Professional Assignment Project

Transcription

1 European School of Physiotherapy Professional Assignment Project Treatment of acute ankle sprains in Turkish professional volleyball players: a comparison with the KNGF ankle guidelines. Alpaslan Erdem Ruben Groenendijk Simon Train Final Product Date: Class: 2011 Coach: Mel Major MSc Client: Antonio Tome del Olmo 1

2 ACKNOWLEDGEMENTS First of all we want to thank our Coach, Mel Major, for all her help and who took the greatest part in this project with her feedback, Antonio Tome del Olmo, for being a great client and to the participants in Turkey who were patient to complete the whole questionnaire Suna Gokturk, who translated the questionnaire from English to Turkish and to her work as one of our external advisers Dr. Özge Cinar who translated the questionnaire from Turkish to English and motivated us with her educational feedback Dr. Tyra Inderwies who provided a number of ideas and motivated us with their educational feedback. We personally thank Jose Hermans, Rob Oskam and Vasiliki Folia taking the time to read the questionnaire and providing feedback as external advisers. 2

3 ABSTRACT Introduction: Ankle sprain is one of the most common injuries in sports. This survey was formulated to find out how Turkish Super League Volleyball players are treated by their team physiotherapists. The survey was sent to the physiotherapists who currently work with top league teams. The author's main idea was to find out if there are differences between the KNGF ankle sprain guideline (2006) and the way treatment is applied on volleyball players in Turkey. Methods: This survey was constructed into four main parts: Background of the participant, assessment, treatment strategies and prevention. The treatment strategies were the most emphasised part to gain an insight into the most efficient treatment to bring the player back to the competition. Results: The results show that in the early stages of injury the physiotherapists aim to reduce the effects of inflammation, later leading to exercise treatment/ prevention programs to maintain/ regain the full physical capabilities of the player and reduce the chance of re-injury. Conclusion: Outcomes shown that in Turkey the physiotherapists are using very similar techniques to those of the KNGF Guideline for ankle sprain (2006). Besides these similarities various electrophysical modalities and manual lymph drainage are used differently. 3

4 1. INTRODUCTION Every form of physical activity comes with the risk for injury. Sport poses a greater risk for injury with ankle injuries as the most common acute injuries in the athletic population (Adamson et al, 1997, Löfvenberg et al, 1995). This is shown in highly competitive sports, where the body is moving within extremes, as well as the external forces that are applied to the body. Injuries occur relative to the functions and structures that are used for this activity. (Peterson et al, 2001). Volleyball is a popular sport that has become a custom within many societies worldwide, with 150 million people playing in 170 countries (Stasinopoulos, 2003). According to Adamson et al (1997) lateral ankle injuries account for 15-25% of all sports injuries. An incidence of 2.6 injuries has been recorded per 1000 hours of playing time, with ankle sprain contributing to 41% of injuries (Verhagen et al, 2004). With ankle sprain contributing to such a large portion of the injuries within volleyball, it is of great importance to monitor these injuries and minimize the recovery time of the injury. Being injury-free is naturally important to each and every person, but in professional sports, players need a fast as well as fully functional recovery. The strategies used by physiotherapists play a huge role in the time and effectiveness of the recovery. Volleyball is the third biggest sport in Turkey, and many believe it s the most popular sport for females. The national league in Turkey is divided into different levels according to their success. The first and highest league is called süper-lig and is divided into 12 male and 12 female teams. Many of the teams compete in the European Champions League (ECL), and within Turkey, the National Cup (NC). In general the teams commence training at least one and a half to two months before the official competition begins, which last for around eight months. Every team has one game per week, but as the National Cup begins the frequency of games increase. Those teams that take part in the ECL may even play up to three games weekly. Since 2010, the World Volleyball Federation made it mandatory for each team to assign a physiotherapist to be able to compete in the 4 EU Cups. Team physiotherapists work almost full-time in top four teams in each of the male and female leagues. The other teams commonly send their players to specialized rehab centres or hire part time physiotherapists. In this project our primary goal is to analyze how physiotherapists working in the Süperlig in Turkey view ankle sprain and compare the findings with the KNGF ankle guidelines from 2006 (van der Wees et al, 2006). Emphasis is made around the treatment methods, with attention also paid towards assessment and prevention strategies from the Physiotherapist. 2. METHODS 2.1 Questionnaire development For this survey a web-based questionnaire with questions on current care of ankle sprain (AS) in süper lig - volleyball players was created. It focuses on all five phases of healing according to the KNGF ankle sprain guidelines (van der Wees et al, 2006). It consists of 40 questions focusing on the following sections: 1- Background of the participant 2- Assessment criteria 3- Treatment strategies and goals 4- Prevention techniques Section 1: Background The background information includes questions on the age of the physiotherapist, level of experience, workload with the team in total, as well as patient related data such as: amount of patients with AS the physiotherapist has treated during the current season. Section 2: Assessment The assessment section covers the use of clinimetrics and guidelines, and views the approach and limitations of the assessment. Section 3: Treatment The treatment section is composed of questions related to the treatment modalities used and treatment goals of the physiotherapists throughout the five phases of healing (see Table 1).

