Overview of the Workshop

Transcription

1 Novel Techniques in the Management of Ankle Sprains Michael G. Dolan, MA, ATC Professor/Athletic Trainer Department of Kinesiology Director, Sports Medicine Research Laboratory Canisius College Buffalo, NY Overview of the Workshop Brief Review Current Management of Ankle Sprains What has changed in the last 60 years? Novel Techniques for immediate application to your clinical practice Some OLD ideas and some NEW ideas Demonstration and trying it yourself! Evidence Based Practice Best Research Best Research Current State of AT Practice Clinical Experience Patient Values Clinical Experience Clinical Experience Patient Best Research Values Evidence Categories SORT Taxonomy Level of Evidence SORT Grade Clinical Practice A Based on consistent and good evidence No Brainer! Not the Place to Find Novel Techniques!! B Based on inconsistent or limited quality evidence Should probably include in our clinical practice C Based on consensus usual practice Up to you 1

2 Ankle Sprains are a BIG Problem Most common injury of the physically active 1 out of 3 people who sustain a LAS continue to have residual symptoms (Hertel JAT2002;37(4) Chronic Ankle Instability (CAI) Functional Rehabilitation Stabilization Current Gold Standard for Ankle Sprain Management + Progressive Exercise. Beynnon et al. Am J Sports Med.2006;34(9): Grade 1 Functional Treatment Grade II Functional Treatment of Ankle Sprains Elastic Wrap Air Cast Air Cast + Elastic Wrap Elastic Wrap Air Cast Air Cast + Elastic Wrap Below Knee Walking Cast. Beynnon et al. Am J Sports Med.2006;34(9): Beynnon et al. Am J Sports Med.2006;34(9): How to Break the Cycle? Functional Ankle Rehabilitation Injury Motor Rehabilitation Functional Rebab Re Injury Functional Rehab RICE Balance Training Range of Motion Resistive Exercise External Supports Return to Activity 2

3 Functional Ankle Rehabilitation Sensory Targeted Ankle Rehabilitation Strategies Motor Rehabilitation Sensory Rehabilitation RICE Balance Training Range of Motion Resistive Exercise External Supports Massage Joint Mobilizations Muscle Tendon At Home Return to Activity Wikstrom & McKeon Sensory targeted ankle rehabilitation strategies 2015 Lower Extremity Review and 2015 EATA Research to Reality Sensory Targeted Ankle Rehabilitation Strategies Sensory Targeted Ankle Rehabilitation Strategies Improvement in Dorsiflexion, Balance and Self Reported Function in subjects who have CAI Introduce during the acute and sub acute phase of rehabilitation Wikstrom & McKeon Sensory targeted ankle rehabilitation strategies 2015 Lower Extremity Review and 2015 EATA Research to Reality Wikstrom and McKeon NIH Grant Massage massage therapy activates potentially beneficial immunomodulatory pathways Application of a 30 minute bout of massage once each day over 4 days reduced the amount of cellular infiltration and tissue necrosis Less inflammation and edema which improved function Delay in massage application decreases the effectiveness for reducing secondary hypoxic injury Decrease leukocyte infiltration and myofiber damage delaying the application for 24 h did not result in the same improvement of function compared to when the compressive loading (massage) was initiated within 30 min Butterfield TA, et al. compressive loading facilitates recovery after eccentric exercise. Med Sci Sports Exerc.2008;40(7):

4 Massage 24.0% to 52.2% of the total number of treatments were massage Most were non specific NATA News July 2014 Galloway SD, Watt JM. Massage provision by physiotherapists at major athletics events between 1987 and Br J Sports Med. 2004;38(2): Protection When did compression become synonymous with protection? Rest What is your Definition of Rest? REST Taking in easy No Activity No Movement While cryotherapy and elevation are applied Movement that does not increase pain Maybe it is all in the Acronym? Br J Sports med 2012:46:

5 PRICE Protection Rest Ice Compression Elevation Acute Care POLICE Protection Optimal Loading Ice Compression Elevation Speaking of ACRONYMS Maybe We Need to Change our Clinical Diet? Bleakley et al. PRICE needs updating, should we call the POLICE? BJSM, (4), Movement Exercise Movement to Pain Tolerance Controlled Exercise High Voltage Pulsed Current (HVPC) Analgesia Treatment Pain Management Modalities Long touted by clinicians as an effective tool in managing pain and edema and thereby hastening recovery No evidence that it hastens recovery!! 2017 EATA Clinical Symposium Effects of cool water immersions and high voltage electrical stimulation on edema formation following blunt trauma to the hind limbs of rats Michael G. Dolan, MA, ATC, CSCS Anna M. Mychaskiw ATC Frank C. Mendel, PhD Change in Limb Volume (ml/kg) Treated Limb 0.3 Untreated Limb JAT 2003, 38(3) Funded EATA Research Grant 0 Pre Trauma JAT 2003, 38(3) Time (min) Funded EATA Research Grant 5

