Do Current Practices Hasten Recovery of Ankle Sprains? Michael G. Dolan, MA, ATC Professor Director, Sports Medicine Research Laboratory 2009 EATA Research to Reality Presentation Boston, MA
Do Current Practices Hasten Recovery? o What will we cover? o Who is it for? o Overview of the Problem o Clinician-Scholars o Basic Science Work o Educators o Results of a recent RCT o Students o Future Direction
My thought process on how this all works Research Reality The By-Product of this process is the creation of CLINICIAN-SCHOLARS New Reality 2009 EATA Research to Reality
What is Evidence-Based Practice? Best Research Clinical Experience Patient Values 2009 Resea esearch t o Rea ealit y
Improved standing of the profession of Athletic Training Refine our educational programs to support these concepts Clinician-Scholars Evidence-Based Practice
q Does it? q If so, what interventions are most effective? q How can we optimize the most effective interventions?
It is not “just” an ankle sprain Ankle sprains are the most common o musculoskeletal injury that occurs in athletics 25% -50% of time loss from athletics is due to ankle o sprains Recurrence rates >70% in basketball (Yeung et al, o BJSM, 1994) 55-72% report residual symptoms 6 months post- o injury (Braun, Arch Fam Med, 1999) Relationship between ankle sprain history and o development of osteoarthritis ( Valderrabano et al, AJSM, 2006 ) 2009 Resea esearch t o Rea ealit y
STIM NSAIDS Massage PRICE Other CONTRAST Stuff BATHS Focal Intermittent TENS Compression Compression ACUTE TRAUMA MANAGEMENT
Systematic Review of Cryotherapy on Return to Play o 83 relevant clinical trials o 79 were excluded because they did not include return to play as an outcome o 4 reviewed studies 2 had a positive 1 had a positive effect 1 showed no RX effect but attributed it to difference compression All had PEDro Scores of 3 or 4 (1-10) Hubbard et al JAT 39(1) 88-94
Human Studies o Limited evidence that cold controls edema 2009 EATA Research to Reality
Summary of Animal Studies McMaster & Liddle, 30 C was Farry et al. Ice increased most effective, however, control swelling but less histology limbs had the least swelling evidence of inflammation Cryotherapy increases swelling after injury!! Jedinsky et al. No treatment Matsen et al. Used water effect from ice from 5-25 CTreated limbs were more swollen limbs swelled after ice was removed
q Does cryotherapy affect sw elling? JAT 1997, 32(3) 233-37
Results Dolan et al. JAT, 1997
Compression o Mechanically control swelling by increasing the hydrostatic pressure against the capillary wall o How much compression is enough? o What mode of compression?
Focal Compression
What type of compression works best? o Compared uniform, focal, and focal+cold compression on 34 subjects o No difference between groups p<.05 o Calculated effect size would suggest a small effect or little clinical significance Wilkerson & Horn-Kingery, JOSPT, 1993(17) 240-246
Comparison of 3 Methods of External Support for Management of Acute Lateral Ankle Sprains Acute Ankle Sprains n= 30 Elastic Wrap & Aircast Omni Multiphase Horseshoe None of the three were superior in increasing range of motion Restoring function, or relieving symptoms Guskiewicz et. al JAT 34(1) 5-10
Intermittent Compression q Static or rhythmic air contraction of sleeve q Affect the pressure gradient of the tissue Tsang et al. JAT 2003, 38(4) 320-24
Elevation Treatment effect is very short o or non-existent o Elevation and intermittent compression effect lasts less than 5 minutes o Statistical effectiveness vs. Clinical effectiveness Tsang et al. JAT 2003, 38(4) 320-24
Summary– So Far o Limited evidence that ice, compression, elevation at typically applied by certified athletic trainers has any meaningful treatment effect o Time to try something new! Evidence –Based Practice
High Voltage Pulsed Current (HVPC) o Long touted by clinicians as an effective tool in managing pain and edema and thereby hastening recovery o No evidence that it hastens recovery!!
