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Free papers #1

Improving treatment for ankle sprains and Chronic Ankle Instability

Chair: Evert Verhagen

#01 -Can a knowledge translation implementation strategy improve the evidence based management of ankle sprains by Canadian Armed Forces Physiotherapists?

Presenting Author: Eric Robitaille

Authors & Affiliations: Eric Robitaille(1,2), Marsha MacRae(2), Peter Rowe(2), Alice Aiken(1)
(1)    Dalhousie University, Halifax, Nova Scotia, Canada
(2)   Canadian Armed Forces Health Services Group, Ottawa, Ontario, Canada

Background: Lateral Ankle Sprains (LAS) are the 3rd most common musculoskeletal injury among military members, resulting in considerable time loss and a substantial rehabilitation workload. The operational relevance of these consequences to the Canadian Armed Forces (CAF) should be minimized through evidence-based practices (EBP). A previous survey of CAF Physiotherapists reported some variances between their management of LAS and recommended EBP, as well as their Knowledge Translation (KT) intervention preferences. Active, multi-component KT interventions guided by an implementation framework and tailored towards known preferences have been recommended to improve the knowledge and use of EBP among physiotherapists.

Objective(s):The purpose of this research project was to investigate the effectiveness of an active, multi-component KT intervention guided by an implementation framework and tailored for the preferences of CAF Physiotherapists, to improve their knowledge and use of EBP rehabilitation interventions and outcome measures recommended in the management of LAS.

Design & Methods:All CAF Physiotherapists (n=89) were sent an email invitation to complete an online questionnaire investigating their self-reported knowledge and use of EBP rehabilitation interventions and outcome measures recommended in the management of LAS. One 3-hour active, multi-component KT intervention including; summarized research, practice tools and guided interaction was then facilitated over a distance learning platform. The primary outcome for this project was the median change (1-5) reported on the online questionnaire distributed prior to and 3-months following participation in the KT intervention.

Results:The response rate was 75% (n=67/89). Respondents reported excellent (5/5) knowledge and use of recommended rehabilitation interventions at both baseline & 3-months, and a varied improvement in knowledge and use of recommended outcome measures from poor (2/5) to good (3/5) or excellent between baseline & 3-months. The most frequent reason respondents provided for non-use of recommended outcome measures was the habitual use of another outcome measure or setting constraints. Most respondents (65%) reported that the distance learning presentation improved their knowledge and use of the recommended rehabilitation interventions and outcome measures, with summarized research reported as their preferred KT intervention.

Conclusions:A KT implementation strategy tailored for CAF Physiotherapists improved their self-reported knowledge and use of EBP recommended in LAS management. Further improvements may require investigation of habitually used outcome measures and setting constraints. Passive dissemination of summarized research may be a uniquely efficient KT intervention among CAF Physiotherapists.


#02 - Comparison of Clinician Practice Patterns with the International Ankle Consortium Recommendations for the Clinical Assessment of Lateral Ankle Sprain Injuries: A Report from the Athletic Training Practice-Based Research Network

Presenting Author: Ashley Marshall

Authors & Affiliations: Ashley Marshall(1), Kenneth Lam(1)
(1)   A.T. Still University

Background:A recent consensus statement from the International Ankle Consortium (IAC) provides evidence-based guidelines for the structured assessment of acute lateral ankle sprains (LAS), including both the diagnosis and identification of mechanical and/or sensorimotor deficits. The goal of the consensus statement was to provide an essential resource for clinicians who regularly assess these injuries, and to ultimately reduce the development of poor long-term consequences (ie, chronic ankle instability, post-traumatic osteoarthritis) following LAS. However, it is unknown if athletic trainers (ATs) incorporate these components into their routine assessment of LAS injuries.

Objective(s):Our objective was to compare evaluation patterns for acute LAS injuries, conducted by ATs within the Athletic Training Practice-Based Research Network, to the IAC recommendations.

Design & Methods:Electronic patient records for LAS injuries, created between October 2009 and May 2018, were retrospectively analyzed. Clinical evaluations were compared to the IAC recommendations, including a diagnostic component (ie, mechanism of injury [MOI], previous medical history [PMH], weight-bearing status [WB], assessment of bones [BONES], assessment of ligaments [LIGAMENTS]) and a rehabilitation-oriented component (ie, ankle joint pain, swelling, range of motion [ROM], arthrokinematics, muscle strength, static balance [STATIC-BAL], dynamic balance [DYNAMIC-BAL], gait, physical activity level prior to injury [PA], and ankle-specific patient-reported outcome measures [PROMs]). Summary statistics (percentages, frequencies) were calculated to describe AT evaluation patterns, respective to the IAC guidelines.

