was carried out for the studied patients immediately post cast removal after complete fracture healing to obtain baseline data using the research tools. Planning phase : stretching and flexibility exercises goals, content and expected outcomes were developed by the researchers. Implementation Phase : The stretching and flexibility exercises were conducted and applied individually to each patient in the previous mentioned sitting, using demonstration, re- demonstration method. Patients also were asked to bring one of the family members to attend the demonstration. The patients were asked to repeat the exercises until the researchers were assured that the patient had gained the skills. Ankle stretching and flexibility exercises were carried out for 4 weeks, three days a week, after patient's recovery (removal of the cast), these exercises were considered as a maintenance program for lifelong protection and health of ankle. Before doing the exercises, warm up with 5 to 10 minutes of low impact activity, like walking was encouraged. After the warm-up, the stretching exercises & flexibility exercises were done. Each session will take approximately 15–20 minutes depending on the degree of tolerance and response of the patients. Evaluation phase : All patients in both groups were evaluated post four weeks and eight weeks of the exercise program using tools II, III, and IV. Data collection was started, and continued for a period of 2 years from January 2022 to January 2024. Subjects : A convenience sample of 50 adult patients with ankle closed fracture, post open reduction &internal fixation were included in the study (aged from 21 to 60 years), able to communicate verbally and have no chronic disease as DM, DVT, venous insufficiency in lower extremities was included in this study. The sample size was calculated using power analysis (Epi-info7) program based on the following parameters: population size = 110/12months, expected frequency = 50%, acceptance error = 5%, confidence coefficient = 95%, design effect = 1and power = 80%. The exclusion criteria of the subjects are associated injury in the distal end of tibia or contra- lateral lower limb, revision surgery for previously failed ankle surgery, and complicated ankle surgery. All methods were conducted in accordance with the relevant guidelines and regulations outlined in the Declaration of Helsinki (DoH–October 2008). Ethical approval was granted by the Ethical Research Committee, of Faculty of Nursing, Alexandria university, [Approval number: (ISO 9001/2008)14/10/2020]. Human Ethics and Consent to Participate declarations was assured as written informed consent from patients to participate in the study was obtained before data collection and after explanation of the aim of the study, privacy of the study participants was asserted, confidentiality of the collected data was assured and participants' voluntary participation and their right to withdraw from the study at any time were emphasized. Clinical trial number: not applicable. Data collection tools : Four tools were used for data collection based on a thorough review of relevant literature [8–13] Tool I: Sociodemographic and clinical data: structured interview schedule. This tool was developed by the researchers .it was divided into two main parts: Part I : Sociodemographic data as: age, sex, area of residence, marital status, level of education, and occupation. Part II : Clinical data: type of fracture, site of fracture, mode of trauma. Tool II: Ankle mobility index : This tool was developed by the researchers to assess ankle mobility based on thorough review of relevant literature [8]&[9] .It divided into two parts as the following: Part I: Range of motion of the affected ankle : This part was measured by digital goniometer to measure range of motion of the affected ankle joint in performing dorsiflexion, planter flexion, inversion and eversion. The obtained data was compared with normal values as shown in table (1) [8] : Motion Degrees Dorsiflexion 20 0 Planter flexion 40 0 Inversion 30 0 Eversion 20 0 Part II: Muscle strength scale of the ankle : A likert type scale that was developed by (Lovett & Martin .,2014) [9] .It was used in the present study by the researchers to assess the strength of ankle muscles .It was composed of six items to be checked by the researchers on a scale ranging from zero to five where (zero)indicated no pliable contraction of muscles,(one) indicated pliable contraction of muscle with joint movement, (two) indicated complete range of motion of the joint with gravity eliminated,(three) indicated complete range of motion against gravity and no added resistance,(four) indicated complete range of motion against gravity with some added resistance, while (five) indicated Complete range of motion against gravity with full resistance. Tool III: Ankle functional ability scale : This tool was adapted by the researchers from Foot and Ankle Ability Measure (FAAM) that was developed by (Martin et al.; 2005) [10] to provide information about person's functional abilities. It includes data about patient's activities including: standing, walking, getting up and down the stairs, home responsibilities, personal hygiene, and heavy work. Each activity was scored separately on 5-pointrating scale ranging from 0–5 as mentioned in table (2). Scoring 0 1 2 3 4 5 NA Unable to do Extreme difficulty Moderate difficulty Slight difficulty No difficulty Total score 0% 20%-< 40% 40%-< 60% 60-< 80% 80%-100% Unable to perform ,dependent Needs to use equipment or devices & supervision Needs Supervision Needs to use equipment or devices Full self-care ,independent Tool IV: Ankle pain during activities assessment scale : The Numeric rating scale was developed by (Dazines. 2008) [11] . It was used by the researchers to assess level of patient's ankle pain during rest and when carrying activities. It is a standardized linear scale, the score was ranged from 0–10 corresponding to degree of pain in the ankle, a score of (zero) means no pain, a score of (one up to three) means mild pain, a score of (four up to six ) means moderate pain, a score of (seven up to nine) means severe pain. While (ten) denotes worst pain. A validation process was conducted to ensure the validity of the research tool, all tools were submitted to 3 experts in medical surgical nursing and two experts in orthopedic field for content validity and the necessary modifications were carried out accordingly. The reliability of the tool was assessed through a test–retest process using a pilot study sample. The tool was administered at the same location but on different occasions, and no modifications were made based on the results of this test–retest process. Statistical Analysis Data collected from the study sample were carefully reviewed, coded, and entered into a personal computer for further analysis. Computerized data entry and statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) version 22. Descriptive statistics were used to present the data and provide a clear understanding of the distribution and characteristics of the study variables, including frequencies, percentages, means, and standard deviations. To determine whether there was a significant association between the categorical variables, the chi-square test & Anova test were used. The significance of the results was evaluated based on p values. P values of less than 0.05 was considered highly significant. Results It can be noticed that about more than one third (40%) their age was ranged between 30–40 years old. More than two thirds (68%) were male, and more than half (52%) of them came from rural areas. As regard their level of education more than one third (36%) of them illiterate &read and write. Around one third (32%) were worked in manual