High Voltage Pulsed Current 1-2% Duty Cycle Short Duration Twin Peak Pulse Minimal Chemical Changes Can select + or - Polarity Voltage 100 Long Interpulse Interval Time (ms) A cute Man e Manag agement of A thlet etic T T rau auma ma
q Does cryotherapy and e-stim have an added effect? q If not, which is more effective q Does either modality provide a “clinical effect” Funded by NYSATA
What effect does initial treatment have on acute edema formation? Decrease in Capillary CHVPC Permeability Greater = RX + Effect? Decreases Metabolic Cryotherapy Activity A cu A cute T rau T rauma M Man anag agement
Results 1.1 1 0.9 0.8 Change in Limb Volume (mL/kg) 0.7 0.6 0.5 0.4 0.3 Treated Limb Untreated Limb 0.2 0.1 0 P re- 0 30 60 90 120 150 180 210 240 Trauma Tim e (m in)
Cryotherapy + HVPC had no added treatment effect Comparison of Treatment 1.2 1 0.8 Change in Volume (ml/kg) 0.6 CWI CHVP C 0.4 CWI+CHVP C 0.2 0 P re- 0 30 60 90 120 150 180 210 240 Trauma -0.2 Time (min)
Why no added treatment effect? Cry ryot hera rapy = HVPC Strong Analgesic Effect Some Analgesic Effect ↓ Metabolic Activity None ↓ in Blood Flow No Change in Blood Flow ↓ Permeability Permeability ??
Normal State of Capillary Physiology Capillary Walls Endothelial Cells Capillary Walls Plasma Proteins Tissue Tissue Cell Cell Lymph Gland
Inflammatory Process Endothelial Cells Edema Formation Tissue Tissue Cell Cell Lymph Gland
Proposed Mechanism of Action Smooth Muscle Actin and Myosin Capillary Walls Endothelial Cells Capillary Walls Tissue Tissue Cell Cell Lymph Gland
Does Polarity Matter? NEG NEG NEG NEG Anode Cathode - + HVPC Unit
“Staircase Effect” RX Limb Volumes RX 30 60 Trauma 0 90 120 Time
q How can we improve the treatment effect? q Is more better? Supported by a NYSATA Grant JAT 2003, 38(4) 225-229
Methods
Subjects and Methods o 21 Zucker Lean rats o Anesthetized by IP injection of Sodium pentobarbital(60mg/ kg of body weight) o Supplemented as needed during the 4 hour experiment
Measurement System
Limb Volume Measurement
Calculating Limb Volume
CHVPC 120 pulses per second at 90% Visible Motor Contraction Anode Cathode
Methodolgy
Effects of Ibuprofen & Electrical Stimulation on Edema Formation following Blunt Trauma to the Hind Limbs of Rats Michael G. Dolan, MA, ATC, CSCS Paul Graves, ATS Chika Nakazawa, ATS Theresa Delano, ATC Alan Hutson, PhD Frank C. Mendel, PhD 2004 EATA Funded Research Award
Ibuprofen o Nonsteroidal anti-inflammatory Drug (NSAID) o Effectiveness of Ibuprofen on acute swelling has not been investigated o Seldom used as a first aid treatment A cut ute T raum T rauma a Man anag agement
Treated vs. Untreated Limb 1.2 1 Change in Limb Volume(mL/Kg) 0.8 0.6 0.4 0.2 Untreated Treated 0 Pre-T 0 30 60 90 120 150 180 210 240 Minutes
No Treatment Was Superior 0.6 0.5 Change in Limb Volume (mL/kg) 0.4 0.3 0.2 Ibuprofen CHVPC Ibuprofen + CHVPC 0.1 0 Pre-T 0 30 60 90 120 150 180 210 240 Minutes
How can we optimize our treatments? Max Untreated Pain & Edema I ntermittent Exercise Continuous Min Return to Play I njury A cu A cute T rau T rauma M Man anag agement
Is Amount of Time Treated Related to RX Effect? Inflammation 100% Cont. HVPC 85% HVPC 1% Elevation 17% 96% Compression Cryotherapy 6% 0 25 50 75 100 Minutes per day expressed as %
Mode of Delivery Tradit ion onal Mod odel o New ew Model el Treatment started hours or days o Treatment started within o after injury minutes of injury 20-30 minute treatments o Continuous Treatment o Variety of settings o Cathodal HVPC at 120 pps at o 90% Visible Motor Contraction A c A cute T T rauma Management
Effects of electrical stimulation on pain, edema and return to play following ankle sprains in college and professional athletes A Multi-Center Clinical Trial Frank C. Mendel PhD Michael G. Dolan, MA, ATC John Marzo, MD Dale Fish, PhD, PT Gregory Wilding, PhD Funded by a grant from The National Football League
How can we apply long term HVPC to Athletes? A cu A cute T rau T rauma M Man anag agement
Application of HVPC for Extended Treatment Time
50 College and Professional athletes who sustained a Grade I or II ankle Sprain Near Continuous HVPC for Near continuous Sham HVPC 72 hours n=28 for 72 hours n=22 Primary Outcome was number of days until fit to play as determined by ATC OUTCOME MEASURES Secondary Outcome included self-reported pain and function, swelling and functional testing (Forward and Lateral Hopping)
Days Lost To Injury 25 20 15 Days Lost 10 Grade 1 * Grade 2 5 0 Live Sham HVPC * p=.0498
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