Article Full Title
The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review
Author Names
Loudon, J; Reiman, M; Sylvain, J
Reviewer Name
Kayla Berezne, SPT
Reviewer Affiliations
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes.
Objective: Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains.
Methods: This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination ‘ankle’, ‘sprain’, ‘injuries’, ’lateral’, ‘manual therapy’, and ‘joint mobilisation’. The methodological quality of individual studies was assessed using the PEDro scale.
Results: After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed.
Conclusions: For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of motion, decreased pain and improved function.
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?
No
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Manual mobilizations can decrease pain in acute lateral ankle sprains.
Key Finding #2
Manual mobilizations and thrust manipulations can decrease pain, improve dorsiflexion ROM, and improve self-rated function in subacute or chronic lateral ankle sprains.
Please provide your summary of the paper
This systematic review concluded that manual therapy could be beneficial following ankle sprains acutely to decrease pain and subacutely/chronically to decrease pain, improve dorsiflexion ROM, and improve function. The study clearly denotes the article inclusion and exclusion process as well as the review criteria. As the first systematic review to consider only manual therapy interventions for lateral ankle sprains, it encourages the use of manual therapy for immediate pain management and the potential for improved dorsiflexion and functional outcomes, though more evaluation is required.
There are several limitations to this study and the implication of the research however. Most notably, 7 of the 8 studies evaluated the outcomes either immediately after the session, after one day, or after one week. The longest follow-up period is one month, pointing towards a lack of consideration for long-term outcomes or notable functional changes especially as the authors note the risk of the progression to long-term symptoms, chronic ankle sprains, ankle arthritis, and chronic ankle instability. Additionally, the interventions included distraction techniques, AP talocrural mobilizations, thrust manipulations, and mobilizations with active ankle movement with variable control groups as well, limiting the similarity of the articles selected and the potential for clinical implementation to achieve similar results. Of note, the studies included in this article evaluated young adults under 32 years old, which limits the generalization permissible to older adults and pediatric populations. Finally, the authors did not discuss that one of the studies included analgesics given to both the control and intervention groups with pain scores as an outcome measure and how this may influence the results of this study. Overall, there is likely a need to further evaluate the efficacy of manual therapy for lateral ankle sprains with clear manual therapy and exercise interventions and long-term follow up that includes functional outcomes, though it suggests that manual therapy techniques can help decrease pain short-term in individuals with 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 variability among manual therapy interventions and control group comparisons limit the feasibility of implementation of these results. Additionally, the clinical relevance is limited by the lack of long-term follow up and limited functional outcomes evaluated, especially as there is a potential for acute lateral ankle sprains to progress to further chronic impairments.
However, these results could be beneficial in young adult patients with a pain-dominant presentation to improve pain and potentially therefore increase self-efficacy of active movements, though that was not established in this study. Also, there is the potential that manual therapy can be of further benefit to individuals with subacute or chronic sprains to decrease pain and improve ankle dorsiflexion ROM, with one of the 8 studies noting an improvement in a functional evaluation scale.
The authors note that manual therapy techniques are likely best implemented in addition to exercise, though they express the importance of their study evaluating manual therapy alone as an intervention. A clinician’s judgement will likely consider the feasibility of ankle manual therapy techniques in comparison with the likelihood of decreased pain in order to guide implementation to further improve patient outcomes.
