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Supervised physiotherapy offers no clinical benefit in patients with simple ankle sprains

Stephen Padilla
25 Nov 2016

The addition of supervised physiotherapy to usual care does not provide clinically important improvement in the management of simple ankle sprains in a general population of patients seeking hospital-based acute care, according to results of a recent randomized controlled trial.

“Our comparator of usual care was the provision of written recommendations for initial rest, cryotherapy, compression and limb elevation, with graduated mobility being encouraged as tolerated,” said researchers, adding that such recommendations stem from basic physiotherapy principles that are commonly provided in emergency departments.

A total of 530 patients (aged ≥16 years) presenting for acute medical assessment and treatment of a simple grade 1 or 2 ankle sprain were randomly assigned to receive either usual care or usual care enhanced with a supervised programme of physiotherapy.

The primary outcome of efficacy was the proportion of participants with excellent recovery, defined as a foot and ankle outcome score ≥450/500 at 3 months. Secondary analyses included the assessment of excellent recovery at 1 and 6 months; change from baseline using continuous scores at 1, 3 and 6 months; and clinical and biochemical measures of ankle function, assessed at 1, 3 and 6 months.

There was no significant difference in the absolute proportion of patients achieving excellent recovery at 3 months between the physiotherapy (43 percent) and usual care (37 percent) arms (absolute difference, 6 percent; 95 percent CI, –3 to 15 percent). [BMJ 2016;doi:10.1136/bmj.i5650]

“The absence of a therapeutic benefit of supervised exercise was confirmed for our primary outcome of excellent functional recovery as assessed by the FAOS at three months, as well as for the FAOS … and objective clinical and biomechanical measures at 1, 3, and 6 months after injury,” researchers said.

In the per protocol analysis, the observed trend towards benefit with physiotherapy did not increase and was in the opposite direction by 6 months. In addition, these trends remained similar and were never statistically or clinically relevant when the FAOS was analysed as a continuous change score.

“Our finding is clinically important as the recommendation of physiotherapy for the management of acute ankle sprains comes with substantial economic costs,” researchers said.

This finding contradicts current evidence base, according to Ulster University lecturer Chris Bleakley, adding that treatment success can be influenced by many other exercise dose parameters. [BMJ 2016;doi:10.1136/bmj.i5984]

“Manipulating the magnitude, nature, intensity and frequency of exercise can have profound effects on the structure and function of the neuromusculoskeletal system. Important details of these parameters, however, are often missing from trials of exercise treatments for ankle sprain (including this one), making it difficult for readers to judge the clinical appropriateness of trial interventions,” he explained.

As 43 and 38 percent of patients in the physiotherapy and controls arms, respectively, did not reach excellent recovery by 6 months, there is potential for the investigation of alternative interventions that would reduce morbidity in patients with grade 1 and 2 ankle sprains, according to researchers.

The study is limited by the application of an extensive protocol, which may have introduced bias in the characteristics of participants in the trial group, they added.

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