Ankle/Foot

Author Names

Heni Ishwarlal Tandel, Yagna Unmesh Shukla

Reviewer Name

Abby Fortenberry, SPT

Reviewer Affiliation(s)

Duke University SPT

Paper Abstract

Background: Plantar fasciitis is a common cause of pain in the heel which occurs as a result of inflammation of the plantar aponeurosis at its attachment on the calcaneal tuberosity. Myofascial Release Technique is intended to improve the mobility of soft tissue through application of a slow, controlled mechanical stress directly into a restriction. Pressure is gradually increased or repeated until the mobility of the tissue is felt to improve.  Purpose: The purpose is to study the scientific evidences regarding the effect of the myofascial release technique in plantar fasciitis.  Methodology: A search for relevant articles was carried out using key words- plantar fasciitis, myofascial release technique, pain and functions and search engines- Google Scholar, PubMed, PEDro, ScienceDirect, ResearchGate and CINAHL. Studies were selected from year 2010-2019. Ten studies were included in which there were 7 RCT, 1 Prospective experimental study, 1 Quasi Experimental study and 1 Prepost interventional study.  Results: 10 studies were reviewed from which 7 studies concluded that MFR is more effective than a control group receiving sham treatment or conventional treatment and 3 studies highlighted MFR to be equally effective to alternative treatments.  Conclusion: Based on the analysis of these 10 articles, it can be concluded that MFR is an effective treatment regimen in individuals with Plantar Fasciitis.  Clinical Implication: MFR is found to be effective in reducing pain and improving functions in individuals with plantar fasciitis, therefore MFR technique can be considered as an adjunctive treatment in plantar fasciitis.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Cannot Determine, Not Reported, Not Applicable

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Cannot Determine, Not Reported, Not Applicable

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

7 studies found that myofascial release (MFR) was more effective than conventional treatment or a “sham” control group treatment.

Key Finding #2

3 studies found that MFR was just as effective to other alternative treatments such as iontophoresis, PRT, or MET.

Key Finding #3

Based on the found effectiveness in the studies, MFR can be used as a complementary treatment for plantar fasciitis.

Key Finding #4

MFR provides an analgesic effect using the afferent and effect pathways that promote pain modulation and suppression in the spinal cord.

Please provide your summary of the paper

This article conducted a systems review of several studies that discuss the effectiveness of myofascial release (MFR) as an adjunctive treatment for plantar fasciitis (PF). Overall, the study included 10 articles after assessing eligibility criteria of 189 articles from the last 10 years. Some of the studies mentioned mixed results regarding MFR’s qulity, but other studies found that MFR is an effective treatment for reducing pain and improving function. However, it was noted that the exact method of MFR was unclear, but the use of MFR was attributed to either decreasing risk factors for PF, such as tightness in the gastroc, or decreasing tension in the plantar fascia. Overall, of the articles selected for this study, it was found that MFR can be used to reduce pain and increase function for people with PF.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This was a relatively brief systems review of articles published within the past 10 years (2010-2019) that addressed MFR as a treatment for PF. While the results yielded that MFR was an effective treatment, the study only included 10 out of 189 articles. Therefore, I think more systems reviews that include a larger number of studies are needed to further explore mechanisms of MFR. In addition, the study had unclear specifics about the technique each of the articles used for MFR. I think it would prove beneficial to include more details about the MFR technique, and the severity of the PF that each person was experiencing in each study.

Author Names

Lubbe, D., Lakhani, E., Brantingham, JW., Parkin-Smith, GF., Cassa, TK., Globe, GA., & Korporaal, C.

Reviewer Name

Hannah Zhao, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective

The purpose of this study was to compare manipulative therapy (MT) plus rehabilitation to rehabilitation alone for recurrent ankle sprain with functional instability (RASFI) to determine short-term outcomes.

Methods

This was an assessor-blind, parallel-group randomized comparative trial. Thirty-three eligible participants with RASFI were randomly allocated to receive rehabilitation alone or chiropractic MT plus rehabilitation. All participants undertook a daily rehabilitation program over the course of the 4-week treatment period. The participants receiving MT had 6 treatments over the same treatment period. The primary outcome measures were the Foot and Ankle Disability Index and the visual analogue pain scale, with the secondary outcome measure being joint motion palpation. Data were collected at baseline and during week 5. Missing scores were replaced using a multiple imputation method. Statistical analysis of the data composed of repeated-measures analysis of variance.

Results

Between-group analysis demonstrated a difference in scores at the final consultation for the visual analogue scale and frequency of joint motion restrictions ( P ≤ .006) but not for the Foot and Ankle Disability Index ( P = .26).

Conclusions

This study showed that the patients with RASFI who received chiropractic MT plus rehabilitation showed significant short-term reduction in pain and the number of joint restrictions in the short-term but not disability when compared with rehabilitation alone.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Key Finding #1

The combination of manual therapy and rehabilitation for ankle injury yielded a greater reduction in pain (VAS scores) compared to rehabilitation alone.

Key Finding #2

The combination of manual therapy and rehabilitation for ankle injury showed a greater decrease in joint restriction, determined by clinician palpation, when compared to rehabilitation alone.

Key Finding #3

There was no significant difference in the disability (FADI scores) reported between the two patient groups.

Key Finding #4

Both treatment groups, rehabilitation alone and rehabilitation plus manual therapy, showed significantly significant outcomes in decreasing pain and joint restriction.

Please provide your summary of the paper

This assessor-blind, parallel group randomized comparative trial looked at thirty-three participants who were diagnosed with recurrent ankle sprain with functional instability (RASFI). A majority of ankle sprain injuries are due to a force that causes excessive inversion and plantarflexion, resulting in inversion ankle sprains that most commonly, impact first the anterior talofibular ligament, followed by the calcaneofibular and posterior talofibular ligaments. Inversion sprains are one of the most common injuries amongst athletes and 40% of the time, RASFI injuries can progress to chronic ankle instability (CAI). Proprioceptive and traditional strength training protocols have been shown to increase ankle stability and range of motion. As more research demonstrates hopeful outcomes from manual therapy techniques (ex: joint mobilization and manipulation) to the ankle and foot joint for ankle sprain injuries, this study considers the impact of combining traditional rehabilitation protocols with these manual therapy techniques. Participants were randomly placed in a control group, which received rehabilitation alone, or in an experimental group, which received rehabilitation plus manual therapy. All participants received a rehabilitation program over a 4-week period and participants in the experimental group received 6 treatments of manual therapy within that same time frame. While both groups demonstrated statistically significant improvement, the study concluded that participants who received rehabilitation plus manual therapy showed a greater decrease in pain (Visual Analogue Pain Scale) and joint restriction (Foot and Ankle Disability Index). However, when looking at disability, both groups were comparable in their results.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The study indicates that incorporating manual therapy techniques along with traditional rehabilitation protocols results in less pain and joint restriction for athletes with recurrent ankle sprains with functional instability (RASFI). These findings are clinically relevant because of the prevalence of inversion ankle sprains in active populations and the possibility of progressing towards chronic ankle instability (CAI). While the findings suggest standard strength training and proprioceptive protocols to be effective in improving pain and joint restriction, these outcomes can improve to a greater extent with the addition of manual therapy techniques. Therefore, when considering return to sport athletes who are under more of a time constraint, it may be beneficial to incorporate manual therapy techniques earlier on in the rehabilitation stages to speed up the recovery process.

Author Names

Kiran, N., Ahmed Awan, W., Sahar, W., Hameed, N., Sarfraz, N., & Niaz, A.

Reviewer Name

Emma Vohringer, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Abstract

Background: Chronic plantar fasciitis has been historically treated with conventional physical therapy. The use of the Garston Technique® (GT) is a new intervention for the management of chronic plantar fascitis, but there is lack of evidence in the literature regarding its efficacy.

Study objective: To evaluate the effectiveness of the GT on pain, foot function and general foot health in patients with plantar fasciitis.

Methods: This was a randomized clinical trial conducted from November 2020 to March 2021. The non-probability purposive sampling technique was used to select 30 patients.

Setting: Madinah Teaching Hospital, Faisalabad, Pakistan.

Participants: A total of 30 patients of both genders with a 6-week history of planter fasciitis and the presence of a calcaneus everted ≥2° were included in this study and randomly assigned to one of two groups.

Intervention: Both groups received conventional physical therapy (CPT) for 4 weeks and the experimental group in addition received GT.

Primary outcome measures: The primary outcome measures were pain, measured at baseline, after the second week and after the end of treatment (ie, the fourth week) on the visual analog scale (VAS); and general foot health and foot function, measured at baseline and after the end of treatment with the Modified Foot Health Status Questionnaire (FHSQ).

Results: The mean age of the study patients was 34.1 ± 6.67 years. There was significant improvement in pain in the GT group compared with the CPT group after the second (P = .005; partial η2 = 0.263) and the 4th (P = .000; partial η2 = 0.535) week of intervention. Foot function was also significantly improved (P < .05) in the GT group compared with the CPT group with a large effect size (Cohen’s d = 0.080). But in the case of general foot health, no significant difference was observed between the groups at the end of the fourth week.

Conclusion: The use of the GT combined with CPT shows significant results compared with CPT alone; ie, GT speeds up the recovery from heel pain and foot function in patients with chronic plantar fasciitis.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Cannot Determine, Not Reported, or Not Applicable

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. 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

Graston technique can speed up the recovery of plantar fasciitis.

Key Finding #2

Graston technique is a good therapetuic intervention alongside other therapies.

Key Finding #3

Graston was only effective in this small group during this short amount of time,further research needs to be conducted to determine if it is effective across a larger population.

