Ankle/Foot

Author Names

 Lawrence, M., Raymond, J., Look, A., Woodard, N., Schicker, C., Swanson, B.

Reviewer Name

 Alyssa Bush, SPT

Reviewer Affiliations

 Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The purpose of this study was to determine whether high-velocity, low-amplitude (HVLA) ankle region manipulations could increase force output and muscle activation of hip musculature in individuals with a history of ankle sprain and unilateral tensor fascia latae (TFL) weakness during muscle testing. This investigation used a single-arm repeated measures design. Twenty-five participants’ force outputs were tested at three time points (before manipulation, immediately after manipulation, and 48 hours after manipulation), and muscle activation of the rectus femoris, gluteus medius, and TFL was measured before and immediately after manipulation. Manipulations were applied to the talocrural, subtalar, proximal, and distal tibiofibular joints of the weaker limb. No contralateral manipulations were applied. Two-way repeated measures analysis of variance was used to compare maximal and average force production for each limb. In addition, paired t tests were used to compare muscle activation before and after manipulations. There was a significant limb × time interaction. The involved limb average force increased from before manipulation (65.7 N) to 48 hours after manipulation (77.8 N; P = .014), maximal force increased (76.9 N) 48 hours after manipulation (87.8 N; P = .030), and gluteus medius activation increased (9.8% maximum, 12.2% average) immediately after manipulation. No significant differences were found in the uninvolved limb. The results of this study suggest that high-velocity, low-amplitude ankle region manipulations might improve hip abductor strength in individuals with a history of ankle sprain and unilateral weakness during a TFL muscle test.

Was the study question or objective clearly stated?

Yes

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

Yes

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

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

No

Was the sample size sufficiently large to provide confidence in the findings?

Yes

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

Yes

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

Yes

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

No

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Yes

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

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)?

Yes

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

Average gluteus medius activity in the involved limb increased by 12.2% immediately following ankle manipulation, and maximal force production for the gluteus medius increased by 9.8%.

Key Finding #2

The study found that a combination of talocrural, subtalar, distal tibiofibular, and proximal tibiofibular joint manipulations increased average force of MVIC in the TFL in MMT testing position in the involved limb by 18.5% and increased the maximal force production by 14.2%.

 Please provide your summary of the paper

The study found that 48 hours after high-velocity, low-amplitude (HVLA) manipulations of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints, average force production of the TFL increased by 18.5% in the involved limb of subjects. Additionally, the study found that gluteus medius activation increased in the involved limb by 12.2% immediately following ankle manipulation. These findings are significant, as previous studies have not suggested that ankle manipulation could impact force production and activation of the hip musculature. However, the increase in gluteus medius activation could be a contributor to the increased force produced by the TFL 48 hours after manipulation since the anterior fibers of the gluteus medius are tested in the same manual muscle testing (MMT) position as the TFL. These findings highlight a limitation of the study and the need to consider synergistic muscles during the physical examination. Despite this noted limitation, the study ultimately suggests that ankle region HVLA manipulations can increase force production in hip region musculature, which is a notable finding. Importantly, increased gluteus medius activation was measured immediately after manipulation, while maximal force production did not occur until 48 hours after manipulation. Due to the short time frame for strength testing immediately after manipulation, it is possible that the hip musculature was fatigued, which is a possible explanation for the lack of significant change in force production immediately following ankle manipulation. Although more research is needed in this area due to limitations of the study, this research presents a notable finding that manipulation of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints may increase force production of the hip musculature in subjects with a history of ankle sprain.

 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 suggests that HVLA manipulation of the talocrural, subtalar, proximal tibiofibular and distal tibiofibular joints may be an effective intervention for patients with a history of ankle sprains who also present with weakness in the hip musculature, specifically TFL, upon MMT. This is a notable finding for clinical practice because patients with a history of chronic ankle sprains often have weakness in the hip abductors, which puts these patients at a higher risk of injury due to a lack of closed chain stability in the lower extremity. The results of this study suggest that HVLA manipulations at the ankle joint in the involved limb may be an effective intervention to increase force production at the hip musculature in patients with chronic ankle sprains, and can potentially decrease risk of ankle injury by improving closed chain stability in the affected lower extremity.

Author Names

Fisher, B; Piraino, A; Lee, Y; Smith, J; Johnson, S; Davenport, T; Kulig, K

Reviewer Name

Andres Carro SPT

Reviewer Affiliations

Duke Doctor of Physical Therapy

Paper Abstract

Study Design: Controlled laboratory study.

Background:  Joint mobilization and manipulation decrease pain and improve patient function. Yet, the processes underlying these changes are not well understood. Measures of corticospinal excitability provide insight into potential mechanisms mediated by the central nervous system.

Objectives: To investigate the differential effects of joint mobilization and manipulation at the talocrural joint on corticospinal excitability in individuals with resolved symptoms following ankle sprain.  Methods Twenty-seven participants with a history of ankle sprain were randomly assigned to the control, joint mobilization, or thrust manipulation group. The motor-evoked potential (MEP) and cortical silent period (CSP) of the tibialis anterior and gastrocnemius were obtained with transcranial magnetic stimulation at rest and during active contraction of the tibialis anterior. The slopes of MEP/CSP input/output curves and the maximal MEP/CSP values were calculated to indicate corticospinal excitability. Behavioral measures, including ankle dorsiflexion and dynamic balance, were evaluated.

Results: A repeated-measures analysis of variance of the MEP slope showed a significant group-by-time interaction for the tibialis anterior at rest (P = .002) and during active contraction (P = .042). After intervention, the thrust manipulation group had an increase in corticospinal excitability, while the corticospinal excitability decreased in the mobilization group. The thrust manipulation group, but not other groups, also demonstrated a significant increase in the maximal MEP amplitude of the tibialis anterior after intervention.

Conclusion: The findings suggest that joint manipulation and mobilization have different effects on corticospinal excitability. The increased corticospinal excitability following thrust manipulation may provide a window for physical therapists to optimize muscle recruitment and subsequently movement. The trial was registered at ClinicalTrials.gov (NCT00847769). J Orthop Sports Phys Ther 2016;46(7):562-570. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6602

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

 No

 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)?

 No

 Were study participants and providers blinded to treatment group assignment?

 No

 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)?

 No

 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?

 Cannot Determine, Not Reported, or Not Applicable

 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?

 No

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

 Cannot Determine, Not Reported, or Not Applicable

 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

 Corticospinal excitability of the tibialis anterior increased after high-velocity talocrural thrust manipulation for approximately 30 minutes after the intervention.

Key Finding #2

 Corticospinal excitability of the tibialis anterior decreased after low-velocity talocrural mobilization.

 Please provide your summary of the paper

The authors of this article sought to determine the effects of talocrural mobilization and manipulation on the corticospinal excitability measured in the gastrocnemius and the tibialis anterior on those who have a history of ankle injury but whose symptoms have resolved. The motor evoked potential (MEP) and cortical silent period slopes and values obtained post-intervention were compared to a control of manual contact. The results of the study showed that corticospinal excitability increased in the tibialis anterior after high-velocity thrust manipulation, but was decreased in the tibialis anterior after low-velocity mobilization. In the gastroc there were no significant changes. The corticospinal increase in excitability of the tibialis anterior lasted approximately 30 minutes following thrust intervention, which may have clinical significance for skill acquisition and movement modulation. One limitation to this study is that the corticospinal excitability was only tested at a single point in time following the interventions, so the actual duration of the effect on the corticospinal tract is unknown and should be further investigated.

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

This article provides clinically significant results for corticospinal excitability in the tibialis anterior, showing that it increased following talocrural high-velocity thrust manipulation. The finding that corticospinal excitability of the tibialis anterior increased has implications that using this intervention may contribute to added potential for motor recruitment of that muscle. Additionally, the finding that this increase lasted at least 30 minutes has clinical significance in that this added motor recruitment potential can be utilized immediately after the intervention during exercise therapy sessions to encourage skill acquisition and may even result in an added strength effect in the long term due to the additional motor recruitment during exercise immediately following the intervention. More research on the long-term effects of this corticospinal excitability change on strength changes and skill acquisition when the intervention is used over multiple sessions would need to be done to determine the clinical effectiveness on function. More research would also need to be done on populations that are more symptomatic in order to make the findings more clinically relevant to general physical therapy patient populations.

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.

Author Names

Yoon, Ki-Seok et al

Reviewer Name

Paige Dewalt

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The purpose of this study was designed to analyze the effects mobilization and active stretching on the difference of weight-bearing distribution, low back pain, and flexibility in pronated-foot subjects. The subjects of this study were 16 chronic low back pain patients. They were randomly divided into the control and experimental group. The experimental group had used the model of ankle mobilization and calf muscle active stretching three times per week, for 4 weeks. The control group did same method without an ankle mobilization. The range of flexion and extension motion of the lumbar vertebrae and low back pain degree and difference of weight-bearing were measured before and after the experiment. The model of ankle mobilization and calf muscle stretching of pronated-foot significantly improved the range of flexion and extension motion of the vertebrae. And the visual analogue scale and distribution of weight-bearing were decreased in both of two groups. In other word, the exercise of this study showed that the model of ankle mobilization and calf muscle stretching of pronated-foot had positive effects on improving the range of flexion and extension motion of the vertebrae. The calf muscle stretching was easy and it is effective in therapy that patients by themselves and helped to recover the balance of the vertebrae to combine ankle mobilization and muscle stretching.

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

No

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)?

Cannot Determine, Not Reported, or Not Applicable

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

The ASG (active stretching group) and ASG + MOG (mobilization) both showed statistical significance between pre- and post- interventions across all 3 categories: trunk flexion/extension test (flexibility), visual analogue scale, and weight bearing distribution.

Key Finding #2

There was no statistical significance between the ASG and ASG+MOG in terms of lumbar region flexion, but there was statistical significance in terms of pain and weight bearing differences with it being more effective in the ASG + MOG group.

Key Finding #3

The control group (no treatment) showed no statistical significance across all three variables.

