Clinical Guide to Positional Release Therapy PDF

Clinical Guide to Positional Release Therapy Injuries to the ankle and lower leg are common, and both initial and recurrent injury can pose long-term consequences. Smith, Harris, and Clauw (2011) proposed that even a simple ankle sprain early in life may trigger the development of fibromyalgia. Of...

Clinical Guide to Positional Release Therapy Injuries to the ankle and lower leg are common, and both initial and recurrent injury can pose long-term consequences. Smith, Harris, and Clauw (2011) proposed that even a simple ankle sprain early in life may trigger the development of fibromyalgia. Of all lower-quarter injuries that do occur, ankle sprain is the most common (Doherty et al. 2015; Swenson et al. 2013). A total of 3,140,132 ankle sprains were reported in the United States in 2010, an incidence of 2.15 per 1,000 (Waterman et al. 2010). More ankle sprains occurred in people between the ages of 10 and 19, and males 15 to 24 years old had the highest rate (Waterman et al. 2010). The majority of ankle sprains (49.3%) occur during athletic activity, and most (41.1%) occur in basketball players (Waterman et al. 2010). A systematic review of American high school athletes (football, soccer, volleyball, basketball, wrestling, baseball, softball) between 2005/2006 and 2010/2011 revealed that athletic trainers (ATs) reported 1,370,545 ankle sprains, which accounted for 16.7% of all the injuries reported (Swenson et al. 2013). In contrast to Waterman’s findings that ankle sprains occur more frequently among young males, Swenson and colleagues (2013) found that in gender-comparable sports such as soccer, girls were more likely (RR = 1.46) to sustain sprains than boys were. The authors proposed that girls may be more susceptible than boys to ankle sprain as a result of a lack of motor development, weak hip abductors, or a hormonal influence. Doherty and colleagues (2015) also found an elevated incidence of ankle sprain among females over males (13.6 vs. 6.94 per 1,000 exposures). The highest rate was found among children, and it decreased throughout the life span. Unlike Swenson and colleagues (2013), Doherty and colleagues (2015) believe that the differences seen in ankle sprain incidence between the sexes cannot be explained by neuromuscular, hormonal, or anatomical differences, but may be related more to training behavior. However, the most significant factor found for ankle sprain regardless of gender was a previous history of sprain; Swenson and colleagues (2013) reported that 15.7% of ankle sprains were recurrent. The type of ankle sprain most often seen is the lateral, or inversion, ankle sprain, which is attributed to the lack of bony block to inversion and weak lateral ligaments (Doherty et al. 2015). Disability from ankle sprain results in time lost not only from athletic competition, but also from 70 school, work, and military duty (Doherty et al. 2015). Recurrent sprains may produce chronic ankle instability (Doherty et al. 2015) and ankle joint osteoarthritis (Valderrabano et al. 2006). With the potential for the development of longterm sequelae of early-onset osteoarthritis and fibromyalgia, there is a critical need to address ankle injury early and to use preventive measures. Once a fracture has been ruled out, it may be prudent to apply PRT to an ankle sprain as soon as possible to avoid the onset of somatic dysfunction, either in the field or at the emergency department (ED). In a prospective randomized control trial by Eisenhart, Gaeta, and Yens (2003), adults (N = 55) with an acute ankle sprain without fracture received a single session of osteopathic manipulative treatment (OMT) from an osteopathic physician in the ED. The treatment consisted of PRT (also called strain counterstrain), muscle energy, and joint manipulation. The OMT intervention group (n = 28) demonstrated a significant reduction of pain and swelling and improved range of motion over the control group that received standard care (ice, anti-inflammatories, and bracing). Of those returning for follow-up examination (75%) one week later, OMT patients demonstrated a significantly better range of motion than controls did. The authors attributed their finding to improved arthrokinematics of the ankle as a result of edema and pain reduction, which may have restored patients’ functional anatomy more quickly. Therefore, it may be plausible that more OMT or manual therapy over a longer period of time would produce improved outcomes over a one-time application. Cleland and colleagues (2013) examined whether the application of low- and high-velocity joint manipulations to the talocrural and proximal and distal tibiofibular joints by a physical therapist twice per week for four weeks would produce better functional outcomes and pain reduction over a home exercise program alone. Although those who received manual therapy did show greater improvement in pain and function at four weeks and at a six-month follow-up, the difference between the groups was not robust enough to indicate a significant minimal clinically important difference (MCID). However, at a sixmonth follow-up, the patients who received only home exercises showed double the rate of recurrence compared to those in the manual therapy and exercise group, although the finding was not statistically significant. Joint mobilization com- T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. Ankle and Lower Leg bined with exercise may appear to be more helpful than exercise alone for ankle sprain recovery, but the authors attributed the differences to a lack of compliance with the home exercise program, the therapeutic touch of the clinician, and a possible placebo effect given that no sham intervention was used. Beyond acute trauma to the ankle mortise, cumulative trauma to the ankle and lower leg may result in chronic inflammatory conditions such as Achilles tendinopathy and medial tibial stress syndrome (MTSS), which may predispose people to stress fractures. Franklyn-Miller and colleagues noted in 2012 that lower-extremity injury rates for military recruits was approximately 20 to 50%, and the most frequent injury was lower-limb stress fractures (Zadpoor and Nikooyan 2011), compared to 25 to 65% among the nonmilitary running population. Nielsen and colleagues (2012) proposed that the majority of running-related injuries (RRIs), including lower-limb fractures and overuse injuries, are related not only to previous injury, but also to training error (novice runners committed the most errors). Although their systematic review findings were inconclusive in regard to the impact of training error on RRIs, Newman and colleagues (2013) found MTSS to be significantly related to fewer years of running experience. A multitude of factors may pose an increased risk for the onset of ankle and lower-limb injury. Early preventive measures such as the reduction of training errors and improved hip abductor strength and proprioception could help curb the incidence of injury. However, because lower-limb injury will occur, the question is whether an early PRT intervention would help to reduce the time lost and improve therapeutic outcomes. Based on the ability of PRT to reduce pain, restore range of motion, improve strength, and potentially improve the perfusion of tissues, this would seem to be the case. However, research is needed on how PRT affects lower-leg and ankle injuries directly as well as how PRT integrates with other therapies for this body region to answer this question. TREATMENT Common Anatomical Areas and Conditions for PRT Anterior Structures • Exertional compartment syndrome • High ankle sprain • Nonacute contusion Medial Structures • Tarsal tunnel syndrome • Medial tibial stress syndrome Posterior Structures • Exertional compartment syndrome • Achilles tendinitis • Retrocalcaneal bursitis • Os trigonum Lateral Structures • Fibular head displacement • Peroneal tendinitis • Peroneal nerve entrapment T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 71