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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 Oct 5, 2006

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The Effect of Manual Therapy on Dorsiflexion Range of Motion Following Lateral Ankle Sprains: A Systematic Review Elizabeth 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% (Denegar et al., 2002)  Lateral Ankle Sprain Sequelae • Loss of: – Ability to forcefully evert ankle – Proprioception/ neuromuscular control – Ligament stability – Range of motion (ROM), especially dorsiflexion (DF) – Function (Denegar et 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 (Denegar et al., 2002)  Physiotherapy Treatment Options • • • • • •  P.R.I.C.E. Electrotherapy Manual therapy Active exercises Bracing/taping Proprioceptive retraining  Manual Therapy • Restoration of joint mobility and normal joint end feels (Canadian Orthopractic Manual Therapy Association, COMTA)  Types of Manual Therapy 1. Mobilization 2. Manipulation 3. Mulligan’s Mobilization with Movement (MWM)  Mobilization • Gentle, rhythmic, repetitive passive movement of graded amplitude aimed at restoring mobility, function and reducing pain (COMTA)  Mobilization  Manipulation • Skilled, passive, quick movement with goal of restoring mobility and function and reducing pain in a stiff joint and the associated tissues (COMTA)  Mulligan’s Mobilization with Movement • 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)  Mulligans Mobilization with Movement  Recent Systematic Review • Effectiveness of exercise therapy and manual mobilizations in acute ankle sprain (Van der Wees et al., 2006) • Appears similar to ours BUT…….  Van der Wees et al., 2006  Dean et al.  Study designs included # of databases searched  RCT  RCT, case studies  7  8  Languages searched Year of publication Type of intervention  English, German, Dutch Until 2005  English, French  Manual mobilization/ Exercise  Manual therapy  Intervention carried out by  Physiotherapist, Chiropractors  Physiotherapists only  Dependent Variable  Acute ankle sprain &/or functional instability  Acute-chronic lateral ankle sprain  Outcome measure  Recurrent sprains, functional disability, gait, ankle ROM  Ankle ROM  Until 2006  Methods Literature search • Databases: – MEDLINE – EMBASE – CINAHL – PEDro – Pubmed – Cochrane Database of Systematic Reviews – Cochrane Central Register of Controlled Trials – Google Scholar  Methods Con’t Search terms: • ankle, ankle joint, talocrural joint AND • manual therapy,mobilization, manipulation, glides, orthopaedic manipulation AND • range of motion  Methods Con’t  • Hand searched 3 journals • Reference lists reviewed • Additional article identified while attending a course  Method Con’t Types of studies: • Randomized Controlled Trials (RCT) • Case Studies  Methods Con’t Outcome Measure: – Range of Motion  Treatment included at least one of: – Mobilization – Manipulation – Mulligan’s MWM  Methods Con’t Manual 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 function  Methods Con’t Exclusion Criteria: • Manual therapy performed by other health care professionals other than physiotherapists • Asymptomatic subjects • Fractures • Degenerative joint disease • Inflammatory arthritis  Methods Con’t • Methodological Quality Assessment tool • Level of Evidence  Methods Con’t • A modified RCT quality assessment tool recommended by The Cochrane Back Review Group (Van Tulder et al., 2003) • High methodological quality: score of ≥7  Table 1: RCT Methodological Quality Assessment Tool* A. Was the study’s purpose clearly stated?  Yes/No/Not Sure  B. Was the method of randomization adequate?  Yes/No/Not Sure  C. Was the treatment allocation concealed from the groups or individuals?  Yes/No/Not Sure  D. Was the patient blinded to the intervention?  Yes/No/Not Sure  E. Were the groups similar at baseline regarding the most important prognostic indicators?  Yes/No/Not Sure  F. Was the therapist providing treatment blinded to the intervention?  Yes/No/Not Sure  G. Was the outcome assessor blinded to the intervention?  Yes/No/Not Sure  H. Were co-interventions avoided or similar?  Yes/No/Not Sure  I. Was the compliance acceptable in all groups  Yes/No/Not Sure  J. Was the dropout rate described and acceptable?  Yes/No/Not Sure  K. Was the timing of the outcome assessment in all groups similar?  Yes/No/Not Sure  L. Did the analysis include an intention to treat analysis?  Yes/No/Not Sure  * Modified from Van Tulder et al., 2003  Quality Assessment Case 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 Tool A. 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 reliable for 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) Level  Therapy/Prevention, Etiology/Harm  1a  Systematic review (SR) (with homogeneity) of RCTs  1b  Individual cohort study, including low quality RCTs (egg, <80% follow-up)  1c  All or none  2a  Systematic review (with homogeneity) of cohort studies  2b  Individual cohort study, including low quality RCTs (e.g., <80% follow-up)  2c  "Outcomes" Research; Ecological studies  3a  SR of case-control studies  3b  Individual Case-Control Study  4  Case-series (and poor quality cohort and case-control studies )  5  Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles  Results Figure. 