A recent study published by BMJ asserts that among those with simple ankle sprain, there is no evidence to support a clinically important improvement in outcome with the addition of supervised physiotherapy to usual care. Usual care in the study involved a medical assessment and advice on basic management of the injury at home, including rest, ice, compression, elevation, ankle protection and graduated weight bearing activities.
The Australian Physiotherapy Association (APA) strongly asserts the important role that physiotherapists play in managing acute ankle sprains and preventing their recurrence, despite some media reports that have suggested otherwise.
Physiotherapists routinely assess injuries to allow patients to either go home with a self-management plan or commence supervised treatment. Increasingly, this assessment role is being successfully performed in emergency departments (ED) by physiotherapists themselves, with positive outcomes for patients and reductions in overall time in the ED, costs to ED and time to pain relief.
The trial in question actually compared two common physiotherapy approaches to managing ankle sprain: one being self-management and one involving more consultations with a physiotherapist. Physiotherapists often provide a self-management approach for the types of ankle sprains assessed in the study.
However, their care doesn’t stop there. Physiotherapists also triage, assess, diagnose, educate and offer self-management or more extensive physiotherapy treatment programs when indicated. They also review progress and refer on when appropriate. Continual review of patients’ progress and modification of exercise programs is very important when looking at optimal short, medium and long-term recovery from ankle sprains.
The biggest risk factor for ankle sprains is a previous sprain, with up to 50 per cent of first time sprains potentially leading to functional instability in the ankle. A number of trial participants had a previous injury to their ankle, indicating that proper recovery to prevent recurring injury is even more important with such sprains.
Prolonged immobilisation is detrimental to muscles and joint surfaces, so early mobilisation should be a treatment goal. A comprehensive balance and strengthening program, designed by a physiotherapist, is essential to regain stability in the injured ankle, and will reduce overall recovery time. Proprioceptive training reduces the risk of ankle sprain recurrence.
Finally, the trial evidence is shaky due to treatment crossover. Sixty-nine people in the traditional physio group did not attend any sessions of physiotherapy and approximately 20% of subjects were lost to follow-up.
Overall, it would be more accurate to interpret these findings as evidence that self-management after an appropriate assessment by a physiotherapist is a cost-effective treatment option widely employed by physiotherapists today.
The idea that physiotherapists simply apply modalities to people is an outdated notion that no longer reflects the evidence base and practice of contemporary physiotherapy.
These comments were provided by Phil Calvert, APA Vice-President, Holly Brasher, National Chair of the APA Sports Physiotherapy group, and Chris Maher, Fellow of the Australian College of Physiotherapists.
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