Key Finding #4

Please provide your summary of the paper

This study shows that active calf stretching combined with ankle mobilization has more significant effects on weight bearing distribution, low back pain, and trunk flexibility in subjects with pronated feet. The ASG also showed positive effects on all three variables, but to a lesser extent. While the non-treatment group showed no significant effects on any three of the variables. This study helps show the importance of evaluating the musculoskeletal system for potential spinal imbalances, which interfere with walking and support, and working to fix them.  Joints are mutually connected so when one area is off it leads to compensations down the chain which creates imbalances. When working with subjects that have chronic LBP and pronated feet, combining active calf stretching with ankle mobilizations would yield the most benefit. Active stretching alone is also more beneficial than no treatment.

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

When working with subjects that are dealing with chronic low back pain and pronated feet, active stretching with ankle mobilization may be the most beneficial in improving pain intensity, flexibility, and weight bearing distribution. However, this study has several limitations so further research is needed to validate these results. Implementation of the study’s results should not be the first line of choice for intervention.

Author Names

Evans, R., Haas, M., Schulz, C., Leininger, B., Hanson, L., & Bronfort, G

Reviewer Name

Erin Dennis, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Low back pain (LBP) is common in adolescence but there is a paucity of high quality research to inform care. We conducted a multicenter randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to ET alone. Participants were 185 adolescents aged 12–18 years with chronic LBP. The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient and caregiver-rated improvement and satisfaction. Outcomes were analyzed using longitudinal linear mixed effect models. An omnibus test assessing differences in individual outcomes over the entire year controlled for multiplicity. Of the 185 enrolled patients, 179 (97%) provided data at 12 weeks and 174 (94%) at 26 and 52 weeks. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of one year (P=0.007). The group difference in LBP severity (0–10 scale) was small at the end of treatment (mean difference=0.5; P=0.08), but was larger at weeks 26 (mean difference=1.1; P=0.001) and 52 (mean difference=0.8; P=0.009). At 26 weeks, SMT with ET performed better than ET alone for disability (P=0.04) and improvement (P=0.02). The SMT with ET group reported significantly greater satisfaction with care at all time points (P≤0.02). There were no serious treatment-related adverse events. For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months. These findings warrant replication and evaluation of cost-effectiveness.

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?

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)?

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?

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

Spinal manipulation combined with exercise was more effective in reducing pain severity compared to exercise alone for adolescents with low back pain over the course of one year.

Key Finding #2

Differences in reported pain between groups were not statistically significant at the end of treatment at 12 weeks, however differences were statistically significant at the 6-month and 12-month follow-ups. The largest between-group differences occurred at 6 months.

Key Finding #3

The SMT + ET group had statistically significant higher patient-rated and parent-rated satisfaction with treatment compared to the exercise alone group at all time points of the study.

Please provide your summary of the paper

The results of this study found significant between-group differences in spinal manipulative therapy combined with exercise (SMT + ET) versus exercise alone in adolescents with low back pain over the course of one year. Due to the abundance of research on the effectiveness of exercise in patients with low back pain, the authors decided to include exercise in both treatment groups rather than looking at SMT alone. One of the limitations of this study was the inability to blind patients and providers to the nature of the interventions. Additionally, this study was unable to differentiate between specific and non-specific treatment effects, such as the effect of patient-provider interactions. This study did not touch on the impact of the provider’s preference on SMT + ET versus ET alone, thus further research on the provider’s preference and resulting patient education and motivation on the reduction of pain severity would be worthwhile. While this is a newer area of research in adolescents, this study clearly supports the use of SMT in conjunction with exercise to reduce LBP severity and enhance long-term outcomes.

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 clearly supports the use of spinal manipulative therapy in adolescents with low back pain alongside traditional therapeutic exercise intervention. Though short-term outcomes were not significantly different between SMT + ET and ET alone groups, there was an increase in long-term benefits when spinal manipulation was included in treatment. Though further research is necessary surrounding chronic low back pain in adolescents and manual therapy, this article is very revealing in the effectiveness of SMT and thus should be integrated into clinical practice. However, it is important to note that this study did not look at SMT alone, and thus exercise is still an essential component of treatment in this population.

Author Names

Beazell, James; Grindstaff, Terry; Sauer, Lindsay; Magrum, Eric; Ingersoll, Christopher; Hertel, Jay

Reviewer Name

Timothy Dow, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

STUDY DESIGN: Randomized clinical trial. 

OBJECTIVES: To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability. 

BACKGROUND: Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function.  METHODS: Forty-three participants (mean +/- SD age, 25.6 +/- 7.6 years; height, 174.3 +/- 10.2 cm; mass, 74.6 +/- 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21). 

RESULTS: There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P&lt;.001) in dorsiflexion at each post-intervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores. 

CONCLUSIONS: The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing. 

LEVEL OF EVIDENCE: Therapy, level 2b–. J Orthop Sports Phys Ther 2012;42(2):125-134. doi:10.2519/jospt.2012.3729  KEY WORDS: ankle sprain, CAI, manual therapy, mobilization

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?

No

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?

Yes

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

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

Yes

Key Finding #1

For patients with chronic ankle instability, the use of proximal or distal tibiofibular manipulations in isolation did not demonstrate improvements in ankle dorsiflexion ROM, balance, functional movement (step-down), and self reported outcomes (FAAM) beyond that of the control group (no treatment).

Key Finding #2

All three study groups, proximal tibiofibular manipulations, distal tibiofibular manipulations, and the control group (no treatment), when pooled (main effect time), saw statistically significant improvements in ankle dorsiflexion range of motion at each post-intervention time interval over the 3-week period.

Key Finding #3

All three study groups, proximal tibiofibular manipulations, distal tibiofibular manipulations, and the control group (no treatment), when pooled (main effect time), did not see statistically significant improvements in balance, functional movement (step-down), and self-reported outcomes (FAAM) over the the 3-week period.

Please provide your summary of the paper

This study assessed the effectiveness of proximal and distal tibiofibular manipulations on individuals with chronic ankle instability (CAI). Specifically, the study assessed how the effect of these manipulation techniques impacted ankle dorsiflexion range of motion (ROM), balance, functional movement via a step down, and self-reported outcomes via the Foot and Ankle Measure Sports Subscale (FAAM). The study was a randomized clinical trial comprised of three study groups: those receiving proximal tibiofibular joint manipulations (n=15), those receiving distal tibiofibular joint manipulations (n=15), and the control group receiving no treatment (n=13). The study was executed over the course of 3 weeks. On day 1, prior to any treatment being administered, baseline measures of ankle dorsiflexion, balance, functional movement via a step down, and the FAAM were all completed. The patients then received their form of manipulation therapy 1 time each week for 3 weeks total. At each therapy session (1x/week), in addition to receiving their respective form of treatment, each patient would re-execute the outcome measures (ankle dorsiflexion, balance, functional movement, and FAAM) to assess if any change had occurred between sessions. Ankle dorsiflexion was measured via a weighted lunge and placing an inclinometer over the tibial tuberosity to measure the tibia angle relative to the ground. Balance was measured by replicating the component of the Balance Error Scoring System (BESS) where the patient balances on a foam pad in a single limb stance for 20 seconds with their eyes close. Functional movement was assessed via a step-down task from a 20cm high step with patients stepping down laterally, bearing weight through their involved limb until the contralateral heel reached the ground. Self-reported outcomes were measured via the completion of the FAAM. The proximal tibiofibular joint manipulation technique received by one group of participants was described as a high-velocity, low-amplitude thrust after bringing the patient to end range flexion and external rotation with the fibular head abutting the therapist’s metacarpal. The distal tibiofibular joint manipulation technique received by one group of participants was also described as a high-velocity, low-amplitude thrust after bringing the distal fibula to end range while stabilizing the distal tibia. The authors of the study concluded that the use of distal or proximal tibiofibular manipulations in isolation did not improve patient outcomes beyond that of the control group (no treatment). The authors did note that both treatment groups and the control group saw statistically significant improvements in ankle dorsiflexion ROM over the 3-week period but no improvements in balance, functional movement (step downs), and self-reported outcomes (FAAM).

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 was a well-executed and clearly documented study that made sound conclusions and future recommendations based on their findings. Based on the format and execution of the study, the conclusions made by the authors are accurate in that proximal or distal tibiofibular joint manipulations performed in isolation did not enhance outcomes for individuals with CAI beyond those of the control group. However, this conclusion is only accurate within the specific context of the study.   One of the most important distinctions the author made in the study conclusions was that the use of proximal and distal tibiofibular manipulations did not prove to be more effective than the control group specifically when these techniques are used in isolation. The study only assessed the effectiveness of these manipulation techniques in isolation, meaning that the patients did not receive any other forms of intervention or did not execute any additional form of a prescribed home exercise plan (HEP). This is a very important distinction to be made, as manual therapy techniques are often viewed to be used in adjunct to other interventions. In this study, the manual therapy techniques were the only therapy provided. Further studies assessing the effectiveness of these techniques when used in adjunct to a HEP would be beneficial to better replicate clinical practice.   An additional consideration for the context of this study is the average age of the participants. The participants in this study were recruited from a local university and surrounding community, yielding an average age of about 25 years old across the three study groups. Therefore, these conclusions may or may not apply to patients with CAI that are older than the participants in this study.   Additionally, the authors discussed various potential causes for why the control group (no treatment) also saw statistically significant improvement in ankle dorsiflexion. Specifically, they noted that repeated performance of the outcome techniques may have resulted in a practice effect. This hypothesis would mean that with the weekly execution or “practice” of each outcome could yield the participants simply improving their ability to perform the outcome itself, which may be a cause for improved dorsiflexion ROM scores across all three groups. The practice effect as opposed to the actual therapeutic effect of the study groups may have been a reason why improvements in dorsiflexion ROM were seen across all three groups. Ultimately, within the context of this study, it is accurate to say that in isolation, proximal and distal tibiofibular manipulations do not improve outcomes for young adult patients with CAI. But as the author indicates, these conclusions should be used with caution because of the specific context in which the study was executed.

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.

Key Finding #4

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.

Author Names

Pollack, Y., Shashua, A., Kalichman, L.

Reviewer Name

Jasmin Flores, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Manual therapy employed in the treatment of plantar heel pain includes joint or soft tissue mobilizations. Efficacy of these methods is still under debate. 

Aims: To determine whether manual therapy, consisting of deep massage, myofascial release or joint mobilization is effective in treating plantar heel pain. 

