Manual therapy in joint and nerve structures combined with
exercises in the treatment of recurrent ankle sprains: A randomized, controlled
trial.
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.
https://www.ncbi.nlm.nih.gov/pubmed/27598553
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.
https://www.ncbi.nlm.nih.gov/pubmed/27598553
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.
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.
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.
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?
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
Fraser, PT, MS, OCS
Reviewed by: Jeffrey Driban
Related Posts:
Plaza-Manzano, G., Vergara-Vila, M., Val-Otero, S., Rivera-Prieto, C., Pecos-Martin, D., Gallego-Izquierdo, T., Ferragut-Garcías, A., & Romero-Franco, N. (2016). Manual therapy in joint and nerve structures combined with exercises in the treatment of recurrent ankle sprains: A randomized, controlled trial Manual Therapy, 26, 141-149 DOI: 10.1016/j.math.2016.08.006
Given the public health problem that CAI is, the results of this study are very important. The most interesting aspect of this study is the emphasis on joint mobilizations post ankle sprain. In my experience, I've found many clinicians to be quite hesitant when integrating joint mobilizations into rehabilitation plans for an ankle sprain. As the article discussed, the effects of joint mobilizations go far beyond just restoring normal joint arthrokinematics. Joint mobilizations can also aid in restoring functional stability, along with improving various other patient reported outcomes.
I personally have recently starting to incorporate joint mobilizations in my rehabilitation programs with patients with CAI and I have had very position results. I find it especially effective when my patients reach a plateau.
Finding the best treatments for those with CAI should be a priority of most researchers and clinicians. It's very encouraging to see well-rounded rehabilitation plans yielding great success.
Ryan, thanks for the comment. It's always nice to hear what other people are doing in their rehab programs.