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Investigating the Combined Effects of Fascial Distortion Model Manual Therapy and Balance–Strength Training in Individuals with Chronic Ankle Instability

Author Names: Mohammadi, A., Sakhtemani, S., Trimmel, L., Petricsevics, K., Makai, A., Zsenak I., Melczer, C., Tardi P.

Reviewer Name: Emily Ryan, SPT

Reviewer Affiliation(s): Duke Doctor of Physical Therapy Program ’26

Paper Abstract

The Fascial Distortion Model (FDM) is a relatively new manual therapy approach in the field of musculoskeletal physical therapy, and its potential effectiveness in treating chronic ankle instability (CAI) remains unexplored. Methods: A randomized controlled trial with 23 participants was conducted. Patients were randomly assigned to either the FDM + balance–strength training (BST) group (n = 8), receiving extra FDM sessions weekly in addition to two sessions of BST, or the BST group (n = 7). Healthy controls (n = 8) did not receive any treatment and participated only in pre- and post-test measurements. Objective measurements including Y-Balance Test Lower Quarter (YBT-LQ), Flamingo Balance Test (FBT), Weight-Bearing Lunge Test (WBLT), ankle joint range of motion (ROM), and Cumberland Ankle Instability Tool (CAIT) were recorded at baseline and the end of the intervention. The results demonstrated significant differences between the FDM + BST and BST groups for supination ROM (p = 0.008) and similarly for WBLT (p = 0.041), FBT (p = 0.40), YBT-LQ (p = 0.023), and CAIT score (p = 0.008). Moreover, while both groups demonstrated significant improvement at the post-test compared with their pre-test for plantarflexion and pronation ROM, WBLT, and CAIT score, the FDM + BST group demonstrated significant improvements in supination ROM, FBT, and YBT-LQ. Conclusion: Our study suggests that the addition of FDM concepts to a BST may lead to enhanced improvements in ankle ROM, static and dynamic balance, and self-reported outcomes in individuals with CAI compared to BST.

Key Finding #1

The combination of Fascial Distortion Model (FDM) manual therapy with the balance strength training (BST) led to more improvement in ROM, static and dynamic balance, and self reported functional outcomes with chronic ankle instability (CAI) compared to BST alone.

Key Finding #2

FDM with the addition of BST showed improvements in plantarflexion, pronation, and supination ROM, while only BST therapy showed significant improvement only in plantar flexion and pronation.

Please provide your summary of the paper

This study explores the relatively new manual therapy approach – Fascial Distorted Manipulation as an additional therapy to balance-strength training (BST) which may lead to enhanced improvement in ankle ROM, static and dynamic balance, and self-reported outcomes in individuals with chronic ankle instability (CAT) compared to BST. The study hypothesized that adding FDM concepts to BST could potentially improve the performance of individuals with CAI, particularly in the domains of static and dynamic balance, as well as ankle ROM with a focus on the role that fascia plays in rehabilitating musculoskeletal injuries.  This study was a randomized controlled trial with 23 participants divided into three groups: FDM+BST (n=8), BST-only group (n=7), and Control group (n=8). The participants were healthy and did not have CAI. The Inclusion criteria to be a part of the FDM+BST or the BST groups included a history of at least one significant ankle sprain, experiencing a feeling of ankle instability or giving way in the last year, not receiving any treatment for the ankle joint in the past year, a score less than 24 on the CAIT, and experiencing pain in the ankle joint. The exclusion criteria for this study included a history of surgery within the past 18 months to the musculoskeletal structure in either lower extremity, acute injury to musculoskeletal structures of other joints of the lower extremity in the previous 3 months, and any neurological or sensorimotor dysfunction in the lower extremity. Pre- and post-test measurements were used to evaluate the effectiveness of the interventions. These outcome measures include the Y-Balance Test Lower Quarter (YBT-LQ), Flamingo Balance Test (FBT), Weight-Bearing Lunge Test (WBLT), Cumberland Ankle Instability Tool, and Ankle Joint ROM.  For interventions, the participants were split into two groups either the BST-only group or the FDM+BST group The BST-only group received two sessions of BST a week for a duration of 6 weeks. During the 6 weeks, the exercises were progressive starting with resistance and bodyweight training with a focus on lower leg muscles, ankle mobility, and dynamic balance by week 6 the patient progressed to dynamic and static balance, jumping and landing exercises, harder resistance exercises, and complex exercises The FDM+BST group included BST with the addition of FDM. FDM involves specific manual actions aimed at addressing Fascial Distortions which refer to various alterations in the connective tissue, which explain the patient’s complaints. During the six-week intervention, this group received this treatment once a week with regular exercise. Four of the six distortions were found during the physical exam, these distortions found and manually corrected are trigger band (TB), continuum distortion (CD), folding distortion (refolding (rFD) and unfolding (uFD)), and cylinder distortion (cyD).  * Trigger Band (TB): the most common distortion patients tend to unconsciously move their fingers in a sweeping manner along a pathway while explaining their discomfort. The clinician will use their thumbs to straighten the twisted fibers and smooth out the wrinkles.  * Continuum Distortion (CD): these are minor injuries at the bone-ligament transition zone and patients usually indicate the area by pointing with their fingers. The clinician will realign the bone component by firm and continuous pressure into the distortion to shift the transition zone.  * Folding Distortion (rDF and uFD): three-dimensional changes of the fascia which are reported as deep pain in the joint. The clinician will apply traction and torquing the fascia or compression of the joint.  * Cylinder Distortion (cyD): this distortion results in deep and strange pain in non-jointed areas and is sometimes referred to as jumping pain from one area to another. The clinician can provide a variety of techniques to correct this distortion such as the double thumb technique, thumb technique, Indian burn, the squeegee technique, and pinching.  To evaluate the null hypothesis a repeated measure analysis of variance (rmANOVA) was used to detect changes in subjects’ ankle ROM, WBLT, FBT, YBT-LQ, and CAIT scores from pre-test and post-test. Both interventions showed significant improvement in plantar flexion and pronation ROM and CAIT score. The FDM+BST group had superior improvements in supination ROM, weight-bearing dorsiflexion (WBLT), static and dynamic balance (FBT and YBT-LQ), and self-reported ankle stability (CAIT). These findings support the null hypothesis that including FDM enhances the effects of BST than BST alone for improving ankle mobility, balance, and functional 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 may impact clinical practice by introducing FDM as a complementary manual therapy treatment to BST when treating chronic ankle instability and ankle injuries. FDM is a relatively new manual therapy technique that can be implemented by healthcare professionals to assess and treat patients’ pain. This technique uses pattern recognition of patients’ hand gestures when describing their symptoms. These descriptions are divided into six distinct categories of dysfunction. Treatment choices are correlated to the patient’s gestures. This paper highlights the importance of patient pattern recognition and the use of FDM as well as the traditional BST to better treat the patient holistically. The FDM technique requires the therapist or clinician to pay attention to the patient and how they are describing their pain to guide their manual therapy interventions. 

A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion Sprains

Author Names

Green, T., Refshauge, K., Crosbie, J., Adams, R.

Reviewer Name

Alex Roque, MA, SPT

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. Subjects. Forty-one subjects with acute ankle inversion sprains (,72 hours) and no other injury to the lower limb entered the trial. Methods. Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. Results. The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. Discussion and Conclusion. Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.

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?

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?

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?

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

Addition of passive anterior to posterior mobilizations of the talocrural joint to a rest, ice, compression, and elevation (RICE) protocol following acute ankle inversion sprain resulted in greater improvement in dorsiflexion range of motion compared to RICE alone before and after each of the initial three treatment sessions.

Key Finding #2

Passive anterior to posterior mobilizations of the talocrural joint with rest, ice, compression, and elevation (RICE) treatment improved gait stride speed during the first and third treatment sessions compared to RICE alone.

Please provide your summary of the paper

Ankle inversion sprains are a common injury among athletes, which result in lateral ankle ligament damage, pain, swelling, and limitation of movement. This randomized controlled trial assessed whether an anterior to posterior (AP) mobilization in addition to rest, ice, compression, and elevation (RICE) improved the outcome of therapy for ankle inversion sprain compared to the (RICE) method alone. 41 subjects were randomly assigned to either control group or the experimental group and finished the study. 38 subjects finished the study. The control group received the RICE method, and the experimental group received passive AP joint mobilization of the talocrural joint before the application of RICE. The subjects were treated every second day for two weeks for a maximum of six treatment sessions by a single physical therapist. Additionally, the subjects were taught to tape their ankles during the third treatment session and were informed to do so every day to avoid exacerbation. Subjects were discharged from the treatment trial once they had pain-free dorsiflexion movement under a 100-N force. Outcome measurements were dorsiflexion and gait parameters, such as stride speed, step length, and single support time. Passive AP joint mobilization with RICE resulted in greater improvement in dorsiflexion range of movement before and after the first three treatment sessions than the RICE alone. Additionally, stride speed was greater in the experimental group during the first and third treatment sessions. There were no differences in step length and single support time between the two groups.