Methods: A critical review of all available studies with an emphasis on randomized controlled trials (RCTs) was performed. PubMed, PEDro, and Google Scholar databases were searched for keywords relating to plantar heel pain, joint, and soft tissue mobilizations. There were no search limitations or language restrictions. The reference lists of all retrieved articles were searched. The PEDro score was used to assess the quality of the reviewed papers. 

Results: A total of six relevant RCTs were found: two examined the effectiveness of joint mobilization on plantar heel pain and four the effectiveness of soft tissue techniques. Five studies showed a positive short-term effect after manual therapy treatment, mostly soft tissue mobilizations, with or without stretching exercises for patients with plantar heel pain, compared to other treatments. One study observed that adding joint mobilization to the treatment of plantar heel pain was not effective. The quality of all studies was moderate to high. 

Conclusions: According to reviewed moderate and high-quality RCTs, soft tissue mobilization is an effective modality for treating plantar heel pain. Outcomes of joint mobilizations are controversial. Further studies are needed to evaluate the short and long-term effect of different soft tissue mobilization techniques.

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)?

No

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

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

No

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

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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

Cannot Determine, Not Reported, or Not Applicable

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)?

Cannot Determine, Not Reported, or Not Applicable

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

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

No

Key Finding #1

In a study where the control group only received a self-stretching exercise protocol and the intervention group received the same exercise protocol and trigger points pressure release, the intervention group experienced a greater reduction in pain and an improvement in physical function.

Key Finding #2

Patients in the intervention group who received myofascial release for gastrocnemius, soleus, and plantar myofascial structures for plantar heel pain demonstrated a significant reduction in pain compared to the control group who received sham ultrasound.

Key Finding #3

No significant difference was found between the intervention group who received joint mobilizations (subtalar traction, a talocrural dorsal glide, subtalar lateral glide, and a first tarsometatarsal joint dorsal glide) combined with stretching and the control group who received a steroid injection for plantar heel pain.

Key Finding #4

Please provide your summary of the paper

In the studies that were reviewed, manual therapy with or without stretching exercises was effective for patients with plantar heel pain. When comparing joint mobilizations and soft tissue mobilizations, patients with plantar heel pain showed a greater reduction in pain and improvement in physical function. Limitations included having a variety of treatment methods in the studies that were used and long-term effects were not evaluated. Finally, even though soft tissue mobilizations appear to be effective, it is still under debate and more research studies are needed.

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 difficult to conclude whether or not manual therapy is beneficial for those with heel pain because of the variability of treatment methods that were used for this study. However, focusing on the studies individually did show that soft tissue mobilizations were effective for patients that have plantar heel pain. There was no harm done to the patients when these techniques were implemented, so it may be beneficial to use for future patients with this diagnosis and they can possibly have a positive outcome out of it. Finally, based on the studies that were used, soft tissue mobilizations seem to be more effective in patients with plantar heel pain compared to joint mobilizations.

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.

Author Names

Renan-Ordine, R., Alburquerque-Sendín, F., Priscila Rodrigues De Souza, D., Cleland, J., Fernández-De-Las-Peñas, C.

Reviewer Name

Maria Hamilton, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

STUDY DESIGN: A randomized controlled clinical trial  OBJECTIVE: To investigate the effects of trigger point (TrP) manual therapy combined with a self-stretching program for the management of patients with plantar heel pain.  BACKGROUND: Previous studies have reported that stretching of the calf musculature and the plantar fascia are effective management strategies for plantar heel pain. However, it is not known if the inclusion of soft tissue therapy can further improve the outcomes in this population.  METHODS: Sixty patients, 15 men and 45 women (mean +/- SD age, 44 +/- 10 years) with a clinical diagnosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. Additionally, pressure pain thresholds (PPT) were assessed over the affected gastrocnemii and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment allocation. Outcomes of interest were captured at baseline and at a 1-month follow-up (end of treatment period). Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction.  RESULTS: The 2 x 2 mixed-model analysis of variance (ANOVA) revealed a significant group-by-time interaction for the main outcomes of the study: physical function (P = .001) and bodily pain (P = .005); patients receiving a combination of self-stretching and TrP tissue intervention experienced a greater improvement in physical function and a greater reduction in pain, as compared to those receiving the self-stretching protocol. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the gastrocnemii and soleus muscles, and the calcaneus (all P&lt;.001). Patients receiving a combination of self-stretching and TrP tissue intervention showed a greater improvement in PPT, as compared to those who received only the self-stretching protocol.  CONCLUSIONS:This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain.  LEVEL OF EVIDENCE: Therapy, level 1b. J Orthop Sports Phys Ther 2011;41(2):43-50. doi:10.2519/jospt.2011.3504  KEY WORDS: ankle plantar flexors, plantar fasciitis, triceps surae

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?

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?

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?

Yes

Key Finding #1

Patients who received the self-stretching program in addition to trigger point manual therapy experienced a greater improvement in physical function and a greater reduction in pain in comparison to the group who only had the self-stretching program.

Key Finding #2

Patients who received the self-stretching program in addition to trigger point manual therapy demonstrated a greater improvement in pressure pain threshold over the gastrocnemius and soleus in comparison to the group who only had the self-stretching program

Key Finding #3

There were significant group-by-time interactions for general health and emotional role found within the group who received the self-stretching program in addition to trigger point manual therapy.

Please provide your summary of the paper

The results of this study suggests that trigger point manual therapy intervention in addition to a self-stretching program can be beneficial for patients with plantar fasciitis/plantar heel pain. Each patient went to physical therapy 4 days a week for 4 weeks, with the difference being the type of intervention they received. The self-stretching program consisted of stretching the gastrocnemius, soleus, and plantar fascia 2 times per day, holding each stretch for 20 seconds followed by 20 seconds of rest. Trigger point manual therapy was personalized to the patient based on the location of their trigger points, however, each patient received a trigger point release technique over the gastrocnemius muscles if indicated. This form of manual therapy was performed for 90 seconds and repeated 3 times. 

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 study suggested that trigger point manual therapy intervention in addition to a self-stretching program can be beneficial for patients with plantar fasciitis/plantar heel pain. However, there are some limitations to the study. Despite giving the patients instructions on how often to perform the self-stretching program, there was nothing in the study that mentioned patient adherence to the stretching program. This could potentially affect the results seen from the self-stretching only group. Additionally, even though the combination group (manual + self-stretching) showed more improvement, these improvements have been short-term. Moving forward, I believe it would be useful to research long-term solutions for individuals with plantar fasciitis/plantar heel pain to help improve their overall quality of life and reduce any healthcare costs associated with the diagnosis.

Author Names

Fraser, John J.; Corbett, Revay; Donner, Chris; Hertel, Jay

Reviewer Name

Brenna Hammer, SPT, LAT, ATC

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions. Methods: A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen’s d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups. Results: Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5-21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES – 0.7-3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 12 variables) and was otherwise equivalent in effectiveness to comparison interventions.  Discussion: MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF.  Level of evidence: Treatment, level 1a. 

NIH Risk of Bias Tool

Systematic Review

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?

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.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Manual therapy combined with routine care (stretching, strengthening, and ultrasound) was more effective in decreasing patient-reported pain associated with plantar fasciitis.

Key Finding #2

Patient-reported function improved with the use of manual therapy from 3 weeks to 3 months to a similar degree as those who received a corticosteroid injection.

Key Finding #3

The inclusion of manual therapy in plantar fasciitis treatment improves pain pressure threshold and function more effectively than comparison interventions.

Key Finding #4

Please provide your summary of the paper

This study found varying degrees of success in using manual therapy in the treatment of plantar fasciitis. It included 7 studies which utilized different forms of manual therapy, including joint mobilizations, soft tissue mobilization, and trigger point release, which may limit the external validity of this article. However, all studies included had favorable or at least comparable outcomes to their comparison treatments, suggesting that all prior listed forms of manual therapy may have some benefit in treating plantar fasciitis. The authors also found that in studies where more significant improvements in function were achieved, there were less improvements in pain. It was hypothesized that increased function lead to increased activity, which may have exacerbated pain. The authors ultimately recommended that manual therapy be included in the rehabilitation plan for plantar fasciitis in combination with stretching and exercise due to the low risk and potential benefits of its use.

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

While this paper favored the use of manual therapy in treating plantar fasciitis, the effect sizes in all but two studies were small and lacking statistical significance. However, all studies also demonstrated low risk in implementing manual therapy in addition to the routine treatment plan of stretching and exercise. Based on this and the proposed mutimodal benefits (physiological, psychological) of manual therapy, implementing manual therapy in the treatment of plantar fasciitis may be beneficial for some patients, but should not be relied on as a definitive solution.

Author Names

Brantingham, J., Cassa, T.

Reviewer Name

Brenna Hammer, SPT, LAT, ATC

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: The objective of this case series is to describe manual manipulative therapy with exercise for 3 patients with mild to moderate osteoarthritis of the great toe. Clinical Features: Three patients, a 32-year-old man, a 55-year-old woman, and a 49-year-old woman, had great toe pain of 8, 1, and 2 years, respectively. Each had a palpable exostosis, a benign outgrowth of bone projecting outward from the bone surface, and decreased dorsiflexion with a hard end-feel. Intervention and Outcome: Manual manipulative therapy with exercise, the Brantingham protocol, was used with patients receiving 6, 9, and 12 treatments over 6 weeks. Specific outcome measures for hallux rigidus and the foot were chosen to document the effects of this intervention including digital inclinometry, the lower extremity functional scale, the foot functional index, overall therapy effectiveness and Visual Analogue Scale (VAS). Each patient had an increase in range of motion that surpassed the minimal clinically important change, an increase in the overall therapy effectiveness and a decrease in the foot functional index that surpassed the minimally clinically important difference. Most importantly for the patients, each reported a decrease in both usual and worst pain on the VAS that exceeded the minimally clinically important difference of 20 to 30 mm. Conclusion: The 3 patients reported decreased pain measured by the VAS, increased range of motion and minimally clinically important difference in 3 other outcome measures.

NIH Risk of Bias Tool

Quality Assessment Tool for Case Series Studies

Was the study question or objective clearly stated?

Yes

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

Yes

Were the cases consecutive?

Yes

Were the subjects comparable?

Yes

Was the intervention clearly described?

No

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

Yes

Was the length of follow-up adequate?

Yes

Were the statistical methods well-described?

