Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: A randomized, controlled trial.
Plaza-Manzano G, Vergara-Vila M, Val-Otero S, Rivera-Prieto C, Pecos-Martin D, Gallego-Izquierdo T, Ferragut-Garcías A, Romero-Franco N. Manual Therapy. 2016;26:141-149. doi:10.1016/j.math.2016.08.006.
Take Home Message: Patients with chronic ankle instability who received a 4-week supervised rehabilitation program consisting of therapeutic exercise, joint mobilization, and neural mobilizations had greater clinical improvements compared with patients who were treated with therapeutic exercise alone.
Forty percent of people with lateral ankle sprains develop chronic ankle instability (CAI). One possible cause of CAI is peripheral nerve injury, which is a common consequence of lateral ankle sprains. Manual therapy and therapeutic exercise (to include balance and proprioceptive training) are beneficial in treating CAI; however, no one has investigated the effectiveness of neural mobilization for these patients. The purpose of this single-blinded randomized control trial was to compare the effects of a 4-week rehabilitation program consisting of strengthening and balance exercises with and without the addition of manual therapy (joint and neural mobilizations) on self-reported pain and function, pain-pressure thresholds, range of motion, and strength in physically active individuals with CAI. Both the experimental (28 participants) and control groups (28 participants) received a progressive balance program and a progressive strengthening program of the ankle evertors. The experimental group also received manual therapy consisting of grade 3 joint mobilizations and peroneal nerve mobilizations. Outcome measures included the pain visual analog scale, the Cumberland Ankle Instability Tool, pain-pressure thresholds around the ankle, active range of motion (dorsiflexion and plantarflexion), and strength (dorsiflexion and plantarflexion). The participants were assessed pre and post the 4-week intervention and 1-month following the end of treatment. Both groups improved in self-reported pain and function, pain-pressure thresholds, range of motion, and strength. However, the authors observed greater improvement among participants who received manual therapy.
This study is innovative as it is the first to study the effects of combined peripheral nerve and joint mobilization in the treatment of patients with CAI. Previous studies have found that patients with CAI have impaired peripheral and central nervous system function. It is plausible that nerve injury from the lateral ankle sprain may cause scarring or impaired neural mobility, pain sensitization, and/or motor inhibition observed in people with CAI. Manual therapy can have both peripheral and central nervous effects. The greater improvement observed among people who received manual therapy is likely attributed to the diverse types of treatment provided to these patients. It would be beneficial to see another trial that compares joint mobilization and exercise with combined nerve and joint mobilization and exercise to assess the added benefits of neural mobilization in the treatment of these patients. Similarly, a study comparing patients treated with combined therapeutic exercise and neural mobilization to patients treated with therapeutic exercise and a sham mobilization may provide information on the added benefit of extended hands on care or placebo effect that may occur. Based on the findings of this study, clinicians should consider the inclusion of peroneal nerve mobilization, talocrural and distal tibiofibular joint mobilizations with a therapeutic exercise program in the treatment of patients with CAI.
Question for Discussion: Do you routinely incorporate neural mobilizations in the treatment of patients with lateral ankle sprains or CAI? If so, how have you seen this intervention improve outcomes in your patients?
Written by: John J. Fraser, PT, MS, OCS
Reviewed by: Jeffrey Driban