SonograPHY: Diagnostic Ultrasonography in Physiotherapy
Study Details
Study Description
Brief Summary
Ankle injuries are among the most common traumatological injuries of the lower limb accounting for approximately 50% of all sports injuries and 25% of musculoskeletal injuries in general. Correct initial diagnosis and proper management is important to reduce the risk of recurrent ankle instability and other complications, such as reduced range of motion, increased ligament laxity, instability, tendon enthesopathy, possible swelling, formation of calcifications, reduced load on the affected limbs while standing and walking, increased pain intensity and pain duration. To date, few studies showed that the effectiveness of physical therapy increases when it is modified based on diagnostic ultrasonography findings. Sonography is not burdensome for the patient, has high reproducibility, and enables dynamic examination and comparison of the interrelationships of individual structures.
The aim of this study is to investigate if targeted physiotherapy for post-traumatic ankle conditions designed based of diagnostic ultrasonography findings is more effective than standard physiotherapy. The study hypothesis is that in the experimental group there will be a smaller number of complications of post-traumatic ankle conditions than in the control group. If confirmed the study could have clinical implications.
Condition or Disease | Intervention/Treatment | Phase |
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Detailed Description
A randomized controlled trial
In a randomized controlled trial, patients with post-traumatic soft tissue damage in the ankle area will be randomly divided into two groups. Both groups will undergo the same number of physiotherapy sessions (10 half-hour outpatient sessions over the course of two months) and will be examined with standard clinical tests and diagnostic ultrasonography at the beginning of the program and at week 8 using a standardized protocol published by the European Society of Musculoskeletal Radiology. Both groups will undergo the same physiotherapy techniques. Their choice will be modified in the experimental group based on the current findings of diagnostic sonography, while in the control group they will be applied according to the standard procedure recommended by the physician.
Randomization
Participants meeting the entry criteria will be examined by diagnostic ultrasonography, then randomly assigned to two groups using software (https://www.randomizer.org/) and sent for an entry examination by an independent investigator. Group 1 will undergo standard physiotherapy without continuous monitoring of the course and effect of treatment with diagnostic ultrasonography. The treatment of the second group will be modified based on the current findings of the diagnostic ultrasonography. The therapeutic protocol for each patient will be given to an independent physiotherapist (the therapist will not know the details of the study) in a sealed envelope.
Study participants
Study participants will be recruited based on referrals from specialists (mainly orthopaedists or surgeons) following the entry and exclusion criteria below. When a patient meeting the criteria is detected, the specialist will offer the patient the opportunity to participate in the study, and if agreed, the patient will be sent to our workplace for an initial examination.
Sample size
A sample size of 26 patients per group (N=52) was estimated to test the difference in pain (primary outcome, scale 0-10; at 80% test power (Cohen´s d=0.8) and at the 0.05 significance level) between the intervention and control groups. We estimate that 15% of participants will not complete the study, therefore 68 patients will be enrolled in the study (34 patients in each group).
Basic statistical analysis of outcome variables
Difference in numeric variables (pain, chronic ankle instability rate, the 10 Metre Walk Test, examination of ankle dorsiflexion muscle strength) between the intervention and control groups will be tested using the two-sample t-test or Mann-Whitney Test, if normality of the data was not fulfilled. Data normality will be assessed using the Shapiro-Wilk test and visually using box and whisker plots, histograms and normal probability plots. Difference in categorical variables (the range of motion of the ankle, the presence of swelling, number of complications) will be tested using chi-square test or Fisher's exact test, if at least one expected frequency will be smaller than 5. R software will be used for analysis.
Examination
Demographic, anthropometric and anamnestic data of all participants will be recorded at the beginning of the programme (age, sex, height, weight, exercise history, injury history, including frequency of past injuries, footwear). The clinical examination will be carried out at the beginning and at the end of the therapeutic program, i.e. after two months from the start of the program.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Standard physiotherapy group Patients will be treated with standard physiotherapy according to the recommendation of the referring physician without modification of the treatment based on the output of the diagnostic ultrasonography examination. |
Other: Diagnostic ultrasonography-guided physiotherapy group
All participants will complete free 10 outpatient 30-minute sessions. The therapy will be focused on increasing the range of motion and muscle strength, optimizing the function of the lower limbs, reducing possible complications of post-traumatic conditions in the ankle area.
The physiotherapy procedures of the intervention group will be modified based on the control diagnostic ultrasonography performed at the fifth therapeutic intervention.