Yes

Were the results well-described?

No

Key Finding #1

The inclusion of manual and manipulative therapy in the treatment of great toe osteoarthritis decreased patient reported pain and increased patient reported function and range of motion.

Key Finding #2

Benefits of manual manipulative therapy in treating great toe osteoarthritis may be seen in as few as 6 treatment sessions; however, less treatment sessions correlated with a greater loss of benefits at the 1 year follow up point.

Key Finding #3

Key Finding #4

Please provide your summary of the paper

This case series examined three patients who had a history of great toe osteoarthritis with the intent of describing the utility of manipulative manual therapy in treating this condition. After ruling out systemic or musculoskeletal pathology that would contraindicate the use of manual therapy in this condition, the subjects were each put through the “Brantingham Protocol” which describes specific protocols and procedures to treat the great toe. It was ultimately suggested that manual therapy be included in treatment of great toe osteoarthritis according to patient and clinician preference, and note was made on the lack of research regarding manual therapy for this particular pathology.

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

While this case series showed promising results in using manipulative therapy to treat great toe osteoarthritis, the results were insufficient to have a significant impact on current practice. The study only included 3 patients who were close in age, therefore decreasing external validity. Additionally, only one specific protocol was examined, which does not accurately reflect all possible manual and manipulative therapies that may be utilized. However, this study did not lead to the belief that manual therapy would be harmful or carry risk in the treatment of great toe OA, and therefore may still be considered for the multimodal benefits. There is very little research on the effect of manual and manipulative therapy in the treatment of great toe osteoarthritis, so this article may be a base for future studies in this area.

Author Names

Wikstrom, E. & McKeon, P.

Reviewer Name

Natalie Hosmer, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context: Therapeutic modalities that stimulate sensory receptors around the foot-ankle complex improve chronic ankle instability (CAI)–associated impairments. However, not all patients have equal responses to these modalities. Identifying predictors of treatment success could improve clinician efficiency when treating patients with CAI.  Objective: To conduct a response analysis on existing data to identify predictors of improved self-reported function in patients with CAI.  Design: Secondary analysis of a randomized controlled clinical trial.  Setting: Sports medicine research laboratories.  Patients or Other Participants: Fifty-nine patients with CAI, which was defined in accordance with the International Ankle Consortium recommendations.  Intervention(s): Participants were randomized into 3 treatment groups (plantar massage [PM], ankle-joint mobilization [AJM], or calf stretching [CS]) that received six 5-minute treatments over 2 weeks.  Main Outcome Measure(s): Treatment success, defined as a patient exceeding the minimally clinically important difference of the Foot and Ankle Ability Measure–Sport (FAAM–S).  Results: Patients with ≤5 recurrent sprains and ≤82.73% on the Foot and Ankle Ability Measure had a 98% probability of having a meaningful FAAM–S improvement after AJM. As well, ≥5 balance errors demonstrated 98% probability of meaningful FAAM–S improvements from AJM. Patients <22 years old and with ≤9.9 cm of dorsiflexion had a 99% probability of a meaningful FAAM–S improvement after PM. Also, those who made ≥2 single-limb–stance errors had a 98% probability of a meaningful FAAM–S improvement from PM. Patients with ≤53.1% on the FAAM–S had an 83% probability of a meaningful FAAM–S improvement after CS.  Conclusions: Each sensory-targeted ankle-rehabilitation strategy resulted in a unique combination of predictors of success for patients with CAI. Specific indicators of success with AJM were deficits in self-reported function, single-limb balance, and <5 previous sprains. Age, weight-bearing–dorsiflexion restrictions, and single-limb balance deficits identified patients with CAI who will respond well to PM. Assessing self-reported sport-related function can identify CAI patients who will respond positively to CS.

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)?

No

Were study participants and providers blinded to treatment group assignment?

No

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

No

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

Cannot Determine, Not Reported, or Not Applicable

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

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

Cannot Determine, Not Reported, or Not Applicable

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)?

Cannot Determine, Not Reported, or Not Applicable

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)?

Cannot Determine, Not Reported, or Not Applicable

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

Ankle joint mobilizations, massage, and stretching all have their own unique predictors of success on self-reported sport-related function.

Key Finding #2

The effect on sport-related self-reported functional improvements varied based on patient characteristics across all three groups.

Key Finding #3

Only about half of participants across all three groups experienced an increase in self-reported sport-related function.

Key Finding #4

Please provide your summary of the paper

This study is a secondary analysis of an RCT that looked at the effects of three different treatments (grade III talocrural joint mobilizations, plantar massage, and calf stretching) on self-reported sport-related function in 59 patients with chronic ankle instability. For this study, participants received six five-minute treatment sessions during a two-week period. At the end of the two weeks, researchers found that about half of individuals across all three treatment groups experienced an improvement in self-reported sport-related function. Researchers found that each group had different predictors of success. Predictors of success for the ankle joint mobilization group were self-reported function, single-limb balance, and number of previous sprains.

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

Clinicians will be able to screen for these predictors during evaluations and use them to better guide their clinical decision making when coming up with a treatment plan for chronic ankle instability.

Author Names

Norouzi, A, Taghizadeh Delkhoush, C, Mirmohammadkhani, M, Bagheri, R

Reviewer Name

Bradley Hudson

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Maitland and Mulligan mobilization techniques are two manual therapy methods to in- crease the range of motion following immobility treatment. The present study was conducted to compare two therapeutic methods, namely mobilization and mobilization with movement (MWM), on the pain and range of motion in people with lateral ankle sprain. Methods: A total of 40 individuals with grade two lateral ankle sprain were randomly divided into two groups, including the Maitland’s mobilization intervention group, and the Mulligan’s mobilization intervention group. Both groups underwent treatment every other day for two consecutive weeks. The pain intensity was measured using the Visual Analogue Scale (VAS), and the ankle dorsi!exion move- ment range using the Weight Bearing Lunge Test (WBLT) before and one day after the intervention. Results: There were no signi”cant differences between the two groups in terms of pain (P ? 0.297) and range of motion (P ? 0.294) before the intervention. Meanwhile, after the intervention, a signi”cant change was observed in both groups in terms of these variables, which indicates the effectiveness of both interventions (P &lt; 0.001) and the greater effect of the mobilization with movement in reducing pain (P ? 0.037) and increasing the range of motion (P ? 0.021). Conclusions: Both techniques signi”cantly improved the range of motion and reduced pain in people with lateral ankle sprain, but Mulligan’s technique was signi”cantly more effective among the two, perhaps due to joining active and passive mobilizing tensile forces as well as interaction of afferents and efferents in the re!ex arc.

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?

Yes

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?

Yes

9. Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Yes

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)?

Cannot Determine, Not Reported, Not Applicable

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?

No

Key Finding #1

Both mobilization groups showed significant differences in the range of motion.

Key Finding #2

Both mobilization groups showed significant improvement in pain ratings.

Key Finding #3

Both groups had statistically significant improvements but favored more in the mobilization with the movement group.

Key Finding #4

Please provide your summary of the paper

The study examined the comparison of mobilization (Maitland technique) and mobilization with movement (Mulligan technique) on pain and range of motion in people with lateral ankle sprains. The method used was a quasi-experimental, double-blind, preliminary study. The subjects were divided equally, with group 1 being the Maitland mobilization group and group 2 being the Mulligan mobilization group. Both groups received treatment every other day for two consecutive weeks with three sessions per week. Each session had two bouts, lasting 120 s, with a 1-minute rest break between each.  Both mobilization groups found significant improvements in pain and range of motion. Still, the mobilization with movement group (Mulligan technique) was found to be more effective because the passive and active mobilizing tensile forces were joined, in addition to the reciprocal action of efferents and afferents in the reflex arc. A limitation seen in this study was the subjects were immobilized for 2-4 weeks before treatment, and the extent of the immobilization could vary among subjects. The study showed improvement for each technique; however, additional analysis is needed to determine an exact prescription and effect persistence for each. Also, it would be advantageous to study other types of groups, various injuries, changing variables, and different body parts. 

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

Mobilization and mobilization with movement are effective tools to reduce pain and increase range of motion is patients post lateral ankle sprain and can be implemented as part of a treatment plan. Even though these mobilization techniques were found effective for people with lateral ankle sprains these concepts should be researched in different areas of the body with various types of injuries. Further research is needed to determine with correct dosing of the mobilizations for optimal results.

Author Names

Izaola-Azkona, L, Vicenzino, B, Olabarrieta-Eguia, I, Saez, M, Lascurain-Aguirrebeña, I

Reviewer Name

Bradley Hudson, SPT

Reviewer Affiliations

Duke School of Medicine, Doctor of Physical Therapy Division  APTA Member  NSCA Member

Paper Abstract

Objective. Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.  Methods. In this double-blind randomized controlled trial, 45 amateur soccer players with acute (&lt;72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.  Results. MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes.  Conclusion. There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit. Impact. Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

NIH Risk of Bias Tool

Was the study question or objective clearly stated?

Yes

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

Yes

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

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

Yes

Was the sample size sufficiently large to provide confidence in the findings?

No

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

No

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

Yes

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

No

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

No

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

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)?

Yes

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

There were no differences between treatment groups in the short term for ADL function.

Key Finding #2

MOB treatment group showed better sport function in the short term.

Key Finding #3

The MWM group showed to be most effective for long term ADL function and sport function when added to physical therapy care.

Key Finding #4

There was no added benefit of the addition of posterior gliding fibular tape.

