Introduction
The ankle is a joint frequently subjected to damage, and the most prevalent damage is the sprain of the lateral ankle ligament. Severe sprain of the lateral ankle ligament accounts for 85% of ankle damage [1]. A frequent ankle sprain can cause chronic ankle instability [2]. Chronic ankle instability refers to symptoms such as ligament laxity, disorders in controlling the situation, and the hollow feeling that remain for at least a year after the initial sprain [3]. This instability can result from a change in neuromuscular control [4], which appears as pattern alterations in motion, muscle function, and stability [5, 6]. Control disorder is observed in people diagnosed with ankle instability [7]. 
Research has demonstrated that biomechanical changes and sense-motion deficiencies occur in chronic ankle instability and can limit daily activities and result in erosive ankle damage [8]. In addition, functional and mechanical deficiencies in athletes result in re-injury during sports activities and eventually lead to losing playing and financial opportunities [9]. Meanwhile, such chronic damage results in negative psychological impacts on athletes and may even lead to their retirement from sports, especially professional sports activities [10]. Accordingly, it is crucial to identify the factors and design proper training protocols that reduce the side effects of ankle sprain damage, facilitate improvement, and prevent further injuries after the sprain. One of the training protocols designed for these people is neuromuscular training [11].
Neuromuscular training enables the central nervous system to activate the muscle motion neurons and increase joint awareness with a specific and organized pattern through mechanoreceptors and increasing the harmony between neurons and muscles [12]. Review studies examining the effects of neuromuscular training on these subjects have demonstrated that such training has a positive impact on the balance and motion function of people diagnosed with this disease [13, 14, 15]. However, no study has examined how neuromuscular training performs compared to other types of training. The question is whether neuromuscular training has a more positive impact compared to other types of training on these people or whether there is a significant difference between this type of training with other training protocols. Accordingly, the present meta-analysis study investigates this subject. It compares neuromuscular training with other types of training to clarify which type of training positively impacts the balance and motion functionality of people with chronic ankle instability. 
Materials and Methods
This research is a systematic review based on the guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). 
Databases 
The following databases were consulted for related articles: MEDLINE/PubMed, Embase/Scopus, LILACS, CINAHL, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, PEDro, and Google Scholar. The search period was from the beginning of 2021 to December 2021. Keywords were selected based on MeSH, but they were slightly revised to ensure that all related articles were found. In addition, a manual search was done to comprehensively search the resources of the articles. The selected databases were searched with the following keywords: “balance control” OR “center of pressure” OR “balance” OR “postural stability” OR “postural balance” OR “postural sway” OR “stability” OR “static balance” OR “static stance” OR “dynamic balance” AND “ankle sprain” OR “ankle instability” OR “chronic ankle instability”, “functional ankle instability” OR “ankle injuries” OR “recurrent ankle sprain” OR “lateral ankle sprain” AND “exercise training” “training” OR “physical exercise” OR “exercise program” OR “exercise therapy” OR “exercise” OR “exercise work-out” OR “balance training” OR “proprioception training” OR “neuromuscular training”.
In addition, this search was conducted on Persian databases, including Magiran, IranDoc, Iranmedex, MedLib, and SID. The equivalent keywords were searched in the selected Persian databases. After obtaining the articles, the summary of the articles was studied to check whether they passed the inclusion and exclusion criteria. The articles that did not pass the criteria were eliminated. According to the study’s objectives, 21 articles were selected after the evaluation stage. The full text of the articles was then gathered. 
Inclusion criteria
The inclusion criteria comprised the following items: published articles in English or Persian, trials without orthopedic conditions that might impact balance or motion functionality, studies that investigated balance and motion functionality, and original research articles with randomized clinical trials.
Quality evaluation of articles
To observe the quality of the articles, we used the PEDro measurement. This measurement includes 11 questions, and each question has 1 score. If an article scores 7 or higher, it shows that the article has a high quality. Scores 5 and 6 show average quality, and scores below 5 show poor quality [16]. 
Article analysis method
To conduct the meta-analysis, we used Hedges’ g (the ratio of the difference between the two groups and the weighted standard deviation). The heterogeneity between the articles was evaluated with the I2 index. If the heterogeneity were obtained above 50%, we would use the random effects model. For the heterogeneity of below 50%, we would use the fixed-effects model. The skewness of articles was observed with the Egger test. We used the Comprehensive Meta-Analysis software, v. 2.0, to perform all the analyses.
Results
Selection of articles 
After reviewing all articles, 21 studies that used 24 training protocols were selected. Finalized articles were divided into two categories for further analysis: articles that compared neuromuscular training with other types of training and articles that compared the new balance training and training combinations with other balance training.
Quality of articles
Using the PEDro tool to examine the quality of articles, the average score for selected studies based on this measurement was higher than 7 (average score of present articles=7.5); this shows that selected articles for this meta-analysis benefit from high quality and the results of the present are valid and reliable. 