work. Table (1): Frequency distribution of post ankle fracture patients according to their socio-demographic characteristics : Demographic characteristics Study group n = 50 No. % Age (years) 21 –< 30 12 24.0 30 –<40 20 40.0 40 – < 50 4 8.0 50–60 14 7 28.0 X ± SD 40.96 ± 13.274 Sex Male 34 68.0 Female 16 32.0 Residence Urban 24 48.0 Rural 26 52.0 Level of education Illiterate &Read and Write 18 36.0 Primary& Preparatory 10 20.0 Secondary 12 24.0 Higher education 10 20.0 Occupation Housewife 8 16.0 Retirement 10 20.0 Manual work 16 32.0 Office work 10 20.0 Professional work 6 12.0 Marital status Single 20 40.0 Married 14 28.0 Divorced &widow 16 32.0 It's obvious that around half (48%) of the patients their fracture occurred post falling down, affected mainly the talus bone, and affected mainly the left side. Table (2): Frequency distribution of post ankle fracture patients according to their Fracture related data : Fracture related data Study group n = 50 No. % Cause of fracture Care accidents 16 32.0 Falling down 24 48.0 Fall from height 6 12.0 Pathological condition 4 8.0 Site of fracture Talus 24 48.0 Tibia (medial malleolus) 6 12.0 Fibula (Lateral malleolus) 4 8.0 Medial& Lateral malleolus 16 32.0 Affected side Right side 20 40.0 Lift side 24 48.0 Right &lift sides 6 12.0 In relation to ankle range of motion pre and post stretching and flexibility exercises, there was significant improvement of all ankle range of motion during dorsiflexion, Planter flexion, inversion& eversion among the two evaluation points with p = (< 0.001*, < 0.001*, 0.012*&0.030*) respectively. Table (3): Comparison among the studied patients as regards ankle range of motion pre and post stretching and flexibility exercises. ROM Pre exercise (immediately after removal of cast ) Post four weeks Post eight weeks Test of significance Dorsiflexion of the affected ankle Mean SD Mean SD Mean SD 12.80 1.527 16.88 1.201 19.08 0.81 F = 22.260 P = < 0.001* Planter flexion of the affected ankle 27.04 2.791 32.60 2.798 37.08 2.039 F = 18.831 P = < 0.001* Inversion of the affected ankle 20.68 3.602 29.52 40.486 22.48 3.731 F = 8.800 P = 0.012* Eversion of the affected ankle 13.08 2.396 14.28 2.051 14.76 1.920 F = 6.325 P = 0.030* F = Anova test *: Statistically significant at p ≤ 0.05 There was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion& eversion respectively (P = 0.033 *, P = 0.012*, P = < 0.000*& P = < 0.000*) with superiority to post eight weeks of stretching and flexibility exercises application. There was significant improvement in the studied patients' foot and ankle ability post stretching and flexibility exercises were P = 0.003 * , as more than two thirds of the studied patients were unable to perform dependent pre the exercises, more than two thirds of them were needed to use equipment or devices during mobility post four weeks of the exercises, while more than two thirds of them became full self-care independent post eight weeks of the exercises. Table (5): Comparison among the studied patients as regards their foot and ankle ability measure pre and post stretching and flexibility exercises. There was a significant decrease in pain severity at rest, during bed activities performance, at sitting position, when standing. When walking, when going up stairs &when going downstairs ( P = 0.003 * , P = < 0.000*, P = 0.003 * , P = < 0.000*, P = < 0.000*, P = < 0.000** P = < 0.000*) respectively with superiority to eight weeks of exercises application Discussion Post-operative rehabilitation may be an obligatory part of the entire management concept after orthopedic surgeries. Stretching and flexibility exercises are key components of rehabilitation programs designed to restore joint mobility, improve muscle elasticity, and enhance neuromuscular coordination. These interventions specifically target the stiffness and muscular imbalances that often follow a period of immobilization or limited weight-bearing [5] . In relation to ankle range of motion (ROM) pre and post stretching and flexibility exercises, there was significant improvement of all ankle range of motion during dorsiflexion, planter flexion, inversion& eversion among the two evaluation points. This improvement can be explained by that stretching exercise may thought to elongate muscle and tendinous tissues, reducing the strain throughout the tissue during dynamic activities and resulting in increased joint flexibility and range of motion which in turn increase ROM allowing better foot positioning during walking, running, and other activities, reducing the risk of compensatory movement patterns that could lead to other injuries. Furthermore; warming up that done prior to stretching exercises preconditioning the muscle-tendon unit to maximal effort exercise is thought to protect against injury by increasing the force and strain required to produce muscle-tendon injury, it changes the connective tissue architecture within the muscle-tendon unit and increase muscle metabolism and temperature. These changes may facilitate blood flow and oxygenation and produce more effective interactions of contractile muscle fibers. This finding was supported by Maeda et al., (2016) [12] who conduct a study to assess the effect of different stretching techniques on ankle joint range of motion and dynamic postural stability after landing, and illustrated that the ROM was significantly greater after static stretching and cyclic stretching compared with the control condition. As regards muscle strength of the ankle pre and post stretching and flexibility exercises. There was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion& eversion respectively with superiority to post eight weeks of stretching and flexibility exercises application. This enhancement is likely due to neuromuscular adaptations and increased muscle activation resulting from the repetitive stretching and flexibility exercises. Thise finding was in line with Al-Khafaji & Al-Masoodi, (2023) [13] who concluded that the use of muscle stretching exercises led to an improvement and a clear increase in the muscular strength of the muscles working on the ankle joint . Functional ability, as assessed by the Foot and Ankle Ability Measure (FAAM), also improved significantly, before the intervention, most patients were dependent in daily activities and required assistive devices. However, after eight weeks, a majority achieved full independence in self-care tasks. These results may be due to starting with stretching exercises which considered a warm-up routine, this helps increase blood flow, warms up the muscles, and prepares the ankle joint for more extensive movement. Furthermore, the flexibility exercises influence the activation of muscles throughout the lower kinetic chain. When the ankle can move through its full range of motion. This suggests a marked improvement in quality of life and supports the inclusion of flexibility and stretching exercises in post-injury rehabilitation protocols. Smeeing et al., (2020) [14] agree with this study results, who explained that early mobilization and exercises would reduce hospital stay, speed up return to work and sport practice, and promote early ROM recovery without resulting in an increase in complications. Pain severity was significantly reduced in various scenarios, including rest, sitting, standing, walking, and stair use. The greater improvements observed at eight weeks may be attributed to the cumulative effect of consistent exercise, leading to enhanced muscle strength, flexibility, and proprioception. These physiological adaptations can significantly alleviate biomechanical stress on joints and soft tissues, thereby reducing pain. Moreover, exercises may have also contributed to central pain modulation, promoting better pain tolerance