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 = 67 Total = 391  Studies excluded after title and abstract screening: N = 40  After extraction of duplicate studies: N = 30  Articles found after hand searching, grey literature, and screening reference lists: N=6  Full text of studies retrieved after using abstract screening tool N= 11  Studies excluded after evaluation of full text: N=5  Results • 5 studies retrieved: – Green et al., 2001 – O’Brien and Vicenzino, 1998 – Whitman et al., 2004 – Collins et al., 2004 – Reid et al., in press  Table 6: Methodological Quality of RCT studies Study  Quality Score (/12)  Level of Evidence  Green et al., 2001  9  1B  Collins et al., 2003  11  1B  Reid et al., 2006 11  1B  Table 7: Methodological Quality of Case Studies Study  Quality Level of Score (/7) evidence  Whitman et al., 2001  6  3B  O’Brien and Vincenzino, 1998  6  3B  Discussion DF 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 (Willems et al., 2005)  Discussion • Potential culprits for decreased DF ROM: – anterior subluxation of the talus – reduced posterior glide of the talus – or both (Green et al., 2001, Denegar et al., 2002, Collins et al., 2004)  talus  Discussion Functional 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 Vicenzino 1998, Whitman et al., 2005  Discussion Pain:  • 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 neurally mediated  (Collins et al., 2004, O’Brien and Vicenzino 1998, Whitman et al., 2005)  Discussion Grades of Recommendation (Phillips et al., 2001)  A  consistent level 1 studies  B  consistent level 2 or 3 studies or extrapolations from level 1 studies  C  level 4 studies or extrapolations from level 2 or 3 studies  D  level 5 evidence or troublingly inconsistent or inconclusive studies of any level  Discussion Grades of Recommendations: • Grade A – To increase ROM – To improve gait characteristics  • Grade B – To decrease pain  Methodological Limitations • None of the RCTs scored 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 Tulder et al., 2003) – Tools were tested on studies not included in this review in order to ensure inter-rater reliability  Methodological Limitations • Lower quality study designs were included – To avoid overlooking potential contributions to the research – Enhanced clinical representation  Methodological 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 given  Future Research • Compare effects of manual therapy on DF ROM through the stages of healing • Long term follow-up • Comparison of manual therapy techniques  Implications for Physiotherapy • Manual therapy found to increase ankle DF ROM • Must understand indications and contraindications for manual therapy  Conclusion • Preliminary evidence to support manual therapy to improve dorsiflexion ROM following lateral ankle sprains • Caution in generalization of outcomes • Review offers important information for practitioners  Thank you!!! • • • •  Elizabeth Dean Susan Harris Andrea Reid May Nolan  References • • • • • • • • • • • • • • • • • •  Baumhauer, JF, Alosa Dm, Renstrom Af, Trevino S, Beynnon B. 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 inadequately treated ankle sprain. American Journal of Sports Medicine 1977; 5: 248-249. Brukner P, Khan K. Clinical Sports Medicine, 2nd edn. Australia: McGraw-Hill, 2002; ch 29, p558559. Canadian Orthopractic Manual Therapy Association. COMTA Guidelines. Available at: http://orthopractic.org/guidelines.html. Accessed June 28, 2006. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Manual Therapy 2004; 9: 77-82. Craik R. Interpreting Systematic Reviews: Sometimes, More is Better. Physical Therapy 2006;86(7):1-2. Crosbie J, Green T, Refshauge KM. Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters. Gait Posture 1999; 9: 167-172. Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. Journal of Orthopaedic and Sports Physical Therapy 2002; 32: 166-173. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. Journal of the American Osteopathic Association. 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. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. Journal of Foot & Ankle Surgery 1998; 37(4): 280-285. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. American Journal of Sports Medicine 1977; 5(6): 241-242. Green T, Refshauge K, Crosbie J, Roger A. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy 2001; 8: 984-994. McClay IS. The use of gait analysis to enhance the understanding of running injuries. In: Craik A, Oatis CA. Gait Analysis: Theory and Application. St. Louis, Missouri: Mosby, 1995; p395-411. Menz HB. 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. Nield S, 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: 161166. O’Brien T, Vicenzino B. A study of the effects of Mulligan’s mobilization 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, Sackett D, Badenoch D, Straus S, Haynes B, Dawes M. Levels of Evidence and Grades of Recommendation 2001. http://www.cebm.net/levels_of_evidence.asp#notes. Accessed July 11, 2006. Reid A, Alcock G, Birmingham T. Effect of mobilization with movement as a method of increasing dorsiflexion following lateral ankle sprain, 2006 submitted for publication. Rimando MP. Ankle sprain. Available at: http://www.emedicine.com/pmr/topic11.htm. Accessed June 28, 2006. Safran MR, Benedetti RS, Bartolozzi AR, Mandelbaum BR. 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 der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. 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 Tulder M, Furlan A, Bombardier C, Bouter L, 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. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of Manipulative Physiological Therapy 1998; 21: 448-453. Vicenzino B., Prangley I., 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. Willems TM, Witvrouw E, Delbaere K, Mahieu N, De Bourdeaudhuij I, De Clercq D. Intrinsic Risk Factors for Inversion Ankle Sprains in Male Subjects. The American Journal of Sports Medicine. 2005; 33(3): 415-423. Yeung MS, Chan KM, So CH, Yuan WY. An epidemiological survey on ankle sprain. British Journal of Sports Medicine 1994; 28: 112-116.  

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