??? Ankle sprains: Proposed protocol

[proud]

I need some feedback. First the background:

Where I work, we have a large athletic/active population where ankle sprains are extremely common. We have a new clinic manager( a Physiotherapist who is a sports certified fellow). In any case, he wants ALL clinicians to follow his protocol on acute ankle sprains:

An aspect of the protocol that I honestly cannot say I agree with is....a very secure ankle lock taping to immobilize the ankle for 2 weeks....followed by mobilization and proprioception training. But that first two weeks is complete immobilization( regardless of grade 1-3)

Does this make sense? Does the literature support this?

[joebrence9]

I guess since all ankle sprains are exactly the same this is a good idea...not. Protocols are ridiculous to begin with especially for a non-surgical injury!!!

I would guess his proposed tx plan for immediate immobilization is likely based off of an article recently published in Sports Medicine, "A Systematic Review on the Treatment of Acute Ankle Sprians: Brace vs. Other Function Treatment Types" which concluded that a higher correlation to functional outcomes in those who were initially braced as compared to those who weren't.

After the immobilization portion of the protocol, which does have evidence to support, I think it should be up to therapists discression. I agree that manual techniques and proprioception activities should be included (there was just an article in JOSPT like a year ago on using steamboats/tubing activities which were effective in the recovery of ankle sprains) but protocols indicate he does not have faith in your ability to clinically reason.

[vavi]

You can check out :Refshauge K. Immobilization vs functional treatment for ankle sprains: a systematic review. Clinical Journal of Sport Medicine. July 2008;18(4):376-377.

and http://www.ncbi.nlm.nih.gov/pubmed/17279044 and http://www.ncbi.nlm.nih.gov/pubmed/17912059

According to Eiff M, Smith A, Smith G. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of Sports Medicine. 1994 Jan-Feb 1994;22(1):83-88. was suggested that in first-time lateral ankle sprains, although both immobilization and early mobilization prevent late residual symptoms and ankle instability, early mobilization allows earlier return to work and may be more comfortable for patients.

Lastly, I am beginning to have an issue with trying fixed protocols to specific diagnoses. As I see it each case is different and requires individualized plan and treatment.

[joebrence9]

I think that its interesting that two highly evidenced based articles, published in the same journal, one year apart, can contradict each other like this. Interesting how the decline effect works!!!

[proud]

Thanks for the input.

I cannot seem to find even the abstract for this one:

Refshauge K. Immobilization vs functional treatment for ankle sprains: a systematic review. Clinical Journal of Sport Medicine. July 2008;18(4):376-377.

Anyone have it?

So is the verdict that functional treatment is superior than immobilization?

[Diane]

proud, LINK.

[vavi]

Originally Posted by proud

Thanks for the input.

I cannot seem to find even the abstract for this one:

Refshauge K. Immobilization vs functional treatment for ankle sprains: a systematic review. Clinical Journal of Sport Medicine. July 2008;18(4):376-377.

Here's what I found:
The article looks into the factors that affect whether early functional treatment of inversion ankle sprains result in faster return to activity, greater patient satisfaction, less subjective instability and lower rate of reinjury than immobilization. Results indicate that immobilization was done through cast or plaster splint for two to six weeks compared to functional treatment that included bandages and aircast applied for the same period. It concludes that the return to previous activities and their rates of instability and reinjury after acute ankle sprain were similar after early functional treatment or immobilization. The commentary states that despite tackling a relevant clinical question, the study failed to supply evidence for the effectiveness of interventions after ankle sprain.

So is the verdict that functional treatment is superior than immobilization?

Webster K, Gribble P. Functional Rehabilitation Interventions for Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation. February 2010;19(1):98-114.

Here's the abstract:

Context: Functional rehabilitation is often employed for ankle instability, but there is little evidence to support its efficacy, especially in those with chronic ankle instability (CAI). Objective: To review studies using both functional rehabilitation interventions and functional measurements to establish the effectiveness of functional rehabilitation for both postural control and self-reported outcomes in those with CAI. Evidence Acquisition: The databases of Medline, SPORTDiscus, and PubMed were searched between the years 1988 and 2008. Inclusion criteria required articles to have used a clinical research trial involving at least 1 functional rehabilitation intervention, have at least 1 outcome measure of function and/or functional performance, and to have used at least 1 group of subjects who reported either repeated lateral ankle sprains or episodes of "giving way." The term functional was operationally defined as dynamic, closed-kinetic-chain activity other than quiet standing. Evidence Synthesis: Six articles met the inclusion criteria. The articles reviewed used multiple functional means for assessment and training, with a wobble board or similar device being the most common. Despite effect sizes being inconsistent for measures of dynamic postural control, all interventions resulted in improvements. Significant improvements and strong effect sizes were demonstrated for self-reported outcomes. Conclusions: The reviewed studies using functional rehabilitation interventions and functional assessment tools were associated with improved ankle stability for both postural control and self-reported function, but more studies may be needed with more consistent effect sizes and confidence intervals to make a definitive conclusion