Please provide your summary of the paper

This study examined the effect of mobilization of the talus and fibula in management of lateral ankle sprains in soccer players. The participants were randomized into 3 groups, (1) anteroposterior mobilization of the talocrural joint (MOB), (2) distal fibular mobilizations with movement (MWM), (3) and distal fibular mobilization with movement plus posterior gliding fibular tape(MWMtape). The study’s inclusion criteria were as follows: amateur soccer players who presented less than 72 hours after injury, with acute grade 2 sprain of the lateral collateral ligament of the ankle, medical diagnosis of mechanism of injury, swelling, pain on the lateral ankle, restricted ankle ROM, and tenderness on palpation of the lateral ankle ligaments. The study’s exclusion criteria were the following: if the athlete had a past fracture involving realignment or an earlier surgery to the musculoskeletal (msk) structures in the lower extremity, went through an acute injury to the msk framework of other joints of the lower extremity in the past 3 months that affected integrity and function or experienced an ankle sprain in the previous 12 months. The participants were given 8 sessions to treat their injury. During the initial six, they were given advice, manual therapy and electrophysical methods, and the last two were used to teach and to advance in proprioceptive exercises. Mobilization and tape were applied 3 times per week for the first 2 weeks. In addition, all 3 groups received general advice for administering their own ankle treatment such as icing or elevating it, 20 minutes of transcutaneous electrical stimulation, and 5 minutes of edema draining massage.  The group undergoing MOB had more sizable FAAM sport scale scores than MWMtape and on the global rating of sports function than MWM, however, no differences on the FAAM ADL subscale or global rating of ADL function in the 2 weeks follow up post treatment. The MWM and MWMtape groups demonstrated better results for the FAAM ADL subscale than the MOB group. There was a global rating of ADL function difference but only between MWMtape and MOB, with MWMtape showing to have increased function. No differences were observed in the FAAM sport subscale or global rating of sports function at the 5 weeks post treatment follow up when compared to the MOB group. At the 12 and 54 week follow ups, MWM and MWMtape groups demonstrated better FAAM ADL subscale, sport subscale, global rating of ADL, and sport function scores compared to the MOB group. These findings suggest that fibular MWM is more effective than MOB treatment in the medium and long-term but the MOB had better outcomes in the short term. There we no differences in the MWM and MWMtape groups through the study therefore, the use of tape as an add on to the fibular mobilization is not recommended. Some limitations to this study were that they lost 8 participants to the 1 year follow up, therefore, the reinjury rate could have been higher and since the sample size was small, there needs to be further investigation for the recurrence rate. There should also be further research done on the dosage of reps and sets, which needs to be established for optimal care. Lastly, there was no control group of standard physical therapy included in 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.

The findings in the article suggest that the fibular MWM is the most appropriate choice of treatment for lateral ankle sprains for medium and long-term care. The talocrural mobilization (MOB) demonstrated greater improvement for the short term in sport functions and can be a useful tool to keep in mind. The use of both MWM and MOB mobilizations may provide the greatest outcomes in addition to standard physical therapy care.

Author Names

Nilgün, B., Suat, E., Engin, S., Fatma, U., Yakut, Y.

Reviewer Name

Alexandra Hultstrom, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Purpose: We aimed to determine the efficacy of the physical therapy program as an adjunct to the Ponseti technique in the treatment of idiopathic clubfoot. This study was carried out with the presumption of a difference in results between the study group who were included in the physiotherapy program and the control group who performed home exercises. Patients and method: Forty affected feet of 29 patients were included in the study. The average ages of the control and study groups were 15.00 ± 21.33 and 20.30 ± 15.78 months, respectively. Passive range of motion of dorsiflexion, plantar flexion, inversion, eversion, rear foot varus angle and forefoot adduction angle were measured and the Dimeglio classification system was utilized in order to determine the severity of clubfoot deformity. Reassessments were carried out for the study group at the end of 1 month’s therapy and for the control group during the first month follow-up. Results: Comparison of pre- and post-treatment assessment results revealed a difference in terms of recovery, concerning all parameters except passive inversion values in the study group and for all parameters in the control group (P &lt; 0.05). For study and control group comparisons, since deformity severity was higher in the study group an effect size analysis was carried out. The effect size analysis showed that the change in range of motion of dorsiflexion and Dimeglio and decrease of rear foot varus angle was higher in the study group. Conclusion: The results of this study imply that an intensive physiotherapy program may enhance the effectiveness of the Ponseti protocol.

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

No

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

Cannot Determine, Not Reported, or Not Applicable

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

No

Were study participants and providers blinded to treatment group assignment?

No

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

Cannot Determine, Not Reported, or Not Applicable

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

No

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

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

Cannot Determine, Not Reported, or Not Applicable

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)?

No

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)?

Cannot Determine, Not Reported, or Not Applicable

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 study group patients had a larger effect size for increase in dorsiflexion range of motion, decreased varus values of the rearfoot angle, and decreased Dimeglio scores compared to the control group.

Key Finding #2

The effect size was slightly larger in the control group for increased range of motion in plantar flexion, eversion, and forefoot adduction values.

Key Finding #3

In both groups, large effect sizes were found for increase in eversion range of motion, and medium effect sizes were found for adduction and plantarflexion range of motion.

Key Finding #4

Please provide your summary of the paper

This study looked at the difference between intense physiotherapy and routine home exercises for the treatment of clubfoot. The subjects were allocated into two groups so that 20 feet were present in each. The patients that were local and able to remain close to the city as well as those with more severe clubfoot were given preference for the intervention group. The average ages for the intervention group were (20.30 ± 15.78 months) and for the control group (15 ± 21.33 months). Goniometry was used to measure passive range of motion for dorsiflexion, plantarflexion, inversion, eversion, rear foot varus angle, and forefoot adduction angle. Dimeglio classification scores were used to determine severity. The study group received intensive physiotherapy for 1 month with visits occurring 5 days/week. The intensive physiotherapy included: moist heat application, light stretching at posterior and medial parts of the foot, mobilization techniques at the tibiotalar, subtalar, and midtarsal joints, and high voltage galvanic stimulation to the peroneal muscle group. The control group performed home exercises that included light stretching to be applied three times daily with 20 repetitions for one month. Pre and post treatment comparisons were performed and effect size analysis was calculated.

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 had many limitations and biases that prevent it from being applicable to larger groups and more research needs to be done before changing clubfoot protocols. The two groups were not randomized, and the intervention group was selected based on living close to the clinic and having worse Dimeglio scores (more severe clubfoot). While the study did correct for effect sizes, the groups were small, not blinded, and not homogenous. Additionally, the physiotherapy given to the study group contained so many aspects that it is hard to determine which intervention led to changes. Thus, this study opens the door for more research into intense physiotherapy for the treatment of clubfoot, but the study cannot be generalized to larger populations and the significance of results is questionable.

Author Names

Stanek, J., Sullivan T., Davis, S.

Reviewer Name

Jake Isaac, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Context:  Restricted dorsiflexion (DF) at the ankle joint can cause acute and chronic injuries at the ankle and knee. Myofascial release and instrument-assisted soft tissue mobilization (IASTM) techniques have been used to increase range of motion (ROM); however, evidence directly comparing their effectiveness is limited.  Objective:  To compare the effects of a single session of compressive myofascial release (CMR) or IASTM using the Graston Technique (GT) on closed chain ankle-DF ROM.  Design:  Randomized controlled trial.  Setting:  Laboratory.  Patients or Other Participants:  Participants were 44 physically active people (53 limbs) with less than 30° of DF.  Intervention(s):  Limbs were randomly assigned to 1 of 3 groups: control, CMR, or GT. Both treatment groups received one 5-minute treatment that included scanning the area and treating specific restrictions. The control group sat for 5 minutes before measurements were retaken.  Main Outcome Measure(s):  Standing and kneeling ankle DF were measured before and immediately after treatment. Change scores were calculated for both positions, and two 1-way analyses of variance were conducted.  Results:  A difference between groups was found in the standing (F2,52 = 13.78, P = .001) and kneeling (F2,52 = 5.85, P = .01) positions. Post hoc testing showed DF improvements in the standing position after CMR compared with the GT and control groups (both P = .001). In the kneeling position, DF improved after CMR compared with the control group (P = .005).  Conclusions:  Compressive myofascial release increased ankle DF after a single treatment in participants with DF ROM deficits. Clinicians should consider adding CMR as a treatment intervention for patients with DF deficits. 

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?

No

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?

Yes

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

No

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

Compressive Myofascial Release may be an effective treatment for those with dorsiflexion range of motion restrictions.

Key Finding #2

A single treatment of Compressive Myofascial Release appears to be more effective than a single treatment of the Graston Technique at increasing dorsiflexion ROM.

Key Finding #3

More research is needed to evaluate the effectiveness of the two techniques over several treatment sessions.

Please provide your summary of the paper

This paper compared the effects of a single treatment of compressive myofascial release (CMR) vs the Graston Technique (GT) on improving closed chain ankle dorsiflexion range of motion. The study included 44 individuals (53 limbs) with the criteria of closed chain dorsiflexion ROM less than 30 degrees. Eligible limbs were randomly assigned to either CMR, GT, or a control group which did not receive any treatment. Each treatment lasted 5 minutes and the control group sat for 5 minutes before any measurements were retaken. The CMR and GT treatments included an assessment of the area and treatment of specific areas of restriction. Closed chain dorsiflexion measurements, both standing and kneeling, were taken before and after treatment using a digital inclinometer. A significant difference was seen in post-treatment standing dorsiflexion ROM with the CMR group compared to both the GT and control groups. Significant difference was seen in post-treatment kneeling dorsiflexion range of motion between the CMR group and the control group. This study demonstrates that a single treatment of CMR may be more effective than a single treatment of GT on improving closed chain dorsiflexion range of motion. More research should be done to observe the effect of the two treatments over several sessions.

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 trial demonstrates the acute effects of two techniques on increasing closed-chain dorsiflexion in those with limited DF-ROM (<30 degrees). Based on this particular study, a single treatment of compressive myofascial release appears to be more effective than the Graston technique on increasing DF-ROM. The clinical significance of this data is limited to the acute timeframe directly after treatment since there is no data to evaluate the effects of the treatments beyond the session. I believe this study does demonstrate that CMR could be used at the beginning of a PT visit to improve dorsiflexion ROM for increased tolerance to therapeutic exercise interventions such as squats or lunges which may have previously been limited by restricted ankle ROM. There are several limitations to this study which may hinder its clinical significance. As previously stated, only one treatment session was applied and the long-term effects of the two techniques could not be analyzed. Furthermore, the same therapist did not perform both techniques and this could have interfered with the effectiveness of the treatments. The pressure applied during each treatment was likely dependent on the therapist performing the intervention. Based on these limitations, I believe more evidence is needed to prove one treatment is more effective than the other. Although CMR may be an effective tool for therapists looking to improve immediate dorsiflexion ROM, each clinician can and should experiment to determine the effectiveness of these two techniques on patients with DF restrictions. 

Author Names

Brumm, L.F, Janiski, C., Balawender, J.L., & Feinstein, A.

