Author Names
Lubbe, D., Lakhani, E., Brantingham, JW., Parkin-Smith, GF., Cassa, TK., Globe, GA., & Korporaal, C.
Reviewer Name
Hannah Zhao, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective
The purpose of this study was to compare manipulative therapy (MT) plus rehabilitation to rehabilitation alone for recurrent ankle sprain with functional instability (RASFI) to determine short-term outcomes.
Methods
This was an assessor-blind, parallel-group randomized comparative trial. Thirty-three eligible participants with RASFI were randomly allocated to receive rehabilitation alone or chiropractic MT plus rehabilitation. All participants undertook a daily rehabilitation program over the course of the 4-week treatment period. The participants receiving MT had 6 treatments over the same treatment period. The primary outcome measures were the Foot and Ankle Disability Index and the visual analogue pain scale, with the secondary outcome measure being joint motion palpation. Data were collected at baseline and during week 5. Missing scores were replaced using a multiple imputation method. Statistical analysis of the data composed of repeated-measures analysis of variance.
Results
Between-group analysis demonstrated a difference in scores at the final consultation for the visual analogue scale and frequency of joint motion restrictions ( P ≤ .006) but not for the Foot and Ankle Disability Index ( P = .26).
Conclusions
This study showed that the patients with RASFI who received chiropractic MT plus rehabilitation showed significant short-term reduction in pain and the number of joint restrictions in the short-term but not disability when compared with rehabilitation alone.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
| 1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT? Yes | |||
| 2. Was the method of randomization adequate (i.e., use of randomly generated assignment) Yes | |||
| 3. Was the treatment allocation concealed (so that assignments could not be predicted)? Yes | |||
| 4. Were study participants and providers blinded to treatment group assignment? No | |||
| 5. Were the people assessing the outcomes blinded to the participants’ group assignments? Yes | |||
| 6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? Yes | |||
| 7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? Yes | |||
| 8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? Yes | |||
| 9. Was there high adherence to the intervention protocols for each treatment group? NR | |||
| 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? NR | |||
| 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 combination of manual therapy and rehabilitation for ankle injury yielded a greater reduction in pain (VAS scores) compared to rehabilitation alone.
Key Finding #2
The combination of manual therapy and rehabilitation for ankle injury showed a greater decrease in joint restriction, determined by clinician palpation, when compared to rehabilitation alone.
Key Finding #3
There was no significant difference in the disability (FADI scores) reported between the two patient groups.
Key Finding #4
Both treatment groups, rehabilitation alone and rehabilitation plus manual therapy, showed significantly significant outcomes in decreasing pain and joint restriction.
Please provide your summary of the paper
This assessor-blind, parallel group randomized comparative trial looked at thirty-three participants who were diagnosed with recurrent ankle sprain with functional instability (RASFI). A majority of ankle sprain injuries are due to a force that causes excessive inversion and plantarflexion, resulting in inversion ankle sprains that most commonly, impact first the anterior talofibular ligament, followed by the calcaneofibular and posterior talofibular ligaments. Inversion sprains are one of the most common injuries amongst athletes and 40% of the time, RASFI injuries can progress to chronic ankle instability (CAI). Proprioceptive and traditional strength training protocols have been shown to increase ankle stability and range of motion. As more research demonstrates hopeful outcomes from manual therapy techniques (ex: joint mobilization and manipulation) to the ankle and foot joint for ankle sprain injuries, this study considers the impact of combining traditional rehabilitation protocols with these manual therapy techniques. Participants were randomly placed in a control group, which received rehabilitation alone, or in an experimental group, which received rehabilitation plus manual therapy. All participants received a rehabilitation program over a 4-week period and participants in the experimental group received 6 treatments of manual therapy within that same time frame. While both groups demonstrated statistically significant improvement, the study concluded that participants who received rehabilitation plus manual therapy showed a greater decrease in pain (Visual Analogue Pain Scale) and joint restriction (Foot and Ankle Disability Index). However, when looking at disability, both groups were comparable in their results.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The study indicates that incorporating manual therapy techniques along with traditional rehabilitation protocols results in less pain and joint restriction for athletes with recurrent ankle sprains with functional instability (RASFI). These findings are clinically relevant because of the prevalence of inversion ankle sprains in active populations and the possibility of progressing towards chronic ankle instability (CAI). While the findings suggest standard strength training and proprioceptive protocols to be effective in improving pain and joint restriction, these outcomes can improve to a greater extent with the addition of manual therapy techniques. Therefore, when considering return to sport athletes who are under more of a time constraint, it may be beneficial to incorporate manual therapy techniques earlier on in the rehabilitation stages to speed up the recovery process.