Results:During the study period, 1,557 patients (male=56.1%, age=16.2±2.0 years, height=170.8±13.9 cm, mass=71.1±17.0 kg) were diagnosed with an acute LAS. ATs generally followed the diagnostic recommendations: MOI=100.0% (n=1,557/1,557), PMH=99.3% (n=1,546/1,557), WB= 93.5% (n=1,457/1,557), BONES: palpation=96.1% (n=1,497/1,557) and special tests=9.3% (n=144/1,557), LIGAMENTS: palpation=96.1% (n=1,497/1,557) and special tests=47.7% (n=742/1,557). However, disparity existed regarding the utility of the recommended rehabilitation-oriented components: pain=99.8% (n=1,554/1,557), swelling=99.7% (n=1,553/1,557), ROM=41.1% (n=640/1,557), arthrokinematics=0.0% (n=0/1,557), strength=62.9% (n=979/1,557), STATIC-BAL=8.8% (n=14/1,557), DYNAMIC-BAL=0.0% (n=0/1,557), gait=49.5% (n=771/1,557), PA=0.0% (n=0/1,557), PROMs=8.2% (n=127/1,557).

Conclusions:ATs are not incorporating several critical components during their clinical evaluations of acute LAS injuries. Clinicians should utilize the evidence-based IAC recommendations to improve evaluations and identify impairments to target during injury rehabilitation. Future research should evaluate how dissemination and implementation of these recommendations impacts long-term outcomes following LAS injuries.


#3 - Four Weeks of Eccentric Training with Anodal Transcranial Direct Current Stimulation Decreases Disablement in Patients with Chronic Ankle Instability: A Preliminary Investigation

Presenting Author: Alan Needle

Authors & Affiliations: Alan Needle(1), Amelia Bruce(1), Jeffrey McBride(1), Herman van Werkhoven(1), Jennifer Howard(1)
(1)   Appalachian State University, Boone, NC, USA

Background:Despite decades of research into rehabilitation strategies, high rates of ankle sprain, recurrent injury, and chronic ankle instability (CAI) continue to negatively affect health-related quality of life across active populations. With emerging evidence into maladaptive neuroplasticity occurring in patients with CAI, it is possible that underlying deficits in cortical excitability may continue to predispose these individuals to poor functional outcomes. Therefore, correcting maladaptive neuroplasticity through interventions that target the cortex may serve to improve functional and perceived outcomes in individuals with CAI.

Objective(s):We aimed to determine the effects of 6-weeks of eccentric strengthening of the ankle pronators with anodal transcranial direct current stimulation (aTDCS) on functional performance and patient-reported outcomes compared to a sham stimulation in patients with CAI.

Design & Methods:A randomized controlled trial design was implemented to measure side-hop test performance, region-specific ankle function (Foot & Ankle Ability Measure, FAAM), perceived disablement (Disablement in the Physically Active, DPA), and kinesiophobia (Tampa Scale for Kinesiophobia, TSK-11) over 4-weeks of eccentric ankle strengthening. Twenty-two participants with CAI (IdFAI>10) were stratified into aTDCS (21.8±2.7yrs, 5M/6F) or sham (22.3±3.1yrs, 3M/8F) groups and measured at week-0, week-2, week-4, and week-6 relative to training. During training, 18-minutes of aTDCS (1.5mA) were applied over the motor cortex in the aTDCS group, while the sham group received only 1-minute of stimulation. Differences were assessed with factorial ANOVA.

Results:A significant main effect of time (F=5.272, p=0.003) revealed both groups improved on the side hop test (F=0.376, p=0.77). Post-hoc tests indicated improvements from week 0 (11.57±4.38s) to week 2 (10.03±2.49s; p=0.024), with no additional improvements observed. No time-by-group effects were observed for the FAAM (F=1.266, p=0.295) or TSK-11 (F=1.387, p=0.255); however, a significant time-by-group effect was detected for DPA (F=3.15, p=0.031). Disablement in sham increased from week 0 (17.91±4.59) to week 2 (21±8.521; p=0.047); while disablement decreased in aTDCS from week 2 (18.09±6.41) to week 6 (15.45±5.48; p=0.046) and was nearly significant at week 4 (15.55±4.82; p=0.053).

Conclusions:Our results suggested that while eccentric training resulted in lasting improvements to functional performance, the addition of aTDCS impacted participants’ perceived disablement. These are the first results tying cortical stimulation to improved outcomes in patients with joint injury, which we suggest is due to modifying maladaptive neuroplasticity.