5 Section4: Prevention The prevention section focuses on the reoccurance of AS injuries and looks towards the levels of participation in prevention programs. Grading system For questions where more detailed information about the physiotherapists opinion, we used graded questions. The respondents have to grade their choices on a scale from 0-4 in terms of how frequent or important they thought their choice is, 0 being not applicable (N/A), 1 being the lowest score and 4 the highest (see Table 2). This questionnaire has been based on personal experience, external advisors in the area of sport physiotherapy, R. Oskam and Dr Ö. Cinar, advisers in the field of evidence-based physiotherapy and research, M. Major, J. Hermans, V. Folia and Dr. T. Inderwies, and the KNGF ankle guidelines from As the target group was composed of both native Turkish and international physiotherapists, a Turkish and English version of the questionnaire were created (see Appendix 1 and 2). 5

6 The English version was then translated into Turkish and then re-translated into English to comply with our quality control procedures. Two translators were selected for this task, and subsequently blinded from each other. After the creation phase a pilot was conducted with an expert group of physiotherapists with regards to design, structure, and content- and construct validity of the questionnaire. The expert panel for content validity consisted of R. Oskam and Dr Ö. Cinar and for construct validity J. Hermans and V. Folia, both professors at the Hogeschool van Amsterdam. Due to the time limitation on this professional assignment it was not possible to test for the reliability of the questionnaire. 2.2 Inclusion/ Exclusion criteria All Physiotherapists who currently work with volleyball players from the current season of male and female süper-lig competitions in Turkey were included in this study. Physiotherapists with less than 2 years work experience were excluded from the study to ensure a certain level of experience and by that aiming for more reliable data. 2.3 Recruitment Contact was made via telephone and with all physiotherapists currently treating professional volleyball players in the male and female National leagues in Turkey (N=20). From this 9 were non-responsive, 11 (n=11) were interested in completing the survey. The web-based questionnaire was sent to the participants and both the English and the Turkish versions were made available. Two dates were set to remind participants that did not fill in the questionnaire yet, at one week and two week intervals after the mailing of the official questionnaire. 3. RESULTS Eleven agreed to participate (N=11). Nine out of these completed the questionnaire (N=9) showing a response rate of 45 % (see Graph 1). Graph 1: Sample size and response rate N=20 Teams contacted Showing interest N=11 in participating N=9 Completed the Questionnaire 3.1 Background The age of the participants ranged within the following groups: 55% (n=5) between 26 and 35 years and 45% (n=4) between 36 and 45 years. Their education level consists of: Bachelor of Arts (22%, n=2); Bachelor of Science (44%, n=4); Master of Science (11%, n=1); Doctor of Physiotherapy (11%, n=1); and N/A (11%, n=1). The participants working 2.4 Statistical Analysis For the descriptive statistics we used Microsoft excel and for a correlational analysis SPSS 17.0 was used. Data will be stated in means and standard deviations (mean/±sd) throughout the article based on the mentioned grading system (see Table 2). 6