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 aims to compare the treatment protocol of rest, ice, compress, and elevation (RICE) to passive anterior to posterior (AP) talocrural joint mobilizations prior to the RICE method for inversion ankle sprain treatment. The results indicate that the addition of AP talocrural joint mobilizations to RICE is superior to RICE alone for the recovery of dorsiflexion range of motion and stride speed. However, the RICE (control) group did not receive any therapeutic exercises or stretches throughout the two-week treatment period. Only the experimental group received therapy that appropriately stressed soft tissue structures of the ankle, which likely contributed to greater dorsiflexion ROM before and after the treatment sessions. Davis’s law describes the how soft tissue adapts the stress and forces placed upon it. The principle helps explain the outcomes of the experimental group. This study provides clinicians an avenue to help patients with an ankle inversion sprain achieve pain-free ankle ROM quicker with passive AP talocrural mobilizations. Additionally, this study indicates that clinicians may be able to apply appropriate stressors to an ankle inversion sprain to facilitate a faster return to pre-injury function, which can also reduce the need for additional therapy sessions.

Exercise-Based Rehabilitation and Manual Therapy Compared With Exercise-Based Rehabilitation Alone in the Treatment of Chronic Ankle Instability: A Critically Appraised Topic

Author Names

Walsh, B. M., Bain, K. A., Gribble, P. A., and Hoch, M. C.

Reviewer Name

Sofia Elena Roa, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy program

Paper Abstract

Clinical Scenario: Patients with chronic ankle instability (CAI) commonly display lower levels of self-reported function and health- related quality of life. Several rehabilitation interventions, including manual therapy, have been investigated to help CAI patients overcome these deficits. However, it is unclear if the addition of manual therapy to exercise-based rehabilitation is more effective than exercise-based rehabilitation alone. Clinical Question: Does incorporating manual therapy with exercise-based rehabilitation improve patient-reported outcomes when compared with exercise-based rehabilitation alone? Summary of Key Findings: The literature was searched for articles that examined the difference in outcomes for patients with CAI between manual therapy with exercise-based rehabilitation and exercise-based rehabilitation alone. A total of 3 peer-reviewed randomized controlled trials were identified. Two articles demonstrated improved patient-reported outcome scores following the incorporation of manual therapy with exercise-based rehabilitation, whereas one study found no statistically significant differences between interventions. Clinical Bottom Line: The current evidence suggests that incorporating manual therapy in addition to exercised-based rehabilitation may improve patient-reported outcome scores in patients with CAI. Strength of Recommendation: In accordance with the Strength of Recommendation Taxonomy, the grade of A is recommended due to consistent evidence from high-quality studies.

Key Finding #1

Incorporating manual therapy in addition to exercise-based rehabilitation creates greater improvements in patient-reported outcomes (PRO) compared with exercise-based rehabilitation alone.

Key Finding #2

In accordance with the Strength of Recommendation Taxonomy, the grade of A is recommended based on the consistent evidence from multiple high-quality randomized controlled trials that addressed the study’s focused clinical question posed in this critically appraised topic.

Please provide your summary of the paper

Chronic ankle instability (CAI), or a history of at least one significant ankle sprain, giving way, recurrent sprain, and/or feelings of instability, is common for many patients who have developed residual symptoms years after the original ankle sprain injury. Those with CAI often exhibit lifelong complications that may affect physical activity levels and their subjective and health-related quality of life. One intervention that has been implemented for patients with CAI in improving ankle dorsiflexion ROM or dynamic postural control is manual therapy. The benefits of joint mobilization on mechanical, sensorimotor, and patient-reported function are evident when these interventions are examined in isolation for patients with CAI. However, this systematic review focuses on the effects of manual therapies used in conjunction with exercise-based interventions in understanding the cumulative effect of these rehabilitation strategies used together. Three studies were found and categorized as high-quality evidence suggesting the improvement in patient-reported outcomes from incorporating manual therapy and exercise-based rehabilitation together versus exercise alone.

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

The purpose of this topic review was to critically appraise and synthesize the currently available evidence which compared interventions that included manual therapy in addition to exercise-based rehabilitation to exercise-based rehabilitation alone in patients with CAI. The results revealed consistent high-quality patient-oriented evidence demonstrating a greater effect when manual therapy was included with an exercise-based rehabilitation on patient-reported outcome scores in patients with CAI. Following this article, it would be necessary to develop more detailed evidence-based practice guidelines for CAI in regards to the incorporation of exercise and manual therapy as probable interventions. Across the three studies reviewed, there was variation in exercises and manual therapy techniques done as well as patient-reported outcomes used. However, there was sufficient evidence to support the benefit of coupling joint mobilizations with exercise-based rehabilitation protocols to improve PROs, but future studies should further examine the long-term differences in outcomes between participants who complete exercise-based rehabilitation versus those who receive manual therapy in conjunction with exercise-based rehabilitation in order to support the use of joint mobilizations as a viable intervention for those with CAI in the long run. Thus, it could influence the management of patients with CAI and influence their overall health-related quality of life.

Effect of Aquatic Versus Conventional Physical Therapy Program on Ankle Sprain Grade III in Elite Athletes: Randomized Controlled Trial

Maryam M. Sadak, Salwa Fadl AbdEIMageed, and Mona Mohamed Ibrahim

Haylee Rice, SPT

Duke University School of Medicine, Doctor of Physical Therapy Division

Abstract

Introduction Ankle sprains are the second most common sports injury after knee injuries, with about 85% of them affecting the lateral ankle ligaments. These injuries are particularly prevalent in sports like basketball and volleyball.

Purpose To investigate the effect of Aquatic therapy as an early rehabilitation protocol for elite athletes with acute lateral ankle sprain grade III on back-to-sport time, dynamic balance, pain, Athletic performance, and muscle power compared to land-based exercise training.

Methods Thirty elite athletes have ankle sprain grade III with sprain onset from 1 to 7 days, their age ranges from 18–30 years old were recruited. All participants are professional athletes; mainly participating in above-head sports such as volleyball and basketball. The patients were randomly allocated into two treatment groups: Group I (control group): 15 patients received a conventional physical therapy program of structured therapeutic exercise program, manual therapy and land-based exercises, in addition to external support, and Group II (Aquatic therapy group): 15 patients received aquatic training. Visual Analog Scale (VAS) was used to measure the pain intensity, while the dynamic balance was measured by the Star Excursion Balance Test. Athletic performance was measured by HOP Tests (Single, Triple, 6-m, and Cross-over hops) aided by the Agility T-Test (ATT) and Illinois Agility Test (IAT). Muscle power was tested by a Single Leg Press. Finally, back to sports time was recorded for each participant in both groups.

Results There was a significant interaction effect of Aquatic therapy and time for VAS (p<0.001), single hop (p<0.001), triple hop (p<0.001), cross-over hop (p<0.001), IAT (p=0.019) and ATT (p<0.001) of both affected and nonaffected. There was no significant interaction effect of Aquatic therapy and time for 6-MHT of affected (p=0.923), and nonaffected (p=0.140). There was a significant main effect of time for all dependent variables (p<0.001) except for 6-MHT of affected (p=0.939), nonaffected (p=0.109), and IAT (p=0.099). The Star excursion dynamic balance test (SEBT) and Single leg press revealed a significant difference between groups on affected and non-affected sides (p<0.001*). Lastly and most importantly the back-to-sport time revealed a significant difference in the return-to-sport time in favor of the Aquatic therapy group who returned faster than the control group (p<0.001*).

Conclusion Aquatic therapy is more effective than traditional protocols regarding early rehabilitation of acute ankle sprain grade III in Elite professional athletes for reducing pain intensity, improving dynamic balance and athletic performance and power and accelerating their return to sports time. Because aquatic therapy produces better outcomes, it is advised to be included in the rehabilitation programs of athletic patients with acute ankle sprains grade III.

Quality Assessment of Controlled Intervention Studies

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

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

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

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

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?

N/A

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

Key Finding #1

Athletes following the Aquatic therapy protocol achieved a faster return to sport, ~4.7 weeks after injury, compared to 7.7 weeks for land based exercises.

Key Finding #2

This study showed that athletes in the aquatic therapy group exhibited significant improvements in muscle power level, agility, and balance compared to those undergoing traditional physiotherapy rehab.