Reviewer Name

Hannah Koch, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Stress fractures occur often among athletes, particularly distance runners, and many theories have been offered regarding the etiologic process of this condition. The authors applied a preventive osteopathic manipulative treatment protocol for cross-country athletes to evaluate the protocol’s effect on the incidence of stress fractures over the course of several years. Stress fracture of the lower extremity is a common injury among athletes, particularly distance runners. Track-and-field sports account for up to 50% of all stress fractures in male athletes and 64% in female athletes.1 Most of the literature in this area is retrospective and comes from studies of cross-country and track- and-field athletes, as well as military recruits. Studies of athletes have reported incidence of stress fracture from 3.9% to 31.3%.2-5 Similarly, studies of military recruits report the incidence of stress fracture from 1% to 31%.6-8 In military studies,7-10 stress fractures are more often diagnosed in women. In studies of male and female athletes, however, the data have been inconclusive. Goldberg and Pecora11 and Hickey et al12 reported a higher incidence of stress fractures in women compared with men, although Bennell et al3 reported a similar incidence of stress fractures among male and female athletes. The etiologic process of stress fracture is widely debated in the literature. Romani et al13categorized stress fracture as a chronic overuse injury due to accelerated bone remodeling. Giladi et al14 and Milgrom et al,15 however, have questioned this distinction, with diagnosis most prevalent in the first month of activity. There are many competing theories for the development of a stress fracture. In the most prominent theory in the literature, osteoblast activity lags behind osteoclast activity and leaves a bone susceptible to microfractures.16 Other researchers have theorized different causes for stress fracture, including repetitive stress at the insertion point of a muscle,16 an initial prolonged focal impaired perfusion of the bone seen in prolonged activity,17 and smaller cross-sectional area that decreases bone strength.14,16,18 Researchers16 have proposed and studied a variety of risk factors for stress fractures, including previous diagnosis of stress fracture, participation in sports involving running and jumping, rapid increase in a physical training program, poor preparticipation physical condition, running on irregular or angled surfaces, inappropriate footwear,19 inadequate muscle strength, poor flexibility, and type A personality. An increased incidence of stress fracture was observed in athletes with high longitudinal arch, excessive forefoot varus, increased hip abduction, and peak rearfoot eversion compared with athletes without these biomechanical traits.20,21 Edwards et al22(using a probabilistic model based on published relationships of bone damage, repair, and adaptation) and Milner et al23 reported a lower incidence of stress fracture with decreased running speed and average vertical loading rate. In addition, women who developed a stress fracture had a statistically significant difference in the following categories: greater leg length difference, later age of menarche, lower fat intake, higher calcium intake, and decreased calf girth.24 Other contributing factors to stress fracture development in women have been noted in the literature, including low bone mineral density, nutritional deficiencies, eating disorders, menstrual disturbances, and amenorrhea.4,16,24 One complication that arises for any investigator is that stress fracture is not consistently defined in published research. In previous studies, stress fracture was diagnosed after clinical presentation and confirmed by means of radiography or triple-phase bone scintigraphy24 or by means of clinical presentation and confirmation by triple-phase bone scintigraphy and computed tomography.19 Only 50% of radiographs, however, reveal a known stress fracture.16 Magnetic resonance (MR) images convey stress fracture and stress reaction better than bone scans.25 Given the multifactoral nature of stress fracture and lack of agreement among authors for given risk factors, prevention of stress fracture is not effectively described in the literature. Suggestions for preventive measures have included adequate stretching during warm-up, gradual increase in exercise intensity, lightweight footwear in good condition, level running surfaces, custom orthotics to address biomechanical concerns, and shock-absorbing insoles.16 The objective of the present study was to investigate the relationship between somatic dysfunction and the incidence of stress fracture in collegiate student-athletes. Somatic dysfunction is defined as impaired or altered function of related components of the somatic system including skeletal, arthrodial, and myofascial structures and related vascular, neural, and lymphatic elements.26 Specifically, we set out to assess the impact of regular, preventive osteopathic manipulative treatment (OMT) on stress fracture incidence in a group of collegiate student-athletes who had not previously engaged in regular preventive OMT. To the authors’ knowledge, there are no studies to date that examine the relationship between somatic dysfunction and stress fracture incidence. We conducted the present study to apply a preventive OMT protocol for cross-country athletes, which we hypothesized would reduce the incidence of stress fractures in this population.

NIH Risk of Bias Tool

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

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

Yes

Was the study population clearly specified and defined?

Yes

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

Yes

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

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

Cannot Determine, Not Reported, Not Applicable

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

No

Key Finding #1

The study’s results indicate implementation of a preventive osteopathic manipulative treatment protocol for cross-country athletes resulted in a statistically significant decrease in the cumulative annual incidence of stress fractures for men.

Key Finding #2

There was no statistically significant decrease in the incidence of stress fractures for women who received osteopathic manipulative treatment in this study.

Key Finding #3

The study hypothesizes that the lack of a statistically significant decrease in the incidence of stress fracture in women when compared to men may be due to somatic dysfunction contributing less to the etiologic process of stress fracture development in females. The study hypothesizes that the etiologic process of stress fracture in female athletes may be complicated by the “female athlete triad.” Ultimately, this decreases the influence of somatic dysfunction on the development of stress fractures, making the impact of osteopathic manipulative treatment decreased compared to the male athletes. However, this hypothesis requires additional research to make conclusive statements.

Please provide your summary of the paper

This study was conducted over the course of five consecutive academic years on NCAA Division I cross-country athletes. Researchers utilized data from the 8 academic years prior to the start of the study to better understand the effects of osteopathic manipulative treatments on male and female cross-country runners. The study utilized a standardized protocol that consisted of evaluation and treatments of the pelvis, sacrum, and lower extremity. Techniques used consisted of muscle energy and articulatory techniques, as well as 3 high-velocity and low-amplitude techniques, which were used to treat cuboid, navicular, and superior innominate shear dysfunctions. Participants continued their usual training throughout the course of the study. 

The results of the study indicated that there was a statistically significant decrease in stress fracture incidences in the male athletes when comparing pre to post osteopathic manipulation treatment data. Male stress fracture incidences decreased from 13.9% before intervention to 1.0% after intervention. However, female stress fracture incidence decreased from 12.9% to 12.0%, which was not statistically significant. 

The researchers acknowledged the complexity of stress fractures and indicated a continued need to study the factors contributing to the development and treatment of stress fractures to improve patient’s outcomes. Researchers hypothesized an increase in the complexity of the development of female stress fractures influenced by the female athlete triad, which may have contributed to the lack of response to the osteopathic manipulative treatments. Overall, research should continue to investigate this topic. 

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 the possibility of osteopathic manipulative treatments aiding in the prevention of stress fracture development in NCAA Division I cross-country male athletes. This finding is significant as “track-and-field sports account for up to 50% of all stress fractures in male athletes.” Implementing these techniques to prevent stress fractures may reduce the overall usage of curative medical services by these athletes. Additionally, avoidance of stress fracture development may enable male athletes to achieve long-term goals due to years of continued health, which is in the best interest of the athletes, coaches, and universities.

This research may influence clinical care by encouraging professionals in the sports world to utilize these techniques for prevention of stress fractures in male cross-country athletes. Unfortunately, this study does not indicate a statistically significant decrease in stress fracture incidences in female athletes, which will likely not influence usage of these techniques for female cross-country runners. 

The study indicates there is a lack of understanding of factors contributing to stress fracture development and treatment. This study may help renew interest on the topic, influencing the development of future studies. The results of this study indicate there may be additional complexity in the development of stress fractures in the female athlete, which may prompt future researchers to develop studies to better understand these factors and the role of osteopathic manipulative therapy in the prevention of stress fracture development. 

Author Names

Kim H, Moon S.

Reviewer Name

Emma Kosbab, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract: Sensorimotor and range of motion deficits due to chronic ankle instability (CAI) are abnormalities of the movement system that make postural control difficult. This review aimed to quantify the effect of joint mobilization on the range of motion, dynamic balance, and function in individuals with CAI. Randomized controlled trials in which joint mobilization was performed in individuals with CAI were searched for in five international databases (CENTRAL, CINAHL, Embase, MEDLINE, PEDro). Qualitative and quantitative analyses were performed using the risk of bias tool and RevMan 5.4 provided by the Cochrane Library. Nine studies with 364 individuals with CAI were included in this study. This meta-analysis reported that joint mobilization showed significant improvement in the dorsiflexion range of motion (standardized mean difference [SMD] = 1.02, 95% confidence interval [CI]: 0.41 to 1.63) and dynamic balance (SMD = 0.49, 95% CI: 0.06 to 0.78) in individuals with CAI. However, there was no significant improvement in function (patient-oriented outcomes) (SMD = 0.76, 95% CI: 􀀀0.00 to 1.52). For individuals with CAI, joint mobilization has limited function but has positive benefits for the dorsiflexion range of motion and dynamic balance.  Keywords: ankle injury; manual therapy; physical therapy; postural balance; joint range of motion

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

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

Was publication bias assessed?

Yes

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

Yes

Key Finding #1

Eight of the nine included studies found significantly improved dorsiflexion range of motion following joint mobilizations. Type of mobilization varied between studies, but included distal tibiofibular joint mobilizations, mobilizations weight bearing and with movement, and talocrural joint mobilizations.

Key Finding #2

Eight of the nine included studies found significantly improved dynamic balance (as seen through step down test, star excursion balance test, single-limb balance test) following joint mobilizations (proximal and distal tibiofibular joint mobilizations dependent on the study).

Key Finding #3

Improvement in function and patient-oriented outcomes was not significant in the 6 studies that examined that variable following joint mobilizations.

Key Finding #4

Please provide your summary of the paper

This study examined the body of literature that is avaliable for the effects of joint mobilizations on chronic ankle instability. There search results found 9 articles that fit the criteria aimed at joint mobilizations as the intervention. Though various types of mobilizations and treatment volumes were seen across the studies included, the results showed statistical significance in the effects of joint mobilization in two of the three measured outcomes.