7 in the national league completed their education in a number of countries (Within Turkey (67%, n=6); Outside Turkey (33%, n=3), (Serbia (11%, n=1), Spain (11%, n=1) and Bulgaria (11%, n=1)). Fifty five percent (n=5) of the physiotherapists surveyed spend more than 20 hours per week with the team, while 22% (n=2) spend between hours and the remaining 22% (n=2) spend less than 5 hours with the team weekly (see Table 3). The assessment that was undertaken by the physiotherapist shows that the mechanism of injury (3.75 SD±0.46) and functional impairments (3.50 SD±0.53) are the main focus. All participants agree that pain is very important in the assessment (3.00 SD±0.00). Seasonal factors also an influence on the assessment (see Table 6). 3.2 Assessment The purpose of this section is to look at how the participants of the survey are examining the players. When asked if they perform a general assessment when first seeing the patient 88.8% (n=8) of the participants answered yes and 11.2 % answered no. In the history taking the mechanism of injury (3.75 SD±0.46) and functional impairments (3.50 SD±0.53) were reported the most important factors, whereas pain (3.0 SD±0.0) was reported slightly less important with participants strongly agreeing on that point (See Table 4). There were major variations in the SD of the most important factors indicating no standard factors, even though means were high. The only factor agreed upon as being of higher importance was the use of special tests (3.37 SD±0.51) (see Table 7). The outcome measurements related to the use of AS guidelines indicated that the participants rarely use guidelines. The major tools to assess ankle sprains reported by the participants include: MRI (3.62 SD±0.51) and Talar tilt test (2.87 SD±0.83). Other clinimetric tools were not commonly used (see Table 5). 3.3 Treatment Recovery Regardless of the grade of AS participants had their players playing games again not more than 6 weeks post injury. In grade one AS the majority of participants reported to let their patients resume competition between 0-2 weeks post-injury, in grade two 3-4 weeks post-injury, and in grade three 5-6 weeks post-injury. 7

8 Overview: Treatment choice and frequency (0-12 weeks) As can be seen in table 8 the overall frequency of treatment reduced gradually from phase to phase starting with treatment amount mean of 2.65 (SD±1.22) in the first three days down to 1.7 (SD±1.07). Interventions such as cold treatment and rest/elevation were most frequently used in phase 1 and phase 2, and decreased progressively in the following phases. Compression bandaging, bracing and taping were most frequently used in phase 1 and 2. With compression bandaging least used in the following phases compared to taping and bracing. Manual therapy was mostly used in phase 2 and 3. Exercise therapy was used most frequently in phase 3 and 4. 8

9 Other reported interventions When participants were asked for other interventions they chose the following treatments: Osteopathic manipulations throughout all phases (n=1), heparin packs (n=1) and balance/ proprioception exercises (n=1), in phase 1 and 2 gait education (n=1) and water exercises in phase 2 (n=1), Isokinetic exercises with a machine (CybexNorm) in phase 4 (n=1). Overview: Treatment goals (0-12 weeks) As can be seen in table 9 respondents agreed that the reduction of pain and swelling were considered most important in phase 1 and 2. Increase of strength was reported most important in phases 3,4, and 5. General basic fitness increased in importance respectively as time progressed in the phases. Increase of stability, proprioception and weight bearing capacity were considered important from phase 2 until phase 5, peaking in phase 3. Functional recovery was considered equally important throughout the phases. Phase 1: Inflammation phase (0-3 days): Treatment goals and choices Reduction of swelling and pain were described as the most important goals in the inflammation phase and general basic fitness as the least important but with varying opinions among participants. In the inflammation phase respondents agreed that cold treatments were used the most followed by rest and elevation, taping, compression bandaging and EPM. There was agreement among the participants that heat treatments were the least used intervention in this phase (see Table 10). Phase 2: Proliferation phase (4-10 days): Treatment goals and choices Functional recovery and the increase of ROM were considered most important goals in this phase. Directly followed by reduction of pain, swelling and the increase of proprioception. General basic fitness was stated as the least important. 9

10 Most frequently used treatments in the proliferation phase were active ROM exercises, taping, cold treatments, EPM and manual therapy. In this phase exercise therapy was agreed to be the most used intervention, followed by active ROM exercises, taping and manual therapy. The two least used interventions were heat treatments and massage but in both cases with considerable variance in opinion (see Table 11). Phase 3: Early remodeling phase (11-21 days): Treatment goals and choices The increase of proprioception was reported to 10

11 be the most important goal in the remodeling phase and highly agreed upon among participants, followed by the improvement of strength, increase of joint stability, weight bearing capacity and ROM. Least important goal was general basic fitness with varying opinion on its importance. Most frequently used interventions were exercise therapy, followed by manual therapy and active ROM exercises. Least used interventions were heat treatments and rest/elevation but with a high standard deviation (see Table 12). 11