Please provide your summary of the paper

This research suggests that aquatic therapy is more effective at reducing pain intensity, improving balance and athletic performance/power, and accelerating return to sports time compared to traditional physical therapy for grade 3 lateral ankle sprains in elite athletes. The traditional physical therapy group received immobilization, therapeutic exercises, stretching, neuromuscular training, and manual therapy (talar mobilization and 1st metatarso-phalangeal joint mobilization grade 1) over a span of 4 weeks while the aquatic therapy group received under-water training which included walking, stepping, squatting, lunging, step ups, vertical jumping and stationary running. While the study demonstrated positive outcomes for Aquatic therapy the sample size was relatively small and the treatment period was short, so further research with a larger and more diverse sample size and longer treatment period is needed to understand the long-term effects of Aquatic therapy versus conventional physical therapy on grade 3 lateral ankle sprains.

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

The results of this study align with previous research and Aquatic therapy should be considered in rehabilitation programs for individuals with acute grade 3 ankle sprains especially in athletes who are looking to return to sport faster and closer to their prior level of function.

Immediate Combined Effect of Gastrocnemius Stretching and Sustained Talocrural Joint Mobilization in Individuals With Limited Ankle Dorsiflexion: A Randomized Controlled Trial

Author Names

Kang, M; Oh, J; Kwon, O; Weon, J; An, D; Yoo, W

Reviewer Name

Elena Renke, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Although gastrocnemius stretching and talocrural joint mobilization have been suggested as effective interventions to address limited ankle dorsiflexion passive range of motion (DF PROM), the effects of a combination of the two interventions have not been identified.

Objective: The aim of the present study was to compare the effects of gastrocnemius stretching combined with joint mobilization and gastrocnemius stretching alone. Design A randomized controlled trial.

Methods: In total, 24 individuals with limited ankle DF PROM were randomized to undergo gastrocnemius stretching combined with joint mobilization (12 feet in 12 individuals) or gastrocnemius stretching alone (12 feet in 12 individuals) for 5 min. Ankle kinematics during gait (time to heel-off and ankle DF before heel-off), ankle DF PROM, posterior talar glide, and displacement of the myotendinous junction (MTJ) of the gastrocnemius were assessed before and after the interventions. The groups were compared using two-way repeated measures analysis of variance.

Results/findings: Greater increases in the time to heel-off and ankle DF before heel-off during gait and posterior talar glide were observed in the stretching combined with joint mobilization group versus the stretching alone group. Ankle DF PROM and displacement of the MTJ of the gastrocnemius were increased significantly after the interventions in both groups, with no significant difference between them.

Conclusions: These findings suggest that gastrocnemius stretching with joint mobilization needs to be considered to improve ankle kinematics during gait.

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?

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

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?

Not reported

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

Not reported

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

Key Finding #1

Static wall gastrocnemius stretching combined with a posterior talar glide mobilization resulted in significantly greater increases in time to heel-off and ankle dorsiflexion during gait compared to just a stretching intervention in individuals with limited ankle dorsiflexion PROM.

Key Finding #2

Key Finding #3

No significant differences were found with regards to changes in measured non-weight bearing ankle dorsiflexion PROM between the two groups; however, both interventions improved dorsiflexion PROM.

Please provide your summary of the paper

This study aimed to determine the effects of combined gastrocnemius stretching and talocrural joint mobilization on ankle kinematics during gait, ankle dorsiflexion (DF) passive range of motion (PROM), posterior talar glide, and displacement of the myotendinous junction (MTJ) of the gastrocnemius in individuals with limited ankle DF PROM compared to gastrocnemius stretching alone. To qualify for this study participants had to have less than 10 degrees of passive ankle DF with the knee extended but greater than 10 degrees of passive ankle DF with the knee flexed with at least 5 degrees of difference between the two measurement positions. Participants were randomized to receive either gastrocnemius wall stretching combined with sustained anterior-posterior talocrural joint mobilization or just stretching. For both interventions participants held the stretch either with or without the sustained mobilization for 10 repetitions of 30 seconds each with 30 seconds of rest in between. It was found that the stretching combined with joint mobilization intervention resulted in significantly greater improvements in ankle gait kinematics with greater increases in time to heel-off and ankle DF before heel-off compared to the stretching only intervention. Despite the significant difference, these increases were smaller than the minimally detectable change for both of these outcomes. Both of the interventions provided resulted in significant improvements in ankle DF PROM and displacement of the MTJ of the gastrocnemius, but neither intervention was found to be more effective than the other. Only the stretching combined with joint mobilization resulted in a significant increase in the posterior glide of the talus. Based on these findings it was concluded that gastrocnemius stretching with sustained talocrural anterior to posterior joint mobilization should be considered as a treatment to provide immediate improvements in ankle kinematics for individuals with limited DF.

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

While gastrocnemius stretching alone is capable of increasing ankle DF PROM, gastrocnemius stretching combined with a sustained anterior to posterior talocrural joint mobilization is more effective for improving ankle kinematics during functional activities such as gait. It is important to note that this study only identified the immediate effects of the provided interventions without following the participants for any potential long term benefits of the treatment. Clinically, the use of talocrural joint mobilizations in combination with gastrocnemius stretching should be implemented as a treatment for immediate improvement of functional mobility in individuals with limited ankle DF PROM.

Effects of Instrument-assisted Soft Tissue Mobilization on Musculoskeletal Properties

Author Names

Ikeda N., Otsuka S., Kawanishi Y., Kawakami Y.

Reviewer Name

Emma Kurtz, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Purpose: Instrument-assisted soft tissue mobilization (IASTM) has been reported to improve joint range of motion (flexibility). However, it is not clear whether this change in the joint range of motion is accompanied by any alterations in the mechanical and/or neural properties. This study aimed to investigate the effects of IASTM in plantarflexors and Achilles tendon on the mechanical and neural properties of them. Methods: This randomized, controlled, crossover study included 14 healthy volunteers (11 men and 3 women, 21-32 yr). IASTM was performed on the skin over the posterior part of the lower leg for 5 min and targeted the soft tissues (gastrocnemii, soleus, and tibialis posterior muscles; overlying deep fascia; and Achilles tendon). As a control condition, the same participants rested for 5 min between pre- and postmeasurements without IASTM on a separate day. The maximal ankle joint dorsiflexion angle (dorsiflexion range of motion), the peak passive torque (stretch tolerance), and the ankle joint stiffness (slope of the relationship between passive torque and ankle joint angle) during the measurement of the dorsiflexion range of motion and muscle stiffness of the triceps surae (using shear wave elastography) were measured before and immediately after the interventions. Results: After IASTM, the dorsiflexion range of motion significantly increased by 10.7% ± 10.8% and ankle joint stiffness significantly decreased by -6.2% ± 10.1%. However, peak passive torque and muscle stiffness did not change. All variables remained unchanged in the repeated measurements of controls. Conclusion: IASTM can improve joint range of motion, without affecting the mechanical and neural properties of the treated muscles.

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)?

N/A

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

N/A

Were study participants and providers blinded to treatment group assignment?

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

N/A

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?

N/A

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

N/A

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)?

N/A

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

Key Finding #1

Utilization of Instrument-assisted Soft Tissue Mobilization (IASTM) improved dorsiflexion range of motion in participants.

Key Finding #2

Utilization of IASTM decreased joint stiffness of the ankle in participants.

Key Finding #3

A significant difference in stiffness of the Medial Gastrocnemius and Soleus muscles was not noted.

Please provide your summary of the paper

The purpose of this study was to investigate the effectiveness of IASTM in muscles of plantarflexion and the Achilles tendon. Participants received both the experimental condition of IASTM and the control condition of resting for 5 minutes between measurements, with the order of treatment randomized and at least 3 days in between treatments. The IASTM utilized the Graston Technique. ROM and stiffness were measured utilizing an isokinetic dynamometer. Results found that dorsiflexion ROM was improved and ankle stiffness was decreased in the IASTM measurements but muscle stiffness was not impacted.

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

Utilization of Instrument-assisted Soft Tissue Mobilization can provide benefits to patient’s with decreased dorsiflexion ROM and increased ankle stiffness. However, variables in this study could have been controlled more. Future studies could utilize different subjects for the control group and the experimental group to eliminate any additional variables.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series

Author Names

Painter, E. E., Deyle, G. D., Allen, C., Peterson, E. J., Croy, T., Rivera, K. P.

Reviewer Name

Shelby Matheson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures. 

Case Description: Patients with stable ankle fractures post-immobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcomes measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks post-baseline.

Outcomes: Eleven patients (mean age, 39.6 years; range 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks.

Discussion: Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population.