through repeated movement exposure. This finding was supported by Støve et al., (2024) [15] who concluded that local and widespread pain sensitivity decreased following acute stretching, regardless of stretching intensity. Strength and Limitations of the study : The strengths include a practical component with objective assessments and a high response rate. However, the study's generalizability is limited by its relatively small sample size, a large number of the study participants didn't complete the exercise regimen due to their noncompliance with follow-up visits. Implications for practice : Findings from this study suggest incorporating structured stretching and flexibility exercises into rehabilitation programs can significantly enhance functional recovery following an ankle fracture. Nurse educators and administrators should incorporate such exercises into continuing education and onboarding protocols to reduce complications and promote patient recovery. The strong correlation between knowledge and practice further supports ongoing competency assessment in clinical settings. Conclusion The findings of this study highlight the significant impact of stretching and flexibility exercises on improving functional outcomes in patients with ankle injuries, support the integration of such exercises into standard post-injury rehabilitation protocols to accelerate functional recovery and improve the quality of life for affected individuals. Declarations Clinical trial number: Not applicable Consent for publication Not Applicable. Competing interests No conflict of interest has been declared by the authors. Funding There is no specific grant from funding agencies in the public, commercial, or not-for-profit sectors for the current study. Author Contributions N.F designed the study, prepared the manuscript, offered methodology and approved the final manuscript. E.S, collected and conducted the data analysis. Supervision, review, and approved the final manuscript. Acknowledgements The authors acknowledge all patients who exhibited great patience in completing the questionnaires, to whom we express our deepest gratitude for their help and support. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request. References Megan, A., Benedick, A., Breslin, M. A., Schmidt, T., & Vallier, H. (2021). Determinants of functional outcome following ankle fracture. OTA International, 4 (3), 1–6. http://dx.doi.org/10.1097/OI9.0000000000000139 Mostafa, N., & Osman, A. (2020). 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Ibero-American Journal of Exercise and Sports Psychology, 18 (4). https://www.riped-online.com/articles/the-effect-of-stretching-exercises-by-proprioceptive-neuromuscular-facilitation-pnf-of-sensory-receptors-in-the-rehabilitation-of--97932.html Smeeing, D. P. J., Houwert, R. M., Briet, J. P., Groenwold, R. H. H., Lansink, K. W. W., Leenen, L. P. H., van der Zwaal, P., Hoogendoorn, J. M., van Heijl, M., Verleisdonk, E. J., et al. (2020). Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: A multicenter randomized controlled trial. European Journal of Trauma and Emergency Surgery, 46 (1), 121–130. https://doi.org/10.1007/s00068-018-1016-6 Støve, M., Hansen, L., Elmbæk, K., Magnusson, S., Thomsen, J., & Riis, A. (2024). The effect of stretching intensity on pain sensitivity: A randomized crossover study on healthy adults. European Journal of Pain, 29 (3), e4750. https://doi.org/10.1002/ejp.4750 Table 4 and 6 Table 4 and 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files supplementaryfileexercises.docx Table4and6.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7255521","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498248296,"identity":"cb0f2a0f-8eb1-4d5b-9d41-a4e331ae6018","order_by":0,"name":"Naglaa Fathalla El-Sayed","email":"","orcid":"","institution":"University of Alexandria","correspondingAuthor":false,"prefix":"","firstName":"Naglaa","middleName":"Fathalla","lastName":"El-Sayed","suffix":""},{"id":498248297,"identity":"362da1e6-1830-44f8-bf44-0d9f0fe9f7ad","order_by":1,"name":"Eshrak Salama Hashem","email":"data:image/png;base64,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","orcid":"","institution":"University of Alexandria","correspondingAuthor":true,"prefix":"","firstName":"Eshrak","middleName":"Salama","lastName":"Hashem","suffix":""}],"badges":[],"createdAt":"2025-07-30 18:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7255521/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7255521/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90580976,"identity":"40c39602-31dc-47a9-b51a-ab576afa015d","added_by":"auto","created_at":"2025-09-04 10:17:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1422399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7255521/v1/47df1e4b-7ea3-4db5-93f7-39bc0dfdc9b3.pdf"},{"id":88995752,"identity":"a570c712-216f-4508-8321-b30ed936a2e8","added_by":"auto","created_at":"2025-08-13 14:27:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":315644,"visible":true,"origin":"","legend":"","description":"","filename":"supplementaryfileexercises.docx","url":"https://assets-eu.researchsquare.com/files/rs-7255521/v1/9757777c72e796538bc33db2.docx"},{"id":88994507,"identity":"e2edbd0d-f7e7-41ef-8a9d-5d1ef9218c2d","added_by":"auto","created_at":"2025-08-13 14:19:05","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":29508,"visible":true,"origin":"","legend":"","description":"","filename":"Table4and6.docx","url":"https://assets-eu.researchsquare.com/files/rs-7255521/v1/136faea27bf6ef1a4517c42c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect Of Stretching and Flexibility Exercises On Ankle Functional Abilities Post Ankle Fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnkle fractures are among the most common orthopedic injuries. Most are relatively mild injuries, with good to excellent clinical outcomes expected for most patients following reduction and fixation of displaced ankle fractures \u003csup\u003e[1].\u003c/sup\u003eTwisting lesions and falls are the most common causes of ankle fractures, followed by sports injuries. Treatments for ankle fractures ranges from conservative plaster casts to surgical fixation. Surgical treatment means reduction if the fractured parts are displaced and fixed using different devices such as metal plates, screws, tension bands or external trying to fix. These operating techniques aim at restoring anatomy and ensuring immediate stabilization, which promotes earlier mobilization \u003csup\u003e[2].\u003c/sup\u003e\u003c/p\u003e"},{"header":"Literature review","content":"\u003cp\u003e\u003cb\u003eConsequences of Ankle Fracture on Physical Function and Independence\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePost ankle fracture patients reported an average 30% loss of pre-injury ankle function. Mainly ankle function becomes poor due to pain, reduced joint motion, lower limb muscle strength deficits, gait abnormalities and subsequent mobility limitations \u003csup\u003e[3]\u003c/sup\u003e. A loss of independence and subsequent reliance on others, disturbed sleep and increased fatigue in their recovery period were considered a significant source of frustration for those patients \u003csup\u003e[4].