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 significance of the improvements in dorsiflexion range of motion and dynamic balance activities, it would seem that joint mobilizations can be an appropriate intervention for pateints with chronic ankle instability. The lack of significance in the functional outcomes could be due to multiple factors. As a clinician, it is important to educate and set expectations for patients, and give them the feedback about the change that is seen in the objective measures. This may improve the effects in patient-oriented outcomes, but it is also valuable to recognize that other treatment to complement this intervention may increase patient buy-in and effect change that is more meaningful to them.

Author Names

Albin, S., Koppenhaver, S., Bailey, B., Blommel, H., Fenter, B., Lowrimore, C., Smith, A., McPoil, T.

Reviewer Name

Emily LaPlante, LAT, ATC, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Study Design: Randomized clinical trial.  Background: Muscle stiffness is a potential complication after injury and has been shown to be a risk factor for injury in healthy individuals. Objectives: The primary purpose of this study was to assess the short-term effects of manual therapy (MT) on muscle stiffness of the gastrocnemius in both a relaxed and contracted state. The secondary purpose was to assess the reliability of a novel clinical tool (MyotonPRO) to measure muscle stiffness in the gastrocnemius in both a passive and contracted state.  Methods: Eighty-four consecutive healthy individuals were randomized to receive Manual Therapy (MT group) directed at the right-side ankle and foot or no treatment (CONTROL group). Muscle stiffness of the gastrocnemius was assessed bilaterally in all participants at baseline and then immediately after intervention in a relaxed and contracted state. Group (MT vs. CONTROL) by side (ipsilateral vs. contralateral) by time (pre vs. post) effects were compared through a 3-way interaction utilizing mixed model ANOVA. Reliability of the MyotonPRO was assessed with two-way mixed model intraclass correlation coefficients.  Results: There was a significant 3-way interaction for muscle stiffness of the gastrocnemius in a relaxed state (p &lt; 0.01), but not contracted state (p = 0.54). All conditions had increased resting muscle stiffness from pre to post measures except for the ipsilateral limb of the MT group. There was not a significant interaction for muscle stiffness in a contracted state. Reliability estimates (ICC) for muscle stiffness measures ranged between 0.898 and 0.986.  Conclusion: The change in muscle stiffness of the gastrocnemius in a relaxed state depended upon whether individuals received MT. Muscle stiffness measures were highly reliable based on single measurements.  Level of evidence: Therapy, level 2.

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)? No
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

There was significant 3-way interaction between group, time and side for resting gastrocnemius muscle stiffness.

Key Finding #2

No significant changes in gastrocnemius muscle stiffness were found in group, time or side for the contracted state following manual therapy.

Key Finding #3

Based on the findings of the study, the authors concluded that the reliability of the MyotonPRO was acceptable for assessment of the gastrocnemius muscle stiffness in weight bearing.

Key Finding #4

Post treatment measurements were only included immediately after treatments, meaning no conclusions can be made about lasting effects of manual therapy.

Please provide your summary of the paper

The study found significance in a 3 way interaction for muscle stiffness of the gastrocnemius in a relaxed state but not in a contracted state. The manual therapy group, for the purposes of this study, received approximately 5 minutes of manual therapy including a subtalar joint distraction manipulation, anterior-posterior talocrural joint mobilizations and lateral subtalar joint mobilizations, all grades III and/or IV. Individuals in the control group rested for 5 minutes between baseline and final assessment. Participants were excluded from the study if they had any prior foot or ankle surgery, if they had manual therapy in the past 48 hours, if they had any restrictions in ankle range of motion that would prevent a single leg heel raise or a calf injury in the past 6 months.  Future studies should look to include individuals with current or past medical histories of injury to the foot, ankle or calf.

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

Changes in muscle stiffness after manual therapy have not previously been assessed for the gastrocnemius muscle. The study only included immediate post test changes in gastrocnemius stiffness and included no information on the lasting effects. Further research should be completed to investigate if there are lasting effects on muscle stiffness from manual therapy. Individuals who received the manual therapy intervention demonstrated no change in muscle stiffness in the resting state, while individuals in the control group showed an increase in muscle stiffness. This information may be important for physical therapists to understand when working with patients who are at increased risk for musculoskeletal injury and may benefit from the addition of manual therapy techniques as part of a warm up or treatment.

Author Names

Grim, C., Kramer, R., Engelhardt, M., John, S.M., Hotfiel, T., Hoppe, M.W.

Review Name

Giulia Marsella

Review Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Plantar fasciitis (PF) is one of the most common causes of plantar heel pain. Objective: To evaluate the effectiveness of three different treatment approaches in the management of PF. Methods: Sixty-three patients (44 female, 19 men; 48.4 ± 9.8 years) were randomly assigned into a manual therapy (MT), customised foot orthosis (FO) and a combined therapy (combined) group. The primary outcomes of pain and function were evaluated using the American Orthopaedic Foot and Ankle Society-Ankle Hindfoot Scale (AOFAS-AHS) and the patient reported outcome measure (PROM) Foot Pain and Function Scale (FPFS). Data were evaluated at baseline (T0) and at follow-up sessions after 1 month, 2 months and 3 months (T1–T3). Results: All three treatments showed statistically significant (p < 0.01) improvements in both scales from T0 to T1. However, the MT group showed greater improvements than both other groups (p < 0.01). Conclusion: Manual therapy, customised foot orthoses and combined treatments of PF all reduced pain and function, with the greatest benefits shown by isolated manual therapy.

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)?

Cannot Determine, Not Reported, or Not Applicable

Was the treatment allocation concealed (so that assignments could not be predicted)?
Cannot Determine, Not Reported, or Not Applicable

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)?
Cannot Determine, Not Reported, or Not Applicable

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

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

Key Finding #1

All three treatments, manual therapy, foot orthoses, and a combination of the two, displayed statistically and clinically significant improvements over three months with manual therapy in isolation yielding the strongest improvements.

Key Finding #2

Baseline outcome scores (prior to treatment) for the group receiving foot orthoses were higher than those in the group receiving manual therapy and a combination of the two, complicating the ability to compare progress data.

Key Finding #3

The risk and prevalence of back pain with plantar fasciitis is significant, therefore back pain was evaluated and treated, as well. Manual therapy performed was that of the foot joints and intervertebral segments of the spine.

Paper Summary

This study aims to compare manual therapy, foot orthoses, and a combination for the two treatments for plantar fasciitis pain and compounded low back pain. This study has weaknesses in a few areas. The inclusion criteria for participants include plantar fasciitis pain, but not low back pain despite the manual therapy treatment of both spine and foot. Low back pain was a variable observed, treated, yet not objectively measured for improvement. Additionally, the combination group (manual therapy and foot orthoses) may have experienced less improvement than isolated manual therapy because some participants complained of foot pain after being mobilized potentially due to a no longer suitable customized foot orthoses. Lastly, selection bias may have played a role in the stratification of groups because low back pain complaints were significantly more reported in the manual therapy group. This may have contributed to more success in this group. In contrast, baseline outcomes scores were higher in foot orthoses group than the other two groups leading to potentially less success in this group. The strengths of this study include reproducible standardized manual therapy, therapist-blinded treatment, and data collection every month for 3 months. This data should be cautiously interpreted and further research must be done to understand the best treatment(s) for plantar fasciitis.

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 in how there can be more utilization of foot joint mobilization for the treatment of plantar fasciitis. Because customized foot orthoses also displayed clinical and statistical significance, both treatments can be considered. The methods of the study demonstrated some biases, so caution should be utilized when interpreting and implementing these treatment approaches.

Author Names

Youn PS, Cho KH, Park SJ

Reviewer Name

Kathi Nevsimal, SPT Class of 2024

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The aim of this study was to investigate the effect of ankle joint mobilization in children with cerebral palsy (CP) to ankle range of motion (ROM), gait, and standing balance. We recruited 32 children (spastic diplegia) diagnosed with CP and categorized them in two groups: the ankle joint mobilization (n = 16) group and sham joint mobilization (n = 16) group. Thus, following a six-week ankle joint mobilization, we examined measures such as passive ROM in ankle dorsiflexion in the sitting and supine position, center of pressure (COP) displacements (sway length, area) with eyes open (EO) and closed (EC), and a gait function test (timed up and go test (TUG) and 10-m walk test). The dorsiflexion ROM, TUG, and 10-m walk test significantly increased in the mobilization group compared to the control group. Ankle joint mobilization can be regarded as a promising method to increase dorsiflexion and improve gait in CP-suffering children.

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?

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)?

No

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?

Cannot Determine, Not Reported, or Not Applicable

Key Finding #1

The experimental group showed significant increase in ankle ROM, specifically DF, after receiving joint mobilizations at the ankle for 6 weeks in sitting and standing position compared to the control group who did not receive ankle joint mobilization.

Key Finding #2

Study had a small sample size of 32 children making it difficult to generalize to a wider population.

Key Finding #3

The study only followed participants for six weeks, it did not compare long-term effects.

Key Finding #4

Please provide your summary of the paper

This study examined the effects of ankle joint mobilization on 32 school aged children (8 to 14 years) with spastic diplegic CP. All children participating in the study had a gross motor function classification system (GMFCS) level I or II, classified as hypermobile according to a 5-point posterior talar gliding test, able to independently walk 10 meters or more, and able to follow verbal directions. The purpose of the study was to research the effect of ankle joint mobilization over a six-week period, in order to improve ankle ROM, standing balance, and gait in children with CP. Ankle joint mobilization was applied in an anterior to posterior direction at the distal tibiofibular joint, talocrural joint, and subtalar joint. The primary outcome measure of this study was to measure ROM in ankle-dorsiflexion, while the secondary outcomes measures analyzed COP displacement and gait function test (TUG and 10-meter walk test) for the participants. While there was no significant difference between both the control group and experimental group in COP displacement, there was a significant difference between the control and experiment group in regard to ankle ROM and gait. Therefore, ankle joint mobilization in children with spastic CP should be considered as a primary treatment option to improve gait and ROM of the ankle. Although this project was very interesting more research on a larger patient population should be conducted in the future.  

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

Ankle joint mobilization in children with spastic CP should be considered as a primary treatment option to help increase dorsiflexion, gait, and standing balance. In order to generalize this information to the public, a larger group of participants need to participate. I think that it would alos be very beneficial to try this on all levels of the GMFCS. This is important because cerebral palsey is one of the most common pediatric diagosis that effect a child’s walking ability.  This study impacted my clinical practice because manual therapy in the pediatric population is still relatively new. This study showed that ankle mobilization manual therapy helps increase ROM of the ankle, specifically DF in children with spastic CP (most of the spasticity occurs at the hip, knee, and ankle with the majority at the distal ankle).

