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Published by: Jorge Campillay Guzmán on Feb 17, 2011
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In the Netherlands around 600 000 people suer every yearrom traumatic injury o the ankle. Functional instabilityas a residual problem ater acute injury has been reportedin 10–60% o the patients (Eils and Rosenbaum 2001,Freeman 1965, Hoiness et al 2003, Moller-Larssen et al1988, Van Dijk 1994, Van Moppes and Van den Hoogenband1982). Symptoms o unctional instability are a eeling o instability, recurrent sprains, or a eeling o apprehension(Karlsson et al 1996). Limitation o dorsifexion range o motion is associated with pain and unctional problems aterankle sprains (Balduini et al 1987), and with an increasedrisk o ankle sprains in healthy subjects (Pope et al 1998).Several reviews have been written about the eectivenesso dierent orms o interventions in acute ankle sprains(Handoll et al 2001, Kerkhos et al
2002a, Kerkhoset al 2002b, Kerkhos et al 2002c, Van der Windt et al2002, Verhagen et al 2000). The eects o interventionscommonly used by physiotherapists are partly described inthose reviews. Van der Windt et al (2002) ound no eectso ultrasound in acute ankle sprains. A review done by theDutch Health Council (1999) shows no eects or the use o ultrasound, electrotherapy, and laser-therapy. Handoll et al(2001) ound limited evidence or the eects o ankle disctraining in reducing recurrent ankle sprains.The use o tape and brace has been reviewed by Kerkhoset al (2002b and 2002c), Verhagen et al (2000) and Handollet al (2001). The review by Kerkhos (2002b) showsthat unctional treatment, based on an early mobilisationprogramme using external ankle support (brace, tape orelastic bandage) and exercises, appears to be the avourablestrategy or treating acute ankle sprains when comparedwith immobilisation in a plaster cast. External ankle supportusing tape or brace is eective in preventing ankle injuries,specically in preventing recurrent sprains (Handoll et al2001, Verhagen et al 2000). Verhagen (2000) concludesthat braces seem to be more eective in preventing anklesprains than tape. A narrative review by Zöch et al (2003)describes the eects o rehabilitation o ligamentous ankleinjuries. He concludes that improvement in proprioceptionis important in ankle rehabilitation, and could be associatedwith better postural control. Van Os et al (2005) comparedsupervised rehabilitation or treatment o acute lateral anklesprains to usual care. The authors ound limited evidencethat the addition o supervised exercises results in greaterreduction o swelling and aster return to work. The eectso exercise therapy and manual mobilisation o the ankle joint as common physiotherapy interventions in acute anklesprains and unctional instability are not yet described ina meta-analysis. The objective o this study is to evaluatequalitatively and quantitatively the eectiveness o exercisetherapy and manual mobilisation o the ankle joint in acute
Australian Journal of Physiotherapy 2006 Vol. 52 © Australian Physiotherapy Association 200627
van der Wees et al: Systematic review of treatments for ankle sprain 
Effectiveness of exercise therapy and manualmobilisation in acute ankle sprain and functionalinstability: A systematic review
Philip J van der Wees
, Anton F Lenssen
, Erik JM Hendriks
, Derrick J Stomp
, Joost Dekker
 and Rob A de Bie
 Department o Epidemiology, Maastricht University
 Royal Dutch Society or Physical Therapy (KNGF)
University Medical Centre, Maastricht 
 Dutch Institute o Allied Health Care (NPi)
VU Medical Centre, AmsterdamThe Netherlands
This study critically reviews the eectiveness o exercise therapy and manual mobilisation in acute ankle sprains and unctionalinstability by conducting a systematic review o randomised controlled trials. Trials were searched electronically and manuallyrom 966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation o the ankle jointwith at least one clinically relevant outcome measure were included. Internal validity o the studies was independently assessedby two reviewers. When applicable, relative risk (RR) or standardised mean dierences (SMD) were calculated or individual andpooled data. In total 7 studies were included. In thirteen studies the intervention included exercise therapy and in our studiesthe eects o manual mobilisation o the ankle joint was evaluated. Average internal validity score o the studies was . (range–7) on a 0-point scale. Exercise therapy was eective in reducing the risk o recurrent sprains ater acute ankle sprain: RR0.7 (95% CI 0.8 to 0.7), and with unctional instability: RR 0.8 (95% CI 0.2 to 0.62). No eects o exercise therapy wereound on postural sway in patients with unctional instability: SMD: 0.8 (95% CI –0.5 to 0.9). Four studies demonstrated aninitial positive eect o dierent modes o manual mobilisation on dorsifexion range o motion. It is likely that exercise therapy,including the use o a wobble board, is eective in the prevention o recurrent ankle sprains. Manual mobilisation has an (initial)eect on dorsifexion range o motion, but the clinical relevance o these ndings or physiotherapy practice may be limited.
