Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1964 (Published 10 May 2010) Cite this as: BMJ 2010;340:c1964
All rapid responses
We would be very interested to see whether direct access to these
exercises, via the internet, would provide the same results. I agree that
in situations where fast access to physiotherapy is difficult; such an
approach might be particularly effective.
Overall, we found that providing patients with a DVD was a good adjunct to
printed exercise sheets. Video is certainly the best medium to highlight
the optimal speed and intensity of an exercise; factors that are important
in the acute stages of injury. Providing more accessible, multimedia
footage is perhaps the next logical step for enhancing patient compliance
and motivation during rehabilitation.
What this approach shouldn’t encourage however, is a trend towards
‘physician free’ rehabilitation. Patients who self diagnose, and opt to
initiate rehabilitation themselves may risk further damage; and as always,
initial contact with a trained clinician is essential for gaining an
accurate diagnosis. In relation, other important factors to consider when
generalising these interventions include: in this study, exercises were
initiated an average of 48 hours after injury and, until further evidence
is available; these early exercises are contraindicated in grade 3
sprains, or syndesmotic injury.
Competing interests:
None declared
Competing interests: No competing interests
I work as a GP without immediate access to physiotherapy for my
patients.This article was useful but I found that there was
insufficientily detailed information even in web extra for me to use this
directly in my own practice. My question now are:
Could the training DVD and instruction sheets go on the internet for
doctors to access for patients with mild to moderate ankle sprains?
Direct acesss to this information might well be a cost and time
effective option for many patient especially as physiotherapy
referral (from General Practice) results in a delay in the patient being
seen during which the window of opportunity for effective intervention may
be lost.
It would be interesting to see this research expanded to see if
access to this information (the training DVD and exercise protocols) via
the internet would produce the same benefits and thus be more widely
applicable to everyday practice.
Competing interests:
None declared
Competing interests: No competing interests
Critical comments on: " Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial"
Dear Sir,
With great interest we read the article of Bleakley et al. "Effect of
accelerated rehabilitation on function after ankle sprain: a randomized
controlled trial." (1, 2) Authors are to be complemented on a well written
report of a well organized and conducted RCT. Bleakley et al. concluded
that ankle function, as defined in the lower extremity functional scale,
improved after an accelerated exercise protocol during the first week post
-injury. We would like to place some remarks that we feel should be
discussed before accepting the above mentioned conclusion.
1. Five to 7 days after an acute ankle sprain, delayed physical
examination is the gold standard to determine lateral ankle ligament
status and it is possible to differentiate between a simple sprain (grade
I) and a lateral ligament injury (grade II and III) (6). In the acute
posttraumatic situation, physical examination is less reliable because of
pain and swelling: it is not possible to adequately perform the anterior
drawer test (3, 4). So we wonder how authors could determine between grade
I, II and III in the patients attending the accident and emergency
department. If grade III patients were not adequately excluded, the
question is raised whether the difference in outcome is not caused by a
different percentage in grade III patients per group.
2. Another issue is the combination of patients with a simple sprain
(grade I) needing no treatment for full recovery, with patients with a
partial lateral ankle ligament rupture (grade II) in need of functional
treatment for 6 weeks for full recovery. If the percentage of grade I
patients is significantly higher in the accelerated rehabilitation group
than the outcome was already clear before application of the intervention.
(7)
3. As authors stated already, the target sample size was not obtained
and there was a higher dropout rate in the accelerated rehabilitation
group. The high dropout rate could have caused a change in outcome.
Hypothesizing that a number of the 11 drop outs were unhappy with the
allocated treatment and did not return, then the conclusion could be
different. The p value of P=0.095 suggests that there is a trend to
difference in outcome between the drop-outs and the non drop-outs. The
authors used last observation carried forward but we suggest performing a
worst case analysis and see if there is still a difference in the primary
outcome after 1 and 2 weeks in functional outcome.
4. The outcome assesses was blinded but the primary outcome (lower
extremity functional scale) is a subjective score assessed by the patient
self who is not blinded. (2, 5) So that would make it an RCT without
blinded primary outcome assessment and the only difference was found in
the primary outcome measure and no differences were observed regarding
pain at rest, pain with activity and swelling. This difference was only
significant for 2 weeks and no differences were observed on longer term
follow-up. The mentioned difference in the lower extremity functional
scale is less than the 9 points as was defined (2, 5) as the minimal
clinically important difference and the minimal detectable change. (2, 5)
5. The follow-up in this RCT is too short to analyze the numbers of
recurrent injuries and chronic instabilities.
In summary, we feel that Bleakley et al. prove that there is a
potential beneficial effect from an accelerated rehabilitation in some of
the patients suffering from an ankle sprain. To determine in detail which
type of patient (grade I, II, II) can benefit most from an accelerated
rehabilitation protocol as described by Bleakley et al., an additional RCT
should be performed with a slightly different set up. A MRI scan would be
useful in future studies to evaluate the grade (I versus II / III) of
injury of the lateral ankle ligaments in an early phase before starting
the treatment. We would be interested to further discuss this with the
authors.
Kind regards,
Michel P. J. van den Bekerom, MD
Gino M. M. J. Kerkhoffs, MD, PhD
Correspondence: Michel P.J. van den Bekerom Academic Medical Center
Department of Orthopaedic Surgery Meibergdreef 15 P.O. Box 22660 1105 AZ
Amsterdam The Netherlands E-mail: Bekerom@gmail.com
References
1. Bleakley CM, O'Connor SR, Tully MA, Rocke LG, Macauley DC,
Bradbury I, Keegan S, McDonough SM. Effect of accelerated rehabilitation
on function after ankle sprain: randomised controlled trial. BMJ. 2010 May
10;340:c1964. doi: 10.1136/bmj.c1964
2. Bleakley CM, O'Connor S, Tully MA, Rocke LG, Macauley DC,
McDonough SM. 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;19;8:125
3. Van Dijk CN, Lim LS, Bossuyt PM, et al.: Physical examination is
sufficient for the diagnosis of sprained ankles. J Bone Joint Surg Br 1996
;78(6):958-962
4. Van Dijk CN, Mol BW, Lim LS, et al.: Diagnosis of ligament rupture
of the ankle joint. Physical examination, arthrography, stress radiography
and sonography compared in 160 patients after inversion trauma. Acta
Orthop Scand 1996;67(6):566-570
5. Binkley JM Stratford PW et al. The Lower Extremity Functional
Scale (LEFS): Scale development measurement properties and clinical
application. Physical Therapy. 1999; 79: 371-383
6. Klenerman L. The management of sprained ankle. J Bone Joint Surg
[Br] 1998;80:11-12
7. Kerkhoffs GM, van den Bekerom MP, Struijs PA, van Dijk CN. 10-day
below-knee cast for management of severe ankle sprains. Lancet
2009;9;373(9675):1601
Competing interests: No competing interests