Please provide your summary of the paper

Through a randomized approach, a study of 30 participants of similar demographics with a history of chronic plantar fasciitis and heel pain were split into two treatment groups. Half of the study participants were allocated to just conventional physical therapy and the other half were allocated to physical therapy along with Graston Technique and taping. The group that was allocated physical therapy in addition to Graston overall had better outcomes in terms of speed of recovery, pain reduction, and increased function/range of motion. Due to the limitations of this study — short duration, smaller sample size of 30 people, and single-centered due to COVID-19 — it is unknown if the results could be replicated in a larger study.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

I do believe that the current research on the use of Graston Technique for plantar fasciitis is limited and while this research study is a great step in that direction, it is still not enough based on its limitations. I think that the results of this study are beneficial though for increased implementation of Graston Technique and taping along with conventional physical therapy. If we had more people using Graston to speed up recovery of heel pain associated with plantar fasciitis and then even converting this more into research, we would have a better vision of the place for Graston in conventional physical therapy.

Author Names

Prabhakaradoss,  D., Sreejesh, M.S., Hameed  Pakkir  Mohamed, S., Vijay  Subbarayalu, A., Prabaharan, S.

Reviewer Name

Kiara Pryor, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Background: Lateral Ankle Sprain (LAS) is the most common musculoskeletal injury among highly active and non-active populations.  Physiotherapy plays a  significant role in  reducing  pain and  improving  range of  motion  (ROM)  and functional outcomes in people with LAS. Aims and Objectives: The study’s main objective is to compare the effects of manual therapy (Mulligan’s MWM) conventional physiotherapy (PRICE and therapeutic exercises) and conventional physiotherapy alone  on pain, ankle  ROM, and function in  subjects with LAS. Study  Design: A  randomized clinical trial was  used,  and  40 patients  diagnosed  with  acute and  sub-acute  grade  I  or  II LAS  were  randomly  allotted  to  two experimental groups. Setting: The patients who  met the selection criteria were recruited from the Team Physio Clinic, Pudukkottai, Tamilnadu, from  January 2020 to June 2021. Materials  and Methods: The experimental group I (n=20) received Mulligan’s MWM and conventional physiotherapy, whereas those assigned to the experimental group II (n=20) received  conventional  physiotherapy  alone.  The  treatment  duration  for  both  groups  was  four  weeks.  Outcome measures  such  as  pain  intensity,  ankle  dorsiflexion  ROM,  and  foot  and  ankle  disability  index  (FADI)  were used. Statistics: The Shapiro-Wilk test was applied to examine whether the data had a normal distribution. A paired ‘t-test’ was used to compare the pre-and post-intervention mean scores within a group. Further, an unpaired ‘t-test’ was used to compare the mean scores of both experimental groups at  pre-and post-intervention stages. The data analysis was carried out using SPSS at  a 5%  level of  significance. Results: Both experimental groups significantly reduced pain and improved ankle dorsiflexion ROM and  function following the treatment duration. There is  a significant difference between the two experimental groups in reducing pain and improving ankle dorsiflexion ROM and function at the post-intervention stage. Conclusion: MWM with conventional physiotherapy is significantly more effective than conventional physiotherapy alone in reducing pain and improving ankle dorsiflexion ROM and function in acute and subacute grade I or II LAS.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

Key Finding #1

When conventional physiotherapy is paired with manual therapy, there is a significant improvement in pain when compared to only utilizing conventional therapy alone.

Key Finding #2

When conventional physiotherapy is paired with manual therapy, there is a significant improvement in ankle dorsiflexion ROM when compared to only utilizing conventional therapy alone.

Key Finding #3

When conventional physiotherapy is paired with manual therapy, there is a significant improvement in overall ankle function, via a self-answered disability index, when compared to only utilizing conventional therapy alone.

Please provide your summary of the paper

This study assessed the outcome of lateral ankle sprains (LAS) when treated either with conventional therapy and manual therapy paired, or with conventional therapy alone. 40 participants were randomly assigned to one of the two intervention groups, 20 in one, and 20 in the other, where they would be compared to each other on the improvement of pain, ankle ROM, and overall function. Participants were aged 18-50 who had a unilateral LAS for the first time. Each patient received ankle immobilizing treatment for two to four weeks before treatment. Outcome measures assessed were a Numeric Pain Rating Scale (NRPS), ankle dorsiflexion (DF) ROM, the Foot and Ankle Disability Index, as well as The Shapiro-Wilk test to ensure normal statistical distribution.  The treatment lasted four weeks, with two sessions per week. Group 1, the experimental group, received Mulligan’s MWM along with therapeutic exercise while Group 2, the controlled group, received only therapeutic exercise.   At the end of the eight weeks, Group 1’s NRPS mean decreased from 6.20/10 to 1.85/10 while Group 2’s decreased from 6.35/10 to 3.30/10. Group 1’s ankle DF ROM increased from a mean of 25.10 degrees to 40.0 degrees while Group 2’s ankle DF ROM increased from 25.65 to 30.65. Lastly, Group 1’s disability index mean score increased from 64.70 to 85.20 and Group 2’s disability mean index increased from 64.25 to 79.60.  In conclusion, it was proven that when conventional therapy is paired with manual therapy, there are better overall outcomes in pain, ROM, and overall function than if conventional therapy is provided alone.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

The article explained that lateral ankle sprains account for up to 30% of all athletic injuries. Ramifications of this injury include but are not limited to, treatment costs, time loss from sport, a decrease in physical activity, and a decrease in mental health if not treated correctly.   This study showed that in order to provide the best recovery for this type of injury, physical therapists should consider adding manual therapy in combination with the traditional therapeutic exercises they prescribe. Not only will this be beneficial in reducing pain and increasing ROM, but overall ankle function improvement as well. Since lateral ankle sprains are such a prevalent injury, knowing best practice techniques is key to promoting the most positive outcome.

Author Names

Nambi, G. & Shah, B.

Reviewer Name

Kathryn O’Reilly, SPT

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

Background: The effectiveness of taping and bracing in the treatment of ankle injuries in hockey has not been investigated, although it has been shown effective in reducing the incidence of Sub-acute ankle injuries in other sports (basketball and US football). The effectiveness of application Mulligan‟s Mobilization with movement technique for talocrural dorsiflexion to sub acute lateral ankle sprains produces an initial dorsiflexion gain, and simultaneously produces a mechanical but not thermal hypoalgesia, so need to be proved the effectiveness in sub-acute lateral ankle sprain in secondary Hockey players. Methods: Thirty Subjects who have fulfilled inclusion and exclusion criteria have been selected from the population and divided into two Groups (A=Kinesiotaping technique & B=Mulligan‟s Mobilization with movement technique.). Ultrasound was given to both groups. Groups were evaluated with Qualitative outcome: Numerical pain Rating Scale and Quantitative outcome: Dorsiflexion range of motion (Knee-to- wall principal). Results: Both the Kinesiotaping and Mulligan‟s Mobilization with movement technique are effective in sub-acute lateral ankle sprain to reduce pain and improve the dorsiflexion range of motion. In Numerical pain rating scale Group B show 74.90% (p=0.01) of reduction as compare to Group A there is 55.69% (p=0.01) of reduction. In Dorsiflexion range of motion Group B there is 71.07% (p=0.000) of improvement as compare to Group A there is 27.64% (p=0.000) of improvement. Conclusions: This study demonstrated an effect of Mulligan‟s Mobilization with movement technique on sub-acute lateral ankle sprain in secoundary hockey players. These results suggest that this technique should be considered in rehabilitation program following subacute lateral ankle sprain. This study provides justification for follow-up research of the longterm effect of Mulligan‟s Mobilization with movement on sub-acute lateral ankle sprain and proposes further work be conducted on the weight-bearing posteroanterior tibial glide Mobilization with movement

NIH Risk of Bias Tool

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

1. Was the study question or objective clearly stated?
   Yes

2. Were eligibility/selection criteria for the study population prespecified and clearly described?
   Yes

3. Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?
   Yes

4. Were all eligible participants that met the prespecified entry criteria enrolled?
   Yes

5. Was the sample size sufficiently large to provide confidence in the findings?
   No

6. Was the test/service/intervention clearly described and delivered consistently across the study population?
   Yes

7. Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?
   Yes

8. Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
   No

9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
   Cannot Determine, Not Reported, Not Applicable

10. Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
    Yes

11. Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?
    No

12. If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?
    Cannot Determine, Not Reported, Not Applicable

Key Finding #1

The study found both Kinesiotaping and Mulligan’s Mobilizations to be successful in improving talocrural dorsiflexion range of motion in secondary-school hockey players with sub-acute lateral ankle sprains.

Key Finding #2

Group B (Mulligan’s Mobilizations with movement) showed a 74.90% reduction in Numerical Pain Rating compared to Group A (Kinesiotaping), who showed a 55.69% reduction.

Key Finding #3

Statistical analysis shows a 71.07% improvement in dorsiflexion range of motion in Group B (Mulligan’s Mobilizations with movement), compared to a 27.64% improvement in Group A (Kinesiotaping).

Please provide your summary of the paper

The purpose of this study was to compare the effectiveness of Kinesiotaping and Mulligan’s Mobilization with movement technique in the treatment of sub-acute lateral ankle sprains to reduce pain and improve dorsiflexion range of motion in secondary-school hockey players. Thirty subjects who fulfilled previously determined inclusion and exclusion criteria were selected from the population and placed into two groups. Subjects were between the ages of 13-17 and had suffered the injury at any point from 10 days to 7 weeks prior to the study’s start. Group A received Kinesiotaping for 3 sessions per week and Group B received Mulligan’s Mobilization with movement technique for 3 sessions per week. Both groups additionally received ultrasound treatment and were evaluated with the Numerical Pain Rating Scale and Dorsiflexion range of motion measurements (knee to wall principal). The results of this study show that Mulligan’s Mobilizations improve both subjective reports of pain as well as quantitative measures of dorsiflexion range of motion in hockey players with subacute lateral ankle sprains. While both Kinesiotaping and Mulligan’s Mobilizations showed improvements in each of these measures, Mulligan’s Mobilizations proved to be more successful. It is possible that the tension provided via the Kinesio-tape was not sufficient enough; as such, this may have altered results.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

It is highly worth noting that this is a comparative study done with a very small sample size and is not randomized. Limitations to the study include its limited sample size, a higher number of male participants compared to female participants, absence of a long-term follow up with patients in the study, and no control group. A strength of this study is its highly detailed descriptions regarding the specific treatment methods and goals of Kinesiotaping and Mulligan’s Mobilizations for this population. Detailed inclusion and exclusion criteria was established prior to choosing subjects. The study was able to reliably utilize the Numeric Pain Rating Scale and Dorsiflexion Range of Motion as outcome measures throughout its duration, which led to excellent inter- and intra-rater reliability. Furthermore, both interventions were described with great detail regarding intervention technique, frequency and duration of the intervention, and general procedure for application. The authors are able to utilize their own findings to compare to additional studies examining Mulligan’s mobilizations and manual therapy for ankle sprains. However, the conclusion is still that further research is vital to determine the long-term effects of this intervention. The results of this study may lead to therapists implementing Mulligan’s mobilizations with movement more frequently for athletes with sub-acute lateral ankle sprains. Additionally, with literature on Kinesiotaping being minimal as is, this further emphasizes the possibility of incorporating a manual technique such as Mulligan’s mobilizations for increasing range of motion and improving subjective pain reports.

