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Effect of Manual Therapy on ROM Following Lateral Ankle Sprains: A Systematic Review Arscott, Sarah; Dessaulles, Patrick; Hughes, Karen; Kotzo, Steven; Preto, Rebecca; Dean, Elizabeth 2006-10-05

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The Effect of Manual Therapy on Dorsiflexion Range of Motion Following Lateral Ankle Sprains: A Systematic ReviewElizabeth Dean, Ph.D., P.T. Sarah Arscott, BHK Patrick Desaulles, BHK Karen Hughes, BSc Steve Kotzo, BA, BHK Rebecca Preto, BSc (Kin)Introduction?Manual therapy effects on the spine are well documented (Ernst & Canter, 2006)?Limited research on manual therapy performed on the ankle ?Common physiotherapy intervention used in practice Lateral Ankle Sprain?One of the most common injuries in athletes (Garrick, 1977)?Most commonly results from an inversion/ plantarflexion force ?Re-occurrence rate   73-80%(Denegaret al., 2002)Lateral Ankle Sprain Sequelae?Loss of:?Ability to forcefully evertankle ?Proprioception/ neuromuscular control ?Ligament stability ?Range of motion (ROM), especially dorsiflexion (DF) ?Function (Denegaret al., 2002)Hypotheses for limited DF ROM post lateral ankle sprain?Tight ankle plantarflexors ?Capsular and soft tissue restriction ?Loss of normal posterior glide of the talus in the mortise ?Loss of other accessory motions at the tibiofibular, subtalar and midtarsal joints(Denegaret al., 2002)Physiotherapy Treatment Options?P.R.I.C.E. ?Electrotherapy ?Manual therapy ?Active exercises ?Bracing/taping ?Proprioceptive retrainingManual Therapy?Restoration of joint mobility and normal joint end feels(Canadian OrthopracticManual Therapy Association, COMTA)Types of Manual Therapy1.Mobilization 2.Manipulation 3.Mulligan?sMobilization with Movement (MWM)Mobilization?Gentle, rhythmic, repetitive passive movement of graded amplitude aimed at restoring mobility, function and reducing pain(COMTA)MobilizationManipulation?Skilled, passive, quick movement with goal of restoring mobility and function and reducing pain in a stiff joint and the associated tissues(COMTA)?Therapist applies a sustained accessory glide at right angles or parallel to the joint  ?Limited painful physiologic movement is performed actively by the patient ?The aim is to reduce the restricted, painful movement and restore pain-free and full ROM (Mulligan, 1999)Mulligan?s Mobilization with MovementMulligansMobilization with MovementRecent Systematic Review?Effectiveness of exercise therapy and manual mobilizations in acute ankle sprain(Van derWeeset al., 2006) ?Appears similar to ours BUT??.Van derWeeset al., 2006Dean et al.Study designs includedRCTRCT, case studies# of databases searched78Languages searchedEnglish, German, DutchEnglish, FrenchYear of publicationUntil 2005Until 2006Type of interventionManual mobilization/ ExerciseManual therapyIntervention carried out byPhysiotherapist, ChiropractorsPhysiotherapists onlyDependent VariableAcute ankle sprain &/or functional instabilityAcute-chronic lateral ankle sprainOutcome measureRecurrent sprains, functional disability, gait, ankle ROMAnkle ROMMethodsLiterature search ?Databases:?MEDLINE  ?EMBASE ?CINAHL ?PEDro ?Pubmed ?Cochrane Database of Systematic Reviews ?Cochrane Central Register of Controlled Trials ?Google ScholarMethods Con?tSearch terms: ?ankle, ankle joint, talocrural joint AND  ?manual therapy,mobilization, manipulation, glides, orthopaedicmanipulation AND ?range of motionMethods Con?t?Hand searched 3 journals ?Reference lists reviewed ?Additional article identified while attending a courseMethod Con?tTypes of studies: ?Randomized Controlled Trials (RCT) ?Case StudiesMethods Con?tOutcome Measure:?Range of MotionTreatment included at least one of:?Mobilization ?Manipulation ?Mulligan?s MWMMethods Con?tManual therapy performed