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Diagnostic ultrasonography-guided physiotherapy group Patients will undergo the same treatment techniques, the application of which will be indicated based on the initial diagnostic ultrasonographic examination, and modified based on control diagnostic ultrasonography performed at the fifth therapeutic intervention. |
Other: Diagnostic ultrasonography-guided physiotherapy group
All participants will complete free 10 outpatient 30-minute sessions. The therapy will be focused on increasing the range of motion and muscle strength, optimizing the function of the lower limbs, reducing possible complications of post-traumatic conditions in the ankle area.
The physiotherapy procedures of the intervention group will be modified based on the control diagnostic ultrasonography performed at the fifth therapeutic intervention.
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Outcome Measures
Primary Outcome Measures
- Pain level [The change from baseline to 8 weeks]
Examination using the Wong-Baker scale. The scale is used to subjectively assess pain. Pain rating scale (0-10): 0 - no pain; 2 - hurts a little; 4 - hurts a little more; 6 - hurts even more; 8 - hurts a lot; 10 - hurts the most (0 is the best value, 10 is the worst).
- The range of motion of the ankle [The change from baseline to 8 weeks]
Goniometry will be performed with a stainless steel two-arm goniometer (ref. SH5103). Measurement of the ankle (talocrural joint) dorsiflexion range of motion: Participants will actively adduct the tip of the injured ankle while sitting on a physical therapy table. The expected range of motion with knee extension is approx. 10 degrees, with 20 degrees of knee flexion. For the evaluation, we will use a 3-point evaluation scale: 0-3 (0 - no limitation in dorsiflexion, 1 - small limitation in dorsiflexion, 2 - great limitation in dorsiflexion, 3 - no movement in dorsiflexion) (0 means the best value, 3 is the worst).
- The measurement of swelling [The change from baseline to 8 weeks]
Over the course of the therapy, we will measure the swelling with a standard retractable four-inch plastic tape measure and a marking pen according to a standardized protocol. (decreasing the size of edema over time marks positive change).
- Number of complications [The change from baseline to 8 weeks]
The following complications will be monitored using sonographic examination based on a standardized protocol issued by the European Society of Musculoskeletal Radiology using a 7L4BP 5-10 MHz linear probe. The following complications will be measured according to standardized methodologies and evaluated by comparison with the same measured parameters on the ankle of the uninjured leg: 1. greater thickness of the ligaments (anterior tibiofibular and anterior talofibular ligament); 2. the presence of exudate in the area of anterior talofibular ligament, 3. the presence of calcifications, 4. a reduction in the continuity of the ligament apparatus in the ankle or the continuity of the syndesmosis compared to the non-affected leg. A higher number means a higher number of complications.
Secondary Outcome Measures
- Chronic ankle instability rate [The change from baseline to 8 weeks]
The Cumberland Ankle Instability Tool (CAIT) is a simple, valid and reliable instrument for discriminating and measuring the severity of functional ankle instability. The CAIT comprises a 9-item 30-point scale questionnaire (the higher final score indicates less severe functional ankle instability). Subjects with a score of 28 or higher are unlikely to have functional ankle instability, whereas subjects with a score of 27 or lower are likely to have functional ankle instability.
- Analysis of standing and walking [The change from baseline to 8 weeks]
The 10 Metre Walk Test. We will measure the gait speed, using a stopwatch and markers, a phone with a camera (the lower value means better result).
- Examination of ankle dorsiflexion muscle strength [The change from baseline to 8 weeks]
The examination will be held using a microFET2 hand-held digital dynamometer (Hoggan Scientific, USA). The examination will be held according to a standardized protocol: Subjects will lie supine with the knee extended and ankle of the tested leg in a neutral position on the bed. Ankle dorsiflexion will be tested by placing a dynamometer over the dorsal surface of the midfoot, just proximal to the metatarsal phalangeal joints. We will measure the isometric muscle strength (in N) when the patient tries for maximum resistance against the dynamometer of the affected ankle for four seconds. A higher value of muscle strength after rehabilitation means an improvement of the condition.