Author Names

Burton, C., Arthur, R., Rivera, M., Powden, C.

Reviewer Name

Katherine Morgan, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context: Chronic ankle instability (CAI) is one of the most common chronic conditions in the world, resulting in millions of dollars contributed to the health care system. Joint mobilizations have been shown to effectively improve patient and disease-specific impairments secondary to CAI. The ability for patients to complete an effective manual therapy intervention without the need for continuous visits to a health care provider can alleviate burdens on the health care system and improve patient satisfaction.  Objective: To examine the effect of clinician-applied Maitland talocrural joint mobilization and self-mobilization (Self-Mob) on dorsiflexion range of motion (DFROM), dynamic balance, strength, and perceived function in those with CAI.  Design: Single-blind randomized trial. Setting: Research laboratory. Participants: A total of 18 participants (7 males and 11 females; age = 20.78 [2.02] y, height = 67.66 [3.83] cm, limb length = 87.74 [5.05] cm) with self-reported CAI participated. Interventions: The participants received 6 interventions over a 2-week period. The participants received either Maitland grade III anterior-to-posterior talocrural joint mobilizations or weight-bearing lunge Self-Mob. Each intervention consisted of four 2-minute sets, with a 1-minute rest between sets.  Main Outcome Measures: The DFROM (weight-bearing lunge), dynamic balance (Y-Balance Test), isometric strength, Foot and Ankle Ability Measure Quick, Disablement of the Physically Active modified, Fear Avoidance Beliefs Questionnaire, and Tampa Scale of Kinesiophobia-11 were measured preintervention and postintervention.  Results: Dynamic balance, isometric strength, and perceived function significantly improved in both groups at postintervention. The DFROM significantly improved in the Self-Mob group. Higher individual responder rates were demonstrated within the Self-Mob group compared with clinician-applied mobilizations.  Conclusions: Clinician-applied mobilizations and Self-Mobs are effective interventions for improving dynamic balance, isometric strength, and perceived function. Application of Self-Mobs can effectively improve DFROM compared with joint mobilization. Self-Mobs may be an effective intervention to incorporate into a home care plan.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. 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

Dorsiflexion ROM significantly improved for the self-mob group, but not for the group that received mobilizations from clinicians.

Key Finding #2

Both groups displayed improved dynamic postural control demonstrated by increased reach in the posteromedial (both groups) and posterolateral (clinician-mob group only) directions on the Y-balance test.

Key Finding #3

Both groups demonstrated increased ankle isometric strength as measured via handheld dynamometry

Key Finding #4

The self-mob group had significant improvements in self reported outcomes including the quick-FAAM, modified DPA, and FABQ. These changes show that self mobilization can increase a patient’s perception of their physical ability and decrease their self-reported fear avoidance and fear of reinjury.

Please provide your summary of the paper

The researchers aimed to evaluate the effect of clinician applied Maitland talocrural joint mobilization (grade III, AP) compared a weight bearing lunge self-mobilization on dorsiflexion range of motion, dynamic balance, isometric ankle strength, and perceived function in people with chronic ankle instability. Participants received 6 interventions over two weeks, with each intervention session consisting of four, two-minute sets of mobilizations with a one minute rest between sets.   Outcome measures assessed pre and post intervention included dorsiflexion ROM (in a weight bearing lunge position), Y-Balance test, ankle isometric strength, the Quick Foot and Ankle Ability Measure, modified Disability of the Physically Active, FABQ, and the Tampa Scale of Kinesiophobia-11.  Both groups showed improvements in dynamic balance, isometric strength, and perceived function. Additionally, the self-mob group showed improvements in DF ROM and higher individual responder rates than the clinician-mob group.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study shows that incorporating self mobilization into a home program may be effective in improving dynamic balance and isometric strength as well as decreasing self-reported fear avoidance and fear of re-injury in people with chronic ankle instability.

Author Names

Lin, C. W., Hiller, C. E., & de Bie, R. A.

Reviewer Name

Mason Dukes, SPT

Reviewer Affiliation(s)

Duke DPT Division

Paper Abstract

The most common ankle injuries are ankle sprain and ankle fracture. This review discusses treatments for ankle sprain (including the management of the acute sprain and chronic instability) and ankle fracture, using evidence from recent systematic reviews and randomized controlled trials. After ankle sprain, there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs. There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects. Electro-physical agents do not appear to enhance outcomes and are not recommended. Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability. After surgical fixation for ankle fracture, an early introduction of activity, administered via early weight-bearing or exercise during the immobilization period, may lead to better outcomes. However, the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events, suggesting that this treatment regimen needs to be applied judiciously. After the immobilization period, the focus of treatment for ankle fracture should be on a progressive exercise program.  Keywords: Ankle injuries, Evidence-based practice, Rehabilitation, Systematic review, Therapy

1. Is the review based on a focused question that is adequately formulated and described?

• Cannot Determine, Not Reported, Not Applicable

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Cannot Determine, Not Reported, Not Applicable

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Cannot Determine, Not Reported, Not Applicable

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Cannot Determine, Not Reported, Not Applicable

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• No

Key Finding #1

Manual therapy was shown to have a limited (weak) effect on ankle sprains, however, strengthening and balance are still better ways to prevent ankle sprains from occurring again. Further, in chronic ankle instability, strengthening and balance are better ways to prevent the ankle from ankle injuries. All the evidence regarding this topic needs to have stronger evidence.

Key Finding #2

The use of manual therapy in people who have ankle fractures did not provide better results. Instead, when an ankle fracture occurs the focus should remain on progressing an exercise program with the surrounding structures.

Please provide your summary of the paper

Ankle sprains and fractures are 2 of the most common ankle injuries. This systematic review discusses the articles on whether manual therapy or exercise is more beneficial for the rehabilitation of these injuries. The use of RCTs used QOl assessments, ROM measures, the Pain Numerical Rating Scale, and disability indexes to determine if manual therapy techniques were effective. It was concluded that manual therapy could be effective when in the acute stages of rehabilitation. Chronic ankle instability does not have conclusive evidence regarding the effectiveness of manual therapy. Further, ankle fractures did not reflect the effectiveness of manual therapy techniques. Ankle sprains and fracture rehabilitation should focus on exercise programs for strengthening, balance, and weight-bearing.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This paper provided good information about the rehabilitation of ankle injuries. I imagined manual therapy would not be the best choice of treatment for acute injury due to pain and swelling. However, I was open to reading about it because I was curious about how these techniques were interpreted by the patients in the articles. There are parts of this article that talk about the ‘deemed improvement’ of the patient’s ankle after these techniques, but their scores did not reflect this same response. This was interesting to me, but I think it has more to do with the healing process as they will begin to feel better over time. I feel more informed and confident about the rehab techniques for this population, and I will focus my treatment on strengthening, balance, and weight-bearing.

Author Names

Vaillant, J., Rouland, A., Martigne, P., Braujou, R., Nissen, M., Caillat-Miousse, J., Vuillerme, N., Nougier, V., Juvin, R.

Reviewer Name

Kylie Dahlberg, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The aim of this study was to evaluate the effects of a session of plantar massage and joint mobilization of the feet and ankles on clinical balance performance in elderly people. A randomized, placebo-controlled, cross-over trial was used to examine the immediate effects of manual massage and mobilization of the feet and ankles. Twenty-eight subjects, aged from 65 to 95 years (78.8 8.5 years – mean SD) were recruited from community nursing homes. Main outcome measures were the performances in three tests: One Leg Balance (OLB) test, Timed Up and Go (TUG) test and Lateral Reach (LR) test. Results demonstrated a significant improvement after massage and mobilization compared with placebo for the OLB test (1.1 1.7 s versus 0.4 1.2 s, p < 0.01) and the TUG test (0.9 2.6 s versus 0.2 1.2 s, p < 0.05). Conversely, performances in the LR test did not improve significantly. These results emphasize the positive impact of a single session of manual therapy applied to the feet and ankles on balance in elderly subjects.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. 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

After massage and mobilization, there were significant improvements in the One Leg Balance test (OLB) and the Timed Up and Go test (TUG) compared with the placebo.

Key Finding #2

The improvements found in this study could be due to the improvement of somatosensory information, which plays a role in postural control and balance.

Key Finding #3

The results found in this study emphasize that there is a positive impact on balance in elderly populations when a single session of manual therapy is applied to the feet and ankles.

Key Finding #4

After massage and mobilization, there were no significant improvements in the lateral reach test compared with the placebo group.