by a physiotherapist Types of participants: ?Acute, sub-acute or chronic lateral ankle sprains ?Pain and/or swelling and/or limited ROM of the ankle and/or decreased functionMethods Con?tExclusion Criteria: ?Manual therapy performed by other health care professionals other than physiotherapists   ?Asymptomatic subjects ?Fractures  ?Degenerative joint disease ?Inflammatory arthritisMethods Con?t ?Methodological QualityAssessment tool?Level of EvidenceMethods Con?t?A modified RCT quality assessment tool recommended by The Cochrane Back Review Group(Van Tulderet al., 2003)?High methodological quality:  score of ?7Table 1:  RCT Methodological Quality Assessment Tool*A.  Was the study?s purpose clearly stated?Yes/No/Not SureB.  Was the method of randomization adequate?Yes/No/Not SureC.  Was the treatment allocation concealed from the groups or individuals?Yes/No/Not SureD.  Was the patient blinded to the intervention?Yes/No/Not SureE.  Were the groups similar at baseline regarding the most important prognostic indicators?Yes/No/Not SureF.  Was the therapist providing treatment blinded to the intervention?Yes/No/Not SureG.  Was the outcome assessor blinded to the intervention?Yes/No/Not SureH.  Were co-interventions avoided or similar?Yes/No/Not SureI.  Was the compliance acceptable in all groupsYes/No/Not SureJ.  Was the dropout rate described and acceptable?Yes/No/Not SureK.  Was the timing of the outcome assessment in all groups similar?Yes/No/Not SureL.  Did the analysis include an intention to treat analysis?Yes/No/Not Sure* Modified from Van Tulderet al., 2003Quality AssessmentCase Studies:?We developed a list of seven criteria to assess the quality of the case studies included in the review (Table 2)?A minimum score of five was required to be considered for the review.  Table 2: Case Study Quality Assessment ToolA.  Was the purpose of the study clearly stated? Yes/No/Not Sure B.  Was the hypothesis clearly stated? Yes/No/Not Sure C.  Were the patients described in detail so that you could decide whether they are comparable to those seen in practice? Yes/No/Not Sure D.  Were the interventions and treatment setting described well enough so that they could be replicated? Yes/No/Not Sure E.  Were the measures used clearly described, valid and reliablefor measuring the outcome of interest? Yes/No/Not Sure F.  Was the size of the effect clinically important? Yes/No/Not Sure G.  Were the limitations of the study identified & discussed? Yes/No/Not Sure TOTAL /7 Table 3: Levels of Evidence Phillips et al. (2001)LevelTherapy/Prevention, Etiology/Harm 1aSystematic review (SR) (with homogeneity) of RCTs1bIndividual cohort study, including low quality RCTs(egg, <80% follow-up) 1cAll or none 2aSystematic review (with homogeneity) ofcohort studies 2bIndividual cohort study, including low qualityRCTs(e.g., <80% follow-up) 2c"Outcomes" Research; Ecological studies 3aSR of case-control studies 3bIndividual Case-Control Study 4Case-series (and poor quality cohort and case-control studies ) 5Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles ResultsFigure. Streaming of study selection Initial search of databases:Medline = 196, Google Scholar = 2, Cochrane Database of Systematic Reviews = 0, Embase= 37, CINAHL = 58, PEDro= 33, PubMed= 67Total = 391Studies excluded after title and abstract screening:  N = 40Articles found after hand searching, grey literature, and screening reference lists:N = 6Studies excluded after evaluation of full text:N = 5After extraction of duplicate studies:N = 30Full text of studies retrieved after using abstract screening toolN= 11Results?5 studies retrieved:?Green et al., 2001 ?O?Brien and Vicenzino, 1998 ?Whitman et al., 2004 ?Collins et al., 2004 ?Reid et al., in pressTable 6: Methodological Quality of RCT studiesStudyQuality  Score  (/12)Level of  