Article Full Title
Manipulative Therapy Plus Ankle Therapeutic Exercises for Adolescent Baseball Players with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial.
Author Names
Shin, Ho-Jin; Kim, Sung-Hyeon; Jung, Han Jo; Cho, Hwi-young; Hahm, Suk-Chan
Reviewer Name
Kendall Bietsch, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Manipulative therapies and exercises are commonly used for the management of chronic ankle instability (CAI), but there is no evidence regarding the efficacy of high-velocity low-amplitude manipulation (HVLA) in addition to ankle therapeutic exercise to improve CAI in adolescent baseball players (ABP). To compare the effects of HVLA plus ankle therapeutic exercise and ankle therapeutic exercise alone on ankle status, pain intensity, pain pressure threshold (PPT), range of motion (ROM) of the ankle joint, and balance ability in ABP with CAI, a single-blinded randomized controlled trial was conducted. A total of 31 ABP with CAI were randomly allocated to the intervention (n = 16) or control (n = 15) groups. The intervention group received HVLA plus resistance exercise twice a week for 4 weeks, while the control group received resistance exercise alone. Ankle status, pain intensity, PPT, ROM, and balance ability were assessed before and after the intervention. The American Orthopedic Foot and Ankle Society scores showed significant group and time interactions (total, p = 0.002; pain, p < 0.001; alignment, p = 0.001). There were significant group and time interactions in pain intensity (resting pain, p = 0.008; movement pain, p < 0.001). For ROM, there were significant group and time interactions on dorsiflexion (p = 0.006) and eversion (p = 0.026). The unipedal stance of the balance ability showed significant group and time interactions in path length (p = 0.006) and velocity (p = 0.006). Adding HVLA to resistance exercises may be synergistically effective in improving the ankle status, pain intensity, ROM, and balance ability in ABP with CAI.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
Were study participants and providers blinded to treatment group assignment?
Yes
Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
Was there high adherence to the intervention protocols for each treatment group?
Yes
Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Cannot Determine, Not Reported, or Not Applicable
Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
High-velocity low-amplitude (HVLA) ankle manipulation used in combination with ankle therapeutic exercises showed significant improvement in ankle status, pain intensity, ROM and balance ability compared to using therapeutic exercises alone in adolescent baseball players with chronic ankle instability.
Key Finding #2
Using HVLA in addition to ankle therapeutic exercise may be effective in the rehabilitation of chronic ankle instability in youth baseball players.
Key Finding #3
Pressure pain threshold (PPT) did not show a clinically significant difference in either the experimental or control groups, suggesting that PPT does not improve with either HVLA and/or therapeutic ankle exercises. However, the experimental group did show significant differences pre- and post-treatment in pain intensity (measured with VAS) during rest and movement, while the control group did not.
Paper Summary:
This single-blinded randomized controlled trial examined the effectiveness of high-velocity low-amplitude manipulation (HVLA) plus therapeutic exercise compared to therapeutic exercise alone in the rehabilitation of chronic ankle instability (CAI) in adolescent baseball players (ABP). The therapeutic exercise was the same in both the control and experimental groups, including a warm-up, main exercise, and a cool down. The main exercise consisted of strength training of the ankle dorsiflexors, plantarflexors, evertors, and invertors using a Theraband, while the warm-up and cool-down consisted of stretching and mobility exercises of the aforementioned muscle groups. This study specifically analyzed the effects of the interventions on ankle status, pain intensity, pain pressure threshold (PPT), ROM, and balance ability using the following outcome measures, respectively: the American Orthopedic Foot and Ankle Society (AOFAS) scores, a visual analog scale (VAS), a digital algometer, a digital inclinometer, and the AMTI Accusway. Comparison between the experimental group (the group receiving HVLA in combination with the therapeutic exercises) and control group (the group receiving therapeutic exercises alone) showed that ABP with CAI who received HVLA achieved significant improvements in ankle status, pain, ROM, and balance ability compared to those that only performed the therpeutic exercises. This suggests that HVLA used in combination with therapeutic exercise can be both appropriate and effective for CAI rehabiliation, although further studies are recommended for the clinical application of HVLA in CAI for ABP.
Paper Clinical Interpretation:
This study suggests that the application of HVLA combined with therapeutic exercises elicits more improvement in the rehabilitation of chronic ankle instability in adolescent baseball players compared to therapeutic exercises alone. Physical therapists should therefore consider this information and its potential clinical impact based on the presentation of each individual patient. Using this multi-faceted approach of combining manipulation techniques with exercise prescription to treat CAI in youth baseball players prompts physical therapists to apply a holistic, well-rounded treatment approach that evolves and adapts according to each patient’s initial testing, response to PT intervention (i.e.: treatment), and re-testing. This encourages therapists to address multiple facets of the bodily system in order to enhance optimal recovery in CAI rehabilitation. For example, in addition to prescribing therapeutic strengthening exercises based on patient presentation and tolerance to specific treatment modalities, it may also be valuable to consider using ROM-enhancing techniques, coordination training by proprioceptive neuromuscular facilitation pattern, postural control training, etc. In this specific case of ABP with CAI, the use of joint thrust manipulations with HVLA techniques in combination with strengthening exercise appears effective to use clinically in similar populations.
