Author Names

  • Plaza-Manzano, G.

Reviewer Name

  • Megan Benzie, SPT, B.S.

Reviewer Affiliations

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

Paper Abstract

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

 

NIH Risk of Bias Tool

Quality Assessment of Case-Control Studies

  1. Was the research question or objective in this paper clearly stated and appropriate?
    • Yes
  1. Was the study population clearly specified and defined?
    • Yes
  1. Did the authors include a sample size justification?
    • No
  1. Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?
    • Yes
  1. 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
  1. Were the cases clearly defined and differentiated from controls?
    • Yes
  1. 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
  1. Was there use of concurrent controls?
    • No
  1. Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?
    • Cannot Determine, Not Reported, Not Applicable
  1. Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?
    • Yes
  1. Were the assessors of exposure/risk blinded to the case or control status of participants?
    • Cannot Determine, Not Reported, Not Applicable
  1. Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?
    • Yes

Key Finding #1

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

Key Finding #2

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

Key Finding #3

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

Key Finding #4

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

Please provide your summary of the paper

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

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

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