EvidenceGreen et al.,  200191BCollins et al.,  2003111BReid et al., 2006111BTable 7: Methodological Quality of Case StudiesStudyQuality  Score (/7)Level of  evidenceWhitman et al., 200163BO?Brien and  Vincenzino,  199863BDiscussionDF ROM: ?Manual Therapy was found to be beneficial in all stages of healing ?DF is essential for many activities and its restoration an integral part of the rehabilitation process (Willemset al., 2005)Discussion?Potential culprits for decreased DF ROM: ?anterior subluxationof the talus?reduced posterior glide of the talus ?or both (Green et al., 2001, Denegaret al., 2002, Collins et al., 2004)talusDiscussionFunctional mobility: ?Subjects: acute and sub-acute lateral ankle sprains  ?MWM treatment technique ?Significantly greater immediate improvements in functional mobility ?Improvements were maintained at the short term and long term follow up (O?Brien and Vicenzino1998, Whitman et al., 2005DiscussionPain:  ?Both found a decrease in pain immediately and at 6 months post mobilization ?Collins et al. (2004) found no significant effect on thermal threshold or pain threshold ?Suggests that pain decrease is mechanical and not neurallymediated(Collins et al., 2004, O?Brien and Vicenzino1998, Whitman et al., 2005)DiscussionGrades of Recommendation (Phillips et al., 2001)Aconsistent level 1 studies Bconsistent level 2 or 3 studies orextrapolations from level 1 studies Clevel 4 studies orextrapolations from level 2 or 3 studies Dlevel 5 evidence or troublingly inconsistent or inconclusive studies of  any levelDiscussionGrades of Recommendations: ?Grade A?To increase ROM ?To improve gait characteristics?Grade B?To decrease painMethodological Limitations?None of the RCTsscored a point for therapist blinding, item ?F? ?Neither case study clearly stated their hypotheses, item ?B?Methodological Limitations?Tools were modified by the reviewers?Reputable quality assessment tool selected as template (Van Tulderet al., 2003)  ?Tools were tested on studies not included in this review in order to ensure inter-raterreliabilityMethodological Limitations?Lower quality study designs were included?To avoid overlooking potential contributions to the research ?Enhanced clinical representationMethodological Limitations?Limited to studies in which manual therapy treatment was performed by a physiotherapist ?Large amount of heterogeneity:?stage of soft tissue healing  ?characteristics of the participants ?treatments givenFuture Research?Compare effects of manual therapy on DF ROM through the stages of healing ?Long term follow-up ?Comparison of manual therapy techniquesImplications for Physiotherapy?Manual therapy found to increase ankle DF ROM ?Must understand indications and contraindications for manual therapyConclusion?Preliminary evidence to support manual therapy to improve dorsiflexionROM following lateral ankle sprains ?Caution in generalization of outcomes ?Review offers important information for practitionersThank you!!! ?Elizabeth Dean ?Susan Harris ?Andrea Reid ?May NolanReferences?Baumhauer, JF, AlosaDm, RenstromAf, Trevino S, BeynnonB.  A prospective study of ankle injury risk factors.  American Journal of Sports Medicine 1995; 23: 564-570. ?Brand RL, Black HM, Cox JS.  The natural history of inadequatelytreated ankle sprain. American Journal of Sports Medicine 1977; 5: 248-249. ?BruknerP, Khan K. Clinical Sports Medicine, 2nd edn. Australia: McGraw-Hill, 2002; ch29, p558-559. ?Canadian OrthopracticManual Therapy Association. COMTA Guidelines. Available at: Accessed June 28, 2006.?Collins N, TeysP, VicenzinoB. The initial effects of a Mulligan?smobilization with movement technique on dorsiflexionand pain in subacuteankle sprains.  Manual Therapy 2004; 9: 77-82. ?CraikR.  Interpreting Systematic Reviews:  Sometimes, More is Better.  