NIH Risk of Bias Tool

Quality Assessment Tool for Case Series Studies

1. Was the study question or objective clearly stated?

Yes

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

Yes

3. Were the cases consecutive?

Yes

4. Were the subjects comparable?

Yes

5. Was the intervention clearly described?

Yes

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

Yes

7. Was the length of follow-up adequate?

Yes

8. Were the statistical methods well-described?

Yes

9. Were the results well-described?

Yes

Key Finding #1

Administering manual therapy techniques to the foot and ankle can improve ankle range of motion – specifically dorsiflexion – as well as enhance soleus activation and single-limb balance following immobilization after stable ankle fracture. 

Key Finding #2

A physical therapy treatment program combining impairment-based manual therapy and exercises targeting the lower leg, ankle, and foot showed a positive and clinically meaningful improvement in ankle function, range of motion, and pain in patients with stable ankle fractures immediately following a period of immobilization. 

Key Finding #3

Implementing clinical reasoning in terms of customizing scope, dose, symptom reassessment, and selection of exercises based on each patient’s specific impairments ensures safety, tolerance, and adherence to the program. 

Key Finding #4

Manual physical therapy techniques applied to the foot and ankle improved patients’ ability to tolerate therapeutic exercises targeting their impairments, i.e., standing calf strengthening. 

Please provide your summary of the paper

Manual therapy techniques have been proven to increase dorsiflexion range of motion, increase activation of the soleus, and enhance single-limb balance when conservatively managing a stable ankle fracture. This case series was designed to observe improvements in ankle function and pain in these patients with an impairment-based manual therapy approach. Eleven patients were treated for an average of 6.6 sessions by the same physical therapist, who was at the time enrolled in a manual therapy fellowship program. An initial evaluation including active and passive range of motion, passive accessory motion, soft tissue mobility, muscle strength, neural mobility, and balance was performed for each patient and the specific impairments were determined. The physical therapist then created a therapeutic program involving manual therapy techniques and exercises that would target each patient’s impairments. Treatment sessions included joint mobilization, soft tissue mobilization, muscle stretching, and neural tension or mobility techniques. Type, grade, and duration of manual therapy interventions was determined by the physical therapist based on exam findings and clinical reasoning. Each patient also received a home exercise program to further improve the ankle impairments identified in the exam. A greater percentage of the session was spent on manual therapy treatment during the early sessions and shifted to a smaller dosage in subsequent sessions. All patients completed the primary outcome measure, the Lower Extremity Functional Scale (LEFS), at the time of evaluation, as well as secondary outcome measures including a numeric pain rating scale (NPRS) and the ankle lunge test (ALT) to determine a baseline measure of perceived ankle function, pain, and range of motion, respectively. These outcome measures were repeated at 4- and 12-week evaluations. Additionally, the patients completed the global rating of change (GROC) to indicate their perceived change in function at the 4- and 12-week appointments. The authors found that all patients involved in this case series achieved a clinically meaningful improvement in ankle function, range of motion, and pain following the treatment program. This outcome suggests that impairment-based manual therapy can be used as an effective treatment approach to managing stable ankle fractures following immobilization in order to improve function, range of motion, and pain. 

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

Applying manual physical therapy techniques in a clinical setting for the purpose of treating stable ankle fractures by improving ankle range of motion, function, and pain after a period of immobilization can be beneficial, specifically when targeted to a patient’s particular impairments and modified or progressed based on the patient’s response. While this case series focuses on distraction and anterior-to-posterior techniques as the primary manual therapy performed, clinical reasoning is necessary for determining which techniques would be most beneficial for the patient based on the impairments determined by a thorough physical examination. Additionally, the authors do not contend that manual therapy should be the primary focus of physical therapy management for stable ankle fractures, but that, as reinforced by the literature cited in this article, it can be an effective initial line of treatment that can help to improve tolerance for therapeutic exercises that will further promote an increase in function. 

Manual Physical Therapy and Exercise Versus Electrophysical Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial

Author Names

(Cleland, J) (Abbott, H) (Kidd, M) (Stockwell, S) (Cheney, S) (Gerrard, D) (Flynn, T)

Reviewer Name

Chenghua Jiang

Reviewer Affiliation(s)

Duke School of Medicine, Doctor of Physical Therapy Division

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

Quality Assessment of Controlled Intervention Studies

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

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

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

Yes

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

Yes

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

Yes

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

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

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

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

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power? 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

Key Finding #1

The Manual Therapy & Exercise group showed significant improvement compared to the Electrophysical group in the lower extremity functional scale (LEFS), Foot and Ankle Ability Measure (FAAM), and overall number pain scale.

Key Finding #2

The data suggests that physical therapists should use manual therapy techniques to manage heel pain over the use of electrophysical modalities (ultrasound, iontophoresis, etc.)

Please provide your summary of the paper

This study wanted to see if manual therapy or electrophysical modalities (ultrasound, iontophoresis) had a larger impact on the outcomes of patients with plantar heel pain. The study had 60 participants with heel pain randomly assigned to each group. Participants ranged from ages 18-60 and periodically filled out the LEFS and FAAM questionnaires. Follow ups occurred at 4 weeks and 6 months, participants were asked to fill the LEFS and FAAM each time. The manual therapy group reported significantly better scores as compared to the electrophysical group. Interventions were joint mobilizations, stretching, and exercise for the manual group. The electrophysical group received ultrasound, iontophoresis, and dexamethasone plus stretching and exercise.

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 further supports the use of manual therapy as an effective intervention for managing pain, specifically for plantar heel pain in this case. With such a large difference between the two groups, this data can give clinicians more confidence in administering the proper treatment for patients who have chronic pain and allow for better pain management.

Comparison of Structural Diagnosis and Management (SDM) Approach and Myofascial Release (MFR) for Improving Plantar Heel Pain, Ankle Range of Motion and Disability: A Randomized Clinical Trial

Author Names: Akter, S; Hossain, M.S; Hossain, K; Uddin, Z; Hossain M.A; Alom, F; Kabir, F; Walton, L; Raigangar, V

Reviewer Name: Victoria Leary

Reviewer Affiliation(s): Duke University Doctorate of Physical Therapy Program

Paper Abstract [Purpose] The purpose of this study was to compare the effectiveness of the Structural Diagnosis and Management (SDM) approach with Myofascial Release (MFR) in improving plantar heel pain, ankle range of motion, and disability. [Subjects] Sixty-four subjects, aged 30–60 years, with a diagnosis of plantar heel pain, plantar fasciitis, or calcaneal spur by a physician according to ICD-10, were equally allocated to the MFR (n = 32) and SDM (n = 32) groups by hospital randomization and concealed allocation. [Methods] In this assessor-blinded randomized clinical trial, the control group performed MFR to the plantar surface of the foot, triceps surae, and deep posterior compartment calf muscles, while the experimental group performed a multimodal approach utilizing the SDM concept for 12 sessions over 4 weeks. Both groups also received strengthening exercises, ice compression, and ultrasound therapy. Pain, activity limitations and disability were assessed as primary outcomes using the Foot Function Index (FFI) and Range of motion (ROM) assessment of the ankle dorsiflexors and plantar flexors using a universal goniometer. Secondary outcomes were measured using the Foot Ankle Disability Index (FADI) and a 10-point manual muscle testing process for the ankle dorsiflexors and plantar flexors. [Results] Both MFR and SDM groups exhibited significant improvements from baseline in all outcome variables, including pain, activity level, disability, range of motion, and function after the 12-week intervention period (p < .05). The SDM group showed more improvements than MFR for FFI pain (p < .01), FFI activity (p < .01), FFI (p < .01) and FADI (p = <.01). [Conclusion] Both MFR and SDM approaches are effective in reducing pain, improving function, ankle range of motion, and reducing disability in plantar heel pain, however, the SDM approach may be a preferred treatment option.

Quality Assessment of Controlled Intervention Studies

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

YES

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

YES

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

YES

Were study participants and providers blinded to treatment group assignment?

YES

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

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?

UNSURE/NOT APPLICABLE

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

UNSURE/NOT APPLICABLE

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

UNSURE/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?

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

Key Finding #1

MFR and SDM approaches are both effective interventions to help reduce plantar heel pain and ankle disability and improve ankle ROM.

Key Finding #2

SDM techniques are shown to be more effective than MFR in this study in terms of improving ROM, reducing pain and disability and improving function.