Author Names

Hernández-Guillén D, Roig-Casasús S, Tolsada-Velasco C, García-Gomáriz C, Blasco JM

Reviewer Name

Katharina Nevsimal SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background- The ankle plays a key role in balance, but ankle range of motion decreases with ageing. Research question- To establish whether a talus mobilization-based manual therapy intervention may be effective for increasing range of motion and balance in older adults with limited ankle mobility due to the ageing process. Methods- Randomized clinical trial in which 42 community-dwelling older adults with limited ankle mobility were allocated to an experimental or a control group. The experimental intervention consisted of six sessions of anteroposterior talus mobilization, whereas the control intervention was a sham treatment. Baseline change in weight and non-weight bearing ankle range of motion (ROM), balance outcome in terms of the Timed up and go (mobility and dynamic balance), Single-leg stand (static balance and stability), Functional reach (margins of stability) and Romberg tests (static balance) were assessed. Analysis of variance based on a mixed-linear model of repeated measures looked for group interactions. Results- Forty participants completed the study. Participants who received six sessions of manual therapy showed greater improvements in the Timed up and go, Functional reach and Single-leg stand tests than participants who received a sham intervention (p &lt; 0.001). Both groups presented similar performance in post-treatment static balance measures (p&gt; 0.05). Significance- An anteroposterior talus mobilization-based manual therapy intervention is effective for increasing ankle ROM, with a positive effect on dynamic balance, mobility, and stability in community-dwelling older adults with limited ankle mobility.

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)?

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

Anteroposterior talus mobilization increased ankle mobility and balance abilities in older adults with weight-bearing ankle dorsiflexion ROM below 35 degrees.

Key Finding #2

Manual Therapy showed no significance in improving bipedal static stability or postural sway while standing. 

Key Finding #3

Key Finding #4

Please provide your summary of the paper

The ankle plays a big role in weight bearing of the human body during both static and dynamic tasks. As a person ages, ankle joint function decreases, especially with the motion of plantarflexion to dorsiflexion. This decrease in ROM can put older adults at a higher risk for falls. This study looked at the effects of anteroposterior talus mobilization-manual therapy over the course of six sessions in a two-week time period. The participants were community-dwelling older adults, 60 years and older, with wight-bearing ankle dorsiflexion ROM below 35 degrees in both the right and left limb. The exclusion criteria included musculoskeletal injury in the last three months prior to starting the trial and any sort of central or vestibular pathology. The participants were divided up into a control group and an experimental group. In each session the experimental group received a grade IV of three 30-second mobilizations of the talus in anteroposterior glide on both limbs. While the control group did not receive mobilization at the talus but instead only physical contact at the talus. Both groups performed a Timed up and go, Functional reach, left and right single-leg stand at baseline (prior to receiving mobilization) and right after the last treatment session. It was found that anteroposterior talus mobilization increased ankle mobility in community dwelling older adults, which in turn helped increase balance and decrease the risk of falls. It was also found that manual therapy was not effective in improving bipedal static stability due to the fact that not much ankle movement is needed to maintain static posture while standing with both legs on the ground.    

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

I think that this study showed the importance of manual therapy in older adults. In my opinion so much of older adults are studied through hip and knee OA. ROM and strength at the ankle decrease with age putting older adults at a greater falls risk but also affecting both their overall balance and gait. Moving forward I think that this study should be performed on a larger group of individuals and implemented in conjunction with a strength program for fall prevention. This can be implemented in senior centers and any sort of physical therapy clinic. I think that the treatment duration would need to last longer than two weeks to test the long term effect of manual therapy mobilization on the talus.  

Author Names

Allois, R., Niglia, A., Pernice, A., & Cuesta-Barriuso, R

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Introduction: Recurrent ankle sprains are common in soccer players, characterized by restricted range of motion, pain, and decreased proprioception, strength, and postural control. The objective was to evaluate the effectiveness of a fascial therapy and strength training program, combined with kinesiotaping, in improving ankle range of motion, pain, strength and stability in footballers with recurrent sprains.   Method: A simple blind randomized clinical trial was conducted on soccer players. Thirty-six federated footballers were recruited and randomized to the two study groups. The experimental group received an intervention using myofascial techniques applied to the subastragaline joint, eccentric training with an isoinertial device and neuromuscular taping. The control group was administered an intervention using myofascial techniques on the subastragaline joint and eccentric training with an isoinertial device. The results were recorded for all players at baseline, after 4 weeks of intervention, and at the end of the 4-week follow-up period.   Results: Subsequent to intervention and follow-up, we found statistically significant improvements in the experimental group in ankle mobility, strength and stability. The control group exhibited improvements in all study variables. No differences in the improvement of variables were found based on the allocation of athletes to one group or another.   Conclusion: The combination of fascial therapy and eccentric strength training with an isoinertial device improves ankle mobility, strength and stability in footballers with recurrent ankle sprains. The use of taping techniques failed to provide a greater improvement of the study variables when combined with manual therapy and strength techniques.

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)?

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)?

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

With the use of fascial therapy to the subtalar joint and eccentric strength training with an isoinertial device, ankle mobility, stability, and strength in soccer players with recurrent ankle sprains improved. 

Key Finding #2

Kinesiotaping in combination with fascial therapy and eccentric strength training can improve overall stability in the lower limbs, increase ankle range of motion and strength in ankle dorsiflexion and plantarflexion, and improve perceived pain.

Key Finding #3

With the goal of decreasing lost training time due to an ankle sprain from poor ankle stability or restricted ankle motion, the study suggests increasing balance training which would in turn decrease pain in the ankle by improving strength around the ankle joint.  

Key Finding #4

Overall ankle function improved in both control and experimental group regardless of the use of kinesiotaping. 

Please provide your summary of the paper

The aim of this study looked at increasing ankle range of motion and strength, while improving pain and ankle stability in male soccer players with recurrent ankle sprains through a combination of fascial therapy, eccentric strength training, and stabilizing taping. The study did not look at the techniques individually, instead it looked at fascial therapy and eccentric strength training as a collective as the control group and fascial therapy, eccentric strength training and kineseotaping as the experimental group. The taping did not show a statistical significance in improving ankle proprioception.  The small sample size, n=36, proved to be a limitation of the study as well as the lack of information on the previous ankle sprains of each soccer player. Information regarding each soccer player’s exercise regime outside of this study was omitted as well. This could bias the study’s findings as it suggests that the participants could be participating in other exercise that would further strengthen the ankle joint and negate the effects of the study. Furthermore, the data only showed the total average of previous injuries, but it did not specify what kind of injury, to what body part, or the number of injuries per player. When describing the methods of data collection, the study had good intra- and interobserver reliability and the instructions were simple to follow. I found the study to be interesting, however, it would have been more beneficial to look at one technique, such as just fascial therapy compared to no facial therapy as the control group to have a clearer justification in the soccer players’ improvement in the four dependent variables of ankle range of motion, pain, strength, and stability. Further work would be beneficial in comparing the techniques separately with multiple experimental groups to indicate the efficacy of each technique.

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 may impact clinical practice by increasing rehabilitation potential to recurrent ankle sprains in soccer players and decrease the time lost to rehabilitation after an ankle sprain. The results indicate that a combination of fascial therapy to the subtalar joint and eccentric strength training of the lower limbs improved the player’s ankle mobility, stability, and strength in an 8-week time period. The results also proved that the former plus kinesotaping of the ankle improved the soccer players stability in the lower limbs, perceived pain, and increased ankle range of motion and strength in ankle dorsiflexion and plantarflexion.

Author Names

de Ruvo R, Russo G, Lena F, Giovannico G, Neville C, Turolla A, Torre M, Pellicciari L

Reviewer Name

Jaime Pardee, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = −1.23; 95% IC −1.73, −0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.

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?

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

Two studies reported an MD value of 8.79 (95% confidence interval [IC] 6.81, 10.77) and 8.85 (95% CI 7.07, 10.63) in favor of manual therapy with exercise to improve dorsiflexion and plantar flexion active range of motion.

Key Finding #2

Two studies reported an MD value of 1.20 (95% IC 0.63, 1.77) in favor of manual therapy with exercise to improve lower limb function.

Key Finding #3

Three studies reported an MD value of -1.23 (95% IC -1.73, -0.72) in favor of manual therapy with exercise to improve pain.

Key Finding #4

Two studies reported an MD value of 1.20 (95% IC 0.63, 1.77) in favor of manual therapy with exercise to improve ankle stability.

Please provide your summary of the paper

This meta-analysis sought to answer whether manual therapy with therapeutic exercise reduces pain and improves function in patients with a lateral ankle sprain (LAS) compared to therapeutic exercise alone. There is no widely agreed-upon therapeutic protocol for LAS rehabilitation, and the topic remains controversial. Old protocols like RICE (i.e., rest, ice, compression, and elevation) and POLICE (i.e., protection, optimal loading, ice, compression, and elevation) have been partially refuted. Newer protocols like PEACE (i.e., protection, elevation, avoid anti-inflammatory, compression, and education) and LOVE (i.e., load, optimism, vascularization, and exercise) have shifted the focus to education, blood flow, early loading, and movement. The newer protocols place a de-emphasis on passive inflammatory control treatments and focus on active treatments like exercise. Manual therapy has research proven that improvements in overall outcomes, range of motion, bony alignment, pain reduction, and overall physical function can occur. The authors gathered data from three randomized clinical trials to assess if adding manual therapy improved LAS patient outcomes. The study concluded that the combination of manual therapy with exercise improves the active range of motion (AROM) of dorsiflexion and plantar flexion, lower limb function, and pain compared to exercise alone. Ultimately, manual therapy can be used with exercise for this patient population to improve outcomes. 

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 showed that manual therapy combined with therapeutic exercise improves AROM of dorsiflexion and plantar flexion, lower limb function, and pain compared to only therapeutic exercise for LAS. These findings are significant clinically because they support manual therapy techniques to improve clinical outcomes, which continue to place less emphasis on passive inflammatory treatment approaches like RICE. It is important to note that these findings support using manual therapy alongside therapeutic exercise to improve outcomes.