Please provide your summary of the paper

The purpose of this study was to evaluate the effects of massage and mobilization on balance performance in elderly adults. This is an important study because older adults are at a higher risk of falls due to the natural aging process. This natural aging process can lead to reduced joint flexibility and reduced afferent sensory information. Having an adequate range of motion in the ankle is also shown to be important for gait and balance. The participants in this study were volunteers from community nursing homes who met the inclusion criteria. The three functional balance performance tests used in this study were the One Leg Balance test (OLB), the Timed Up and Go (TUG), and the Lateral Reach (LR). The tests were performed in that order for every participant. Both the massage and mobilization interventions were applied for a total of 20 minutes for each participant not in the placebo group. The aim of these interventions was to target the somatosensory system, which plays an important role in balance. This study found that there was a statistically significant improvement in balance performance for both the OLB and the TUG test, where the LR test showed no statistical improvements. Researchers hypothesize that improvements in the somatosensory system from the interventions could explain the results found in this study. One limitation of this study was that it assessed balance performance immediately after the intervention and it is hard to tell how long the effects of that intervention will last.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study can impact clinical practice because the results show that massage and mobilization on the ankle do have a positive impact on balance performance, specifically the Timed Up and Go and the One Leg Balance test. This information is helpful for clinicians because it shows that massage and mobilization can make a difference in balance, which could lead to a decrease in falls in elderly adults. This study also used a test, treat, retest method, which is what is used in the clinical practice. Researchers tested balance, treated with massage and mobilization, and then retested to see if there were any improvements, which there were. This study emphasizes that just 20 minutes of massage and mobilization can make a positive impact on older adults balance, therefore decreasing their risk of falls.

Author Names

Plessis, M. Zipfel, B. Brantingham, J. Parkin-Smith, G. Birdsey, P. Globe, G. Cassa, T.

Reviewer Name

Jack Commeville SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program CO 2025

Paper Abstract

Context: Hallux abducto valgus (HAV) is a frequent cause of great toe pain and disability, yet common treatments are only supported by mixed or equivocal research findings. Surgery often only provides modest improvement and post-surgery complications may significantly hamper outcomes, implying the need for trials testing conservative treatment, such as manual and manipulative therapy, particularly in cases where surgery may be contraindicated or premature. The purpose of this exploratory trial was to test an innovative protocol of manual and manipulative therapy (MMT) and compare it to standard care of a night splint(s) for symptomatic mild to moderate HAV, with a view gather insight into the effectiveness of MMT and inform the design of a definitive trial.  Design: Parallel-group randomised trial set in an out-patient teaching clinic.  Participants: A convenience sample of 75 patients was assessed for eligibility, with 30 participants (15 per group) being consented and randomly allocated to either the control group (standard care with a night splint) or the experimental group (MMT).  Intervention: Participants in the control group used a night splint(s) and those in the experimental group (MMT) received a structured protocol of MMT, with the participants in the experimental group receiving 4 treatments over a 2-week period.  Outcome measures: Visual analogue scale (HAV-related pain), foot function index (HAV-related disability) and hallux dorsiflexion (goniometry).  Results: There were no participant dropouts and no data was missing. There were no statistical (p<0.05) or clinically meaningful differences (MCID<20%) between the two groups based on outcome measure scores. However, the outcome measure scores in the control group (night splint) regressed between the 1-week follow-up and 1-month follow-up, while the scores in the experimental group (MMT) were sustained up to the 1-month follow-up. The within-group data analysis produced statistically and clinically significant changes from baseline to the 1-week flow-up across all outcome measures. Post hoc power analysis and sample size calculations suggest that the average between group power of this trial was approximately 60% (ES = 0.33) and that a definitive trial would require a minimum of 102 participants per group (N = 204) to achieve satisfactory power of ≥80%.  Conclusions: The trend in results of this trial suggest that an innovative structured protocol of manual and manipulative therapy (experimental group) is equivalent to standard care of a night splint(s) (control group) for symptomatic mild to moderate HAV in the short term. The protocol of MMT maintains its treatment effect from 1-week to 1-month follow-up without further treatment, while patients receiving standard care seem to regress when not using the night splint. Insights from this study support further testing of MMT for symptomatic mild to moderate HAV, particularly where surgery is premature or where surgical outcomes may be equivocal, and serve to inform the design of a future definitive trial.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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?

• Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

The outcome measure scores in the control group regressed between the 1-week and 1-month follow-up, while the scores in the experimental group were sustained up to the 1-month follow-up.

Key Finding #2

The within-group data analysis produced statistically and clinically significant changes from baseline to the 1-week follow-up across all outcome measures.

Key Finding #3

A structured protocol of manual and manipulative therapy is equivalent to standard care of a night splinting for symptomatic mild to moderate HAV in the short term.

Key Finding #4

Please provide your summary of the paper

Hallux abducto valgus (HAV) is a common cause of great toe pain and disability, but common treatments are only supported by mixed research findings. This randomized clinical trial in an outpatient clinic decided to test a technique concerning manual and manipulative therapy (MMT) and compare it to the use of night splints for mild to moderate HAV. The control group used night splints while the experimental group received 4 treatments of MMT over 2 weeks. The study found that MMT is a good short-term equivalent to the use of night splints, however, the use of MMT had longer-lasting effects compared to the traditional night splints. Further testing of MMT as a treatment for HAV is needed.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This can apply to patients who are diagnosed with HAV. To give the most adequate care as a physical therapist, it is necessary to figure out the greatest outcome for the patient. When working with the patient, this study supports the use of MMT and night splints, which can be discussed with the patient moving forward on which form of treatment they would prefer.

Author Names

Weerasekara,I., Deam,H., Bamborough, N., Brown,S., Donnelly, J., Thorp, N., Rivett, D.

Reviewer Name

Alexander Caspary-Isar, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Purpose: To investigate the evidence for the effectiveness of MWM’s in isolation for ankle sprains.

Materials and methods: Medline, Embase, CINHAL and SPORTDiscuss were searched. Any RCT or cross-over trial assessing adolescents to adults with grade I/II lateral ankle sprains, and treated with any MWM technique was included. Any conservative intervention was chosen as the comparator, and any clinical outcome was eligible as the outcome. Methodological quality was determined using the Cochrane Handbook risk of bias assessment tool.

Results: Eighty-two full-texts were included after screening 1707 of title and abstracts. Six full-texts were included and data were extracted based on the outcomes of range of movement, balance or pain from patients with sub-acute to chronic sprains. Pooled data from four studies with 201 participants with chronic recurrent sprains were grouped for analysis of the effects of weight-bearing MWM on dorsiflexion range and has shown significant immediate improvements after treatment (MD = 0.91, CI = 0.06-1.76, p = 0.04). There was insufficient data to permit analysis for evaluation of immediate or short-term benefits of MWM on other assessed outcomes.

Conclusion: Weight-bearing MWM appears to be beneficial for improving weight-bearing dorsiflexion immediately after application for chronic recurrent ankle sprains compared to no treatment or sham. Long-term benefits have not been adequately investigated.

Keywords: Ankle sprains; Mulligan taping; Mulligan’s mobilisation with movement; Systematic review.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Cannot Determine, Not Reported, Not Applicable

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Yes

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Yes

Key Finding #1

 Mobilizations with movement known as Mulligan’s technique do not have any clinical benefits on acute ankle sprains, due to the pain the patient is experiencing. This technique should be explored only with chronic lateral ankle sprain patients.

Key Finding #2

There was an immediate positive effect of utilizing weight bearing mobilizations with movement for improving dorsiflexion range of motion for patients presenting with chronic ankle sprains.

Key Finding #3

There was an improvement in dynamic balance over time, due to mulligan’s technique being performed at the talocrural joint. A combination of patient confidence and perceived stability contributed to the improvements exhibited by the patients.

Key Finding #4

Talar stiffness has shown to improve over time when mobilizations with movement are performed at the subtalar and talocrural joint. They especially helped grade I and II lateral ankle sprains.

Please provide your summary of the paper

 This systematic review and meta analysis study sought out to evaluate the effectiveness of Mulligan’s mobilization with movement (MWM) technique in isolation from the other techniques on patients presenting with lateral ankle sprains focusing on balance, talar stiffness and dorsiflexion range of motion. The data were analyzed utilizing the validated measures emphasized in the methods section. They found that this technique in isolation was effective in improving various outcomes in patients presenting with chronic lateral ankle sprains. They found that the technique was effective in immediate benefits for the patient such as an improvement in dorsiflexion range of motion assessed by having the patient perform a weight bearing lunge test. The study also found acute benefits with dynamic balance when applying mulligan’s technique to the talocrural joint, however, no improvements were shown with static balance.This supports that mulligans technique performed at the talocrural joint have an immediate impact on ankle dorsiflexion ROM that can help with patients demonstrating chronic lateral ankle sprains.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

The results of this systematic review support the benefit of manual therapy in improving impairments in the body structure and function such as limitations in ankle dorsiflexion after developing a chronic lateral ankle sprain. It also shows the benefits it has on function such as helping with any reduced dorsiflexion ROM required in gait and improving dynamic balance over time. This study may impact clinical practice by implementing this technique at the talocrural and subtalar joints for patients presenting with the decreased range of motion as well as being applicable to patients that have had lateral ankle sprain for more than six months. It helps provide the patient with an objective measure of their progress by being able to notice acute improvements that will help with their confidence and trust in physical therapy. Further research should be done to assess the long term effects of mobilizations with movement beyond the time span they used of three days to three months being defined as acute.

Author Names

Jayaseelan, D. Kecman, M. Alcorn, D. Sault, J

Reviewer Name

Miranda Cano- SPT, LAT, ATC

Reviewer Affiliation(s)

Duke Doctor of Physical Therapy Division

Paper Abstract

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT.

NIH Risk of Bias Tool

Quality Assessment Tool for Case Series Studies

1. Was the study question or objective clearly stated?

• Yes

2. Was the study population clearly and fully described, including a case definition?

• Yes

3. Were the cases consecutive?

• Yes

4. Were the subjects comparable?

• Yes

5. Was the intervention clearly described?

• Yes

6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?

• Yes

7. Was the length of follow-up adequate?

• Yes

8. Were the statistical methods well-described?

• Cannot Determine, Not Recorded, Not Applicable

9. Were the results well-described?

• Yes

Key Finding #1

For patients with chronic degenerative tendon changes, eccentric exercises have been shown to decrease pain and show improvements in functions, but those who have symptoms lasting for a longer period of time may require additional treatment.