#4 - Effect of Graston Technique™ on Edema Following a Sprain to the Lateral Ankle Ligaments

Presenting Author: Carrie Docherty

Authors & Affiliations: Carrie Docherty(1), Noah Thaman(1), Leif Madsen(1)
(1)   Indiana University, Bloomington, IN

Background:Lateral ankle sprains are one of the most common orthopedic injuries experienced by active individuals. Deleterious effects of swelling within the ankle joint include pain and reduced functionality resulting in complications with sport and daily living activities. Treatment techniques resulting in rapid reduction of edema offer significant benefits to patients by reducing pain and increasing function. The Graston Technique™ (GT), a form of soft tissue mobilization, presents a novel approach in edema reduction and requires further study.

Objective(s):To evaluate the effect of a single application of GT on edema following an acute ankle sprain.

Design & Methods: A repeated measures design was utilized for this study. Sixteen participants who had sustained an acute ankle sprain volunteered to participate in the study. All participants used rest, ice, compression, and elevation for the first 48 hours post injury, at which point they were randomly assigned to either the GT(n=8) or control(n=8) group. Subjects in the GT group received a single, non-inflammatory application of instrument assisted soft tissue treatment that lasted approximately 10 minutes.  The Control subjects reported to the laboratory and simply sat on the treatment table for the same length of time as the GT subjects. Ankle circumference was assessed using the figure-of-8 measurement at three times(pre-treatment, 10 minutes post-treatment, and 24 hours post-treatment).

Results:Interpretation of the results of the 2x3x2 repeated measures analysis of variance yielded a significant time by side interaction (F2,28 = 4.84, p = .01). Specifically, the injured ankle had more swelling than the uninjured side (F1,14 = 42.25, p = .01), and swelling in the injured ankle significantly decreased from pre-treatment to both post-treatment measures (F2,28 = 15.91, p = .01). However, we did not identify any differences between the groups, time by group interaction, side by group interaction, nor time by side by group interaction (p>.05).

Conclusions:The primary finding of this study is that a single application of GT did not have a significant effect compared to the nonintervention on swelling in the ankle following an acute ankle sprain.


#5 - Intercollegiate Athletes’ Perceptions of Ankle Sprains

Presenting Author: Revay Corbett

Authors & Affiliations: Revay O. Corbett(1), Luzita Vela(1), Sue Saliba(1), Paul Harris(1), Jay Hertel(1)
(1)   University of Virginia

Background:Ankle sprains are a prevalent injury for athletes to sustain. Although ankle sprains occur often, athletes on average return to play within a week’s time of their injury. This short return to play timeline may impact the perception athletes have concerning the seriousness of their injury and the importance of seeking and complying with adequate rehabilitation. Evaluating what student-athletes know and perceive about ankle sprains could provide additional insight into the role patients play in receiving treatment.

Objective(s):To evaluate the current perception and knowledge intercollegiate athletes have in regards to the treatment, management and long-term effects of sustaining an ankle sprain.

Design & Methods:We performed a cross-sectional study using an online survey. 119 National Collegiate Athletic Association student-athletes within Division I and Division III (age=19.9±1.4 years old, females=82). Participants completed a 57-question survey that recorded demographics, previous ankle injury history, perceptions, and basic knowledge regarding ankle sprains. Participants also documented their self-reported level of ankle function using the Identification of Functional Ankle Instability (IdFAI) and the Foot and Ankle Ability Measure (FAAM) Sport. Sources of pressure to return to play (RTP) and lingering symptoms following an ankle sprain were also recorded.

Results:54% of participants exhibited a high level of understanding of basic ankle sprain information. 47% perceived ankle sprains as the most prevalent injury among 5 common injuries, but only 1.8% felt ankle sprains were the most important injury in seeking care compared to those same injuries. 76.5% reported history of ankle sprain. Of these, 76.9% qualified as having functional ankle instability per the IdFAI and 95% reported a “normal” or “nearly normal” level of function per the FAAM. 45% reported at least one source of pressure to RTP after injury and 41% reported presence of at least one lingering symptom.

Conclusions:These results provide insight into the knowledge and perceptions that intercollegiate student-athletes have about ankle sprains. The tendency of student-athletes with a history of ankle sprains to report normal or near-normal ankle function despite lingering symptoms and episodes of ankle instability may speak to competitive athlete’s high levels of self-efficacy.


#6 - Outcome of a neuromuscular training program on recurrent ankle sprains. Does the initial type of healthcare matter? 