12 Phase 4: Late remodeling phase (3-6 weeks): Treatment goals and choices: In terms of treatment goals improving muscle strength, the increase of proprioception, functional recovery, the increase of stability and weight bearing capacity were rated highest but also showed a wide spread of opinion. The reduction of swelling in this phase was considered the least important. In this phase exercise therapy was agreed to be the most used intervention, followed by active ROM exercises, taping and manual therapy. Heat treatments were reported least used in this phase (see Table 13). Phase 5: Transfer phase (6-12 weeks): Treatment goals and choices The highest rated goals in the transfer phase were the improvement of muscle strength, general basic fitness and the increase of joint stability. The least important for the participants in this phase was decreasing pain and swelling. In the last phase exercise therapy was graded most used and active ROM exercises were still used but with varying opinions about the frequency of use. Rest & elevation and compression bandaging were least used (see Table 14). 3.4 Prevention Participants were asked if they perform injury prevention programs, 88.9% (n=8) stated that they do and 11.1 % (n=1) did not. In this part we found that Physiotherapists are mainly focusing on proprioception and balance exercises (4.00 SD± 0,0) for both of them and additionally muscle strength training (3.50 SD ±0.53). The Physiotherapists also reported that 12 they use following written prevention techniques, such as: kinesiology based muscle balance techniques, additional insoles, and manipulation for dysfunction. 4. CONCLUSION Even though the physiotherapists stated that they never used any guidelines, the overall impression is that they follow the KNGF ankle sprain guidelines recommendations for treatment. Exceptions were the use of EPM and MLD and the early start of exercise therapy. 5. DISCUSSION The physiotherapists working within the Turkish Volleyball league roughly follow the KNGF guidelines. This shows that whether treatment is based on flowcharts or experience, there are standard tools and treatment options that benefit the healing process. (Even though the KNGF guidelines for ankle sprain are the choice of comparison it must be said that almost 50% of the evidence reported in the KNGF are based on the authors experience rather than scientific evidence.) MRI is frequently used by majority of physiotherapists, in which seems to make further manual testing unnecessary. With money not being a limiting factor in many of the teams, physiotherapists choose MRI as the best available diagnostic tool. According to Magee (2008), the use of MRI in combination with manual stress tests (MST) gives an accurate indication to the level of injury. In addition to this, the use of MST alone has been reported as not sufficient for accurate diagnosis of ligament injuries (Fuji et al, 2000). The RICE techniques are used around the world as a golden standard and are beneficial in early stages, leading to a patient based exercise program (van der Wees et al, 2006). Both the participants and the KNGF guidelines agree on this. The use of EPM in the early phases appears to be popular amongst the physiotherapists. Some open answers showed that Turkish physiotherapists are aware of the strong evidence that does not support the use of EPM in ankle sprain (van der Windt, 2002, van der Wees et al, 2006). However their personal