\u003c/sup\u003e\u003cp\u003eFunctional Rehabilitation for Ankle Recovery\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEffective rehabilitation is crucial for restoring ankle function and preventing long-term complications. The aim of functional rehabilitation is to prepare the patient for return to the pre-injury level of activity as quickly as possible without hazard on the surgical joint and functional outcome. Functional rehabilitation should include well-designed exercises that stress the tendons, ligaments, and muscles of the ankle, it should be reminded that functional exercises are to be tailored according to the individual needs of the patient \u003csup\u003e[5]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Role of Stretching and Flexibility in Ankle Rehabilitation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStretching and flexibility exercises are an essential part of ankle rehabilitation program, these exercises not only promote healing of the injured tissues but also reduce the risk of re-injury and complications associated with long-term immobility. Stretching exercises were a mainstay for decades for warm-ups before activities, maintaining the health and performance of the joints and the musculoskeletal system, reduce muscle stiffness, prevent the development of secondary complications such as contractures; facilitate optimal positioning and comfort; and reduce pain \u003csup\u003e[6]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe term \"flexibility\" commonly apply to denote the ability to move a joint through its maximum range of motion (ROM). It involves the ability of the ankle to stretch, extend, and contract without restriction, allowing for optimal movement. Joints require movement through a full range of motion to maintain the health of cartilage and other structures within the joint (e.g. Synovium). Inflexible muscles tire more quickly, causing opposing muscle groups to work harder. Muscle fatigue can lead to muscular injuries and the inability of the muscles to protect joints from more severe injuries. Decreased flexibility may also lead to abnormal stress on structures and tissues distant from the initial site of inflexibility. The combination of stretching and flexibility work is also linked to neuromuscular benefits, such as enhanced proprioception and joint position sense \u003csup\u003e[7]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIdentified Gaps and Rationale for This Study\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAnkle fractures represent one of the most prevalent types of fractures in the lower extremities, with an annual incidence of approximately 187 cases per 100,000 individuals \u003csup\u003e[1]\u003c/sup\u003e. This type of injury often results in prolonged functional impairments, including reduced joint mobility, pain, muscle weakness, and instability. These complications can significantly hinder an individual’s ability to walk, perform daily activities, and return to work or sports. Despite these findings, there remains a lack of researches that isolate the effects of stretching and flexibility exercises from other rehabilitation components such as strengthening and balance training. Consequently, more focused research is needed to establish standardized protocols and determine the specific contributions of these interventions in ankle fracture recovery, therefore, this study aims to examine the effect of stretching and flexibility exercises on the functional abilities of individuals who have experienced an ankle fracture, exploring their role in improving rehabilitation outcomes and long-term ankle health.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cb\u003eResearch design\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA quasi experimental (one group pre and post intervention design) was utilized to meet the aim of the study. This design allows the researcher to measure changes in the same group of participants before and after the intervention, providing insight into the potential effectiveness of the exercise regimen.\u003c/p\u003e\u003cp\u003eMoreover, the quasi-experimental design allowed the study to be conducted in real-world clinical settings, reflecting the actual conditions and practices of post ankle fracture patients in out at inpatient and outpatient Orthopedic Clinics. This increases the external validity of the findings to similar healthcare settings.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHypothesis\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ePost ankle fracture patients who receive stretching and flexibility exercises exhibit higher ankle functional abilities than those patients who don’t receive it.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e Meetings were arranged with eligible participants at their convenience to provide a clear explanation of the study's purpose and obtain informed consent from those willing to participate. The study was carried out on four phases: \u003cb\u003eAssessment Phase\u003c/b\u003e: an initial assessment was carried out for the studied patients immediately post cast removal after complete fracture healing to obtain baseline data using the research tools. \u003cb\u003ePlanning phase\u003c/b\u003e: stretching and flexibility exercises goals, content and expected outcomes were developed by the researchers. \u003cb\u003eImplementation Phase\u003c/b\u003e: The stretching and flexibility exercises were conducted and applied individually to each patient in the previous mentioned sitting, using demonstration, re- demonstration method. Patients also were asked to bring one of the family members to attend the demonstration. The patients were asked to repeat the exercises until the researchers were assured that the patient had gained the skills. Ankle stretching and flexibility exercises were carried out for 4 weeks, three days a week, after patient's recovery (removal of the cast), these exercises were considered as a maintenance program for lifelong protection and health of ankle. Before doing the exercises, warm up with 5 to 10 minutes of low impact activity, like walking was encouraged. After the warm-up, the stretching exercises \u0026amp; flexibility exercises were done. Each session will take approximately 15–20 minutes depending on the degree of tolerance and response of the patients. \u003cb\u003eEvaluation phase\u003c/b\u003e: All patients in both groups were evaluated post four weeks and eight weeks of the exercise program using tools II, III, and IV. Data collection was started, and continued for a period of 2 years from January 2022 to January 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubjects\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA convenience sample of 50 adult patients with ankle closed fracture, post open reduction \u0026amp;internal fixation were included in the study (aged from 21 to 60 years), able to communicate verbally and have no chronic disease as DM, DVT, venous insufficiency in lower extremities was included in this study. The sample size was calculated using power analysis (Epi-info7) program based on the following parameters: population size = 110/12months, expected frequency = 50%, acceptance error = 5%, confidence coefficient = 95%, design effect = 1and power = 80%. The exclusion criteria of the subjects are associated injury in the distal end of tibia or contra- lateral lower limb, revision surgery for previously failed ankle surgery, and complicated ankle surgery.\u003c/p\u003e\u003cp\u003e All methods were conducted in accordance with the relevant guidelines and regulations outlined in the Declaration of Helsinki (DoH–October 2008). Ethical approval was granted by the Ethical Research Committee, of Faculty of Nursing, Alexandria university, [Approval number: (ISO 9001/2008)14/10/2020]. Human Ethics and Consent to Participate declarations was assured as written informed consent from patients to participate in the study was obtained before data collection and after explanation of the aim of the study, privacy of the study participants was asserted, confidentiality of the collected data was assured and participants' voluntary participation and their right to withdraw from the study at any time were emphasized. Clinical trial number: not applicable.