Presenting Author: Adinda Mailuhu

Authors & Affiliations: Adinda Mailuhu(1), Marienke van Middelkoop(1), Sita Bierma-Zeinstra(1), Patrick Bindels(1), Evert Verhagen(2)
(1)   Department of General Practice, Erasmus MC University Medical Center, Rotterdam, The Netherlands
(2)    Amsterdam Collaboration for Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands

Background:After sustaining a lateral ankle sprain there is an increased risk of a recurrent sprain. Different types of healthcare can be assessed for the treatment of an ankle sprain. Neuromuscular training (NMT) has been proven effective in preventing recurrent sprains after an initial ankle sprain. It was specifically beneficial in athletes whose sprain was self-treated rather than by a healthcare provider. This raises the question whether there is an association between the healthcare provider who treated the index sprain initially and the effect of NMT on recurrent sprains, and if athlete characteristics differ between the different type of healthcare providers.

Objective(s):To study the impact of the initial healthcare for a lateral ankle sprain on the outcome of NMT on recurrent sprains and to describe athlete characteristics receiving different types of healthcare.

Design & Methods:This study presents a secondary analysis of three previous randomized trials that evaluated NMT. 705 athletes were included who sustained a lateral ankle sprain. Data were collected on athlete characteristics, type of initial healthcare provided and a recurrent sprain during one-year follow-up. Multilevel logistic regression analyses were used to test the impact of the type of healthcare on the outcome of NMT on recurrent sprains. Potential differences in athlete characteristics between the different types of healthcare were examined using one-way analysis of variance and Pearson chi-square test.

Results:After NMT, 39.7% of the athletes initially visiting a paramedical care setting (physiotherapist, manual therapist, exercise therapist) reported a recurrent sprain, 21.8% of secondary care (general surgeon, orthopaedic surgeon, emergency physician) and 34.0% of primary care (general practitioner, sports physician). Athletes who initially visited a physiotherapist reported more recurrent sprains after NMT, than those not visiting a physiotherapist (adjusted OR 3.15;95%CI 1.88-5.23). Athletes from paramedical (49.7%) and primary care setting (48.4%) used more braces and/or tape during sport than those not visiting a healthcare provider (34.2%).

Conclusions:The initial type of healthcare of athletes with an ankle sprain, that thereafter received NMT, seems to impact the occurrence of recurrent sprains. This may be explained by different athlete characteristics and should make physiotherapists aware of the fact that they may be visited by athletes with a poorer prognosis.


#7 - The Effects of Therapeutic Exercises With and Without Mobilization in Participants with Chronic Ankle Instability; A Randomized Controlled Trial

Presenting Author: Cameron Bolton

Authors & Affiliations: Cameron Bolton(1), Sheri Hale(1), Todd Telemeco(2)
(1)   Division of Physical Therapy, Shenandoah University, US
(2)   University of North Carolina at Pembroke, US

Background:Joint mobilizations are reported to increase range of motion (ROM), postural control, and decrease pain in individuals with chronic ankle instability (CAI). However, there is no research supporting the combined effects of thrust mobilization (TM) and exercise on function in this population. We hypothesized that completing a rehabilitation program in conjunction with mobilization would optimize functional performance.

Objective(s):The purpose of this study was to examine the effects of adding TM techniques to a comprehensive ankle rehabilitation program on lower extremity function in subjects reporting chronic ankle instability (CAI).

Design & Methods:30 subjects with CAI (mean age = 23.7 +/- 3.65 yrs) were randomly allocated to the exercise (n=14) or exercise + TM group (n=16) and completed a six-week exercise program. The exercise + TM group also received TM at the talocrural, proximal and distal tibiofibular joints at the first three sessions. Subjective reports of function were recorded at baseline and follow-up using the Foot and Ankle Ability Measure (FAAM), the FAAM-sport, and the Ankle Joint Functional Assessment Tool (AJFAT). Weight-bearing dorsiflexion ROM, side-hop test, figure-of-eight hop test, and the Star Excursion Balance Test (SEBT) were also administered at baseline and follow-up.

Results:Only the exercise + TM group demonstrated an improvement in weight-bearing dorsiflexion with the knee flexed following treatment (p = 0.02). For all outcome measures, except ROM, subjects improved significantly at follow-up regardless of group assignment (p < 0.01). Effect sizes were moderate to large (0.72-1.70) for subjective outcomes and small to moderate (0.43-0.58) for objective measures. For the four measures that subjects performed at or below the published cut-off scores used to identify CAI at baseline, they scored better than these cut-off scores at follow-up, suggestive of resolution of CAI.

Conclusions:Our data suggest that rehabilitation of patients with CAI is related to improved functional performance and ROM. This provides evidence that the addition of thrust mobilization to exercise may enhance improvements in dorsiflexion ROM as compared to exercise alone. Additional research is needed to identify optimal parameters to maximize therapeutic benefit.