Here are a few more that I thought were interesting:

Bleakley C, McDonough S, MacAuley D. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Australian Journal of Physiotherapy. March 2008;54(1):7-20.

Questions: Which intervention(s) best augment early mobilisation and external support after an acute ankle sprain? What is the most appropriate method of preventing re-injury? Design: A systematic review of randomised controlled trials published from 1993 to April 2005. Participants: People with an acute ankle sprain. Intervention: Any pharmacological, physiotherapeutic, complementary or electrotherapeutic intervention added to controlled mobilisation with external support. Immobilisation, surgical intervention, and use of external ankle supports in isolation were excluded. Outcomes: Pain, function, swelling, re-injury, and global improvement; assessed at short, intermediate, and long-term follow-up. Results: 23 trials were included with a mean PEDro score of 6/10. There was strong evidence that non-steroidal anti-inflammatory drugs can reduce pain and improve short-term ankle function. There was moderate evidence that neuromuscular training decreases functional instability and minimises re-injury; and that comfrey root ointment decreases pain and improves function. There was also moderate evidence that manual therapy techniques improve ankle dorsiflexion. There was no evidence to support the use of electrophysical agents or hyperbaric oxygen therapy. Very few long-term follow-ups were undertaken, and few studies focused on preventing long-term morbidity. Conclusions: Non-steroidal anti-inflammatory drugs, comfrey root ointment, and manual therapy can significantly improve short-term symptoms after ankle sprain, and neuromuscular training may prevent re-injury. More high quality studies are needed to develop evidence-based guidelines on ankle rehabilitation beyond the acute phases of injury management.

Hultman K, Faltstrom A, Oberg U. The effect of early physiotherapy after an acute ankle sprain. Advances in Physiotherapy. June 2010;12(2):65-73.

Ankle sprain is one of the most common injuries treated in emergency departments (ED). In clinical practice, these injuries are expected to heal by themselves, often without any treatment other than short information about the RICE regime (rest, ice, compression and elevation). Still, remaining symptoms are reported to occur in 30% of the cases. The aim of this study was to evaluate the effect of early physiotherapy intervention after an acute ankle sprain. Sixty-five patients were recruited from the ED at a general hospital in Sweden (mean age = 35 years; 30 women), and allocated into an intervention group with early physiotherapy or a control group. Both groups were evaluated 6 weeks and 3 months after their injury. As primary outcome, the disease-specific Foot and Ankle Outcome Score (FAOS) was used. The patients also rated their physical activity ability and how satisfied they were with their ankle on a visual analogue scale (VAS). The intervention group made significant improvements compared with the control group at both evaluations measured with FAOS and the VAS questions. These findings indicate that early physiotherapy intervention has a positive effect on patient-focused foot and ankle function after an acute ankle sprain.

Osborne M, Rizzo T. Prevention and treatment of ankle sprain in athletes. Sports Medicine. December 2003;33(15):1145-1150.

The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.

Hubbard T, Hicks-Little C. Ankle ligament healing after an acute ankle sprain: an evidence-based approach. Journal of Athletic Training. September 2008;43(5):523-529.