Please provide your summary of the paper

In this study, Structural Diagnosis and Management (SDM) and Myofascial Release (MFR) were used as interventions to help improve plantar heel pain, ankle ROM and disability. Interventions of the MFR group included a three-phase treatment including deep stripping on the plantar surface of the foot towards the calcaneus, deep stripping towards the triceps surae and active engagement lengthening to the deep posterior compartment of the calf muscles. These interventions were performed for 5-7 reps with 15-30 second holds. The SDM group also received a three-phase intervention which included a manual dorsiflexion stretch to the gastrocnemii and soleus muscles, a myofascial release of the local triggers in the calf muscles and a myoneural stretch performed by a specialized physiotherapist. There were no details regarding the duration and volume of interventions for the SDM group. Both the MFR and SDM groups received a total of 30 minutes’ worth of interventions, 3 times a week for 4 weeks total. In addition to their respective interventions, both groups also received exercises for strengthening of the dorsiflexor and plantarflexor muscles as well as additional conventional treatments (ie: ultrasound, shoe modification education and ice/hot compressions). This study found that both SDM and MFR were effective in reducing pain, improving dorsiflexion and plantarflexion ranges of motion and improving foot function and disability within four weeks of intervention. However, the SDM approach of releasing the gastroc/soleus muscles was more effective compared to the MFR approach in terms of reducing pain and improving activity.

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

Both approaches utilized manual therapy techniques to help with plantar heel pain, ankle ROM limitations and ankle disability. Clinically, this is helpful to know as while long-term effects were not assessed, it can be clinically useful to utilize SDM approaches in manual techniques to help improve plantar heel pain and ankle ROM.

Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A case series

Author Names: Jennings J., Davies GJ.

Reviewer Name: Elizabeth Liriano

Reviewer Affiliation(s): Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract:

Study design: Case series.

Background: Plantar flexion/inversion ankle sprains are one of the most frequently occurring sports injuries. Cuboid syndrome, which is difficult to diagnose, may result from a plantar flexion/ inversion ankle injury and could become the source of lateral ankle/midfoot pain. The objective of this case series is to describe the examination, evaluation, and treatment of the cuboid syndrome following a lateral ankle sprain.

Case description: Seven patients were seen in our clinic 1 to 8 weeks following a lateral ankle sprain with a chief complaint of lateral ankle/midfoot pain. In these 7 patients, the presence of cuboid syndrome was identified independently by 2 examiners. Treatment consisted of a cuboid manipulation.

Outcomes: All 7 patients returned to sports activities following 1 to 2 treatments consisting of the “cuboid whip” manipulation. No recurrence of symptoms was reported upon immediate return to competition or during the remainder of the season (mean follow-up, 5.7 months; range, 2 to 8 months).

Discussion: Based on those 7 patients, our results suggest that patients who are properly diagnosed with cuboid syndrome and receive the cuboid manipulation can return to competitive activity within 1 or 2 visits without injury recurrence.

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?

Was the intervention clearly described?

Yes

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

Yes

Was the length of follow-up adequate?

N/A

Were the statistical methods well-described?

Yes

Were the results well-described?

Yes

Key Finding #1: The “cuboid whip” manipulation produces a positive response in patients who are diagnosed with cuboid syndrome secondary to a lateral ankle injury.

Key Finding #2: After 1-2 visits receiving the “cuboid whip” manipulation, participants were able to return to their sport/activity within 24 hours.

Please provide your summary of the paper:

This article looked at the examination, evaluation, treatment of cuboid syndrome secondary to a lateral ankle injury. In this case series two physical therapists identified seven patients who were competitive or recreational players out of one hundred and four with a presentation of cuboid syndrome. Cuboid syndrome is a term used to describe a variety of injuries to the calcaneocuboid joint. Each patient was treated with a cuboid manipulation known as the “cuboid whip”. Prior to the intervention a visual analog pain scale (VAS) was used to determine the patients pain levels out of 10 at rest and during cuboid palpation, midtarsal mobility, gait, and single leg hops. Following the cuboid manipulation, the patients experienced a decrease in symptoms and were able to return to their activities/sports within 24 hours. The authors go on to discuss their methods to clinically diagnose cuboid syndrome as well as the theory of joint realignment within the calcaneocuboid joint. They further talk about the impact of manipulation therapy and the possible placebo and analgesic effects it has on patients. Overall, the patients in this case series had a positive response to the treatment that resulted in long term non recurrence of the injury.

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

Given that this case series design lacked a comparison group, it could not be concluded whether other approaches would have had a similar effect. The findings in this article suggests that manipulation of the calcaneocuboid joint can be considered when treating patients diagnosed with cuboid syndrome. However, while the article discusses the secondary impacts followed by a lateral ankle injury, the mechanism of injury is very common in populations such as dancers, gymnasts, and other sports that differ from the participants in this case series. That being said, the positive response to the “cuboid whip” manipulation is a treatment that should be in a clinician’s toolbox if they were to encounter a patient diagnosed with cuboid syndrome

Treatment and Prevention of Acute and Recurrent Ankle Sprain: An Overview of Systematic Reviews With Meta-Analysis

Author Names

Doherty, C., Bleakley, C., Delahunt, E., Holden, S.

Reviewer Name

Jordan Keeley, MA, SPT

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

ABSTRACT

Background: Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI), with a coinciding proliferation of review articles summarizing these reports.

Objective: To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

Design: Overview of intervention systematic reviews. Participants: Individuals with acute ankle sprain/CAI. Main outcome measurements: The primary outcomes were injury/reinjury incidence and function.

Results: 46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilization, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

Conclusions: For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilization, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

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?

Yes

Was publication bias assessed?

Yes

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

Yes

Key Finding #1

For ankle sprains and chronic ankle instability, both exercise and bracing interventions can improve function as well as decrease risk of sustaining another ankle sprain in the future.

Key Finding #2

In conjunction with exercise therapy, ice and compression can be beneficial in the treatment of acute ankle sprains.

Key Finding #3

In conjunction with exercise therapy, ice and compression can be beneficial in the treatment of acute ankle sprains.

Key Finding #4

Manual therapy can improve dorsiflexion range of motion, but it is unclear if manual therapy interventions affect functional outcomes or recurrence rates.

Please provide your summary of the paper

The purpose of this paper was to synthesize the current systematic reviews on the effect of varying interventions on pain, swelling, and functional ability, in acute ankle sprains and chronic ankle instability. Six databases were searched for systematic reviews that evaluated the effect of a treatment strategy on preventing or managing an acute ankle sprain or chronic ankle instability, and had outcomes that were quantifiable. Of the 2506 articles found, 46 systematic reviews were selected for the study where their trends were further analyzed. These systematic reviews included 309 reports discussing interventions such as surgery, physical therapy, external joint support, electrophysical methods (ice or compression), complementary treatment (acupuncture), or a combination thereof. Of the aforementioned articles, primary outcomes such as injury incidence/prevalence and measures of ankle function/disability, and secondary outcomes like range of motion, strength, muscle activity, proprioception, performance, and pain were measured. For treatment of acute ankle sprains and chronic ankle instability, exercise therapy and external support interventions demonstrated an improvement in self-reported function and prevention/recurrence of ankle sprains. There are mixed reports on if manual therapy interventions are beneficial for improving measures of function or prevention/recurrence, however, it does have an initial positive effect on ankle dorsiflexion range of motion. Electrophysical interventions like ice and compression can improve functional outcomes for acute ankle sprains when used in conjunction with exercise therapy. There is mixed evidence reported on the benefits of surgical interventions and complementary therapy for treatment. In the future, further research could be conducted to clarify the effectiveness of interventions where mixed literature is reported.

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

This systematic review attempts to synthesize the existing research regarding interventional treatment for acute ankle sprains and chronic ankle instability. According to the results of the meta-analysis, exercise interventions and external bracing significantly decreases the risk of sustaining a recurrent ankle sprain. Additionally, exercise interventions, combined electrophysical and exercise interventions, and bracing can positively impact ankle sprain recovery. The research on the effectiveness of manual therapy is inconclusive, but it has been shown to increase dorsiflexion range of motion. Taking all of these findings into account, physical therapists can develop more effective rehabilitation and preventative protocols for patients. These protocols could employ a combination of exercise, bracing, electrophysical, and manual interventions to improve patient function, swelling, and pain post-injury. Aspects of these protocols could also be used to prevent/reduce the recurrence of ankle sprains. In the clinic, physical therapists can use this information in conjunction with individual patient response to guide their treatment decisions and improve patient’s quality of life.

Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals with Recurrent Ankle Sprain

Author Names

Vicenzino,B. et al.