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection tools\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eFour tools were used for data collection based on a thorough review of relevant literature \u003csup\u003e[8–13]\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTool I: Sociodemographic and clinical data: structured interview schedule.\u003c/b\u003e This tool was developed by the researchers .it was divided into two main parts:\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePart I\u003c/b\u003e: Sociodemographic data as: age, sex, area of residence, marital status, level of education, and occupation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePart II\u003c/b\u003e: Clinical data: type of fracture, site of fracture, mode of trauma.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cb\u003eTool II: Ankle mobility index\u003c/b\u003e: This tool was developed by the researchers to assess ankle mobility based on thorough review of relevant literature \u003csup\u003e[8]\u0026amp;[9]\u003c/sup\u003e.It divided into two parts as the following:\u003c/p\u003e\u003cp\u003e\u003cb\u003ePart I: Range of motion of the affected ankle\u003c/b\u003e: This part was measured by digital goniometer to measure range of motion of the affected ankle joint in performing dorsiflexion, planter flexion, inversion and eversion. The obtained data was compared with normal values as shown in \u003cb\u003etable (1)\u003c/b\u003e \u003csup\u003e[8]\u003c/sup\u003e:\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDegrees\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDorsiflexion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003csup\u003e0\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlanter flexion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40\u003csup\u003e0\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInversion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003csup\u003e0\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEversion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003csup\u003e0\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003cb\u003ePart II: Muscle strength scale of the ankle\u003c/b\u003e: A likert type scale that was developed by \u003cb\u003e(Lovett \u0026amp; Martin .,2014)\u003c/b\u003e \u003csup\u003e[9]\u003c/sup\u003e.It was used in the present study by the researchers to assess the strength of ankle muscles .It was composed of six items to be checked by the researchers on a scale ranging from zero to five where (zero)indicated no pliable contraction of muscles,(one) indicated pliable contraction of muscle with joint movement, (two) indicated complete range of motion of the joint with gravity eliminated,(three) indicated complete range of motion against gravity and no added resistance,(four) indicated complete range of motion against gravity with some added resistance, while (five) indicated Complete range of motion against gravity with full resistance.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTool III: Ankle functional ability scale\u003c/span\u003e: This tool was adapted by the researchers from Foot and Ankle Ability Measure (FAAM) that was developed by \u003cb\u003e(Martin et al.; 2005)\u003c/b\u003e \u003csup\u003e[10]\u003c/sup\u003e to provide information about person's functional abilities. It includes data about patient's activities including: standing, walking, getting up and down the stairs, home responsibilities, personal hygiene, and heavy work. Each activity was scored separately on 5-pointrating scale ranging from 0–5 as mentioned in table (2).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eScoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnable to do\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExtreme difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSlight difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo difficulty\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eTotal score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20%-\u0026lt; 40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40%-\u0026lt; 60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60-\u0026lt; 80%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e80%-100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnable to perform ,dependent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNeeds to use equipment or devices \u0026amp; supervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNeeds Supervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNeeds to use equipment or devices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eFull self-care ,independent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eTool IV: Ankle pain during activities assessment scale\u003c/span\u003e: The Numeric rating scale was developed by \u003cb\u003e(Dazines. 2008)\u003c/b\u003e \u003csup\u003e[11]\u003c/sup\u003e. It was used by the researchers to assess level of patient's ankle pain during rest and when carrying activities. It is a standardized linear scale, the score was ranged from 0–10 corresponding to degree of pain in the ankle, a score of (zero) means no pain, a score of (one up to three) means mild pain, a score of (four up to six ) means moderate pain, a score of (seven up to nine) means severe pain. While (ten) denotes worst pain.\u003c/p\u003e\u003cp\u003eA validation process was conducted to ensure the validity of the research tool, all tools were submitted to 3 experts in medical surgical nursing and two experts in orthopedic field for content validity and the necessary modifications were carried out accordingly. The reliability of the tool was assessed through a test–retest process using a pilot study sample. The tool was administered at the same location but on different occasions, and no modifications were made based on the results of this test–retest process.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData collected from the study sample were carefully reviewed, coded, and entered into a personal computer for further analysis. Computerized data entry and statistical analyses were conducted using Statistical Package for the Social Sciences \u003cem\u003e(SPSS)\u003c/em\u003e version 22. Descriptive statistics were used to present the data and provide a clear understanding of the distribution and characteristics of the study variables, including frequencies, percentages, means, and standard deviations. To determine whether there was a significant association between the categorical variables, the chi-square test \u0026amp; Anova test were used. The significance of the results was evaluated based on \u003cem\u003ep\u003c/em\u003e values. \u003cem\u003eP\u003c/em\u003e values of less than 0.05 was considered highly significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIt can be noticed that about more than one third (40%) their age was ranged between 30\u0026ndash;40 years old. More than two thirds (68%) were male, and more than half (52%) of them came from rural areas. As regard their level of education more than one third (36%) of them illiterate \u0026amp;read and write. Around one third (32%) were worked in manual work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(1): Frequency distribution of post ankle fracture patients according to their socio-demographic characteristics\u003c/strong\u003e:\u003c/p\u003e\n\u003ctable id=\"Tabc\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDemographic characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eStudy group\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003cp\u003e21 \u0026ndash;\u0026lt; 30\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 \u0026ndash;\u0026lt;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e40.