Manual physical therapy and exercise versus supervised home exercise in the management of patients with inversion ankle sprain: a multicenter randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND: An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP. METHODS: Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P ≤.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION: The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368). LEVEL OF EVIDENCE: Therapy, level 1b-.

Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial.

BACKGROUND: It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions. OBJECTIVE: The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation. DESIGN: This was a prospective single-arm trial. SETTING: This study was conducted in outpatient physical therapy clinics. PARTICIPANTS: The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain. INTERVENTION AND MEASUREMENTS: Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. RESULTS: Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3). LIMITATIONS: A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in "overfitting" of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables. CONCLUSIONS: The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings.

Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain.

STUDY DESIGN: Prospective-cohort/predictive-validity study. OBJECTIVES: To develop a clinical prediction rule (CPR) to identify patients who had sustained an inversion ankle sprain who would likely benefit from manual therapy and exercise. BACKGROUND: No studies have investigated the predictive value of items from the clinical examination to identify patients with ankle sprains likely to benefit from manual therapy and general mobility exercises. METHODS AND MEASURES: Consecutive patients with a status of post inversion ankle sprain underwent a standardized examination followed by manual therapy (both thrust and nonthrust manipulation) and general mobility exercises. Patients were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. RESULTS: Eighty-five patients were included in the data analysis, of which 64 had a successful outcome (75%). A CPR with 4 variables was identified. If 3 of the 4 variables were present the accuracy of the rule was maximized (positive likelihood ratio, 5.9; 95% CI: 1.1, 41.6) and the posttest probability of success increased to 95%. CONCLUSIONS: The CPR provides the ability to a priori identify patients with an inversion ankle sprain who are likely to exhibit rapid and dramatic short-term success with a treatment approach, including manual therapy and general mobility exercises. LEVEL OF EVIDENCE: Prognosis, level 2b.