Reviewer Name

Devin Hage

Reviewer Affiliation(s)

Duke University

Paper Abstract

Study Design: A double-blind randomized crossover experimental study with repeated measures,including a no-treatment control condition.Objective: To evaluate the initial effect of 2 mobilization with movement (MWM) treatment techniques performed in weight bearing and non-weight bearing on posterior talar glide and talocrural dorsiflexion in individuals with recurrent lateral ankle sprain.Background: MWM treatment techniques are commonly used in the treatment of musculoskeletal pain, such as lateral ankle sprain. Recent evidence indicates that a lack of posterior talar glide and weight-bearing ankle dorsiflexion are common physical impairments in individuals with recurrent ankle sprains. MWM of the ankle joint involves the application of a combined posterior talar glide mobilization and active dorsiflexion movement. The recurrent ankle sprain injury and the MWM treatment techniques for the ankle seemingly provide an appropriate model to further evaluate the effects and mechanism(s) of action of the MWM treatment techniques in a way that they have not been tested to date. Methods: Sixteen subjects (mean ± SD age, 19.8 ± 2.3 years) with a history of recurrent lateral ankle sprain and deficits in posterior talar glide (71%) and weight-bearing dorsiflexion (34%) were studied. A within-subjects study design was used to evaluate the effect of 2 independent variables:treatment conditions (weight-bearing MWM, non–weight-bearing MWM, and a no-treatment control group) and time (pretreatment and posttreatment) on the dependent variables of posterior talar glide and weight-bearing dorsiflexion.Results: Both the weight-bearing and non–weight-bearing MWM treatment techniques significantly improved posterior talar glide by 55% and 50% of the pre-application deficit between affected and unaffected sides, respectively, which was significantly greater than that of the control group(P.001). The weight-bearing and non–weight-bearing MWM treatment techniques improved weight-bearing dorsiflexion by 26% (P.017), compared to 9% for the control condition. The change in posterior talar glide, expressed as a proportion of pretreatment deficit, was correlated to the change in weight-bearing dorsiflexion (r = .88, P.001), but only after the weight-bearing MWM technique. Conclusion: This preliminary study demonstrated an initial ameliorative effect of MWM treatment techniques on posterior talar glide and dorsiflexion range of motion in individuals with recurrent lateral ankle sprain. These results suggest that this technique should be considered in rehabilitation programs following lateral ankle sprain. This study provides justification for follow-up research of the long-term effects of MWM on lateral ankle sprain and proposes further work be conducted on the posterior talar glide test. J Orthop Sports Phys Ther 2006;36(6):464-471. doi:10.2519/jospt.2006.2265

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

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

Both weight bearing and non-weight bearing mobilizations with movement improved ankle dorsiflexion

Key Finding #2

Mobilization with movement while weight bearing appeared to slightly be the better intervention compared to mobilization while non-weight bearing to improve ankle dorsiflexion, but the improvement is not necessarily significant enough to prefer one technique over the other.

Key Finding #3

Movement with mobilization techniques showcased an immediate effect on posterior talar glide and talocrural dorsiflexion.

Key Finding #4

Those with more limited ankle dorsiflexion following a lateral ankle sprain have a higher ceiling for improving ankle dorsiflexion following mobilization with movement compared to individuals who are relatively not restricted in the ankle dorsiflexion range of motion.

Please provide your summary of the paper

This paper served as a randomized control trial to evaluate the effects of mobilization with movement on ankle posterior talar glide and dorsiflexion on subjects with continuous lateral ankle sprains. Within the mobilizations with movement, researchers added a component of weight-bearing mobilizations and non-weight bearing mobilizations. The control group did not receive any treatment and stood for a time similar to that of which it took to perform the posterior talar glide in weight bearing and non-weightbearing. Dependent variables include posterior glide of the talus, which was measured through the tibial inclination during dorsiflexion of the ankle on the exam table, and ankle dorsiflexion which was assessed through a weight-bearing lunge. Subjects were similar on baseline demographics and appropriate inclusion criteria. Overall, the study found that mobilization with movement did yield immediate improvement in both dependent variables, with a slight more adventitious result in those with MWM in weight-bearing compared to non-weight bearing, but the results were not conclusive enough to rule out MWM in non-weight bearing as being inferior. Thus, both techniques are appropriate to perform for desired outcomes. Compared to the control trial, these individuals did not improve in posterior talar glide nor ankle dorsiflexion. In conclusion, movement with mobilizations produced immediate improvements in posterior talar glide and weight-bearing ankle dorsiflexion.

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

Overall, I believe this paper presented good evidence for the clinical application of MWM in recurrent lateral ankle sprains. Since MWM appeared to improve both the osteokinematics and arthrokinematics at the ankle, whether it be weight bearing or non-weight bearing mobilizations, this should be a technique used in clinical populations who suffer from recurrent lateral ankle sprains. Additionally, no adverse effects were reported from any of the treatment groups showcasing this is a safe practice technique indicating low risk if a therapist is debating using this technique. I think this paper presents an opportunity for further research to assess the long-term effects of mobilization with movement and whether this technique’s improvements are long term or if patients would need to see a therapist recurrently to preserve the new ranges of motion.

Effectiveness of Manual Therapy, Customized Foot Orthoses and Combined Therapy in the Management of Plantar Fasciitis—A RCT Study Design: RCT

Author Names

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

Reviewer Name

Annabelle Frantz, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program

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)?

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

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

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

Key Finding #1

For plantar fasciitis, manual therapy alone was found to be more effective than custom foot orthoses or a combination of manual therapy and custom foot orthoses.

Key Finding #2

Participants in all groups saw improvement in pain and function.

Key Finding #3

The study found that adding spinal treatment for patients who experience back complaints and plantar fasciitis could lead to an improved outcome.

Please provide your summary of the paper

This randomized controlled trial investigated the effectiveness of manual therapy, custom foot orthoses, or a combined treatment. Patients required 3 months of therapy to become symptom free. No stretching of the lower leg muscles or plantar fascia or other treatments of the knee or hip were performed. The focus was on the local impairment. All groups showed improvement in symptoms with the only manual therapy group showing the greatest improvement in symptoms. Patients’ symptoms were tracked over time with multiple outcome measures.

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 from this study could impact clinical practice by influencing physical therapists to try manual therapy before suggesting customized foot orthotics, which may save patients cost. It also provides therapists with options to offer patients since all groups showed improvement, which can impact patient autonomy and satisfaction. The results can be implemented by integrating manual therapy into treatment of plantar fasciitis early on and for 3 months before moving on to other treatments if it is unsuccessful.

Immediate Effects of Bilateral Manipulation of Talocrural Joints on Standing Stability in Healthy Subjects

Author Names

Alburquerque-Sendín, F; Fernández-de-las-Peñas, C; Santos-del-Rey, M; Martín-Vallejo, F J

Reviewer Name

Lauren Dreusicke

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

The purpose of this study was to investigate the immediate effects of bilateral talocrural joint manipulation on standing stability in healthy subjects. Sixty-two healthy subjects, 16 males and 46 females, aged from 18 to 32 years old (mean: 21 ± 3 years old) participated in the study. Subjects were randomly divided into two groups: an intervention group (n = 32), who received manipulation of bilateral talocrural joints and a control group (n = 30) which did not receive any intervention. Baropodometric and stabilometric evaluations were assessed pre- and 5 min post-intervention by an assessor blinded to the treatment allocation. Intra-group and inter-group comparisons were analysed using appropriate parametric tests. The results indicated that changes on the X coordinate range, length of motion, and mean speed approximated to statistical significance (P = 0.06), and changes on the Y coordinate range reached statistical significance (P = 0.02). Average X and Y motions, and anterior–posterior or lateral velocities did not show significant differences. Our results showed that bilateral thrust manipulation of the talocrural joint did not modify standing stability, that is, the behavioural pattern of the projection of the centre of pressure, in healthy subjects.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

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

Yes

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

Yes

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

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Bilateral talocrural manipulation did not have an influence on standing stability in healthy subjects.

Key Finding #2

Velocity of displacements did not show a significant difference between the control group and experimental group.

Key Finding #3

Providing manipulation to the talocrural join may induce changes in stability, but further studies with larger sample sizes and populations expressing symptoms should be used.

