PTH 661 Article Review Assignment- Prompt 5

Alex Caudy

I have only been involved in the world of physical therapy for a few years, but in my

short time I have observed many different styles and approaches that physical therapists take

when treating their patients. I have shadowed in a small outpatient clinic where the pace was

slow and patients received one on one time with the therapist for the entirety of the visit, which

consisted of a lot of manual therapy. I had a job at a larger outpatient clinic where patients spent

the majority of their time doing exercises run by the techs, while the therapists spent minimal

time doing manual therapy and were usually double booked for most slots. I have also helped out

at a clinic that was somewhere in between those two extremes. All of those opportunities helped

me to get to where I am today, but as I sit here in physical therapy school right now, I often ask

myself the same question: what will my “style” be? Will I focus on primarily manual

techniques? Will I assign my patients a lot of exercises? Which one is more important? That last

question is one that was looked at more closely in a study by Cleland et al. (2013). Their study

examined whether a combination of manual therapy and exercise was more or less effective than

a treatment plan consisting solely of exercise for the treatment of lateral ankle sprains.

The study consisted of 74 participants (mean age 35.1 ± 11.0 years, 36 female and 38

male). In order to be eligible to participate in the study, patients had to meet several different

criteria. The patient had to have current symptoms associated with a grade 1 or 2 ankle sprain

(West Point Ankle Sprain Grading System), be between the ages of 16 and 60, have a pain score

greater than 3/10 using a Numeric Pain Rating Scale (NPRS), and be negative with the Ottawa

Ankle Rules. Once the full subject pool was finalized, participants were randomly assigned to

one of two treatment groups, with 37 going to the Manual Therapy and Exercise (MTEX) group
and 37 going to the Home Exercise Program (HEP) group. Seven physical therapists were

involved in examination and treatment of the patients. These therapists had an average of 17 ± 15

years of clinical experience in an outpatient orthopedic setting.

Primary outcomes the study was concerned with were pain and disability scores. Pain

outcomes were measured with a 0-10 NPRS, while disability scores were measured using the

Foot and Ankle Ability Measure (FAAM) scale as well as the Lower Extremity Functional Scale

(LEFS). For both of these scales a higher number indicates a higher level of function. In the

study, all of these outcome measures were completed at baseline as well as at a 4 week and 6

month follow up. For the MTEX group, treatment consisted of twice per week for 4 weeks (8

total treatment sessions). Each session lasted 30 minutes, and included manual therapy

interventions appropriate for treatment of lateral ankle sprains. Manual techniques included were

anteriorly directed high velocity end-range thrusts to the head of the fibula on the tibia, low

velocity oscillatory forces anterior to posterior of the distal fibula, high velocity end-range

longitudinal traction to the dorsum of the foot on the lower leg at the talocrural and subtalar

joints, low velocity anterior to posterior oscillatory force to the talus on the distal tibiofibular

joint, low velocity medial to lateral oscillatory force to the medial talus on the lower leg, and low

velocity anterior to posterior glides to the talus in weight-bearing. The goal of treatment was for

the therapist to stay within the range of grades III to IV Maitland for five bouts of 30 seconds.

Participants in this group were also given the same strengthening and mobilizing exercises to do

at home as the HEP group. For the HEP group, treatment consisted of once per week for 4

weeks, and the focus was on progression of the strengthening and mobilizing exercises they were

assigned. Treatment sessions also lasted 30 minutes for the HEP group. Both treatment groups
were educated on compression, ice, and elevation and given advice to stay active as their

symptoms were not aggravated.

Statistically and clinically significant improvements in outcomes were observed for pain

(p<.001) using the numeric pain scale, disability using the FAAM scale (p<.001) and the LEFS

scale (p<.001) for the MTEX group when compared to the HEP group. The study did

demonstrate that both groups experienced improved scores in pain and disability as well, with

MTEX just resulting in larger improvements. These results lead the authors to recommend that,

“clinicians should consider using a multimodal approach incorporating manual physical therapy

interventions and exercise for the management of patients with inversion ankle sprains”.

While this study was not perfect, I feel that it was pretty well written and could be

reproducible with the proper resources. I think this is a study I can use and refer back to as I

continue to grow in the field of physical therapy, and I agree with the conclusion that they came

to. This study has to do with ankle sprains, but I think the concepts can be applied anywhere in

the body. I obviously don’t have a ton of experience yet, but after seeing practices on both ends

of the spectrum, I believe that a treatment approach consisting of manual therapy supplemented

with proper exercises seems to be a good way to go, and at least in this case the literature

supports that. There were some problems and limitations with this study though. First of all,

there was no true control group for the interventions to be compared to. A control group

consisting of no treatment is necessary in order to ensure that the good outcomes weren’t just a

product of time and natural healing. Another problem with the study is the fact that the MTEX

group received 8 total treatment sessions, while the HEP group only received 4. The results

report that the MTEX group was more effective than the HEP group, but it’s tough to conclude

that the treatment is really what mattered as opposed to the fact that they got twice as much of it.
One more issue with the study is the fact that it doesn’t appear that they have any standard way

to ensure adherence to the HEP. This is a major confounding variable because if some people are

doing a better job of completing the prescribed exercises than others, that could definitely affect

their final outcome measures. But other than those problems, I thought this was a pretty sound

study and a good read.

Cleland JA, Mintken PE, McDevitt A, et al. Manual physical therapy and exercise versus

supervised home exercise in the management of patients with inversion ankle sprain: a

multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2013;43(7):443-455.

doi:10.2519/jospt.2013.4792