Key Finding #2

Abnormal motion in the ankle or abnormal joint mobility can play a role in developing Achilles tendinopathy and causing it to be a chronic issue.

Key Finding #3

Joint mobilization and manipulation that were introduced along with eccentric exercises for patients with Achilles tendinopathy were seen to have immediate improvements in function and symptoms that lasted past discharge.

Key Finding #4

Manual therapy has been seen to be safe and effective when treating chronic tendinopathies.

Please provide your summary of the paper

This case series examined joint mobilization and manipulation in three runners with chronic Achilles tendinopathy. Joint mobilization and manipulation were performed locally and at nearby sites where immediate improvements were seen in pain levels, single leg calf raises and in PPT readings. At discharge, all three patients significantly improved their VISA-A questionnaire scores and their pain pressure threshold values as well as surpassed the MCID for the NPRS and GROC. Additionally, improvements in symptoms and function were maintained for at least nine months when reported in a follow up email.

Given that only three patients participated in this case series, these results cannot be easily generalized. With a lack of a control group and a non-experimental study design, it is possible that the joint thrust manipulation and non-thrust manipulation were not the only factors contributing to success. However, each patient did show immediate improvement in pain and function following this treatment which suggests instant benefit and positive reported outcomes over time.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

Based on the results of this study, it has been found that tendinopathies can benefit from more than eccentric exercise. Given that patients with Achilles tendinopathy have seen improvements with manual therapy techniques, clinicians should incorporate both eccentric exercises and manual techniques such as joint mobilization and manipulation. It is important to perform an initial detailed examination on the patient in order to get a full picture of the patient and properly address any deficits in mobility that they may have which could be a root cause of their tendinopathy.

Author Names

Celik, D., Kuş, G., & Sırma, S. Ö.

Reviewer Name

Abby Bergeron, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: This study compared the effectiveness of joint mobilization combined with stretching exercises (JM&Str) vs steroid injection (SI) in the treatment of plantar fasciitis (PF).

Methods: A total of 43 patients (mean age, 45.5 ± 8.5 years; range, 30-60 years; 23 females) with PF were randomly assigned to receive either JM&Str (n = 22) or SIs (n = 21). JM&Str was applied 3 times per week for 3 weeks for a total of 9 visits. The SI group received 1 injection at baseline. The patients’ functional scores were assessed using the Foot and Ankle Ability Measure (FAAM), and pain was evaluated using the Visual Analog Scale (VAS). Outcomes of interest were captured at baseline and at 3-week, 6-week, 12-week, and 1-year follow-ups. The primary aim was examined using a mixed-model analysis of variance (ANOVA). Pairwise comparisons were performed to examine differences between the baseline and follow-up periods using Bonferroni equality at an alpha level of 0.05.

Results: Age, sex, body mass index, and dorsiflexion range of motion did not significantly impact pain relief or functional outcome (P > .05) at the 3-, 6- or 12-week follow-ups compared to baseline. Planned pairwise comparisons demonstrated significant improvements in pain relief and functional outcomes in both groups (P < .05) at the 3-, 6-, and 12-week follow-ups compared to baseline. However, at the 12-week and 1-year follow-ups, pain and functional outcomes were significantly improved in only the JM&Str group (P = .002). The overall group-by-time interaction was statistically significant for both FAAM (P = .001; F = 7.0) and VAS (P = .001; F = 8.3) scores. Between-group differences favored the SI group at the 3-week (P = .001, P = .001), 6-week (P = .002, P = .001), and 12-week (P = .008, P = .001) follow-ups for pain relief and functional outcomes. However, no significant differences (P = .62, P = .57) were detected in the measured outcomes at the 1-year follow-up.

Conclusion: Our study demonstrated that while both groups achieved significant improvements at the 3-, 6-, and 12-week follow-ups, the SI group exhibited better outcomes at all 3 time points. The noted improvements continued in only the JM&Str group for a period of time ranging from 12 weeks to 1 year.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Cannot Determine, Not Reported, or Not Applicable

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

•  Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Cannot Determine, Not Reported, or Not Applicable

12. 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?

• Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. 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

When compared to baseline, both steroid injections and joint mobilization/stretching interventions significantly improved pain and function in patients with plantar fasciitis at 3-, 6-, and 12-week follow-ups.

Key Finding #2

The group that received steroid injections experienced greater improvements in pain and function than did the joint mobilization/stretching group throughout the 3 to 12-week time frame.

Key Finding #3

Only the joint mobilization/stretching group demonstrated improvements in pain and function for the period of 12 weeks to 1 year (though not statistically significant).

Please provide your summary of the paper

This 2016 randomized controlled study examined and compared the effectiveness of joint mobilization combined with stretching exercises to that of a steroid injection in reducing pain and improving function in patients with plantar fasciitis. Forty-three patients were randomly assigned to receive either joint mobilization with stretching interventions or the steroid injection, though four participants (two from each group) dropped out of the study by the time it was completed. The joint mobilization/stretching group received Grade I and Grade II rhythmic oscillations to control pain. The same physical therapist applied subtalar traction, talocrural dorsal glides, subtalar lateral glides, and first tarsometatarsal joint dorsal glides at each session. Stretching exercises (gastrocnemius stretching and plantar fascia-specific stretching) were completed over 9 visits to the clinic and twice at home. For participants who were allocated to the steroid injection group, the injection was administered once at baseline at the point of maximal tenderness of palpation.

At multiple time points (3-week, 6-week, 12-week, and 1-year follow-ups) the Foot and Ankle Ability Measure (FAAM) (both the ADL and sports subscales) was used to measure function and the Visual Analog Scale (VAS) was used to monitor pain intensity. When compared to baseline, both steroid injections and joint mobilization/stretching interventions significantly improved pain and function in patients with plantar fasciitis at 3-, 6-, and 12-week follow-ups, though the group that received steroid injections experienced greater improvements. Of note, only the joint mobilization/stretching group demonstrated improvements in pain and function for the period of 12 weeks to 1 year (though not significant).

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This randomized controlled study demonstrates the effectiveness of commonly implemented treatments for plantar fasciitis: steroid injections and joint mobilizations combined with stretching. However, these appear to provide significant improvements in pain and function only in the short term (up to 12 weeks). It is therefore important to consider patient goals when recommending a treatment approach for plantar fasciitis. That is, it is essential to determine if your patient needs shorter-term pain relief versus a longer-term solution. Though steroid injections can provide significant short term pain relief and improved function, results from this study may indicate that manual therapy may be a more appropriate treatment approach to achieve longer-term improvements in these outcomes when compared to steroid injections.

Author Names

Koszalinski, A., Flynn, T., Hellman, M., Cleland, J.A.

Reviewer Name

Payton Bellows, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Objectives The effects of trigger point dry needling (TDN) on myofascial trigger points (MTP) in Achilles tendinopathy (AT) are unknown. We conducted a study to test the feasibility of a large randomized controlled trial (RCT) to compare the effects of TDN to MT and exercise in a patient population with AT.  Methods Twenty-two subjects were randomly assigned to a control (MT+Ex) or experimental group (TDN+MT+Ex) and completed eight treatment sessions over 4 weeks with follow up at 3 months. TDN was performed to MTPs in the gastrocnemius, soleus or tibialis posterior each session. The same MT and exercise program was conducted in both groups.  Results Two of three criteria for feasibility were met. The attrition rate at 4-week and 3-month follow-up was 18.1% and 68%, respectively. Significant differences (p &lt; .05) reported for within group analysis for FAAM, NPRS, pain pressure threshold and strength in both groups at 4 weeks and 3 months. The GROC was significant for MT + Ex at 3 months. No between group differences were found.  The MCID for the FAAM, GROC was surpassed in both groups at 4 weeks and 3 months and NPRS for the MT + Ex group at 4 weeks.  Discussion A large RCT to investigate the effects of TDN on MTP in AT is not feasible without modifications due to low recruitment and high attrition rate. Modifications to study design should give consideration for closed or national health-care system for access to large patient populations and reduced financial burden to subjects.  Trial Registration ClinicalTrials.gov identifier: NCT03261504F.  KEYWORDS: Trigger point dry needling, myofascial trigger points, feasibility, Achilles, eccentric

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• No

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• No

14. 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

The MDIC of the global rating of change (GROC) was met and exceeded for both the (MT+Ex) and (TDN+MT+Ex) groups. This indicates improvement for patients who received manual therapy.

Key Finding #2

The results of the study were overshadowed by low recruitment and retention. Low recruitment of patients to RTC were due to factors such as aversions to needles, time commitment, and finances. Low retention due to no further incentive to return at 3 months  after their pain was reduced with the 4 week treatments.

Key Finding #3

Post- treatment soreness was commonly reported in both (MT+Ex) and (TDN+MT+Ex).

Key Finding #4

Significant improvements where shown clinically for pain, strength, and functional outcomes but both (MT+Ex) and (TDN+MT+Ex).