6 Normal State of Capillary Physiology Inflammatory Process Capillary Walls Endothelial Cells Endothelial Cells Capillary Walls Plasma Proteins Tissue Cell Tissue Cell Edema Formation Tissue Cell Tissue Cell Lymph Gland Lymph Gland Proposed Mechanism of Action Smooth Muscle Actin and Myosin Effects of Continuous Treatment on Edema Formation 1.2 Capillary Walls Golden Minute for Acute Management 1 Capillary Walls Endothelial Cells Change in Limb Volume(mL/Kg) Curbing of Edema Tissue Cell Tissue Cell Lymph Gland 0.2 Untreated Treated 0 Pre-T Minutes Dolan et al. JAT 2003, 38(4) Effect of high voltage pulsed current on recovery after grades I and II lateral ankle sprains Does aggressive application of HVPC influence recovery? Days Lost To Injury Days Lost 10 5 * Grade 1 Grade 2 0 Live HVPC Sham * p=.0498 JSR (4) Mendel FC, Dolan MG, Marzo JM, Fish DF, Wilding GW JSR (4) Mendel, Dolan, Marzo, Fish, Wilding 6

7 Is Amount of Time Treated Related to RX Effect? Heat or Cold for Acute Pain? Inflammation 100% Cont. HVPC 85% HVPC 1% Elevation 17% Compression 96% 6% Cryotherapy y Minutes per day expressed as % Chronic Tendon Injury DOMS Acute Joint Injury? Nerve Injury Low Back Pain Subjects with non specific low back pain Which Interventions Improve Outcomes of Ankle Sprains? Do heat wraps worn overnight affect pain, stiffness and ROM? 72 Studies Reviewed in Detail 9 Electrophysical 7 NSAID Heat Wrap worn overnight Control 4098 Eligible Studies 23 Reviewed Studies 2 Manual Therapy 2 Alternative Overnight use of heatwrap therapy provided effective pain relief throughout the next day, reduced muscle stiffness and disability, and improved trunk flexibility. Positive effects were sustained more than 48 hours after treatments were completed were excluded 49 Excluded 2 Neuromuscular Hyperbaric O2 Nadler et al. Overnight use of continuous low level heatwrap therapy for relief of low back pain. Arch of Phys. Med 2003:84(3) Bleakley et al. Aust. J. of Phys 2008:54:7 18 Ultrasound Effects of piroxicam on ankle sprains in military recruits 9 Electrophysical Low Level Laser Cryotherapy Compression High Voltage Pulsed Current Minimal evidence that these interventions curb traditional signs of inflammation or hasten recovery NSAID s improve function at day 14, 1,3 and 6 months BUT Reported that treated ankles had mechanical instability at days 3, 7 and 14 days Some controversy exists regarding long term benefit SORT Grade = A Bleakley et al. Aust. J. of Phys 2008:54:7 18 Slater et al. AJSM :

8 Topical NSAID s Ketoprofen patch applied over the painful region 1 time per day for 7 days This intervention resulted in reduced pain and swelling and improved self reported function as compared to control limbs Well tolerated and no systemic side effects as opposed to oral NSAID s Addition of a posterior anterior joint mobilization increased stride length and hasten time to pain free joint mobilization More effective than ice alone Not allowing inflammation to limit range of motion Green et al. PT 2001 (81) Green et al. Phys Ther. 2001;81(4): Mobilization with Movement Video of MWM to Increase DF Clinician leans backward creating an Posterior to anterior glide Forefoot is stabilized and glide is applied to the talus Patient moves knee over the second and third toes MWM increased ankle DF Collins et al. Man Ther May;9(2): NWB Mobilization with Movement MWM Non Weight Bearing Glides the talus anteroposteriorly Tibia is fixed against plinth Active dorsiflexion the ankle to end of available pain free motion 8

9 Anterior Positional Faults Brian Mulligan introduced the concept of anterior positional fault of the fibula following lateral ankle sprains Tension of the ATF during plantar flexion /inversion caused the fibula to displace anteriorly which increases pain and swelling Anterior Positional Faults Sub acute sprains had increased anterior positioning of the fibula as compared to the uninjured limb and matched controls Strong correlation between anterior positioning of the fibula and swelling Hubbard TJ, Hertel J. Man Ther. 2008;13(1): Mobilization Force Joint Mobilization to Correct an Anterior Positional Fault Mobilization to Correct Anterior Positional Fault Tape Job to Maintain Mobilization Position Mobilization and Tape Job 9

10 Joint Mobilizations SORT Grade = B Joint Mobilizations should be an integral part of a comprehensive rehabilitation program A and moving toward an A Cuboid Mobilization/Manipulation Jennings and Davies. JOSPT 2005, 35(7) Novel Techniques Take out your phone! Go to your App Source and search for Ankle App Ankle ReApp University of Ulster Maybe Cell Phones Can Prevent Ankle Injuries! Verhagen E. Br J Sports Med 2015;

11 Effects of Topically Applied Comfrey on Ankle Sprains Topically applied Comfrey Product (Traumaplant) 4X per day Significant Reduction in Pain and Swelling 300+ Subjects in a Double Blind RCT Kinesiotape Claims to lift the skin to allow lymphatic and venous drainage. The opposite of Compression!!!!!!! Kucera et al. Wiener Medizinische 2004;154: Best Practices The Take Home Message Apply intervention ASAP and consider extended treatment times Consider sub acute interventions during the Acute phase of injury Joint Mobilizations and Manual Therapy During the Acute Phase Best Practices The Take Home Message Motor and Sensory Rehabiliation Strong evidence that NSAID s reduce pain and swelling and improve function Alternative treatments will continue to emerge Keep an open mind! An open mind allows you to explore and create and grow. Remember that progress in all endeavors would be impossible if we always did things the we always have. Thank You The Peter Canisius Distinguished Teaching Professorship 11

12 Thank You for Attending! Questions? Mike Dolan