Physical Therapy 2006;86(7):1-2.?CrosbieJ, Green T, RefshaugeKM. Effects of reduced ankle dorsiflexionfollowing lateral ligament sprain on temporal and spatial gait parameters. Gait Posture 1999; 9: 167-172.?DenegarCR, HertelJ, Fonseca J. The effect of lateral ankle sprain on dorsiflexionrange of motion, posterior talarglide, and joint laxity. Journal of Orthopaedic and Sports Physical Therapy 2002; 32: 166-173.?EisenhartAW, GaetaTJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. Journal of the American OsteopathicAssociation. 2003; 103: 417-421. ?Ernst E, Canter PH.   A systematic review of systematic reviews of spinal manipulation.  Journal of the Royal Society of Medicine 2006; 99: 192-196. ?FallatL, Grimm DJ, SaraccoJA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. Journal of Foot & Ankle Surgery 1998; 37(4): 280-285. ?GarrickJG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. American Journal of Sports Medicine1977; 5(6): 241-242. ?Green T, RefshaugeK, CrosbieJ, Roger A.  A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy 2001; 8: 984-994.?McClayIS. The use of gait analysis to enhance the understanding of running injuries. In: CraikA, OatisCA.Gait Analysis: Theory and Application. St. Louis, Missouri: Mosby,  1995; p395-411. ?MenzHB. Manipulative Therapy of the foot and ankle: science or mesmerism. The Foot 1998; 8: 68-74.  ?Mulligan BR.  Manual therapy ?NAGS?, ?SNAG?, ?MWM?, etc, 4th ed.  Wellington:  Plane View Services Ltd; 1999; p104-107. ?NieldS, Davis K, Latimer J, Maher C, Adams, R.  The effect of manipulation on range of movement at the ankle joint.  Scandinavian Journal of Rehabilitation Medicine 1993; 25: 161-166.?O?Brien T, VicenzinoB.  A study of the effects of Mulligan?smobilization with movement treatment of lateral ankle pain using a case study design. Manual Therapy 1998; 3: 78-84.References con?t ?Phillips B, Ball C, SackettD, BadenochD, Straus S, Haynes B, Dawes M.   Levels of Evidence and Grades of Recommendation 2001. Accessed July 11, 2006.?Reid A, AlcockG, Birmingham T.  Effect of mobilization with movement as a method of increasing dorsiflexionfollowing lateral ankle sprain, 2006 submitted for publication.?RimandoMP. Ankle sprain.  Available at: Accessed June 28, 2006.?SafranMR, Benedetti RS, BartolozziAR, MandelbaumBR. Lateral ankle sprains: a comprehensive review part 1: eitiology, pathoanatomy, histopathogenesis, and diagnosis. Medicine and Science in Sports and Exercise 1999; 31(7): 429-437. ?Van derWeesPJ, LenssenAF, HendriksEJM, Stomp DJ, Dekker J, de BieRA. Effectiveness of exercise therapy and manual mobilization in acute ankle sprain and functional instability: a systematic review. Australian Journal of Physiotherapy 2006; 53: 27-37.?Van TulderM, FurlanA, Bombardier C, BouterL, The Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the Cochrane collaboration back review group. Spine 2003; 28(12): 1290-1299. ?VicenzinoB, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesiaand sympathoexcitation. Journal of Manipulative Physiological Therapy 1998; 21: 448-453.?VicenzinoB., PrangleyI., and Martin D. The initial effect of two Mulligan mobilization with movement treatment techniques on ankle dorsiflexion. Australian Conference of Science and Medicine in Sport.  A Sports Medicine Odyssey.  Challenges, Controversies and Change [CD ROM]  Sports Medicine Australia; 2001.?Whitman JM, Childs JD, Walker V.  The use manipulation in a patient with an ankle sprain injury not responding to conventional management: a case report.Manual Therapy 2005; 10: 224-231. ?WillemsTM, WitvrouwE, DelbaereK, MahieuN, De BourdeaudhuijI, De ClercqD. Intrinsic Risk Factors for Inversion Ankle Sprains in Male Subjects. The American Journal  of Sports Medicine. 2005; 33(3): 415-423.?YeungMS, Chan KM, So CH, Yuan WY. 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