[vander Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J and de Bie RA (2006): Effectiveness of exercise therapyand manual mobilisation in acute ankle sprain and functional instability: A systematic review.
Australian Journal of Physiotherapy 
52: 27-37]
Key words: Ankle, Ligament, Injury, Review, Exercise Therapy, Manipulation Therapy
ankle sprains and in patients with unctional instability.This systematic review was perormed to collect evidenceto update the Clinical Practice Guideline Ankle Injury o theRoyal Dutch Society or Physical Therapy (KNGF).
 Literature search
Two reviewers (TL and PvdW) searchedcomputerised databases independently. The ollowingdatabases were searched: MEDLINE (1966 to March2005), EMBASE (1988 to March 2005), CINAHL (1982to March 2005). In addition the Cochrane Central Registero Controlled Trials (2005, Issue 1), the PEDro database (toMarch 2005) and the DocOnline database (to March 2005)o the Dutch Institute o Allied Health Proessions weresearched. Subject-specic search was based on combinationso ‘ankle’, ‘sprains’, ‘injuries’, ‘prevention’, ‘ligamentous’,‘lateral’, ‘unctional instability’, ‘rehabilitation’,‘physiotherapy’, ‘physical therapy’. Finally, reerencesrom retrieved articles were screened.
Types of studies
This review includes randomised controlledtrials. Full text articles until March 2005, published inEnglish, German or Dutch, were considered or this study. Todetermine whether a study should be included, the abstractso all identied articles were assessed by both reviewers. I there was any doubt, the ull text article was retrieved andread independently by both reviewers. Disagreement wasresolved by consensus.
Types of participants
Trials that include patients with acuteankle sprain, or with unctional instability, or trials with arecognisable subgroup with a history o ankle injury wereconsidered. In acute ankle sprain symptoms may be pain,swelling and unctional disability. Functional instabilityincludes residual problems ater acute injury such asrecurrent sprains, a eeling o giving way or a eeling o apprehension.
Types of interventions
At least one o the interventionsin the trial had to be an intervention aimed at exercisetherapy (including proprioceptive training, co-ordinationtraining, strength training or unctional exercises), or atmanual mobilisation o the ankle joint. The interventionhad to be compared with placebo, no treatment or otherinterventions.
Outcome measures
At least one o the ollowing outcomemeasures had to be used or inclusion in this study: recurrentsprains, unctional disability, gait pattern, subjectiveinstability, postural control, ankle joint range o motion,pain.
Quality assessment
Two reviewers (PvdW and TL) assessedthe methodological quality independently. A slightlymodied version o the Amsterdam-Maastricht consensuslist (Smidt et al 2002) was used to assess the quality o the internal validity o the studies. The list o criteria orassessment o the methodological quality is shown in Table1. The reviewers scored each item with a ‘Yes’ (sucientinormation is available and bias is considered to beunlikely), ‘No’ (bias was considered to be likely), or ‘Don’tknow’ (insucient inormation is given, the criterion israted as inconclusive). Positive scores (Yes) were added.A study was considered high quality when it had a minimumscore o 4. Disagreement was ollowed by discussion,ollowed i necessary by scrutiny rom another reviewer(EH).