13 opinion and experience says that the combination of treatments seems to be the answer. For ankle injuries they reported to use TENS and ice for pain-relief and some others Ultrasound with the goal to reduce ecchymosis. Even though Turkish physiotherapists use EPM, they take a critical view of it and are aware of the current evidence that evaluates EPM. The use of manual lymph drainage techniques (MLDT) is not mentioned by the KNGF ankle sprain guidelines (2006) at all, most recent research has shown that MLDTs are useful in the early stages of treatment with the main goal of aiding resolution of post-traumatic oedema. Vairo et al (2009) and Korosec (2004) support this idea, but state that there still is not enough conclusive evidence to validate the biomechanical process in MLDT in humans, even though animal experiments have shown significant effects. We think further research in the area of MLD is needed to give more valid evidence on the effects of MLDT in physiotherapeutic practice. The application of dorsi-flexion mobilisation in is reported by the KNGF guidelines (van der Wees et al, 2006) and the systematic review by Brantingham et al (2009) to have a positive effect on ROM and proprioception during the acute/ sub-acute phases. Majority of physiotherapists sent their players back to play again before 6 weeks post injury. The systematic review from Hubbardt et al (2008) though reports that significant improvement of mechanical stability did not occur until at least 6 weeks to 3months after injury. This could indicate that players start playing again before fully healed and could inherit the risk of re-occuring injuries due to functional and/or structural instability (Oskam, 2008). In addition treatment decisions for professional sports athletes are based on different factors than for everyday patients. The main goal for players is to be able to play again as fast and with the best performance possible in contrast to everyday patients, where recovery and pain reduction are generally the primary goals. This is why preventative measures like taping, bracing and prevention programs in the form of balance and proprioception exercises gain even more importance in professional sports. The treatment of AS is a relevant clinical matter, both in sports physiotherapy and in normal practice as it is an extremely common injury. For every physiotherapist it is important to be in state to offer his patients the best available treatment. 5. Limiting factors The low response rate to the questionnaire was a limiting factor in this survey. It is possible that this occurred due to the fact that it was conducted during the final period of the playing season (final games). The questionnaire was not designed to cover all possible combinations of treatments or the specific treatment applications used by the participants. Therefore no information can be given to the use of combinations of treatments. The reliability of the questionnaire could not be tested due to limited time and budget. A separate reliability study in the future could make this questionnaire a valid AND reliable tool to investigate the treatment of ankle sprain around the world. This was the first time a questionnaire has been developed by the writers of this article. Errors have been noticed at the end this research. Such things as translational miscommunications were discovered and possibly leading to an effect on the results. The grouping of data that would lead to a more accurate outcome if it was based on a more specific baseline (separating zero from one and above, i.e. 0: 1-4 instead of 0-4). KEY OUTCOME/ MESSAGE 1. KNGF ankle sprain guidelines are consistant with the techniques used by the physiotherapists that work in the highest level of sport in Turkey. When treating ankle sprain, following the KNGF guidelines are a good base for treatment. 2. An insight into the effects of various combinations of treatment may prove very useful for the application of treatment in ankle sprain injuries. No view into this was implemented into this survey, but was stated multiple times by various participants. 13

14 REFERENCES Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Manipulative therapy for lower extremity conditions: expansion of literature review.j Manipulative Physiol Ther. 2009;32(1): Buckley WE, Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice Approach,The Journal of Manual & Manipulative Therapy, 2009;17;3 Eisenhart AW, Gaeta TJ, Yens DP, Osteopathic Manipulative Treatment in the Emergency Department for Patients With Acute Ankle Injuries, JAOA,2003; 103(9) Fuji T, Luo ZP, Kitaoka HB, An KN. The manual stress test maynot be sufficient to differentiate ankle ligament injuries. Clin Biomech (Bristol, Avon). 2000;15(8): Hubbardt TJ, Hicks-Little CA, Ankle Ligament Healing After an Acute Ankle Sprain: An Evidence-Based Approach, Journal of Athletic Training, 2008;43(5): Stasinopoulos D. Comparison of three preventative methods in order to reduce the incidence of ankle inversion sprains among female volleyball players, Br J Sports Med, 2004;38: Vairo GL, Miller SJ, McBrier NM, Buckley W, Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence- Based Practice Approach, Journal of Manual & Manipulative Therapy, 2009;17:3 Verhagen EALM, Van der Beek AJ, Bouter LM, Bahr RM, Van Mechelen W. A one season prospective cohort study of volleyball injuries, Br J Sports Med, 2004;38: van der Wees J, Lenssen AF, Feijts YAEJ et al, KNGF-Guideline for Physical Therapy in patients with acute ankle sprain, Dutch Journal of Physical Therapy, 2006; 116:5 van der Windt DAWM, van der Heijden GJMG, van den Berg SGM, ter Riet R, de Winter AF, Bouter LM. Ultrasound Therapy for acute ankle sprains Cochrane Database Syst. Rev. Korosec BJ. Manual lymphatic drainage therapy. Home Health Care Mang Pract 2004; 17: Löfvenberg R, Kärrholm J, Sundelin G, Ahlgren O, Prolonged Reaction Time in Patients with Chronic Lateral Instability of the Ankle, Am J Sports Med, 1995; 23(4): Magee DJ, Orthopedic physical assessment, 5th ed. Oxford,Elsevier, 2008; Oskam R, ASM:Applied sports medicine ESP, Module 2.3; 2009 Peterson L, Renström P. Sports Injuries: Their prevention and Treatment. 3rd ed. London: Dunitz;

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59 Hogeschool van Amsterdam Amsterdam School of Health Professions European School of Physiotherapy Tafelbergweg BD Amsterdam The Netherlands 59