Results
Figure 1 shows the meta-analysis results of comparing the impact of neuromuscular training with other types of training on the static balance of people diagnosed with chronic ankle instability. The I2 index shows 0% heterogeneity among the studies; therefore, we used the fixed effect meta-analysis model. The Hedges’ g for the effects of training programs on static balance is obtained at 0.31 with a 95% confidence interval (0.02-0.060). The results of the meta-analysis demonstrate a significant difference between neuromuscular training with other types of training on the static balance of people with chronic ankle instability (P=0.03). Accordingly, neuromuscular training affects the static balance of these patients better than other types of training. Meanwhile, the Egger test between articles is 0.65, which shows no skewness.
Figure 2 demonstrates the results of the meta-analysis on comparing the effects of neuromuscular training with other types of training on the dynamic stability of people with chronic ankle instability. The I2 index shows 41.35% heterogeneity among the studies; therefore, we used the fixed effect meta-analysis model. The Hedgers’ g for training programs on dynamic stability was obtained at 0.47 with a 95% confidence interval (0.15–0.74). The meta-analysis results show a significant difference between neuromuscular training and other types of training on the dynamic stability of people with chronic ankle instability (P=0.001). Accordingly, neuromuscular training affects the dynamic stability of people compared to other types of training. Also, the result of the Egger test was obtained at 0.4, which shows no skewness.
Figure 3 demonstrates the effects of neuromuscular training compared to other types of training on the motion functionality of people with chronic ankle instability. The I2 index is obtained at 0%, which shows no heterogeneity between the articles; therefore, we used the fixed effect meta-analysis model. The Hedgers’ g of training programs on motion functionality was obtained at 0.03 with a 95% confidence interval (-0.23–0.28). The meta-analysis results show no significant difference between neuromuscular training and other types of training on the motion functionality of people with chronic ankle instability (P=0.85). Accordingly, the two types of training have the same impact on the motion functionality of people with chronic ankle instability. In addition, the Egger test results were obtained at 0.62, which shows no skewness. 
Figure 4 shows the results of the meta-analysis on the comparison of traditional balance training with other combinatory balance training or balance training with a device on the static balance of people with chronic ankle instability. The I2 index shows 81.81% heterogeneity among the articles; therefore, we used the random effect meta-analysis model. The Hedgers’ g for training programs on the static balance was obtained at 1.17 with a 95% confidence interval (-1.80–0.55). The meta-analysis results show a significant difference between neuromuscular training with other balance-combinatory training or balance training with a device on people with chronic ankle instability (P=0.0001). Accordingly, balance-combinatory training or balance training with a device better affects the static balance of people with chronic ankle instability compared to traditional balance training. Meanwhile, the Egger test result was obtained at 0.6, which shows no skewness.
Figure 5 shows the results of the meta-analysis on the comparison of traditional balance training with other combinatory balance training or balance training with a device on the dynamic balance of people with chronic ankle instability. The I2 index shows 0% heterogeneity among the articles; therefore, we used the fixed effect meta-analysis model. The Hedgers g for training programs on the dynamic balance was obtained at 0.27 with a 95% confidence interval (-0.58–0.05). The meta-analysis results show no significant difference between neuromuscular training with other balance-combinatory training or balance training with a device on people with chronic ankle instability (P=0.1), even though the impact of balance-combinatory training or balance training with a device was better than traditional balance training. Meanwhile, the Egger test result was obtained at 0.57, which shows no skewness.
Figure 6 shows the results of the meta-analysis on the comparison of traditional balance training with other combinatory balance training or balance training with a device on the motion functionality of people with chronic ankle instability. The I2 index shows 28.09% heterogeneity among the articles; therefore, we used the fixed effect meta-analysis model. The Hedgers’ g for training programs on the dynamic balance was obtained at 0.49 with a 95% confidence interval (-0.81–0.19). The meta-analysis results show a significant difference between neuromuscular training with other balance-combinatory training or balance training with a device on people with chronic ankle instability (P=0.001). Accordingly, the impact of balance-combinatory training or balance training with a device was better than traditional balance training. Meanwhile, the Egger test result was obtained at 0.67, which shows no skewness.
Discussion
This study aimed to compare neuromuscular training with other types of training on the balance motion functionality of people with chronic ankle instability. It was found that other studies have compared the effects of neuromuscular training with other types of training on the balance and motion functionality of people with chronic ankle instability. These studies have compared the effects of new balance training and combinatory balance training on the balance and motion functionality of people with chronic ankle instability. This study showed that neuromuscular training better affects the static and dynamic balance of people with chronic ankle instability compared to other training protocols; however, no difference was observed between the two groups in terms of motion functionality. In addition, the study showed that balance-combinatory training and new balance training affect the static balance and motion functionality of people with chronic ankle instability compared to traditional balance training. However, in terms of dynamic stability, no significant difference was observed between the two groups, even though the impact of balance-combinatory training and new training was higher than the traditional balance training. 