Please provide your summary of the paper

The goal of this study was to examine the relationship between bilateral talocrural joint manipulations and the immediate effects on standing stability of participants. In this single-blind randomized controlled trial, participants consisted of 62 healthy volunteers with ages ranging from 18-22 that were then given a physical examination prior to their inclusion in the study. After the subjects met qualification for the study, each stood on a force platform for 5 minutes to gather baseline balance data which tracked subject velocity of displacements, anterior-posterior displacements (Y coordinates), and medial-lateral displacements (X coordinates). All data taken at baseline and post-intervention was pulled from the 5th minute of data collection of the force platform. The control group received no additional interventions while the experimental group received one talocrural distractive thrust manipulation on each foot. After reevaluation of all study participants’ stabilometric values from the fifth minute and comparison to their own baseline values, anterior-posterior, lateral displacements, displacement length, displacement velocity were smaller after the talocrural manipulation than those of the control group. While there was a difference between groups in these variables, further analysis found that the change was not large enough to show significant difference. Limitations to this study include a small sample size that didn’t allow for statistically significant differences and a sham-manual procedure could have been introduced to the control group instead of receiving no 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 provides clinicians and researchers with lots of ideas to extract from its findings and procedures. Clinicians should include the use of talocrural manipulation when treating balance deficits. This would be especially helpful in the case that an individual has decreased proprioception surrounding the ankles or restricted motion that could be contributing to a loss of balance. Since the therapists in this trial only performed one manipulation at each talocrural joint, other therapists should further explore the effects multiple manipulations on the joint have on patient balance and how pairing these with exercise-based interventions can impact balance function as well. Additionally, the use of force plates, such as those used in the procedures to gather objective data in this study, provides a useful tool for clinicians to carry over into clinical practice. Integrating these into clinics would be helpful in objectifying weight distribution data as it pertains to balance and corrective responses, the diagnostic process of balance deficits, and providing feedback to the clinician and patient on how their different balance strategies are functioning. This trial provides ways to interpret this data collected from the force plates to help objectify and provide numbers to support the need for a patient’s treatment.

Effect of Manual Therapy in Patients With Hemophilia and Ankle Arthropathy: A Randomized Clinical Trial

Author Names

Elena Donoso-Úbeda 1, Javier Meroño-Gallut 2, José Antonio López-Pina 3, Rubén Cuesta-Barriuso

Reviewer Name

Julia Douglas

Reviewer Affiliation(s)

Duke University DPT

Paper Abstract

Objective: The aim of this study was to evaluate the effects of a manual therapy using fascial therapy on joint bleeding, joint pain and joint function in patients with hemophilic ankle arthropathy. Setting: Hemophilia patient associations. Design: Randomized, controlled trial, multicenter and intention-to-treat analysis. Participants: A total of 65 patients with hemophilic ankle arthropathy. Intervention: The experimental group (n = 33) received one fascial therapy session per week for three weeks. The control group (n = 32) received no treatment. Outcome measure: The primary outcome was frequency of joint bleeding measured using self-reporting. Secondary outcomes were joint pain (under load-bearing and non-load-bearing conditions) measured using the visual analog scale; joint condition was measured using the Hemophilia Joint Health Score. Outcomes were measured at baseline, posttreatment and after five months of follow-up. Results: Improvements in the frequency joint bleeding at T0, T1 and T2 were significantly higher in the experimental group (T0: mean (SD) = 1.56 (1.30); T1: mean (SD) = 0.00 (0.00); T2: mean (SD) = 0.27 (0.57)) compared to the control group (T0: mean (SD) = 1.70 (1.78); T1: mean (SD) = 0.05 (0.21); T2: mean (SD) = 0.58 (0.85)). Mean improvement of joint state after the study period was 1.74 points (±1.66) for patients in the experimental group, while the control group exhibited a joint deterioration with 0.43 points (±0.85). Ankle joint pain under load-bearing and non-load-bearing conditions improved in the experimental group with -1.72 (±1.86) and -0.50 (±1.39) points, respectively. Conclusion: The study showed that fascial therapy is favorable for patients with hemophilic ankle arthropathy. Keywords: Hemophilia; ankle arthropathy; fascial therapy; physical therapy; randomized clinical trial.

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?

unknown

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

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

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?

unknown

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

unknown

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)?

unknown

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?

Key Finding #1

This study showed a significant difference between participants that underwent manual therapy compared to those that did not undergo manual therapy as treatment for hemophilic ankle arthropathy. Those that received manual therapy experienced a greater decrease in joint bleeding and pain, compared to those that did not receive manual therapy treatment.

Key Finding #2

It was observed that in fascial therapy in patients with hemophilic ankle arthropathy resulted in no episodes of joint bleeding during or after the intervention. Thus, fascial therapy is deemed safe for patients with hemophilic ankle arthropathy.

Please provide your summary of the paper

This study focused on manual therapy treatment for patients with hemophilic ankle arthropathy, specifically using fascial therapy techniques. In this randomized control trial, one group participated in 3 weekly treatment sessions that focused on utilizing fascial therapy techniques. This group showed a significant improvement in pain, joint bleeding, and overall joint health in comparison to the group that did not undergo manual therapy treatment, and the benefits persisted after a 5-month period. Although there is concern for manual therapy in hemophilic patients, the therapy was shown to be safe for this patient population. Overall, thus study suggests that manual therapy, specifically fascial therapy, can reduce pain and improve quality of life for patients with hemophilic ankle arthropathy.

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 focuses on the potential of fascial therapy as safe and effective treatment for hemophilic ankle arthropathy. Results showed that this technique is safe for hemophilic patients, and it improved joint health, reduced bleeding, and improved quality of life. Clinicians should consider incorporating manual fascial therapy sessions in plans of care of patients with hemophilic ankle arthropathy, while continuing standard treatments.

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial

Author Names
Albin, S. Koppenhaver, S. Marcus, R. Dibble, L. Cornwall, M. Fritz, J.

Reviewer Name
Adriana Maldonado, PT, DPT

Reviewer Affiliation(s)
Duke University, Orthopedic Physical Therapy Residency

Paper Abstract
The purpose of this study was to assess the short-term effects of manual therapy on ankle range of motion, muscle stiffness, gait, and balance in patients following ORIF of an ankle and/or hindfoot fracture. In this RCT, 72 patients between 18 and 70 years old were randomized into two groups: one received impairment-based manual therapy, and the other received light soft tissue mobilizations and proximal tib-fib mobilizations. Both groups also received exercise and gait training. Patients were given three treatment sessions over 7-10 days. Outcomes were taken at baseline, after the second session, and 7-10 days after the last session. Outcomes included: LEFS, NPRS, the ankle lunge test for ankle dorsiflexion ROM, the foot assessment platform for midfoot mobility, the MyotonPROdevice for gastrocnemius muscle stiffness, gait analysis using an instrumented walkway, the single-limb stance (SLS) test for balance, and the Star Excursion Balance Test for balance and reach. No significant differences were found between the manual therapy and control groups in ROM, gait, or balance outcomes. The manual therapy group reported no change in gastrocnemius muscle stiffness, while the control group reported an increase in stiffness.

Quality Assessment of Controlled Intervention Studies

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

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

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

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

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

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

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

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

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

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

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

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
No

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

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

Key Finding #1
The findings of this study suggest that 3 sessions of impairment-based manual therapy does not result in greater improvement in ROM, gait, or balance compared to sham manual therapy after ankle and/or hindfoot surgical fixation.

Key Finding #2
The findings of this study suggest that manual therapy may decrease short-term muscle stiffness after ankle and/or hindfoot surgical fixation compared to
sham manual therapy.

Please provide your summary of the paper
The results did not show a statistically significant difference between impairment-based manual therapy and sham therapy in patients following ankle and/or hindfoot ORIF in: LEFS, NPRS, the ankle lunge test for ankle dorsiflexion ROM, the foot assessment platform for midfoot mobility, the MyotonPROdevice for gastrocnemius muscle stiffness, gait analysis using an instrumented walkway), the single-limb stance (SLS) test for balance, and the Star Excursion BalanceTest for balance and reach. There was a statistically significant difference in stiffness of the patient’s gastrocnemius, with the sham group reporting an increase in stiffness and the manual therapy group reporting no change in stiffness. Treatment varied for each patient based on the location of their fracture and the deficits identified by the physical therapist. Treatments were given in 3 sessions over the course of 7-10 days.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The patients in this study were immobilized for 10-16 weeks following ORIF. It is possible that patients immobilized for this length of time would require more than just 3 manual therapy sessions over the course of 7-10 days to see significant improvements.

A Study of the Effects of Mulligan's Mobilization With Movement Treatment of Lateral Ankle Pain Using a Case Study Design

Author Names O’Brien, T. Vicenzino, B.

Reviewer Name Mallory Martlock

Reviewer Affiliation(s) Duke Orthopedic Hybrid Residency Program

Paper Abstract A single case study design was used to investigate the effects of Mulligan’s mobilization with movement treatment technique for lateral ankle sprains. The technique involved the physiotherapist sustaining a posterior glide to the distal fibula, while the patient actively inverted the ankle several times. Passive overpressure at end of range was then applied by the therapist. Outcome measures used in this study were the modified Kaikkonen test, range
of dorsiflexion and inversion as well as a visual analogue scale for pain and function. Control for the natural resolution of ankle sprains was facilitated by using two subjects. Subject I underwent an ABAC protocol while subject II underwent an BABC protocol: where A was the no treatment phase, B was the treatment phase and C was the post-treatment return to sport phase. A comparison of the trends for both subjects indicated that the treatment technique produced improvements far in excess of that attributable to the natural history of a sprained ankle. This study provides preliminary evidence of the beneficial effects of this treatment technique, thus providing impetus for further investigations.