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 \u0026ndash; \u0026lt; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e40.96\u0026thinsp;\u0026plusmn;\u0026thinsp;13.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e68.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e52.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of education\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIlliterate \u0026amp;Read and Write\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e36.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u0026amp; Preparatory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigher education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetirement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManual work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e32.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOffice work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProfessional work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e40.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced \u0026amp;widow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eIt\u0026apos;s obvious that around half (48%) of the patients their fracture occurred post falling down, affected mainly the talus bone, and affected mainly the left side.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(2): Frequency distribution of post ankle fracture patients according to their Fracture related data\u003c/strong\u003e:\u003c/p\u003e\n\u003ctable id=\"Tabd\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFracture related data\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eStudy group n\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCause of fracture\u003c/p\u003e\n \u003cp\u003eCare accidents\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling down\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e48.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFall from height\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePathological condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite of fracture\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e48.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTibia (medial malleolus)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibula (Lateral malleolus)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedial\u0026amp; Lateral malleolus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffected side\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRight side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLift side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e48.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight \u0026amp;lift sides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eIn relation to ankle range of motion pre and post stretching and flexibility exercises, there was significant improvement of all ankle range of motion during dorsiflexion, Planter flexion, inversion\u0026amp; eversion among the two evaluation points with p = (\u0026lt;\u0026thinsp;0.001*, \u0026lt;\u0026thinsp;0.001*, 0.012*\u0026amp;0.030*) respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3): Comparison among the studied patients as regards ankle range of motion pre and post stretching and flexibility exercises.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003ctable id=\"Tabe\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eROM\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePre exercise (immediately after removal of cast )\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePost four weeks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePost eight weeks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTest of significance\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDorsiflexion of the affected ankle\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e12.80\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1.527\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e16.88\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1.201\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e19.08\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;22.260\u003c/p\u003e\n \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanter flexion of the affected ankle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.798\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;18.831\u003c/p\u003e\n \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInversion of the affected ankle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.602\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;8.800\u003c/p\u003e\n \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEversion of the affected ankle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.396\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.920\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u0026thinsp;=\u0026thinsp;6.325\u003c/p\u003e\n \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.030*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eF\u0026thinsp;=\u0026thinsp;Anova test *: Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThere was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion\u0026amp; eversion respectively (P\u0026thinsp;=\u0026thinsp;0.033\u003csup\u003e*,\u003c/sup\u003e P\u0026thinsp;=\u0026thinsp;0.012*, P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*\u0026amp; P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*) with superiority to post eight weeks of stretching and flexibility exercises application.\u003c/p\u003e\n\u003cp\u003eThere was significant improvement in the studied patients\u0026apos; foot and ankle ability post stretching and flexibility exercises were P\u0026thinsp;=\u0026thinsp;0.003\u003csup\u003e*\u003c/sup\u003e, as more than two thirds of the studied patients were unable to perform dependent pre the exercises, more than two thirds of them were needed to use equipment or devices during mobility post four weeks of the exercises, while more than two thirds of them became full self-care independent post eight weeks of the exercises.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(5): Comparison among the studied patients as regards their foot and ankle ability measure pre and post stretching and flexibility exercises.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n\u003cp\u003eThere was a significant decrease in pain severity at rest, during bed activities performance, at sitting position, when standing. When walking, when going up stairs \u0026amp;when going downstairs ( P\u0026thinsp;=\u0026thinsp;0.003\u003csup\u003e*\u003c/sup\u003e, P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*, P\u0026thinsp;=\u0026thinsp;0.003\u003csup\u003e*\u003c/sup\u003e, P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*, P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*, P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000** P\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.000*) respectively with superiority to eight weeks of exercises application\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePost-operative rehabilitation may be an obligatory part of the entire management concept after orthopedic surgeries. Stretching and flexibility exercises are key components of rehabilitation programs designed to restore joint mobility, improve muscle elasticity, and enhance neuromuscular coordination. These interventions specifically target the stiffness and muscular imbalances that often follow a period of immobilization or limited weight-bearing \u003csup\u003e[5]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn relation to ankle \u003cb\u003erange of motion (ROM)\u003c/b\u003e pre and post stretching and flexibility exercises, there was significant improvement of all ankle range of motion during dorsiflexion, planter flexion, inversion\u0026amp; eversion among the two evaluation points. This improvement can be explained by that stretching exercise may thought to elongate muscle and tendinous tissues, reducing the strain throughout the tissue during dynamic activities and resulting in increased joint flexibility and range of motion which in turn increase ROM allowing better foot positioning during walking, running, and other activities, reducing the risk of compensatory movement patterns that could lead to other injuries.