Comparing neuromuscular training with other types of training on balance and motion functionality of people with chronic ankle instability
A total of 11 articles with 12 trials had been conducted to compare the effects of neuromuscular training with other types of training on the balance and motion functionality of people with chronic ankle instability [17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27]. The results of the meta-analysis showed that neuromuscular training, compared to other training protocols, has a more significant effect on the static (with an effect size of 0.31) and dynamic (with an effect size of 0.47) balance of people with chronic ankle instability. However, no significant difference was observed between the two groups of training in terms of motion functionality.
Neuromuscular training enables the central nervous system to activate the muscle motion neurons and increase joint awareness with a specific and organized pattern through mechanoreceptors and increasing the harmony between neurons and muscles. This condition leads to a better transition of information from joint receptors to the central nervous system while standing and performing the trials of dynamic balance [28]. These types of functionality training can have a crucial role in enhancing skill learning, calling motion units, increasing the plasticity of motion cortical, and improving the usage of muscles through creating physiological adaptabilities. Therefore, they result in better balance in people with chronic ankle instability. Accordingly, to increase the dynamic and static stability of people with chronic ankle instability, it is better to perform neuromuscular training as it affects the static and dynamic stability compared to other types of training.
Comparing the effects of traditional balance training with balance-combinatory training on the balance and motion functionality of people with chronic ankle instability
A total of 11 articles with 12 trials had been conducted comparing the effects of traditional balance training and balance-combinatory training or new balance training on the balance and motion functionality of people with chronic ankle instability [23, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39]. The meta-analysis results showed that balance-combinatory or new balance training, compared to traditional training, better affects the static balance (with an effect size of 1.17) and dynamic (with an effect size of 0.49) balance of people with chronic ankle instability. However, in terms of dynamic stability, no significant difference was observed between the two groups, even though the impact of balance-combinatory and new balance training was higher than traditional training. To enhance the balance and motion functionality of people with chronic ankle instability, it is better to use new balance training protocols and merge balance training protocols, as such training has better effects and beneficial results than traditional training.
Balance training protocols that were designed in the studies and are provided in this review study were designed combinatory as the protocols to cover the deficiencies of people who have chronic ankle instability. Therefore, these studies combined balance training with power training or other types of training that improve the proprioceptors. To justify this method, researchers believe that improving the sense of the joint after gaining power is because of the following two reasons. First, the unbalance between the power of the invertor and evertor muscles may result in mechanical instability of the ankle joint and subsequently stimulate the free nerve endings. In addition, the increase in power may eliminate free nerve endings and increase the transmission of β neurons to the central nervous system by improving the biomechanical balance of the ankle. Secondly, the result might be because of the increase in muscle spindles and Golgi tendon organs. Accordingly, when the muscle moves, impulses must come up from different parts of the central nervous system, including the ovarian ligaments and joint capsules, proprioceptors in the skin, muscle spindles, and tendons. 
Conclusion
The present study showed that neuromuscular training better affects the static and dynamic stability of people with chronic ankle instability compared to other training protocols. However, in terms of motion functionality, no significant difference was observed between the two groups. Also, the results of the present study showed that balance-combinatory training and new balance training methods, compared to traditional balance training, have a more significant impact on the static balance and motion functionality of people with chronic ankle instability. However, in terms of dynamic balance, there was no significant difference between the two groups, even though the impact of balance-combinatory training and new balance training was higher than the traditional training on dynamic balance. Balance-combinatory training and new balance training methods are more beneficial compared to other training protocols on balance and controlling the posture of people with chronic ankle instability.

Ethical Considerations
Compliance with ethical guidelines
This study was a systematic review and no experiments on animal or human samples were conducted.

Funding
This study did not receive funding from any organizations in for-profit or non-profit sectors.

Authors' contributions
Conceptualization and supervision, investigation, writing-original draft, writing-review & editing, data collection & data analysis: Ali Fatahi and Mahboobeh Dehnavi.

Conflict of interest
The authors declared no conflict of interest.
 


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