Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial ...healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.
The Hertel model of chronic ankle instability (CAI) is commonly used in research but may not be sufficiently comprehensive. Mechanical instability and functional instability are considered part of a ...continuum, and recurrent sprain occurs when both conditions are present. A modification of the Hertel model is proposed whereby these 3 components can exist independently or in combination.
To examine the fit of data from people with CAI to 2 CAI models and to explore whether the different subgroups display impairments when compared with a control group.
Cross-sectional study.
Community-dwelling adults and adolescent dancers were recruited: 137 ankles with ankle sprain for objective 1 and 81 with CAI and 43 controls for objective 2.
Two balance tasks and time to recover from an inversion perturbation were assessed to determine if the subgroups demonstrated impairments when compared with a control group (objective 2).
For objective 1 (fit to the 2 models), outcomes were Cumberland Ankle Instability Tool score, anterior drawer test results, and number of sprains. For objective 2, outcomes were 2 balance tasks (number of foot lifts in 30 seconds, ability to balance on the ball of the foot) and time to recover from an inversion perturbation. The Cohen d was calculated to compare each subgroup with the control group.
A total of 56.5% of ankles (n = 61) fit the Hertel model, whereas all ankles (n = 108) fit the proposed model. In the proposed model, 42.6% of ankles were classified as perceived instability, 30.5% as recurrent sprain and perceived instability, and 26.9% as among the remaining groups. All CAI subgroups performed more poorly on the balance and inversion-perturbation tasks than the control group. Subgroups with perceived instability had greater impairment in single-leg stance, whereas participants with recurrent sprain performed more poorly than the other subgroups when balancing on the ball of the foot. Only individuals with hypomobility appeared unimpaired when recovering from an inversion perturbation.
The new model of CAI is supported by the available data. Perceived instability alone and in combination characterized the majority of participants. Several impairments distinguished the sprain groups from the control group.
The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been ...previously investigated.
The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes.
This was a retrospective observational study nested within a randomized controlled trial.
One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment.
The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures.
Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.
Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.
Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high ...proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.
Abstract Background context The relationships between obesity and low back pain (LBP) and lumbar disc degeneration (LDD) remain unclear. It is possible that familial factors, including genetics and ...early environment, affect these relationships. Purpose To investigate the relationship between obesity-related measures (eg, weight, body mass index BMI) and LBP and LDD using twin studies, where the effect of genetics and early environment can be controlled. Study design A systematic review with meta-analysis. Methods MEDLINE, CINAHL, Scopus, Web of Science, and EMBASE databases were searched from the earliest records to August 2014. All cross-sectional and longitudinal observational twin studies identified by the search strategy were considered for inclusion. Two investigators independently assessed the eligibility, conducted the quality assessment, and extracted the data. Metaanalyses (fixed or random effects, as appropriate) were used to pool studies' estimates of association. Results In total, 11 articles met the inclusion criteria. Five studies were included in the LBP analysis and seven in the LDD analysis. For the LBP analysis, pooling of the five studies showed that the risk of having LBP for individuals with the highest levels of BMI or weight was almost twice that of people with a lower BMI (odds ratio OR 1.8; 95% confidence interval CI 1.6–2.0; I2 =0%). A dose-response relationship was also identified. When genetics and the effects of a shared early environment were adjusted for using a within-pair twin case-control analysis, pooling of three studies showed a reduced but statistically positive association between obesity and prevalence of LBP (OR 1.5; 95% CI 1.1–2.1; I2 =0%). However, the association was further diminished and not significant (OR 1.4; 95% CI 0.8–2.3; I2 =0%) when pooling included two studies on monozygotic twin pairs only. Seven studies met the inclusion criteria for LDD. When familial factors were not controlled for, body weight was positively associated with LDD in all five cross-sectional studies. Only two cross-sectional studies investigated the relationship between obesity-related measures and LDD accounting for familial factors, and the results were conflicting. One longitudinal study in LBP and three longitudinal studies in LDD found no increase in risk in obese individuals, whether or not familial factors were controlled for. Conclusions Findings from this review suggest that genetics and early environment are possible mechanisms underlying the relationship between obesity and LBP; however, a direct causal link between these conditions appears to be weak. Further longitudinal studies using the twin design are needed to better understand the complex mechanisms underlying the associations between obesity, LBP, and LDD.
To determine the point prevalence of chronic musculoskeletal ankle disorders in the community.
Cross-sectional stratified (metropolitan vs regional) random sample.
General community.
Population-based ...computer-aided telephone survey of people (N=2078) aged 18 to 65 years in New South Wales, Australia. Of those contacted, 751 participants provided data.
Not applicable.
Point prevalence for no history of ankle injury or chronic ankle problems (no ankle problems), history of ankle injury without residual problems, and chronic ankle disorders. Chronic musculoskeletal ankle disorders due to ankle sprain, fracture, arthritis, or other disorder compared by chi-square test for the presence of pain, weakness, giving way, swelling and instability, activity limitation, and health care use in the past year.
There were 231 (30.8%) participants with no ankle problems, 342 (45.5%) with a history of ankle injury but no chronic problems, and 178 (23.7%) with chronic ankle disorders. The major component of chronic ankle disorders was musculoskeletal disorders (n=147, 19.6% of the total sample), most of which were due to ankle injury (n=117, 15.6% of the total). There was no difference among the arthritis, fracture, sprain, and other groups in the prevalence of the specific complaints, or health care use. Significantly more participants with arthritis had to limit activity than in the sprain group (Chi-square test, P=.035).