\u003c/p\u003e\u003cp\u003eFurthermore; warming up that done prior to stretching exercises preconditioning the muscle-tendon unit to maximal effort exercise is thought to protect against injury by increasing the force and strain required to produce muscle-tendon injury, it changes the connective tissue architecture within the muscle-tendon unit and increase muscle metabolism and temperature. These changes may facilitate blood flow and oxygenation and produce more effective interactions of contractile muscle fibers.\u003c/p\u003e\u003cp\u003eThis finding was supported by \u003cb\u003eMaeda et al., (2016)\u003c/b\u003e \u003csup\u003e[12]\u003c/sup\u003e who conduct a study to assess the effect of different stretching techniques on ankle joint range of motion and dynamic postural stability after landing, and illustrated that the ROM was significantly greater after static stretching and cyclic stretching compared with the control condition.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAs regards muscle strength of the ankle pre and post stretching and flexibility exercises.\u003c/b\u003e There was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion\u0026amp; eversion respectively with superiority to post eight weeks of stretching and flexibility exercises application. This enhancement is likely due to neuromuscular adaptations and increased muscle activation resulting from the repetitive stretching and flexibility exercises. Thise finding was in line with \u003cb\u003eAl-Khafaji \u0026amp; Al-Masoodi, (2023)\u003c/b\u003e \u003csup\u003e[13]\u003c/sup\u003e who concluded that the use of muscle stretching exercises led to an improvement and a clear increase in the muscular strength of the muscles working on the ankle joint .\u003c/p\u003e\u003cp\u003eFunctional ability, as assessed by the Foot and Ankle Ability Measure (FAAM), also improved significantly, before the intervention, most patients were dependent in daily activities and required assistive devices. However, after eight weeks, a majority achieved full independence in self-care tasks. These results may be due to starting with stretching exercises which considered a warm-up routine, this helps increase blood flow, warms up the muscles, and prepares the ankle joint for more extensive movement. Furthermore, the flexibility exercises influence the activation of muscles throughout the lower kinetic chain. When the ankle can move through its full range of motion. This suggests a marked improvement in quality of life and supports the inclusion of flexibility and stretching exercises in post-injury rehabilitation protocols. \u003cb\u003eSmeeing et al., (2020)\u003c/b\u003e \u003csup\u003e[14]\u003c/sup\u003e agree with this study results, who explained that early mobilization and exercises would reduce hospital stay, speed up return to work and sport practice, and promote early ROM recovery without resulting in an increase in complications.\u003c/p\u003e\u003cp\u003ePain severity was significantly reduced in various scenarios, including rest, sitting, standing, walking, and stair use. The greater improvements observed at eight weeks may be attributed to the cumulative effect of consistent exercise, leading to enhanced muscle strength, flexibility, and proprioception. These physiological adaptations can significantly alleviate biomechanical stress on joints and soft tissues, thereby reducing pain. Moreover, exercises may have also contributed to central pain modulation, promoting better pain tolerance through repeated movement exposure. This finding was supported by \u003cb\u003eSt\u0026oslash;ve et al., (2024)\u003c/b\u003e \u003csup\u003e[15]\u003c/sup\u003e who concluded that local and widespread pain sensitivity decreased following acute stretching, regardless of stretching intensity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrength and Limitations of the study\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe strengths include a practical component with objective assessments and a high response rate. However, the study's generalizability is limited by its relatively small sample size, a large number of the study participants didn't complete the exercise regimen due to their noncompliance with follow-up visits.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for practice\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eFindings from this study suggest incorporating structured stretching and flexibility exercises into rehabilitation programs can significantly enhance functional recovery following an ankle fracture. Nurse educators and administrators should incorporate such exercises into continuing education and onboarding protocols to reduce complications and promote patient recovery. The strong correlation between knowledge and practice further supports ongoing competency assessment in clinical settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study highlight the significant impact of stretching and flexibility exercises on improving functional outcomes in patients with ankle injuries, support the integration of such exercises into standard post-injury rehabilitation protocols to accelerate functional recovery and improve the quality of life for affected individuals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest has been declared by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no specific grant from funding agencies in the public, commercial, or not-for-profit sectors for the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eN.F designed the study, prepared the manuscript, offered methodology and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003eE.S, collected and conducted the data analysis. Supervision, review, and approved the final manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge all patients who exhibited great patience in completing the questionnaires, to whom we express our deepest gratitude for their help and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMegan, A., Benedick, A., Breslin, M. A., Schmidt, T., \u0026amp; Vallier, H. (2021). Determinants of functional outcome following ankle fracture. \u003cem\u003eOTA International, 4\u003c/em\u003e(3), 1\u0026ndash;6. http://dx.doi.org/10.1097/OI9.0000000000000139\u003c/li\u003e\n\u003cli\u003eMostafa, N., \u0026amp; Osman, A. (2020). Effect of applying postoperative nursing instructions on ankle open reduction internal fixation surgery patients. \u003cem\u003eAssiut Scientific Nursing Journal, 8\u003c/em\u003e(23), 86\u0026ndash;95. DOI: 10.21608/asnj.2020.47999.1065\u003c/li\u003e\n\u003cli\u003eKeene, D., Costa, M., Peckham, N., Tutton, E., Barber, V., Dutton, S., Hopewell, S., Redmond, A., Willett, K., \u0026amp; Sarah, E. (2022). Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: The AFTER pilot randomized controlled trial. \u003cem\u003eBMJ Open, 12\u003c/em\u003e, e059235. https://doi.org/10.1136/bmjopen-2021-059235\u003c/li\u003e\n\u003cli\u003eMcKeown, R., Kearney, R., Liew, Z., \u0026amp; Ellard, D. (2020). Patient experiences of an ankle fracture and the most important factors in their recovery: A qualitative interview study. \u003cem\u003eBMJ Open, 10\u003c/em\u003e(2), e033539. https://doi.org/10.1136/bmjopen-2019-033539\u003c/li\u003e\n\u003cli\u003eKaya, D., Yuksel, I., Turhan, E., Aşik, M., \u0026amp; Dora, M. (2023). Proprioceptive and functional exercises after ankle surgery. In \u003cem\u003eSports Injuries\u003c/em\u003e (pp. 1779\u0026ndash;1791). Springer. https://link.springer.com/referenceworkentry/10.1007/978-3-642-36569-0_147\u003c/li\u003e\n\u003cli\u003eMosc\u0026atilde;o, J., Alves, J., \u0026amp; Afonso, J. (2020). A review of the effects of static stretching in human mobility and strength training as a more powerful alternative: Towards a different paradigm. \u003cem\u003eMotricidade, 16\u003c/em\u003e(1), 18\u0026ndash;27. http://dx.doi.org/10.6063/motricidade.20191\u003c/li\u003e\n\u003cli\u003eJensen, C., Serritslev, R., \u0026amp; Abrahamsen, C. (2022). Patients\u0026rsquo; perspective on treatment and early rehabilitation after an ankle fracture: A longitudinal qualitative study. \u003cem\u003eInternational Journal of Orthopaedic and Trauma Nursing, 46\u003c/em\u003e, 100916. https://doi.org/10.1016/j.ijotn.2021.100916\u003c/li\u003e\n\u003cli\u003eCho, K., Jeon, Y., \u0026amp; Lee, H. (2016). Range of motion of the ankle according to pushing force, gender and knee position. \u003cem\u003eAnnals of Rehabilitation Medicine, 40\u003c/em\u003e(2), 271\u0026ndash;278. DOI: 10.5535/arm.2016.40.2.271\u003c/li\u003e\n\u003cli\u003eLovett, R. W., \u0026amp; Martin, E. G. (2014). Certain aspects of infantile paralysis and a description of a method of muscle testing. \u003cem\u003eJAMA, 66\u003c/em\u003e, 729\u0026ndash;733.\u003c/li\u003e\n\u003cli\u003eMartin, R., Irrgang, J., Burdett, R., Conti, S., \u0026amp; VanSwearingen, J. (2005). Evidence of validity for the Foot and Ankle Ability Measure. \u003cem\u003eFoot \u0026amp; Ankle International, 25\u003c/em\u003e(11), 986\u0026ndash;983. DOI: 10.1177/107110070502601113\u003c/li\u003e\n\u003cli\u003eDazines, L. (2008). Numeric pain rating scale. Retrieved December 18, 2015, from http://www.orthopedicsores.com\u003c/li\u003e\n\u003cli\u003eMaeda, N., Urabe, Y., Fujii, E., Moriyama, N., Iwata, S., \u0026amp; Sasadai, J. (2016). The effect of different stretching techniques on ankle joint range of motion and dynamic postural stability after landing. \u003cem\u003eJournal of Sports Medicine and Physical Fitness, 56\u003c/em\u003e(6), 692\u0026ndash;698. https://pubmed.ncbi.nlm.nih.gov/25854771/\u003c/li\u003e\n\u003cli\u003eAl-Khafaji, W., \u0026amp; Al-Masoodi, F. (2023). The effect of stretching exercises by proprioceptive neuromuscular facilitation (PNF) of sensory receptors in the rehabilitation of ankle injury for athletes. \u003cem\u003eIbero-American Journal of Exercise and Sports Psychology, 18\u003c/em\u003e(4). https://www.riped-online.com/articles/the-effect-of-stretching-exercises-by-proprioceptive-neuromuscular-facilitation-pnf-of-sensory-receptors-in-the-rehabilitation-of--97932.html\u003c/li\u003e\n\u003cli\u003eSmeeing, D. P. J., Houwert, R. M., Briet, J. P., Groenwold, R. H. H., Lansink, K. W. W., Leenen, L. P. H., van der Zwaal, P., Hoogendoorn, J. M., van Heijl, M., Verleisdonk, E. J., et al. (2020). Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: A multicenter randomized controlled trial. \u003cem\u003eEuropean Journal of Trauma and Emergency Surgery, 46\u003c/em\u003e(1), 121\u0026ndash;130. https://doi.org/10.1007/s00068-018-1016-6\u003c/li\u003e\n\u003cli\u003eSt\u0026oslash;ve, M., Hansen, L., Elmb\u0026aelig;k, K., Magnusson, S., Thomsen, J., \u0026amp; Riis, A. (2024). The effect of stretching intensity on pain sensitivity: A randomized crossover study on healthy adults. \u003cem\u003eEuropean Journal of Pain, 29\u003c/em\u003e(3), e4750. https://doi.org/10.1002/ejp.4750\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 4 and 6","content":"\u003cp\u003eTable 4 and 6 are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stretching exercises, Flexibility exercises, Ankle functional abilities, Ankle Fracture","lastPublishedDoi":"10.21203/rs.3.rs-7255521/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7255521/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAnkle fractures are one of the most common fractures of the lower extremity, with an incidence of 187 per 100,000 patients each year\u003cstrong\u003e.\u003c/strong\u003e Post ankle fracture patients reported an average 30% loss of pre injury ankle function. Function is poor due to pain and reduced joint motion, lower limb muscle strength deficits, gait abnormalities and resultant mobility limitations\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim : \u003c/strong\u003edetermine the effect of stretching and flexibility exercises on ankle functional abilities post ankle fracture\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign: \u003c/strong\u003eQuasi experimental (one group pre and post intervention design) was utilized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSettings: \u003c/strong\u003eThe study was carried out at inpatient and outpatient Orthopedic Clinics, El- Hadra University Hospital, Alexandria -University, Egypt.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubjects: \u003c/strong\u003ea convenience sample of 50 adult patients with ankle closed fracture, post open reduction \u0026amp;internal fixation were included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTools:\u003c/strong\u003e Four tools were used for data collection. Tool I: Sociodemographic and clinical data: structured interview schedule. Tool II: Ankle mobility index. Tool III: Ankle functional ability scale and Tool IV: Ankle pain during activities assessment scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e there was significant improvement of all ankle range of motion during dorsiflexion, planter flexion, inversion\u0026amp; eversion among the two evaluation points. There was significant improvement in ankle muscle strength during dorsiflexion, planter flexion, inversion\u0026amp; eversion superiority to post eight weeks of stretching and flexibility exercises application. There was significant improvement in the studied patients' foot and ankle ability post stretching and flexibility exercises. There was a significant decrease in pain severity at rest, during bed activities performance, at sitting position, when standing. When walking, when going up stairs \u0026amp;when going with superiority to eight weeks of exercises application\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe findings of this study highlight the significant impact of stretching and flexibility exercises on improving functional outcomes in patients with ankle injuries, support the integration of such exercises into standard post-injury rehabilitation protocols to accelerate functional recovery and improve the quality of life for affected individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations:\u003c/strong\u003e Future studies could further explore the comparative effects of different exercise modalities, durations, and intensities. Moreover, investigating the long-term sustainability of pain reduction and functional improvement post-intervention would be valuable in guiding ongoing rehabilitation protocols.\u003c/p\u003e","manuscriptTitle":"Effect Of Stretching and Flexibility Exercises On Ankle Functional Abilities Post Ankle Fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 14:19:00","doi":"10.21203/rs.3.rs-7255521/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"240d4763-cde5-468a-9fa1-027c14eef0fb","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-04T10:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 14:19:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7255521","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7255521","identity":"rs-7255521","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}