March Discussion Post

[Erik Lineberry]

For a sprained ankle, Physical Therapy no better than self care.

These headlines were popping up pretty frequently at the end of 2016 and they took me by surprise. Our recent discussions about hip OA and PT brought up some good thoughts on what may be our limitations as a profession. I thought this may be good opportunity to bring up the topic of ankle sprains and PT to see what others’ thoughts are in our effectiveness in treating these patients.

NYT article

I have added a NYT article, but if you search “physical therapy ankle sprain” in the google and select the news tab you will get plenty of results. At the end of this post I attached the research article that these headlines are drawing from. An overview of that article follows.

Objective
To assess the efficacy of a program of supervised physiotherapy on the recovery of simple grade 1 and 2 ankle sprains.
Design
A randomized controlled trial of 503 participants followed for six months. Primary outcome was the Foot and Ankle Outcome Score(FAOS). An excellent outcome was a score of >450/500 on the FAOS. Measurements were taken at baseline, one month, three months, and six months. Baseline assessments were taken one week following injury to determine true level of dysfunction related to injury. Randomization into usual ER care and usual ER care plus physiotherapy routine were made.
Participants
Inclusion criteria was deliberately left broad. It included patients aged ≥16 presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain and included clinically unimportant avulsions. Symptoms must have been present for less than 72 hours.
Exclusions criteria included patients with multiple injuries, other conditions limiting mobility, and ankle injuries that required immobilization and those unable to accommodate the time intensive study protocol. They also excluded anyone that was seeking physical therapy at another facility.
Intervention
Participants received either usual care, consisting of written instructions regarding protection, rest, cryotherapy, compression, elevation, and graduated weight bearing activities, or usual care enhanced with a supervised program of physiotherapy.
Usual ER care included medical assessment and information on self-management including ankle protection, ice, rest, compression, elevation, use of analgesics, gradual weight bearing activity, and information on expected recovery. The PT group included this initial care plus an IE with a physio and up to 7 subsequent visits. Intervention included functional exercises to progress patients through 4 stages of ankle sprain recovery. Each session was 30min long and augmented with HEP of ankle AROM, isometric strengthening, and resistance exercises with theraband or bodyweight. No manual therapy, immobilization, or bracing/taping was used.

Results
The absolute proportion of patients achieving excellent recovery at three months was not significantly different between the physiotherapy (98/229, 43%) and usual care (79/214, 37%) arms (absolute difference 6%, 95% confidence interval −3% to 15%). The observed trend towards benefit with physiotherapy did not increase in the per protocol analysis and was in the opposite direction by six months. These trends remained similar and were never statistically or clinically important when the FAOS was analyzed as a continuous change score.
Conclusions
In a general population of patients seeking hospital based acute care for simple ankle sprains, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care, as provided in this protocol. At 6 months 43% of physiotherapy participants and 38% of usual care participants did not reach excellent recovery. This may indicate that other intervention others may need to be considered for this patient population

1) General thoughts on this study, its design, and its findings.
2) What are your thoughts about the PT intervention provided and the frequency and duration of care?
3) What is your typical PoC for patients with a “simple” ankle sprain?
4) What would you tell a patient that has been referred to you and tells you that they do not think they will get better because they read they wouldn’t in the New York Times?

Attachments:

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[August Winter]

1. Overall I liked this study. I thought their analysis was easy to follow, they had a long-term follow up, and had a large and heterogeneous mix of participants. As with our conversation about the BMJ OA paper, I think some of our conversation of research that is critical of our interventions devolves into ‘losing sight of the forest for the trees’. That being said a few things stood out to me for this paper. I would have liked to have seen an objective measure that may be more relevant for injury prediction, like the Y balance or SEBT. I like that they broke down their analysis to subgroups, but would have preferred if they had looked at previous ankle injury (152) versus first ankle injury (101).

2. We have literature that suggests manual therapy can be effective for ankle sprains in the acute and subacute phases of healing, so obviously my biggest gripe is the exclusion of this intervention from their treatment arm. The subjects were able to attend up to 7 sessions, and at that length of time out from a sprain I would think that some manual therapy intervention, whether it be soft tissue or joint mobilization, would be indicated. The apparent exclusion of more balance oriented interventions also surprises me.

3. Thinking about this question, I’m not sure I’ve ever seen a first time ankle sprain acutely. Everyone I have seen acutely have had multiple sprains and CAI issues such as giving out, or I see them subacutely after they have been immobilized due to more serious sprains. I think the early treatments would be similar to what was prescribed in this study, with ankle ROM, band ankle strengthening, and advice on edema management and activity modification. I think as swelling goes down and weightbearing becomes normalized I would begin focusing interventions on prevention of future sprains. The total PoC length would likely depend on how they did with return to activity. I had one patient who I saw for longer than 7 visits because she wanted to get back to rockclimbing and she was still having significant difficulty with that activity.

4. I think the easiest way to combat this would be to ask the patient what their goals are and relate my interventions into helping them achieve those goals. At the end of the article they mention that very few people had an ‘excellent’ outcome regardless of the group, and if you have any work or sport related demands at a high level then you likely want that high level outcome. I would highlight the wide range of interventions I have to offer that were not included in that research (for good reason due to the nature of RCTs) such as soft tissue massage, joint mobilization/manipulation, plyometric therex, gait retraining, specific exercise prescription, etc.

[Scott Resetar]

1) General thoughts on this study, its design, and its findings.

No manual therapy included. (GASP!)

Ineligible if you were immobilized – *Personal anecdote trigger warning* – I had a bad ankle sprain that actually resulted in a tibial osteochondral defect. I received terrible PCP care and received no education regarding immobilization, bracing, weightbearing, etc. I didn’t present to an ER, as in the study, but what are the odds the ER doctor is up to date on ankle sprain guidelines, vs a PCP, vs DPTs? I honestly don’t know the answer.

very high number of people did not participate in the study. (maybe if you were not very injured you’d say…hey why not participate? And if you were more badly injured and in pain you were more likely to tell the researcher to “buzz off!”)

2) What are your thoughts about the PT intervention provided and the frequency and duration of care?

PT interventions seemed solid except for not having manual therapy. They don’t start proprioceptive training until the final stage of their treatment, whereas I would like to start as early as possible.

3) What is your typical PoC for patients with a “simple” ankle sprain?

My POC is likely to change after reading this. Unless the patient is an athlete and trying to return to sport faster, or has a physically demanding job where their ankle is limiting them, I will likely decrease frequency of visits and do more education, basic proprioception, LE NM control drills, and manual therapy.

I think the data in the article “trend toward” getting better a bit faster with PT, but no difference overall at 6 months.

I think that this article does make me think about ankle sprains a bit more like the Hip OA article Justin did his journal club on. There are probably a group of people who need minimal PT and I should try to identify those. Others will need more due to occupational demands, psychosocial factors.

4) What would you tell a patient that has been referred to you and tells you that they do not think they will get better because they read they wouldn’t in the New York Times?

I would say “that’s not what the article says! It says 60% of people have an excellent recovery if they do nothing. You are here in my office and are motivated to get better, so I think you will do better.”

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