As I progress through my fellowship training, I have been busier than ever (sorry for the infrequent updates to the site). It has also forced me to read even more literature on manual therapy and its effectiveness in the treatment of musculoskeletal conditions. One article, in particular caught my eye this afternoon so I thought I would review it:
Beazell JR, Grindstaff TL, et al. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals with Chronic Ankle Instability. JOSPT 2012: 42; 125-134.
This randomized clinical trial assessed the effects of joint mobilization in 43 individuals classified with chronic ankle instability (CAI).
CAI was defined as a history of at least one ankle sprain followed by additional episodes of ankle instability/giving way, and an 85% of greater on the Foot and Ankle Ability Measure (FAAM) sport subscale. Additionally all participants had to have an ankle dorsiflexion ROM deficit of at leat 5 degrees compared to the opposite side.
After baseline data was taken, the subjects were randomized into one of three groups: proximal tibiofibular manipulation, distal tibiofibular manipulation or no treatment. Once the subjects were randomized, outcome measures were taken including: ankle dorsiflexion ROM, single-limb stance on foam, the step-down test and the FAAM sport subscale. The intervention was then performed and the same data was recollected. Data was then taken during three follow-up visits 1,2, and 3 weeks post initial intervention. The participants would recieve the same intervetion during these subsequent sessions.
The results in this study indicated that there was not a significant difference between participants who recieved ankle manipulation vs. no intervention.
Bottom Line: “So what. This study tells me that ankle manipulation as an isolated intervention is likely not effective. But how many therapists treat CAI with manipulation only for one session per week for three weeks? None.”
“The subjects included in this study were not seeking care for CAI but were instead subjects of convenience who were recruited for participation. Does this represent a patient who seeks our services? No. Expectations have a large effect on results and patients who seek our services have an expectation for recovery. This group lacked that variable.”
“The sample size was very small (Proximal tibfib group: n=15, distal tibfib group: n=15, control = 13). To extract information from a study which includes such a small sample size should be done with caution. This must have been picked up in the peer review because the authors included a power analysis in the methods portion of the published version. They said they needed 12 subjects per group to have an 80% chance of detecting a significant difference in ankle dorsiflexion ROM (which they are stating would yield the smallest effect size among the outcome variables) but I question that ankle dorsiflexion would demonstrate the smallest effect size.”
“Overall, no offense to the authors, but this study just wasted my past hour.”