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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 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) • 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 Movement 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 RCT RCT, case studies # of databases searched 7 8 Languages searched English, German, Dutch English, French Year of publication Until 2005 Until 2006 Type of intervention 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 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 Articles found after hand searching, grey literature, and screening reference lists: N = 6 Studies excluded after evaluation of full text: N = 5 After extraction of duplicate studies: N = 30 Full text of studies retrieved after using abstract screening tool N= 11 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 Score (/7) Level of 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.  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