Quality Assessment of Case-Control Studies

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

2. Was the study population clearly specified and defined?

Yes
3. Did the authors include a sample size justification?

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

No
5. Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?

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

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

Yes
8. Was there use of concurrent controls?

No
9. Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?

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

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

No
12. Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?

Cannot Determine, Not
Reported, Not Applicable

Key Finding #1

Dorsiflexion and inversion ROM on the injured ankle improved after using the MWM treatment technique in both case study participants.

Key Finding #2

There were immediate decreases in pain which resulted in improvements in more global measures of function in both case study participants.

Key Finding #3

There was a more rapid improvement in symptoms for the participant that received treatment earlier on in their recovery compared to the participant who
followed the natural progression of recovery first.

Key Finding #4

Please provide your summary of the paper

The case study investigated the effects of a MWM on two male, athletic patients that were post lateral ankle sprain. The participants were similar in age and had injured themselves within a day of eachother. The MWM that was performed required the therapist to maintain a posterior glide to the distal fibula while the patient actively inverted the ankle several times. This was followed up with passive overpressure at end range applied by the therapist. Dorsiflexion and inversion ROM, VAS for pain and function as well as the modified Kaikkonen test were measured to assess for the effects of the MWM post ankle sprain. One of the subjects received treatment at a later time than the other subject to observe the differences in symptom progression when receiving early intervention compared to allowing for the natural healing process to take place. The study showed that the intervention allowed for more rapid improvements in ROM, function and pain compared to natural history of an ankle sprain recovery.

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

A limitation to this paper is that it was published several years ago. It is also a case study that investigated only two participants. These two factors call into question the validity and reliability of the findings of this study. However, the MWM intervention that was used was deemed successful in improving ROM, pain and function. Due to the high number of lateral ankle sprain patients that are seen in physical therapy, I believe that this case study and treatment approach is clinically significant because it provides an additional technique to help treat this patient population. The case study was done on
two young athletic males, a patient population that is often trying to return back to activity quickly. This technique could allow for the resolution of symptoms sooner and allow for that quicker return to function.

Instrument-Assisted Soft Tissue Mobilization Technique versus Static Stretching in Patients with Pronated Dominant Foot: A Comparison in Effectiveness on Flexibility, Foot Posture, Foot Function Index, and Dynamic Balance

Author Names:
Gupta, U., Sharma, A., Rizvi, M., Alqahtani, M., Ahmad, F., Kashoo, F., Miraj, M., Asad, M., Uddin, S., Ahamed, W., Nanjan, S., Hussain, S.,
Ahmad, I.

Reviewer Name:
Jake Isaac, DPT

Reviewer Affiliation(s):
X3 Performance and Physical Therapy, Duke University Hybrid Orthopedic Residency

Paper Abstract:
Background: Pronated foot is a deformity with various degrees of physical impact. Patients with a pronated foot experience issues such as foot pain,
ankle pain, heel pain, shin splints, impaired balance, plantar fasciitis, etc. Objective: The study intended to compare the effectiveness of IASTM
(instrument-assisted soft tissue mobilization) and static stretching on ankle flexibility, foot posture, foot function, and balance in patients with a flexible
pronated foot. Methods: Seventy-two participants between the ages of 18–25 years with a flexible pronated foot were included and allocated into three
groups: Control, stretching, and IASTM group using single-blinded randomization. Range of motion (ROM) measuring ankle flexibility, foot posture index
(FPI), foot function index (FFI), and dynamic balance was measured at baseline and after 4 weeks of intervention. Soft tissue mobilization was applied
on to the IASTM group, while the stretching group was directed in static stretching of the gastrocnemius-soleus complex, tibialis anterior, and Achilles
tendon in addition to the foot exercises. The control group received only foot exercises for 4 weeks. Results: The result shows the significant
improvement of the right dominant foot in ROM plantar flexion, (F = 3.94, p = 0.03), dorsiflexion (F = 3.15, p = 0.05), inversion (F = 8.54, p = 0.001) and
eversion (F = 5.93, p = 0.005), FFI (control vs. IASTM, mean difference (MD) = 5.9, p < 0.001), FPI (right foot, control vs. IASTM MD = 0.88, p =
0.004), and in dynamic balance of the right-leg stance (anterior, pre vs. post = 88.55 ± 2.28 vs. 94.65 ± 2.28; anteromedial, pre vs. post = 80.65 ± 2.3 vs.
85.55 ± 2.93; posterior, pre vs. post = 83 ± 3.52 vs. 87 ± 2.99 and lateral, pre vs. post = 73.2 ± 5.02 vs. 78.05 ± 4.29) in the IASTM group. The FFI was
increased remarkably in the stretching group as compared to the control group. Conclusions: Myofascial release technique, i.e., IASTM with foot
exercises, significantly improves flexibility, foot posture, foot function, and dynamic balance as compared to stretching, making it a choice of treatment for
patients with a flexible pronated foot.

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? N/A

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? Not reported

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

The IASTM group showed significant improvements in ankle ROM in the dominant foot compared to the stretching and exercise groups.

Key Finding #2

Participants in the IASTM group experienced significant improvements in the Foot Function Index (FFI) and Foot Posture Index (FPI) compared to the
control groups.

Please provide your summary of the paper

This study aimed to compare the effectiveness of IASTM and static stretching on ankle flexibility, foot posture, foot function, and dynamic balance in
individuals with a flexible pronated foot. The study included 60 individuals between the ages of 18-25 who were randomized into three groups: control
group (exercise only), stretching group, and IASTM group. Over the four-week period, the IASTM group received myofascial release techniques around
the ankle in addition to foot exercises; the stretching group performed static stretching of the gastrocnemius-soleus complex, tibialis anterior, and achilles
tendon along with foot exercises; and the control group received foot exercises alone. Key measures of the study were ROM, Foot Posture Index (FPI),
Foot Function Index (FFI), and dynamic balance. Results indicated that the IASTM group experienced significant improvements in ankle flexibility, foot
posture, foot function, and dynamic balance compared to the control group. The stretching group also demonstrated improvements in Foot Function
Index relative to the control group. The study indicates that utilization of IASTM with foot exercises may be more effective than static stretching for
improving ROM, foot posture, foot function, and dynamic balance.

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 potential effectiveness of IASTM combined with foot exercises for improving ankle ROM, foot posture, foot function, and dynamic
balance. While the study demonstrated improvements in IASTM, there are some limitations to the findings. It is unclear whether these patients were
performing a home exercise program during the 4-week treatment period. Compliance and performance of an HEP could have a large effect on the
results of the study. Another limitation is the specificity of the participants’ age and condition. The study utilized only 18-25 year olds with a flexible
pronated foot which limits the generalizability of the findings. Regardless, this paper indicates the potential benefit of using IASTM vs. static stretching
when both are combined with foot exercises.

What Really Happens When We Use Manual Therapy? A Fresh Look at the Mechanisms Behind Hands-On Approaches
Authors: Damian Keter DPT, PhD, Chad Cook PT, PhD, FAPTA Manual therapy (MT) has been part of musculoskeletal care for centuries, yet one question continues…
When the Numbers Don’t Move: Understanding Ceiling Effects, Floor Effects, and Limited Score Spread in MSK Patient‑Reported Outcomes
By: Chad Cook PT, PhD, FAPTA Introduction: I recently responded to a very supportive post on Linked-In that discussed a study we published two years…
Why Individualized Treatment Effects Matter More Than Averages in Musculoskeletal Care
By: Chad Cook PT, PhD, FAPTA Introduction: Imagine being able to say: “Based on your profile, you’re likely to respond better to graded activity than…
Spinal Manipulation: Lack of Precision Doesn’t Mean Lack of Skill
By: Mark Shepherd, PT, DPT, DSc Spinal thrust manipulation has been used for centuries, with evidence supporting its inclusion in neck and low back guidelines.1,2…
Advantages and Disadvantages of Research Metrics used to Evaluate a Researcher’s Impact or Influence
By: Chad E Cook PT, PhD, FAPTA Background: Each year, in Duke University’s Division of Physical Therapy, I teach a class on research methodology. One…
“It’s Not You, It’s Us…”: Heterogeneity of Treatment Effects as a Challenge to Effectiveness Trials.
By: Damian L Keter, PT, DPT, PhD Background: Comparative effectiveness studies are the cornerstone of medicine and health sciences research. They have a goal of…

Ankle/Foot

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“It’s Not You, It’s Us…”: Heterogeneity of Treatment Effects as a Challenge to Effectiveness Trials.