Physiotherapy for Patients with Lateral Ankle Sprains

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

Physiotherapists' compliance with ankle injury guidelines is different for patients with acute injuries and patients with functional instability: an observational study

QUESTIONS

What are the characteristics of patients with acute ankle injuries or functional instability of the ankle? Do physiotherapists treat these patients according to evidence-based guidelines? What are the determinants of adherence to the guidelines?

DESIGN

Observational study using multi-level analyses of data from the National Information Service for Allied Health Care in the Netherlands. This network continuously collects healthcare-related information on characteristics of patients and their referral, health problem, and treatment plan.

PARTICIPANTS

1413 patients treated for ankle injuries.

OUTCOME MEASURES

Adherence to the guidelines was measured using three quality indicators: number of sessions, interventions, and accomplished treatment goals.

RESULTS

Interventions and treatment goals were often aimed at the improvement of body functions, especially in patients with functional instability. Although not advised in the guidelines, manual manipulation was applied during treatment in 21% of the patients with functional instability. On average, patients with acute ankle injuries have a 38% chance of being treated according to the guidelines. Adherence can be explained partly by the duration of the complaint, whether the complaint is recurrent, the patient's age and the experience of the therapist, but it depends substantially on the therapist.

CONCLUSION

There is some discrepancy between the guidelines and practice, especially regarding the interventions applied to patients with functional instability. However, there is large variation between therapists. The sooner a patient presents for treatment and the greater the experience of the physiotherapist with ankle injuries, the greater the likelihood that treatment will follow the guidelines.

Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review

QUESTIONS

Which intervention(s) best augment early mobilisation and external support after an acute ankle sprain? What is the most appropriate method of preventing re-injury?

DESIGN

A systematic review of randomised controlled trials published from 1993 to April 2005.

PARTICIPANTS

People with an acute ankle sprain.

INTERVENTION

Any pharmacological, physiotherapeutic, complementary or electrotherapeutic intervention added to controlled mobilisation with external support. Immobilisation, surgical intervention, and use of external ankle supports in isolation were excluded.

OUTCOMES

Pain, function, swelling, re-injury, and global improvement; assessed at short, intermediate, and long-term follow-up.

RESULTS

23 trials were included with a mean PEDro score of 6/10. There was strong evidence that non-steroidal anti-inflammatory drugs can reduce pain and improve short-term ankle function. There was moderate evidence that neuromuscular training decreases functional instability and minimises re-injury; and that comfrey root ointment decreases pain and improves function. There was also moderate evidence that manual therapy techniques improve ankle dorsiflexion. There was no evidence to support the use of electrophysical agents or hyperbaric oxygen therapy. Very few long-term follow-ups were undertaken, and few studies focused on preventing long-term morbidity.

CONCLUSIONS

Non-steroidal anti-inflammatory drugs, comfrey root ointment, and manual therapy can significantly improve short-term symptoms after ankle sprain, and neuromuscular training may prevent re-injury. More high quality studies are needed to develop evidence-based guidelines on ankle rehabilitation beyond the acute phases of injury management.

Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains

BACKGROUND AND PURPOSE

To some extent, favorable treatment outcomes for physical therapy intervention programs depend on patients attending their clinic appointments and adhering to the program requirements. Previous studies have found less-than-optimal levels of clinic attendance, and a viable option might be physical therapy intervention programs with a large component of home treatment. This study investigated the effects of a standard physical therapy intervention program--delivered primarily at either the clinic or home--on ankle function, rehabilitation adherence, and motivation in patients with ankle sprains.

SUBJECTS

Forty-seven people with acute ankle sprains who were about to start a course of physical therapy intervention participated in the study.

METHODS

Using a prospective design, subjects were randomly assigned to either a clinic intervention group or a home intervention group. Ankle function and motivation were measured before and after rehabilitation, and adherence to the clinic- and home-based programs was measured throughout the study.

RESULTS

The groups had similar scores for post-treatment ankle function, adherence, and motivation. The home intervention group had a significantly higher percentage of attendance at clinic appointments and better physical therapy intervention program completion rate.

DISCUSSION AND CONCLUSION

Home-based physical therapy intervention appears to be a viable option for patients with sprained ankles.

Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study

Background

Clinical guidelines are considered important instruments to improve quality in health care. In physiotherapy, insight in adherence to guidelines is limited. Knowledge of adherence is important to identify barriers and to enhance implementation. Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury, and to identify patient characteristics that determine adherence to the guideline.

Methods

Twenty-two physiotherapists collected data of 174 patients in a prospective cohort study, in which the course of treatment was systematically registered. Indicators were used to investigate adherence to recommendations. Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline. Correlation between patient characteristics and adherence to outcome-indicators (treatment sessions, functioning of patient, accomplished goals) was calculated using univariate logistic regression. To calculate explained variance of combined patient characteristics, multivariate analysis was performed.

Results

Adherence to individual recommendations varied from 71% to 100%. In 99 patients (57%) the physiotherapists showed adherence to all indicators. Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81% (132 patients).

The odds to receive more than six sessions were statistically significant for three patient characteristics: females (OR:3.89; 95%CI: 1.41–10.72), recurrent sprain (OR: 6.90; 95%CI: 2.34 – 20.37), co-morbidity (OR: 25.92; 95% CI: 6.79 – 98.93). All factors together explained 40% of the variance. Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions (OR: 0.2; 95%CI: 0.06 – 0.77), and increased explained variance to 45%.

Conclusion

Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice. Adherence to the guideline, even in a group of physiotherapists familiar with the guideline, showed possibilities for improvement. The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains. It is not clear why female patients were treated with more sessions. Experience of the physiotherapist reduced the number of treatment sessions. Quality indicators may be used for audit and feedback as part of the implementation strategy.