Please provide your summary of the paper

The randomized control trial showed that a combination of manual therapy and exercise (MT+Ex), and trigger point dry needling, manual therapy, and exercise (TDN+MT+Ex) resulted in a significant improvements for pain, strength, and functional outcomes. This study included 22 participants over a 3 year period (May 2015-Aug 2018) in 7 private outpatient clinics across North Carolina, Tennessee, and Iowa with different physical therapists providing treatments. The manual therapy and exercise treatments were kept consistent for the 2 groups throughout the 4 weeks and 8 sessions. FAAM, NPRS, GROC, pain pressure threshold and strength were all used to measure the significant changes at 4 weeks and 3 months. No differences were found between the two groups, but the MCID was exceeded with the FAAM, GROC, and NPRS at 4 weeks and 3 months. This study was not a large RTC due to low recruitment and high attrition rate. The low recruitment was due to the inclusion criteria (which was altered after the first year), raising out-of-pocket costs and changes in referring provider health system network, along with other barriers to participation such as needle aversion and time commitment. This study showed that a large RCT was not feasible due to the inability to meet the primary and secondary objectives of the study. Recommendations were given to aid in the replications of the study to provide a feasible large RCT.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study can impact clinical practice if replicated with a large RTC to investigate the effect of trigger point dry needling with manual therapy and exercise on pain and functional outcome compared to just manual therapy and exercise. While the study was deemed not feasible, there are currently no published literature that investigates the effects of TDN for myofascial trigger points in Achilles tendinopathy. This study can help contribute to reduced rates of Achilles tendinopathy and Achilles rupture with appropriate treatment methods of tendinopathy prior to rupture. Current studies have shown that eccentric strengthening is effective for the healing response in tendons with slow gradual improvements over a 4-5 year period. Myofascial trigger points have shorter healing times than eccentric exercises. The study demonstrated that manual therapy techniques are best implemented alongside exercise for the clinical improvement of pain, strength, and functional outcomes in Achilles tendinopathy.

Author Names

Hidalgo, Benjamina; * | Hall, Tobyb | Berwart, Mathildec | Biernaux, Elinorc | Detrembleur, Christinec

Reviewer Name

Gabrielle Stanley, Duke SPT2

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Ankle rigidity is a common musculoskeletal disorder affecting the talocrural joint, which can impair weight-bearing ankle dorsiflexion (WBADF) and daily-life in people with or without history of ankle injuries. The objective of this study was to compare the immediate effects of efficacy of Mulligan Mobilization with Movement (MWM) and Osteopathic Mobilization (OM) for improving ankle dorsiflexion range of motion (ROM) and musculoarticular stiffness (MAS) in people with chronic ankle dorsiflexion rigidity. In a randomized controlled clinical trial with two arms, patients were recruited by word of mouth and via social network as well as posters, and analyzed in the neuro musculoskeletal laboratory of the “Université Catholique de Louvain-la-Neuve”, Brussels, Belgium. A total of 40 men (n=40) ranging in age from 18-40 years presented with nonspecific unilateral ankle mobility deficits during WBDF were randomly assigned to receive either Mobilization with Movement, MWM, (n=20) or Osteopathic Movement, OM (n= 20) manual therapy on their affected ankle. A two way ANOVA revealed a non-significant interaction between either mobilization technique and time with all outcome measures. Outcome measures included Lehmann’s device to measure musculoarticular stiffness, in terms of elastic stiffness (p=.37), viscous stiffness (p=.83), and total stiffness (p=.58) as well as toe-wall distance (p=.58) and angular range of motion to measure limited WBDF (p=.68). A one-way ANOVVA demonstrated non-significant differences with small to moderate effect sizes (d=.003-.580) on all outcome measures before and after intervention. The only time based, significant interaction between groups that existed was viscous stiffness (p=.04. d=-.55).

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• • Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• • Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• • Cannot Determine, Not Reported, or Not Applicable

4. Were study participants and providers blinded to treatment group assignment?

• • Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• • Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• • No

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• • Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• • Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• • Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• • Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• • Yes

12. 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?

• • No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• • No

14. 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

• A single session of Mobilization with Movement and Osteopathic Mobilization at the ankle does not immediately improve measures of joint range of motion or joint musculoarticular stiffness.

Key Finding #2

Viscous stiffness increases in people with a history of ankle injury following Mobilization with Movement and Osteopathic Mobilization; however, this may contribute to prevention of future abnormal ankle kinematics.

Please provide your summary of the paper

Mobilization of the talocrural joint in patients with dorsiflexion rigidity does not appear to improve range of motion immediately. However, the lack of dorsiflexion in the ankle is a direct result of an injury, mobilization may contribute to preventing further abnormal ankle movements. However, it should be noted that this study never clearly defined how many of its participants who possessed “ankle rigidity” acquired said stiffness from an injury. In other words, the concluding key finding may be insignificant if the number of previously injured patients who saw improvements was of an insufficient sample size.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

It should be noted that despite being listed as a “randomized controlled trial” in PubMed, the study never explicitly states which manipulation technique is considered the control and why. The study often references its findings in comparison to “control groups” but there is no explicit specification of what the control group would be (i.e. perhaps a group of individuals with ankle sprains who received no mobilization or were given general range of motion exercises as opposed to manual therapy) or what studies these referenced control groups are from. This study may lead practitioners to be more inclined to use manual therapy in patients with rigidity due to ankle injuries.I would be curious to see how this study would compare to a control group of individuals who did not receive manual therapy, to see if there is any benefit to manual therapy over autonomous range of motion exercises in patients with ankle rigidity.

Author Names

• Plaza-Manzano, G.

Reviewer Name

• Megan Benzie, SPT, B.S.

Reviewer Affiliations

• Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Recurrent ankle sprains often involve residual symptoms for which subjects often perform proprioceptive or/and strengthening exercises. However, the effectiveness of mobilization to influence important nerve structures due to its anatomical distribution like tibial and peroneal nerves is unclear. Objectives: To analyze the effects of proprioceptive/strengthening exercises versus the same exercises and manual therapy including mobilizations to influence joint and nerve structures in the management of recurrent ankle sprains. Study design: A randomized single-blind controlled clinical trial. Method: Fifty-six patients with recurrent ankle sprains and regular sports practice were randomly assigned to experimental or control group. The control group performed 4 weeks of proprioceptive/ strengthening exercises; the experimental group performed 4 weeks of the same exercises combined with manual therapy (mobilizations to influence joint and nerve structures). Pain, self-reported functional ankle instability, pressure pain threshold (PPT), ankle muscle strength, and active range of motion (ROM) were evaluated in the ankle joint before, just after and one month after the interventions. Results: The within-group differences revealed improvements in all of the variables in both groups throughout the time. Between-group differences revealed that the experimental group exhibited lower pain levels and self-reported functional ankle instability and higher PPT, ankle muscle strength and ROM values compared to the control group immediately after the interventions and one month later. Conclusions: A protocol involving proprioceptive and strengthening exercises and manual therapy (mobilizations to influence joint and nerve structures) resulted in greater improvements in pain, self-reported functional joint stability, strength and ROM compared to exercises alone.

NIH Risk of Bias Tool

Quality Assessment of Case-Control Studies

1. Was the research question or objective in this paper clearly stated and appropriate?

• • Yes

2. Was the study population clearly specified and defined?

• • Yes

3. Did the authors include a sample size justification?

• • No

4. Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?

• • Yes

5. Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?

• • Yes

6. Were the cases clearly defined and differentiated from controls?

• • Yes

7. If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?

• • Yes

8. Was there use of concurrent controls?

• • No

9. Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?

• • Cannot Determine, Not Reported, Not Applicable

10. Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?

• • Yes

11. Were the assessors of exposure/risk blinded to the case or control status of participants?

• • Cannot Determine, Not Reported, Not Applicable

12. Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?

• • Yes

Key Finding #1

 A treatment plan that includes manual therapy in combination with proprioceptive and strengthening exercise provided better patient function, reduced pain, and better self-reported ankle stability than exercise alone.

Key Finding #2

Using joint mobilizations in recurrent ankle sprains aids in gaining dorsiflexion, which helps to decrease the risk of another lateral ankle sprain. 

Key Finding #3

This study was done with the athletic population and the participants were participating in their individual sports during the trial. This makes this trial not as applicable to sedentary individuals.

Key Finding #4

Those participants that received manual therapy and exercise reported a significantly higher scores Cumberland Ankle Instability Tool (CAIT). A higher score on the CAIT signifies more self-reported ankle stability.

Please provide your summary of the paper

This randomized control trial studied the effects of using manual therapy in combination with strengthening and proprioceptive exercise when compared to just exercise for pain, range of motion, strength, and self-reported instability. The study used the visual analog scale (VAS), Cumberland Ankle Instability Tool (CAIT), pressure pain threshold (PPT), range of motion, and dynamic dynamometry were used to measure change.  The manual therapy protocol included talocrural distraction, antero-posterior and postero-anterior talocrural and distal tibiofibular mobilization, and superficial peroneal nerve mobilization. One of the predictors for future ankle sprains is limited dorsiflexion. This study elaborated on how limited dorsiflexion may be from a lack of medial glide of the talocrural joint. Using manual therapy can help gain motion of the talocrural joint, thus improving functioning and decreasing risk for future lateral ankle sprains. This study was done with an athlete population for a period of four weeks. This limits the results because it is not as applicable to the sedentary population and does not address long term results.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This paper showed the value of manual therapy for this patient population when used in conjunction with exercise. It discussed the importance of gaining full dorsiflexion after a lateral ankle sprain to help decrease the risk of a future sprain. This study noted that the manual therapy done was based on protocol for the study rather than individualized, which is important for the clinic. The study also showed that exercise alone still shows improvement in function and pain levels, which can be useful in the clinic if a patient is or telehealth or out of town and not able to receive manual therapy for various reasons.

Article Full Title

Two-Week Joint Mobilization Intervention Improves Self-Reported Function, Range of Motion, and Dynamic Balance in Those With Chronic Ankle Instability

Author Names

Hoch, M. Andreatta, R. Mullineaux, D. English, R. Medina McKeon, J. Mattacola, C. McKeon, P.

Reviewer Name

Brielle Ciccio, SPT, CSCS

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

We examined the effect of a 2-week anterior-to-posterior ankle joint mobilization intervention on weight-bearing dorsiflexion range of motion (ROM), dynamic balance, and self-reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior-to-posterior joint mobilization treatments over 2 weeks. Weight-bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre-intervention), 24–48 h following the final treatment (post-intervention), and 1 week later (1-week follow-up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre-intervention measures or between the post-intervention and 1-week follow-up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week. ” 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1798–1804, 2012

NIH Risk of Bias Tool

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

1. Was the research question or objective in this paper clearly stated?

Yes

2. Was the study population clearly specified and defined?

Yes

3. Was the participation rate of eligible persons at least 50%?

Cannot Determine, Not Reported, Not Applicable

4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?