OBJECTIVE: To perform a systematic review to determine the healing time of the lateral ankle ligaments after an acute ankle sprain. DATA SOURCES: We identified English-language research studies from 1964 to 2007 by searching MEDLINE, Physiotherapy Evidence Database (PEDro), SportDiscus, and CINAHL using the terms ankle sprain, ankle rehabilitation, ankle injury, ligament healing, and immobilization. STUDY SELECTION: We selected studies that described randomized, controlled clinical trials measuring ligament laxity either objectively or subjectively immediately after injury and at least 1 more time after injury. DATA EXTRACTION: Two reviewers independently scored the 7 studies that met the inclusion criteria. Because of differences in study designs, a meta-analysis could not be performed. Effect sizes and confidence intervals could be calculated only for 1 study. The percentages of subjective and objective instability were calculated for the remaining studies. DATA SYNTHESIS: Ankle laxity improved over a period of 6 weeks to 1 year. One author showed stress talar tilt values of 16.10 +/- 8.8 degrees immediately after injury and 3.4 +/- 3.6 degrees at 3 months after injury. In 2 articles, the authors reported that positive anterior drawer tests were still present in 3% to 31% of participants at 6 months after injury. Additionally, feelings of instability affected 7% to 42% of participants up to 1 year after injury. CONCLUSIONS/RECOMMENDATIONS: In the studies that we examined, it took at least 6 weeks to 3 months before ligament healing occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had objective mechanical laxity and subjective ankle instability. Direct comparison among articles is difficult because of differences in methods. More research focusing on more reliable methods of measuring ankle laxity is needed so that clinicians can know how long ligament healing takes after injury. This knowledge will help clinicians to make better decisions during rehabilitation and for return to play

This study by Hicks et al gives a time frame from 6 weeks-3 months for acute ankle sprains. Additionally, we need to ask ourselves how does degree of healing in tissues relates to function (and if it does at all relate). Even at 1 year post a large percentage had substantial mechanical and subjective laxity. I could not find definitive evidence with regards to specific interventions based on grades of sprain.
To me personally, it is safe to assume that functional treatment interventions are generally better than immobilization in ankle sprains and especially so in the cases of chronic ankle instability.

[proud]

WOW! Thanks very much for this information.

Now, would taping be considered "immobilization" by the definitions I am reading within these articles? It seems they refer to plaster spints and castings?

I get confused with this because I've read some articles that include taping in the "functional treatment" category, while others suggest it is in the immobilization category?

Certainly taping will allow at least some mobilization however I still see it as a means of immobilization primarily.

What are the current accepted definitions/protocols of "functional treatment"?

Thoughts?

[Diane]

proud, kinesio taping supports (something non-mesodermal) and doesn't immobilize.

[vavi]

Originally Posted by proud

What are the current accepted definitions/protocols of "functional treatment"?

Thoughts?

The articles included in Webster K, Gribble P. Functional Rehabilitation Interventions for Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation. February 2010;19(1):98-114.
Had interventions as Balance training on Biodex 3×/wk, 4 wk, Technical training in
jump landing, balance board, stirrup braces. Entire volleyball season, Combination of
stretching, TheraBand strengthening in multiple directions,neuromuscular control, jumping and running drills 3.5×/week for 4 weeks.,Group 1: ankle-disk training 30 min/d. Group 2: eversion strengthening with TheraBand. Group 3:Air-Stirrup (Aircast Inc). Group 4: control, Single-leg stance balance on foam, circumotion on wobble board, resistance-band kicks in 4 directions10 min/d, 5 d/wk, 6 wk.Progressive balance training including multidirectional hop landing and singleleg-stance progres-sions. 20 min/d, 3 dwk, 4 wk.

So I do not think taping would be considered functional.

[proud]

Originally Posted by vavi

The articles included in Webster K, Gribble P. Functional Rehabilitation Interventions for Chronic Ankle Instability: A Systematic Review. Journal of Sport Rehabilitation. February 2010;19(1):98-114.
Had interventions as Balance training on Biodex 3×/wk, 4 wk, Technical training in
jump landing, balance board, stirrup braces. Entire volleyball season, Combination of
stretching, TheraBand strengthening in multiple directions,neuromuscular control, jumping and running drills 3.5×/week for 4 weeks.,Group 1: ankle-disk training 30 min/d. Group 2: eversion strengthening with TheraBand. Group 3:Air-Stirrup (Aircast Inc). Group 4: control, Single-leg stance balance on foam, circumotion on wobble board, resistance-band kicks in 4 directions10 min/d, 5 d/wk, 6 wk.Progressive balance training including multidirectional hop landing and singleleg-stance progres-sions. 20 min/d, 3 dwk, 4 wk.

So I do not think taping would be considered functional.

Would they be doing all this training in the first 2 weeks? Many clients I see have great difficulty just bearing weight let alone the above....

I can see the above once the significant chemical component has settled....but the first two weeks?

I certainly cannot see a needed role for a fancy dancy athletic taping( thus my question)...but I don't think I'm throwing my clients into the above the first 7-14 days I don't think.

I think( my opinion)...I'd be using some sort of ankle bracing, ice and advice to get out of the brace often and simply perform some non painful ROM both NWB and WB.

Thoughts?

