Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review

Abstract

This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1 to 7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an (initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited.

Ankle proprioception is not targeted by exercises on an unstable surface

“…In a meta-analysis Van der Wees et al (2006) found a pooled relative risk of 0.38, which can be considered as a substantial clinical effect. After their review was written, two randomized controlled trials were published.…”

“…a hip strategy) (Otten 1999). Although some studies showed beneficial effects of exercise programs on proprioceptive outcomes, like muscle reaction times (Hughes and Rochester 2008) and postural sway (Hughes and Rochester 2008), others found no evidence for an effect of rehabilitation programs on postural sway (van der Wees et al 2006). Moreover, both postural sway and muscle reaction time are characteristics that in addition to peripheral proprioceptive signals are dependent on an abundance of other variables.…”

Increased treatment durations lead to greater improvements in non-weight bearing dorsiflexion range of motion for asymptomatic individuals immediately following an anteroposterior grade IV mobilisation of the talus

“…Static stretching techniques may not be sufficient to address these arthrokinematic restrictions, justifying the use of talocrural joint mobilisations (Denegar et al, 2002). A Maitland anteroposterior (AP) glide of the talus within the mortise has been shown to lead to improvements in DF-ROM (Landrum et al, 2004;Van der Wees et al, 2006). Various treatment doses have been utilised by researchers in an attempt to study the effects of AP mobilisations of the talus on DF-ROM.…”

Neuromuscular control and rehabilitation of the unstable ankle

“…The majority of the literature reports positive therapeutic effects of balance training (e.g., single limb standing, standing on an ankle disc/wobble board) [29,4555] . However, there are a few studies that disagree with its treatment effect [56,57] . In the "Clinical Practice Guidelines" published in the Journal of Orthopaedic and Sports Physical Therapy, a panel of experts also concluded that the evidence is weak (grade of recommendation "C") on implementing weight bearing functional exercises and balance activities on unstable surfaces [18] .…”