Chronic musculoskeletal ankle disorders affected almost 20% of the Australian community. The majority were due to a previous ankle injury, and most people had to limit or change their physical activity because of the ankle disorder.
Abstract Question What influence do physiotherapists’ beliefs and attitudes about chronic low back pain have on their clinical management of people with chronic low back pain? Design Systematic ...review with data from quantitative and qualitative studies. Quantitative and qualitative studies were included if they investigated an association between physiotherapists’ attitudes and beliefs about chronic low back pain and their clinical management of people with chronic low back pain. Results Five quantitative and five qualitative studies were included. Quantitative studies used measures of treatment orientation and fear avoidance to indicate physiotherapists’ beliefs and attitudes about chronic low back pain. Quantitative studies showed that a higher biomedical orientation score (indicating a belief that pain and disability result from a specific structural impairment, and treatment is selected to address that impairment) was associated with: advice to delay return to work, advice to delay return to activity, and a belief that return to work or activity is a threat to the patient. Physiotherapists’ fear avoidance scores were positively correlated with: increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. Qualitative studies revealed two main themes attributed to beliefs and attitudes of physiotherapists who have a relationship to their management of chronic low back pain: treatment orientation and patient factors. Conclusion Both quantitative and qualitative studies showed a relationship between treatment orientation and clinical practice. The inclusion of qualitative studies captured the influence of patient factors in clinical practice in chronic low back pain. There is a need to recognise that both beliefs and attitudes regarding treatment orientation of physiotherapists, and therapist-patient factors need to be considered when introducing new clinical practice models, so that the adoption of new clinical practice is maximised. Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S (2017) Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy XX: XX–XX
Abstract Background Context It has been proposed that depression plays an important role in the course of low back pain; however, there is considerable uncertainty on its predictive value. Purpose ...This systematic review aims to investigate the effect of depression on the course of acute and subacute low back pain. Study Design This is a systematic review. Methods We searched the following databases using optimized search strategies: AMED, CINAHL, EMBASE, Health & Society Database, LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science. We only included prospective studies that investigated a cohort of participants with acute or subacute non-specific low back pain (pain of less than 12 weeks' duration). The prognostic factor of interest was depression or symptoms of depression assessed at baseline. The outcomes of interest included pain intensity, chronicity (non-recovery from low back pain), disability, return to work, health-related quality of life, and overall patient satisfaction. Two independent reviewers selected the studies, extracted the data, and assessed the methodological quality of the studies that were included. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest-associated biases. Results Seventeen articles reporting 13 cohort studies were included in this review. There was considerable variability between studies in terms of the method of assessment of depression and low back pain, statistical methods, and follow-up length, which precluded the quantitative synthesis of the results. Definition of outcomes varied across studies, but overall they could be divided into work-related outcome measures, followed by disability, pain, self-perceived recovery, and mixed outcomes. Eleven out of 17 articles (or 8 out of 13 cohorts) reported that symptoms of depression at baseline are related to worse low back pain outcomes (measured in various ways) at follow-up, and the effect sizes (odds ratio OR) ranged from 1.04 to 2.47. Only two studies that did not find a statistically significant association reported quantitative results: OR=1.03, 95% confidence interval (CI) 0.98–1.08; and OR=1.02, 95% CI 0.99–1.06. All included studies, regardless of statistical significance, showed an effect in the direction of harm. Conclusions Although a definitive answer on the effect of depression on the course of low back pain is not available, the findings of this systematic review suggest that depression might have an adverse effect on the prognosis of low back pain. Future large studies that enroll an inception cohort and that employ a standardized method for assessing depression and low back pain are needed.
The Executive Committee of the International Ankle Consortium presents this 2016 position paper with recommendations for information implementation and continued research based on the paradigm that ...lateral ankle sprain (LAS), and the development of chronic ankle instability (CAI), serve as a conduit to a significant global healthcare burden. We intend our recommendations to serve as a mechanism to promote efforts to improve prevention and early management of LAS. We believe this will reduce the prevalence of CAI and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and promotion of physical activity.
Dynamic postural control has gained popularity as a more useful assessment of function than static postural control. One measurement of dynamic postural control that has increased in frequency of use ...is the Star Excursion Balance Test (SEBT). Although the intrarater reliability of the SEBT is excellent, few authors have determined interrater reliability. Preliminary evidence has shown poor reliability between assessors.
To determine interrater reliability using a group of investigators at 2 testing sites. A corollary purpose was to examine the interrater reliability when using normalized and nonnormalized performance scores on the SEBT.
Descriptive laboratory study.
University research laboratory.
A total of 29 healthy participants between 18 and 50 years of age.
Participants were evaluated by 5 raters at 2 testing sites. After participants performed 4 practice trials, each rater assessed 3 test trials in the anterior, posteromedial, and posterolateral reaching directions of the SEBT.
Normalized and nonnormalized (leg-length) reaching distances were analyzed. Additionally, the mean and maximum values from the 3 test trials were analyzed, producing a total of 16 variables.
For all 16 measures, the interrater reliability was excellent. For the normalized maximum excursion distances, the intraclass correlation coefficients (1,1) ranged from 0.86 to 0.92. Reliability for the nonnormalized measurements was stronger, ranging from 0.89 to 0.94.
When the raters have been trained by an experienced rater, the SEBT is a test with excellent reliability when used across multiple raters in different settings. This information adds to the body of knowledge that exists regarding the usefulness of the SEBT as an assessment tool in clinical and research practice. Establishing excellent interrater reliability with normalized and nonnormalized scores strengthens the evidence for using the SEBT, especially at multiple sites.
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