 Data collection
Two reviewers (PvdW and TL) extractedthe data independently rom the studies using a standarddata-extraction orm and cross checked or accuracy.Disagreement was resolved by a consensus procedure,ollowed i necessary by scrutiny rom a third reviewer(EH). When appropriate and possible, additional data wereobtained rom authors o the studies.
Table 1.
Criteria or assessment o methodological qualityo studies.Adequate randomisation: adequate procedure orgeneration o a random number sequence.2 Baseline similarity: treatment and control group arecomparable at entry.Co-intervention: standardised or avoided.Adherence: > 70% in intervention and control group(s),5 Blinding o the therapist.6 Blinding o the patient.7 Withdrawals and drop outs: < 20% or short termollow up; and < 0% or intermediate and long termollow-up.8 Identical timing o outcome measures or all groups.9 Intention to treat analysis.0 Blinding o the outcome assessors.Based on the Amsterdam-Maastricht consensus list (Smidtet al 2002).
Table 2.
Hierarchy o quality o individual studies andstrength o evidence.Hierarchy o evidenceA Systematic reviews, which include trials at quality levelA2, and have consistent resultsA2 Randomised controlled trials o good quality andsucient power and consistencyB Randomised controlled trials o moderate quality orinsucient power, or other non-randomised controlledstudiesC Non-controlled studiesD Expert opinion, such as working group members
Strength of evidence
Level  systematic review (A) or 2 studies at level A2Level 2 2 studies o level BLevel  study o level A2 or B or CLevel Expert opinion, such as working group members
Formulation of recommendations
Level It has been shown that Level 2 It is likely that …Level There are indications that Level The opinion o the working group is …Source: CBO 2005
Australian Journal of Physiotherapy 2006 Vol. 52 © Australian Physiotherapy Association 200628
van der Wees et al: Systematic review of treatments for ankle sprain 
 Data analysis
For dichotomous outcomes we calculatedRelative Risks (RR) and 95% condence intervals (CI).For continuous outcomes, Standardised Mean Dierences(SMD) were calculated. RR and SMD were calculated orthree most common outcome measures (recurrent sprains,postural sway, range o motion) when sucient datawere available. A random eects model was used i thestudies or subgroups o studies were considered clinicallyheterogeneous; otherwise where appropriate a xed eectsmodel was used to pool the outcomes.
 Best evidence synthesis
Further analysis to weigh thequality o the evidence rom the selected studies wasdone using a rating system with a hierarchy o our levels.The strength o the evidence o combined studies is alsoexpressed in our levels. The levels o evidence are derived
Figure 1.
Selection o studiesComputerised searches (n = 6)MEDLINE (69)EMBASE (9)CINAHL (2)PEDro (80)Cochrane (66)DocOnline (29)98 titles considered or initial selectionExcluded (n = 69)Study design (5)Type o patients (22)Intervention (2)Full text articles retrieved or urtheranalysis (n = 29)Excluded (n = 2)Study design (2)Type o patients ()Intervention (6)Outcome measure ()Included in review (n = 7)
Table 3.
Quality o studies.Study2567890ScoreQualityBernier 998-----+++--BBrooks 98-------+--BCollins 200---+-+++-+5A2Eils 200-+-----+--2BEisenhart 200-+++---+--A2Green 200+--+--++-+5A2Hess 200--+----+--2BHoiness 200++++--+++-7A2Holme 999+------+--2BNilsson 98------++--2BOostendorp 987------++++A2Pellow 200+----+++--A2Powers 200-------+-+2BStasinopoulos 200+------+--2BTropp 985------
+--BVerhagen 200-+-----+-+BWester 996+-----++--B* study design allows ‘voluntary’ withdrawals in experimental group
Australian Journal of Physiotherapy 2006 Vol. 52 © Australian Physiotherapy Association 200629
van der Wees et al: Systematic review of treatments for ankle sprain 

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