By Critically Appraising Relevant Evidence Discuss How a Progressive Exercise Programme Might Be Used to Promote Tissue Healing and Restore Function.

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Essay Title for BR0107 year 2010/11

A 35 year-old mother of two pre-school children sustained a grade 2 sprain of the lateral ankle ligaments of her right leg whilst stepping off an escalator 2 days ago. She is currently mobilising independently using 2 elbow crutches. By critically appraising relevant evidence discuss how a progressive exercise programme might be used to promote tissue healing and restore function.

Lateral ankle sprains, like the one this 35 year old mother suffered, are among the most common orthopaedic conditions treated by healthcare professionals (Stanley 1991). The mechanism of injury associated with ankle sprains, especially when stepping down, is landing on a plantiflexed and inverted foot. This action causes the anterior talofibular and calcaneofibular ligaments to be most at risk due to the force that the whole body weight exerts upon them. A ‘Grade 2’ sprain of the anterior talofibular and/or the calcaneofibular ligament (partial tear) follows the normal tissue healing pattern – bleeding, inflammation, proliferation, remodelling. Since the patient only recently suffered the injury, she is likely to be in the inflammation stage, showing pain, redness, heat and edema. As part of the patient’s rehabilitation, a progressive exercise programme may be used in order to aid the healing process and restore function in the ankle joint.

Bleakly et al (2010) carried out a study investigating the early application of therapeutic exercises following an acute ankle sprain. 101 participants with grade 1 or 2 ankle sprains were split into two groups, using randomised control trial techniques. One group received an accelerated exercise programme and the other group received standard PRICE (Protection, Rest, Ice, Compression, Elevation) treatment – the popular method used in “most cases” by 70% of respondants (Cooke et al 2003).

The outcome measures were noted by a blinded researcher. By not knowing which intervention the patient received, there was little chance the results would be biased. Improvements were measured using the Lower Extremity Functionality Scale (LEFS) (Binkley et al 1999). Twenty functional leg exercises were performed which scored 0-4 depending on how easily they were carried out. LEFS was performed on all patients at initial injury stage and again after 4 weeks of treatment. The overall findings of the study were that the accelerated exercise group undertook significantly more weight-bearing mobilisation and enjoyed significant improvements in short-term ankle function, compared with the standard treatment group. The early mobilisation and weight-bearing appears to have improved ankle functionality. The exercises could be home based and designed to fit around the mother’s time constraints.

Hupperets (2009) wanted to see what effect home based proprioceptive exercise programmes would have on reinjury rates of sprained ankles. This is important, since long-term effects of ankle trauma can lead to degenerative changes, including a reduction in proprioception, causing further instability (Fu 2005). This study took the form of a randomised control trial, using 522 participants. However, all 522 were athletes and thus the study may not be appropriate for the mother in this case study. It would be interesting to find out Hupperets’ definition of an athlete, as the term can apply to a range of people, such as professional athletes, players who participate for a local club, or people who participate casually a few times a week.

Despite confining the sample study to athletes, 522 is a large sample size, especially as there was a follow-up after one year. Follow-ups can often be difficult to arrange and often never materialize, leading to dropout figures which reduces the integrity of the study. This was shown in this study as, for a variety of reasons, 17% of the intervention group and 12% of the...
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