Author Names
Espi-Lopez GV, Lopez-Martinez S, Ingles M, Serra-Ano P, Aguilar-Rodriguez M
Reviewer Name
Ericka Boeger, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objectives: To compare the effectiveness of a specific Manual Therapy (MT) protocol applied to field hockey players (FHP), versus a Proprioceptive Neuromuscular Facilitation (PNF) protocol, in the improvement of dynamic balance, active range of movement and lumbar flexibility one-week and four-weeks after the treatment.
Design: Randomized controlled trial. Participants were assigned to 2 groups: MT and PNF. 30 min’ sessions were performed once a week for three weeks. Three evaluations were performed: basal, one-week and four-weeks post-treatment.
Setting: University of Valencia (Spain).
Participants: 22 in MT group and 20 in PNF group.
Main outcome measures: Dynamic Balance, measured with Star Excursion Balance Test; Active Range of Motion (ROM), using a manual goniometer and Lumbar Flexibility, assessed with Fingertip-to-floor test.
Results: Both groups significantly improved in lateral and medial dynamic balance one-week posttreatment (p < 0.05); but the improvement in the MT group lasted until the fourth-week after treatment in both reaches (lateral and medial) (p < 0.05). MT group also obtained significant improvements in dorsal flexion of the ankle in the fourth week post-treatment (p < 0.05) and in lumbar flexibility one-week post-treatment (p < 0.05).
Conclusions: MT and PNF improve dynamic balance one-week post-treatment; however, the improvement obtained through MT is maintained four-weeks later. Only MT improves dorsal flexion of the ankle four-weeks post-treatment and lumbar flexibility one-week post-treatment.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- 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 manual therapy (MT) and proprioceptive neuromuscular facilitation (PNF) groups experience increases in dynamic balance (Star Excursion Balance Test) for medial and lateral reach. However, only the MT group maintains this increase at the 4-week follow up. This demonstrates that the benefits of manual therapy have lasting impacts on dynamic balance when compared to PNF stretching. The anterior dynamic balance demonstrates no difference, which the authors deem not significant because this movement isn’t as common in field hockey.
Key Finding #2
Only the manual therapy group demonstrates an increase in lumbar flexibility (fingertip-to-toe test) at the 1-week post-treatment session. However, there is no significant improvement in lumbar flexibility at the 4-week follow-up. This demonstrates that manual therapy can improve lumbar flexibility in the short term but may not maintain lumbar flexibility long-term (4-week follow-up).
Key Finding #3
There are no statistically different active range of motion (AROM) measurements between the manual therapy (MT) or proprioceptive neuromuscular facilitation (PNF) stretching groups between before treatment and 1-week follow-up or between 1-week follow-up and 4-weeks follow-up. Only ankle dorsiflexion demonstrates a significant increase in AROM in the MT groups between pre-treatment and the 4-week follow-up goniometric measurements. This demonstrates that manual therapy can have a lasting impact on ankle dorsiflexion AROM and may be more effective than PNF stretching.
Please provide your summary of the paper
This paper is a randomized controlled trial that compares the effectiveness of manual therapy (MT) versus proprioceptive neuromuscular facilitation (PNF) stretching in improving dynamic balance, lumbar flexibility (flexion), and lower extremity range of motion in field hockey players. These outcomes were chosen based on the importance to field hockey and prevalence of injuries in the sport.
There are 42 participants included in this study. They are randomly assigned to a PNF (control) group or a MT group. They receive 30 min sessions one time per week for 3 weeks. They are evaluated using the Star Excursion Balance Test (dynamic balance), active range of motion using a goniometer (hip internal and external rotation, hip flexion, knee flexion, and ankle dorsiflexion), and the fingertip-to-toe test (lumbar flexibility) at T0 (before treatment), T1 (1 week after treatment), and T2 (4-weeks post treatment).
The results demonstrate that MT and PNF stretching improve dynamic balance (medial and lateral reach) at one-week follow-up appointments. However, only the MT group maintains the improvement in balance at the four-week follow-up. Additionally, only the MT group demonstrates improvements in lumbar flexibility (at 1-week follow-up) and ankle dorsiflexion active range of motion goniometric measurements (at 4-week follow-up).
The authors discuss the importance of joint stability of the lower limb in field hockey players and how this can be a major predisposition factor for injuries. They conclude that manual therapy has greater benefits than PNF stretching on mobility and joint stability of the lower extremity in field hockey players. They acknowledge their major limitation of not assessing strength and how these techniques could impact strength.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The authors discuss the importance of joint stability in field hockey players and how it can be applied to other sports. Joint stability is vital in preventing injuries. In clinical practice, it may be beneficial to combine techniques of manual therapy and PNF stretching, depending on the patient and situation. PNF stretching can still complement active ROM and prevent injuries. It is also important to consider the long-term impacts that manual therapy can have on dynamic balance and ROM. Although this article researches field hockey players, this can be applied to other sports and athletes that require dynamic balance and lower extremity joint stability. Additionally, this information could be applied to other populations where dynamic balance is important (such as older adults and preventing falls).