[smith]

Taping for Immobilization doesn't seem to work. Need walking boots and air cast for that. If it is a true ligament tear? I see alot of ankle sprains with just nerve irritation. Even in unstable ankles, it's the nerve not gliding right in the nerve sheath that gives the sensation of instablility. My thesis anyway.

Using ace and elastic type tape (more expensive$$) does seem to work. More biofeedback as Diane pointed out, control swelling, less restrictive etc. Ace for around the house and elastic tape for games.

[gollygosh]

Diane, how would you tape for an ankle sprain?
X's inferior the mallei? Spirals in the direction of post tib? Seems like we'd want to cross the joint line? I learned to tape mesodermally, and tend to put the tape where I'd put my hands, which would include some tape over the talus.
Just curious.

Geralyn

[Diane]

Whichever way feels best to the patient.

I had a little tape system I used off the bat, and would try first. It didn't always work, so I never turned it into any protocol.
1. A strip around the back of the heel, medial to lateral
2. 4 longitudinal pieces (narrow):

1. front of foot: a piece in a downward direction front of tibia, over ankle, toward medial side of foot
2. front of foot: a piece in an upward direction over front of fibula
3. back of foot: a piece upward over beck of tibia from heel
4. back of foot: a piece downward along fibula to heel.

3. It's good to throw a few little bits of tape up at the top of the tib/fib too.

[vavi]

Originally Posted by proud

Would they be doing all this training in the first 2 weeks? Many clients I see have great difficulty just bearing weight let alone the above....

I can see the above once the significant chemical component has settled....but the first two weeks?

I certainly cannot see a needed role for a fancy dancy athletic taping( thus my question)...but I don't think I'm throwing my clients into the above the first 7-14 days I don't think.

I think( my opinion)...I'd be using some sort of ankle bracing, ice and advice to get out of the brace often and simply perform some non painful ROM both NWB and WB.

Thoughts?

Proud these are all the Functional Rehabilitation Interventions for Chronic Ankle Instability.
The things to follow in case of an acute ankle sprain will be very different and would involve Ice, Bracing and some other interventions like you said. I do not feel that athletic tape would help achieve anything but provide feedback and certainly not not immobilize. All that said we need to work on pain free movement with eventual goal towards function. Athletic taping as a sole intervention in itself wouldn't do much for a client. Lastly, all of us realize the ankle sprains have a tendency that predisposes individuals to chronic ankle instability.

[gollygosh]

Thanks.

[vavi]

Originally Posted by gollygosh

Thanks.

You're welcome

[Jon Newman]

What about the use of an ASO?

[Jon Newman]

Here's and interesting review that I haven't reviewed before.

Unique Identifier 19530753

Hupperets, Maarten D W. Verhagen, Evert A L M. van Mechelen, Willem.

Effect of sensorimotor training on morphological, neurophysiological and functional characteristics of the ankle: a critical review. [Review] [62 refs]

Sports Medicine. 39(7):591-605, 2009.

Sensorimotor training is effective in preventing ankle sprain recurrences, but the pathway through which this effect occurs is unknown. Biomechanical and neurophysiological analyses of sensorimotor training leading to functional changes of the ankle are needed to establish this pathway. This article reviews the effect of sensorimotor training on morphological, neurophysiological and functional characteristics of the ankle. A MEDLINE and CINAHL computerized literature search was conducted to search for relevant articles. A study was included if (i) the study contained research questions regarding the effect of sensorimotor training on mechanical, neurophysiological, and/or functional ankle functioning; (ii) the study dealt with subjects with a history of ankle sprain; (iii) the study contained a control group; (iv) the results contained measures of mechanical, neurophysiological or functional insufficiencies as study outcome; and (v) the study met a predefined cut-off score set for methodological quality. Results on joint position sense and muscle reaction times showed a learning effect of repeated measures and not a training effect. Decrements of postural sway after sensorimotor training were mainly attributable to a learning effect as well. Effects on muscle strength were not found. Evidence for an effect of sensorimotor training on neurophysiological, morphological and functional characteristics is limited, if present at all. Thus, the pathway of sensorimotor training remains unclear. Future studies need to focus on (i) differentiating between morphological, physiological and functional changes; (ii) larger sample sizes with a priori sample size calculations; (iii) correspondence between training and test method; (iv) using measures other than postural sway more closely linked to functional stability; and (v) using a longer follow-up period than 6 weeks.

That bolded part seems like it could be a problem for a lot of different studies.