Advertisement

Rehabilitation Exercises Reduce Reinjury Post Ankle Sprain, But the Content and Parameters of an Optimal Exercise Program Have Yet to Be Established: A Systematic Review and Meta-analysis

Published:October 26, 2018DOI:https://doi.org/10.1016/j.apmr.2018.10.005

      Abstract

      Objectives

      To determine if exercise-based rehabilitation reduces reinjury following acute ankle sprain. Our secondary objective was to assess if rehabilitation efficacy varies according to exercise content and training volume.

      Data Sources

      The following electronic databases were searched: EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro).

      Study Selection

      Randomized controlled trials investigating the effect of exercise-based rehabilitation programs on reinjury and patient-reported outcomes (perceived instability, function, pain) in people with an acute ankle sprain. No restrictions were made on the exercise type, duration, or frequency. Exercise-based programs could have been administered in isolation or as an adjunct to usual care. Comparisons were made to usual care consisting of 1 or all components of PRICE (protection, rest, ice, compression, elevation).

      Data Extraction

      Effect sizes with 95% CIs were calculated in the form of mean differences for continuous outcomes and odds ratios (ORs) for dichotomous outcomes. Pooled effects were calculated for reinjury prevalence with meta-analysis undertaken using RevMan software.

      Data Synthesis

      Seven trials (n=1417) were included (median PEDro score, 8/10). Pooled data found trends toward a reduction in reinjury in favor of the exercise-based rehabilitation compared with usual care at 3-6 months (OR, 0.87; 95% CI, 0.48-1.58) with significant reductions reported at 7-12 months (OR, 0.53; 95% CI, 0.38-0.73). Sensitivity analysis based on pooled reinjury data from 2 high quality studies (n=629) also found effects in favor of exercise-based rehabilitation at 12 months (OR, 0.60; 95% CI, 0.49-0.89). Training volume differed substantially across rehabilitation programs with total rehabilitation time ranging from 3.5-21 hours. The majority of rehabilitation programs focused primarily on postural balance or strength training.

      Conclusions

      Exercise-based rehabilitation reduces the risk of reinjury following acute ankle sprain when compared with usual care alone. There is no consensus on optimal exercise content and training volume in this field. Future research must explicitly report all details of administered exercise-based rehabilitation programs.

      Keywords

      List of abbreviations:

      MD (mean difference), NNT (number needed to treat), OR (odds ratio), PEDro (Physiotherapy Evidence Database), RR (relative risk)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Doherty C.
        • Bleakley C.
        • Delahunt E.
        • Holden S.
        Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis.
        Br J Sports Med. 2017; 51: 113-125
        • Gribble P.A.
        • Bleakley C.M.
        • Caulfield B.M.
        • et al.
        Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains.
        Br J Sports Med. 2016; 50: 1496-1505
        • van Rijn R.M.
        • van Os A.G.
        • Bernsen R.M.
        • Luijsterburg P.A.
        • Koes B.W.
        • Bierma-Zeinstra S.M.
        What is the clinical course of acute ankle sprains? A systematic literature review.
        Am J Med. 2008; 121: 324-331.e6
        • Gribble P.A.
        • Delahunt E.
        • Bleakley C.M.
        • et al.
        Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium.
        J Athl Train. 2014; 49: 121-127
        • Lamb S.E.
        • Marsh J.L.
        • Hutton J.L.
        • Nakash R.
        • Cooke M.W.
        • Collaborative Ankle Support Trial (CAST Group)
        Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial.
        Lancet. 2009; 373: 575-581
        • van den Bekerom M.P.
        • Kerkhoffs G.M.
        • McCollum G.A.
        • Calder J.D.
        • van Dijk C.N.
        Management of acute lateral ankle ligament injury in the athlete.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1390-1395
        • Kerkhoffs G.M.
        • van den Bekerom M.
        • Elders L.A.
        • et al.
        Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline.
        Br J Sports Med. 2012; 46: 854-860
        • Cooke M.W.
        • Lamb S.E.
        • Marsh J.
        • Dale J.
        A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom.
        Emerg Med J. 2003; 20: 505-507
        • Brison R.J.
        • Day A.G.
        • Pelland L.
        • et al.
        Effect of early supervised physiotherapy on recovery from acute ankle sprain: randomised controlled trial.
        BMJ. 2016; 355: i5650
        • Bleakley C.
        The addition of supervised physiotherapy sessions for management of acute ankle sprain does not aid recovery more than providing standardised written instruction about early management.
        J Physiother. 2017; 63 ([commentary]): 115
        • Taylor J.B.
        • Waxman J.P.
        • Richter S.J.
        • Shultz S.J.
        Evaluation of the effectiveness of anterior cruciate ligament injury prevention programme training components: a systematic review and meta-analysis.
        Br J Sports Med. 2015; 49: 79-87
        • Yoo J.H.
        • Lim B.O.
        • Ha M.
        • et al.
        A meta-analysis of the effect of neuromuscular training on the prevention of the anterior cruciate ligament injury in female athletes.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 824-830
        • Gagnier J.J.
        • Morgenstern H.
        • Chess L.
        Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis.
        Am J Sports Med. 2013; 41: 1952-1962
        • Macedo L.G.
        • Elkins M.R.
        • Maher C.G.
        • Moseley A.M.
        • Herbert R.D.
        • Sherrington C.
        There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials.
        J Clin Epidemiol. 2010; 63: 920-925
        • Higgins J.G.S.
        Cochrane Handbook for Systematic Reviews of Interventions.
        John Wiley & Sons, Chichester, United Kingdom2011
        • Hultman K.
        • Fältström A.
        • Öberg U.
        The effect of early physiotherapy after an acute ankle sprain.
        Adv Physiother. 2010; 12: 65-73
        • Bleakley C.M.
        • O'Connor S.R.
        • Tully M.A.
        • et al.
        Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial.
        BMJ. 2010; 340: c1964
        • Hupperets M.D.
        • Verhagen E.A.
        • van Mechelen W.
        Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial.
        BMJ. 2009; 339: b2684
        • van Rijn R.M.
        • van Os A.G.
        • Kleinrensink G.J.
        • et al.
        Supervised exercises for adults with acute lateral ankle sprain: a randomised controlled trial.
        Br J Gen Pract. 2007; 57: 793-800
        • Holme E.
        • Magnusson S.P.
        • Becher K.
        • Bieler T.
        • Aagaard P.
        • Kjaer M.
        The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain.
        Scand J Med Sci Sports. 1999; 9: 104-109
        • Wester J.U.
        • Jespersen S.M.
        • Nielsen K.D.
        • Neumann L.
        Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study.
        J Orthop Sports Phys Ther. 1996; 23: 332-336
        • Bleakley C.M.
        • O'Connor S.
        • Tully M.A.
        • Rocke L.G.
        • Macauley D.C.
        • McDonough S.M.
        The PRICE study (Protection Rest Ice Compression Elevation): design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain [ISRCTN13903946].
        BMC Musculoskelet Disord. 2007; 8: 125
        • Hupperets M.D.
        • Verhagen E.A.
        • van Mechelen W.
        The 2BFit study: is an unsupervised proprioceptive balance board training programme, given in addition to usual care, effective in preventing ankle sprain recurrences? Design of a randomized controlled trial.
        BMC Musculoskelet Disord. 2008; 9: 71
        • Mok K.M.
        • Fong D.T.
        • Krosshaug T.
        • et al.
        Kinematics analysis of ankle inversion ligamentous sprain injuries in sports: 2 cases during the 2008 Beijing Olympics.
        Am J Sports Med. 2011; 39: 1548-1552
        • Fong D.T.
        • Hong Y.
        • Shima Y.
        • Krosshaug T.
        • Yung P.S.
        • Chan K.M.
        Biomechanics of supination ankle sprain: a case report of an accidental injury event in the laboratory.
        Am J Sports Med. 2009; 37: 822-827
        • Rogol I.M.
        • Ernst G.
        • Perrin D.H.
        Open and closed kinetic chain exercises improve shoulder joint reposition sense equally in healthy subjects.
        J Athl Train. 1998; 33: 315-318
        • Edwards S.E.
        • Lin Y.L.
        • King H.J.
        • Karduna R.A.
        Joint position sense – there’s an app for that.
        J Biomech. 2016; 49: 3529-3533
        • Doherty C.
        • Bleakley C.
        • Hertel J.
        • Caulfield B.
        • Ryan J.
        • Delahunt E.
        Recovery from a first-time lateral ankle sprain and the predictors of chronic ankle instability: a prospective cohort analysis.
        Am J Sports Med. 2016; 44: 995-1003
        • Doherty C.
        • Bleakley C.
        • Hertel J.
        • Caulfield B.
        • Ryan J.
        • Delahunt E.
        Gait biomechanics in participants, six months after first-time lateral ankle sprain.
        Int J Sports Med. 2016; 37: 577-583
        • Doherty C.
        • Bleakley C.
        • Hertel J.
        • Caulfield B.
        • Ryan J.
        • Delahunt E.
        Single-leg drop landing movement strategies 6 months following first-time acute lateral ankle sprain injury.
        Scand J Med Sci Sports. 2015; 25: 806-817
        • Khan K.M.
        • Scott A.
        Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair.
        Br J Sports Med. 2009; 43: 247-252
        • Glasgow P.
        • Phillips N.
        • Bleakley C.
        Optimal loading: key variables and mechanisms.
        Br J Sports Med. 2015; 49: 278-279
        • Rein S.
        • Hagert E.
        • Schneiders W.
        • Fieguth A.
        • Zwipp H.
        Histological analysis of the structural composition of ankle ligaments.
        Foot Ankle Int. 2015; 36: 211-224
        • Noyes F.R.
        • DeLucas J.L.
        • Torvik P.J.
        Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates.
        J Bone Joint Surg Am. 1974; 56: 236-253
        • Yu J.
        • Wong D.W.
        • Zhang H.
        • Luo Z.P.
        • Zhang M.
        The influence of high-heeled shoes on strain and tension force of the anterior talofibular ligament and plantar fascia during balanced standing and walking.
        Med Eng Phys. 2016; 38: 1152-1156
        • Roemer F.W.
        • Jomaah N.
        • Niu J.
        • et al.
        Ligamentous injuries and the risk of associated tissue damage in acute ankle sprains in athletes: a cross-sectional MRI study.
        Am J Sports Med. 2014; 42: 1549-1557
        • Lin C.F.
        • Gross M.L.
        • Weinhold P.
        Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention.
        J Orthop Sports Phys Ther. 2006; 36: 372-384
        • van Dijk C.N.
        • Longo U.G.
        • Loppini M.
        • et al.
        Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1200-1216
        • Slade S.C.
        • Dionne C.E.
        • Underwood M.
        • Buchbinder R.
        Consensus on Exercise Reporting Template (CERT): explanation and elaboration statement.
        Br J Sports Med. 2016; 50: 1428-1437