• • Yes

5. Was a sample size justification, power description, or variance and effect estimates provided?

• • Yes

6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?

• • Yes

7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?

• • Yes

8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?

• • No

9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

• • Yes

10. Was the exposure(s) assessed more than once over time?

• • Yes

11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?

• • Yes

12. Were the outcome assessors blinded to the exposure status of participants?

• • No

13. Was loss to follow-up after baseline 20% or less?

• • Yes

14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?

• • Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Joint mobilization intervention that targeted posterior talar glide (especially Maitland Grade III) improved measures of function in adults with CAI for at least 1 week.

Key Finding #2

Improvements in self-reported function were found 1 week following intervention that exceed previously established MCID and MCD scores with the FAAM-ADL revealing 8% change and FAAM-Sport revealing 15% change (moderate-to-large effect size).

Key Finding #3

Baseline to pre-intervention measures and post-intervention to 1-week follow-up measures revealed no differences in dorsiflexion ROM, normalized reach distances on SEBT, or self-reported function (p > 0.05).

Key Finding #4

Post-intervention and 1-week follow-up measures were significantly improved for all (p /< 0.01) when compared to baseline and pre-intervention measures.

Please provide your summary of the paper

This prospective cohort study examined the effect of anterior-to-posterior ankle joint mobilizations (emphasis on Maitland Grade III) performed for 2 weeks in patients with CAI. Although there were only twelve volunteer participants with CAI in this study (6 male, 6 female), all participants had to report a history of >/1 ankle sprain, >/2 episodes of “giving way” within the past 3 months, and functional loss in order to be included in the study. Weight-bearing dorsiflexion range of motion (ROM), Star Excursion Balance Test (SEBT), and self-reported function on the Foot and Ankle Ability Measure (FAAM) were utilized as dependent variables in the study. Data was collected at baseline (1 week prior to intervention), pre-intervention, post-intervention (24-48 h following the final treatment), and at a 1-week follow-up (1 week later). This article should prompt clinicians to consider all aspects of CAI treatment benefits, especially including patient reported outcomes and quality of life as seen with FAAM-ADL and FAAM-Sport measures. Utilizing joint mobilizations in patients with CAI should always be considered in a treatment plan for both mechanical and functional improvements. Improvements in function in adults with CAI were seen for at least 1 week with intervention that targeted posterior talar glide. It would be helpful to explore results if further research were performed with a longer follow-up period, an adolescent population, a larger sample size, or the implementation of a control-group. Although limitations were found in this study, positive effect sizes found emphasize the importance of implementing joint mobilization intervention for individuals with CAI as a part of their comprehensive treatment plan. Overall, this article supports the use of manual therapy for patients with CAI.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

The utilization of posterior talar glide joint mobilizations in patients with CAI should be considered for mechanical benefits in underlying dorsiflexion ROM deficits. Specifically noted, Maitland Grade III anterior-to-posterior talar glide joint mobilizations have promising potential to influence noncontractile tissues local to the talocrural joint regarding flexibility and extensibility. Furthermore, it is important to recognize and consider that joint mobilization combined with dynamic balance can improve sensorimotor control and self-reported function in individuals with CAI. The authors discussed that patients with CAI are associated with a decreased quality of life, post-traumatic ankle osteoarthritis, and further comorbidities that must be considered when developing a comprehensive treatment plan. Although this article researched 12 individuals with CAI of a similar age, utilizing manual therapy techniques in the ankle can be beneficial to patients both mechnically and in their quality of life and is therefore important to explore in other populations when appropriate.

Article Full Title

Examination and Treatment of Cuboid Syndrome: A Literature Review

Author Names

Durall, C.

Reviewer Name

Anastasia Engelsman

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context: Cuboid syndrome is thought to be a common source of lateral midfoot pain in athletes. Evidence Acquisition: A Medline search was performed via PubMed (through June 2010) using the search terms cuboid, syndrome, subluxed, locked, fault, dropped, peroneal, lateral, plantar, and neuritis with the Boolean term AND in all possi- ble combinations. Retrieved articles were hand searched for additional relevant references. Results: Cuboid syndrome is thought to arise from subtle disruption of the arthrokinematics or structural congruity of the calcaneocuboid joint, although the precise pathomechanic mechanism has not been elucidated. Fibroadipose synovial folds (or labra) within the calcaneocuboid joint may play a role in the cause of cuboid syndrome, but this is highly speculative. The symptoms of cuboid syndrome resemble those of a ligament sprain. Currently, there are no definitive diagnostic tests for this condition. Case reports suggest that cuboid syndrome often responds favorably to manipulation and/or external support. Conclusions: Evidence-based guidelines regarding cuboid syndrome are lacking. Consequently, the diagnosis of cuboid syndrome is often based on a constellation of signs and symptoms and a high index of suspicion. Unless contraindicated, manipulation of the cuboid should be considered as an initial treatment.

NIH Risk of Bias Tool

 Quality Assessment of Systematic Reviews and Meta-Analyses 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis

1. Is the review based on a focused question that is adequately formulated and described?

• • No

2. Were eligibility criteria for included and excluded studies predefined and specified?

• • Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• • Cannot Determine, Not Reported, Not Applicable

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• • Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• • Cannot Determine, Not Reported, Not Applicable

6. Were the included studies listed along with important characteristics and results of each study?

• • No

7. Was publication bias assessed?

• • No

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• • Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Diagnosis of cuboid syndrome has been made with high suspicion given the lack diagnosis procedures, instead relying on the patient’s symptoms and history.

Key Finding #2

Cuboid syndrome may respond favorably to manipulation of the cuboid.

Key Finding #3

Manipulations, such as the cuboid whip and cuboid squeeze, may increase heel raise tolerance and decrease discomfort with dorsal-plantar cuboid gliding for patients with cuboid syndrome.

Please provide your summary of the paper

Cuboid syndrome, or a dysfunction of the arthrokinematics of the calcaneocuboid joint, is difficult to identify clinically and is thus, easily misdiagnosed. It is commonly mislabeled as a lateral ankle sprain as symptoms resemble those of a ligament sprain and may occur due to an inversion ankle sprain. This pathology has been shown to respond well to manipulation. Two manipulations commonly used include the cuboid whip and cuboid squeeze. Additional manipulations may be used to relieve pain and improve heel raise tolerance. Other modalities, such as cryotherapy and padding to support the plantar cuboid, may be warranted to achieve full resolution of symptoms and/or prevent recurrence.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

Following this article, it would be necessary to develop more detailed evidence based practice guidelines for cuboid syndrome. This pathology is commonly misdiagnosed and requires more research to determine what key factors make this different from lateral ankle sprains. This study did, however, clearly outline helpful treatments for cuboid syndrome. Manipulations such as the cuboid whip and cuboid squeeze were given with instructions and proper dosage, thus making it easy for clinicians to implement. Because these manipulations have had high success, they should be adopted by clinicians and utilized in treatment. Furthermore, this article highlighted why clinicians should consider cuboid syndrome in their differential diagnosis of lateral foot pathologies.

Article Full Title

The immediate effect of talocrural joint manipulation on functional performance of 15-40 years old athletes with chronic ankle instability: A double-blind randomized clinical tria

Author Names

Fahimeh Kamali, Ehsan Sinaei, Sara Bahadorian

Reviewer Name

Jessica Fritson, SPT, ATC

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective To evaluate the immediate effect of talocrural joint manipulation (TCJM) on functional performance of athletes with chronic ankle instability (CAI).  Participants Forty athletes (18males, 22females) with CAI divided into TCJM group (n = 20) and sham manipulation group (n = 20).  Intervention TCJM was performed as a quick thrust on the involved talus, in the posterior direction. Sham manipulation was maintaining the same position, without any thrust.  Main outcome measures Functional performance of athletes was assessed with single leg hop; speed and Y balance tests, before and after the interventions.  Results All functional tests evaluated in this study improved significantly after TCJM (p-value&lt;0.05). These findings were not seen in the control group. Between-group comparisons also showed significant changes for all the measurements after the interventions (p &lt; 0.05).  Conclusions TCJM can significantly increase the functional performance of athletes with CIA and can be an effective supplementary treatment for these subjects. However, this was a pre-post study and future studies with long-term follow-ups may provide more reliable results about the long-term effectiveness of this type of treatment.

NIH Risk of Bias Tool 

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• • Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• • Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• • Yes

4. Were study participants and providers blinded to treatment group assignment?

• • Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• • Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• • Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• • Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• • Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• • Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

• • Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• • Yes

12. 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?

• • Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• • Yes

14. 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

There was a statistically significant difference in performance of functional testing in athletes with chronic ankle instability who received talocrural joint manipulation treatment.

Key Finding #2

Talocrural joint manipulations may aid in increasing ankle dorsiflexion range of motion which improved dynamic balance seen through functional testing.

Key Finding #3

Talocrural joint manipulations could increase soleus muscle activation which positively influences performance in athletes with chronic ankle instability.

Key Finding #4

 Manual therapy such as talocrural joint manipulation can stimulate articular mechanoreceptors increasing afferent input to the talocrural joint that may be impaired in individuals with CAI.

Please provide your summary of the paper

The double-blind randomized clinical trial found there was a statistically significant difference between the athletes with chronic ankle instability who received talocrural joint manipulation interventions in comparison to the control sham manipulation. The study is limited to the immediate, short-term effects of talocrural joint manipulation in athletes 15-40 years old as the study looked at pre and post-test performance of the Speed, Hop, and Y-tests after three consecutive days of intervention.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study indicates there is value in the utilization of talocrural joint manipulation techniques as a supplemental treatment for athletes who have chronic ankle instability. This information can impact clinical practice and help bridge the gap between treatment of symptoms and functionally preparing an athlete for high-level competition. The immediate effects that were found in this trial may be significant for those who are struggling with sport performance because of chronic ankle instability within athletic activities that require jumping, cutting, and balancing on one leg. There is the potential for many benefits including increasing dorsiflexion range of motion, soleus muscle activation, and afferent input to the talocrural joint. All these benefits would also optimize performance and decrease absences from sporting activities. Though the research supports implementing talocrural manipulation for these athletes, it is important to consider each specific individual when making clinical decisions about manipulations. It is important moving forward from this study to replicate this study and further research the long-term effects that talocrural joint manipulations may have on athletic performance for athletes with chronic ankle instability. It is also important that dosage is studied to optimize manipulations as a supplemental treatment.

Article Full Title

Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial

Author Names 

Cleland, J. et. al

Reviewer Name

Megan Benzie, SPT, B.S.

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study design: Randomized clinical trial. Objective: To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain. Background: There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects. Methods: Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes of interest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time). Results: Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups. Conclusion: The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs. Level of evidence: Therapy, level 1b.

NIH Risk of Bias Tool

Quality Assessment of Case-Control Studies

Was the research question or objective in this paper clearly stated and appropriate?

Yes

Was the study population clearly specified and defined?

Yes

Did the authors include a sample size justification?

Yes 

Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?

Yes

Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?

Yes

Were the cases clearly defined and differentiated from controls?

Yes

If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?

Yes

Was there use of concurrent controls?

Cannot Determine, Not Reported, Not Applicable

Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?

Cannot Determine, Not Reported, Not Applicable

Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?

Yes 

Were the assessors of exposure/risk blinded to the case or control status of participants?

Yes

Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?

Yes

Key Finding #1

The EPAX group did not meet the MCID for the LEFS at the 4-week follow up, while the manual group did. This indicates more improvement for the patients who received manual therapy than those receiving electrophysical agents.

Key Finding #2

Manual therapy techniques were targeted at the triceps surae and medial calcaneal tubercle.

Key Finding #3

This study looked at the Lower Extremity Functional Scale (LEFS), as well as the Beck Anxiety Scale (BAI), and the Numeric Pain Rating Scale (NRPS). This gives a holistic picture of patient presentation because it includes self-reported function, pain, and anxiety.

Key Finding #4

At the time this was written, there were no randomized trials looking at manual therapy for plantar heel pain.

Please provide your summary of the paper

This randomized clinical trial showed that a combination of manual therapy and exercise was superior when compared to electrotherapy and exercise for treating plantar heel pain. This study used Lower Extremity Functional Scale (LEFS), as well as the Beck Anxiety Scale (BAI), and the Numeric Pain Rating Scale (NRPS). The manual therapy protocol was not consistent, as it was individualized based on the patient’s needs. In further studies, specific techniques could be looked at to isolate which may be the most effective for treating plantar heel pain. The study showed significantly better results for the manual therapy group in pain and function at both the 4-week and 6 month follow ups. The electrotherapy group group did not meet the MCID for the LEFS at the 4-week follow up, while the manual did. This study included participants age 18-60, so conclusions cannot be made about specific population groups (ie athletes vs sedentary) from this study.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

This study can impact clinical practice because at the time it was written, it shows differing views from the Clinical Practice Guidelines. The article touches on how the CPG shows minimal evidence for manual therapy for plantar heel pain, but this study suggests otherwise. While the manual therapy techniques performed were not the same for each participant, it shows the importance of clinical reasoning and individualizing your care based on the patient’s presentation and needs. Both groups had exercise as a part of their treatment, which should always be present in clinical practice. This article spoke on how the compliance of the home exercise plan may have impacted the results. In clinical practice, the therapist should consistently check in with the patient for compliance and any adjustments that need to be made to the home exercise program.

Article Full Title

The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review

Author Names

Loudon, J; Reiman, M; Sylvain, J

Reviewer Name

Kayla Berezne, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes.

Objective: Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains.

Methods: This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination ‘ankle’, ‘sprain’, ‘injuries’, ’lateral’, ‘manual therapy’, and ‘joint mobilisation’. The methodological quality of individual studies was assessed using the PEDro scale.

Results: After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed.

Conclusions: For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of motion, decreased pain and improved function.

NIH Risk of Bias Tool 

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

 Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? 

Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

6. Were the included studies listed along with important characteristics and results of each study?

Yes

7. Was publication bias assessed?

No

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable 

Key Finding #1

Manual mobilizations can decrease pain in acute lateral ankle sprains. 

Key Finding #2

Manual mobilizations and thrust manipulations can decrease pain, improve dorsiflexion ROM, and improve self-rated function in subacute or chronic lateral ankle sprains.

Please provide your summary of the paper

This systematic review concluded that manual therapy could be beneficial following ankle sprains acutely to decrease pain and subacutely/chronically to decrease pain, improve dorsiflexion ROM, and improve function. The study clearly denotes the article inclusion and exclusion process as well as the review criteria. As the first systematic review to consider only manual therapy interventions for lateral ankle sprains, it encourages the use of manual therapy for immediate pain management and the potential for improved dorsiflexion and functional outcomes, though more evaluation is required.

There are several limitations to this study and the implication of the research however. Most notably, 7 of the 8 studies evaluated the outcomes either immediately after the session, after one day, or after one week. The longest follow-up period is one month, pointing towards a lack of consideration for long-term outcomes or notable functional changes especially as the authors note the risk of the progression to long-term symptoms, chronic ankle sprains, ankle arthritis, and chronic ankle instability. Additionally, the interventions included distraction techniques, AP talocrural mobilizations, thrust manipulations, and mobilizations with active ankle movement with variable control groups as well, limiting the similarity of the articles selected and the potential for clinical implementation to achieve similar results. Of note, the studies included in this article evaluated young adults under 32 years old, which limits the generalization permissible to older adults and pediatric populations. Finally, the authors did not discuss that one of the studies included analgesics given to both the control and intervention groups with pain scores as an outcome measure and how this may influence the results of this study. Overall, there is likely a need to further evaluate the efficacy of manual therapy for lateral ankle sprains with clear manual therapy and exercise interventions and long-term follow up that includes functional outcomes, though it suggests that manual therapy techniques can help decrease pain short-term in individuals with lateral ankle sprains. 

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

The variability among manual therapy interventions and control group comparisons limit the feasibility of implementation of these results. Additionally, the clinical relevance is limited by the lack of long-term follow up and limited functional outcomes evaluated, especially as there is a potential for acute lateral ankle sprains to progress to further chronic impairments.

However, these results could be beneficial in young adult patients with a pain-dominant presentation to improve pain and potentially therefore increase self-efficacy of active movements, though that was not established in this study. Also, there is the potential that manual therapy can be of further benefit to individuals with subacute or chronic sprains to decrease pain and improve ankle dorsiflexion ROM, with one of the 8 studies noting an improvement in a functional evaluation scale.

The authors note that manual therapy techniques are likely best implemented in addition to exercise, though they express the importance of their study evaluating manual therapy alone as an intervention. A clinician’s judgement will likely consider the feasibility of ankle manual therapy techniques in comparison with the likelihood of decreased pain in order to guide implementation to further improve patient outcomes.

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 &lt; 0.001; alignment, p = 0.001). There were significant group and time interactions in pain intensity (resting pain, p = 0.008; movement pain, p &lt; 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.

Article Full Title

The Symptomatic and Functional Effects of Manual Physical Therapy on Plantar Heel Pain: A Systematic Review

Author Names

Mischke, J; Jayaseelan, D; Sault, J; Kavchak, A

Reviewer Name

Jordan Burnett, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: Plantar heel pain is common and can be severely disabling. Unfortunately, a gap in the literature exists regarding the optimal intervention for this painful condition. Consequently, a systematic review of the current literature regarding manual therapy for the treatment of plantar heel pain was performed.  Methods: A computer-assisted literature search for randomized controlled trials in MEDLINE, EMBASE, Cochrane, CINAHL, and Rehabilitation & Sports Medicine Source, was concluded on 7 January 2014. After identification of titles, three independent reviewers selected abstracts and then full-text articles for review.  Results: Eight articles were selected for the final review and underwent PEDro scale assessment for quality. Heterogeneity of the articles did not allow for quantitative analysis. Only two studies scored ≥7/10 on the PEDro scale and included joint, soft tissue, and neural mobilization techniques. These two studies showed statistically greater symptomatic and functional outcomes in the manual therapy group.  Discussion: This review suggests that manual therapy is effective in the treatment of plantar heel pain; however, further research is needed to validate these findings given the preponderance of low quality studies.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses 

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

 Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

 Yes 

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

 Cannot Determine, Not Reported, Not Applicable

Key Finding #1

There is a paucity of quality literature describing the effects of manual therapy on plantar heel pain.

 Key Finding #2

 Variety in study design, intervention choice, and outcome measure used creates a challenge in determining an overall effect of manual therapy on plantar heel pain.

 Key Finding #3

 Multiple studies observed short and long term beneficial effects of manual therapy on pain and function in patients with plantar heel pain.

Please provide your summary of the paper

 The primary author searched for papers describing manual therapy’s (MT) effects on plantar heel pain through five databases with specific search terms and inclusion/exclusion criteria. Titles derived from the search were screened independently by the authors and their quality was assessed using the PEDro scale. After screening, the articles were divided into those analyzing short term effects of MT, four weeks or fewer, and long term effects, greater than four weeks. There were four studies on the short term effects of MT, three of which found statistically significant decreases in pain and the last of which stated patient reports of decreased pain. Of the four long term effect studies, three showed statistically significant decreases in pain and/or increases in function and the last saw improvement of pain that was not statistically significant. Overall, the authors determined that manual therapy is likely effective in treating plantar heel pain, though the effects are difficult to determine specifically due to unclear dosing and the variety in study design and outcome measure.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This systematic review highlights the variety of manual therapy interventions that can be used to treat plantar heel pain and how more specific and quality literature is necessary to make broad statements about the efficacy of manual therapy on pain and function. Also, the article found that even the few, quality studies observed beneficial effects of manual therapy for treatment of plantar heel pain; this suggests that various types of manual therapy can be used to decrease pain and increase function for patients with plantar heel pain.