Eligibility Criteria
Criteria
Inclusion Criteria:
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Age ≥ 15 years and ≤ 65 years
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Post-traumatic conditions in the ankle area, 4 - 6 weeks after the primary injury
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Ability to undergo continuous outpatient physiotherapy treatment
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Active cooperation of the patient
Exclusion Criteria:
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Age < 15 years and > 65 years
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Serious diseases affecting effective physiotherapy (e.g. tissue damage of metabolic, degenerative, neurological or oncological origin)
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Previous ankle surgery
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Gypsum fixation
Contacts and Locations
Locations
No locations specified.Sponsors and Collaborators
- Petr Routner
Investigators
- Principal Investigator: Petr Routner, MSc., Department of Rehabilitation Medicine, Third Faculty of Medicine, Charles University in Prague
- Study Director: Kamila Řasová, PT, PhD., Department of Rehabilitation Medicine, Third Faculty of Medicine, Charles University in Prague
Study Documents (Full-Text)
None provided.More Information
Additional Information:
- Goniometry: Ankle (Talocrural) Dorsiflexion - Physiopedia
- CORE MEASURE: 10 METER WALK TEST (10mWT)
- Gait Range of Motion Animation
- microFET2 User Guide
Publications
- Bandinelli S, Benvenuti E, Del Lungo I, Baccini M, Benvenuti F, Di Iorio A, Ferrucci L. Measuring muscular strength of the lower limbs by hand-held dynamometer: a standard protocol. Aging (Milano). 1999 Oct;11(5):287-93. doi: 10.1007/BF03339802.
- BEGGS, Ian, STEFANO BIANCHI, ANGEL BUENO, MICHEL COHEN, MICHEL COURT-PAYEN, ANDREW GRAINGER, FRANZ KAINBERGER, ANDREA KLAUSER, CARLO MARTINOLI, EUGENE MCNALLY, J PHILIPO, PHILIPPE PEETRONS, MONIQUE REIJNIERSE. European Society of MusculoSkeletal Radiology Musculoskeletal Ultrasound Technical Guidelines VI. Ankle [online]. 2016 [cit. 2023-03-08]. Available at: https://essr.org/content-essr/uploads/2016/10/ankle.pdf
- Bohannon RW. Reference values for extremity muscle strength obtained by hand-held dynamometry from adults aged 20 to 79 years. Arch Phys Med Rehabil. 1997 Jan;78(1):26-32. doi: 10.1016/s0003-9993(97)90005-8.
- De Maeseneer M, Marcelis S, Jager T, Shahabpour M, Van Roy P, Weaver J, Jacobson JA. Sonography of the normal ankle: a target approach using skeletal reference points. AJR Am J Roentgenol. 2009 Feb;192(2):487-95. doi: 10.2214/AJR.08.1316.
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- Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med. 2007 Jul;14(7):641-5. doi: 10.1197/j.aem.2007.03.1354. Epub 2007 May 18.
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- MCNALLY, E. Practical musculoskeletal ultrasound E-Book [online]. 2nd Edition. Churchill Livingstone, 2014. ISBN 978-1-4557-7404-3.
- Melanson SW, Shuman VL. Acute Ankle Sprain. 2023 May 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK459212/
- PAZ, JC, QUINLAN, D. Acute Pain Management. Acute Care Handbook for Physical Therapists-E-Book. 2013; 7: 457-465.
- Petersen EJ, Irish SM, Lyons CL, Miklaski SF, Bryan JM, Henderson NE, Masullo LN. Reliability of water volumetry and the figure of eight method on subjects with ankle joint swelling. J Orthop Sports Phys Ther. 1999 Oct;29(10):609-15. doi: 10.2519/jospt.1999.29.10.609.
- R CORE TEAM. R Core Team 2021 R: A language and environment for statistical computing. R foundation for statistical computing. https://www.R-project.org/. R Foundation for Statistical Computing [online]. 2022, 2, 2019 [cit. 2023-01-30]. Available at: https://www.scirp.org/(S(czeh2tfqw2orz553k1w0r45))/reference/referencespapers.aspx?referenceid=3131254
- SCHMITZ, Marc J.H. Musculoskeletal ultrasound of the extremity joints : technical scanning guidelines [online]. SonoSkills, 2022. ISBN 9083240304.
- Sconfienza LM, Adriaensen M, Albano D, Alcala-Galiano A, Allen G, Aparisi Gomez MP, Aringhieri G, Bazzocchi A, Beggs I, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gitto S, Grainger AJ, Greenwood S, Gupta H, Isaac A, Ivanoski S, Khanna M, Klauser A, Mansour R, Martin S, Mascarenhas V, Mauri G, McCarthy C, McKean D, McNally E, Melaki K, Messina C, Miron Mombiela R, Moutinho R, Olchowy C, Orlandi D, Prada Gonzalez R, Prakash M, Posadzy M, Rutkauskas S, Snoj Z, Tagliafico AS, Talaska A, Tomas X, Vasilevska Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Obradov M. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle. Eur Radiol. 2022 Feb;32(2):1384-1394. doi: 10.1007/s00330-021-08125-z. Epub 2021 Aug 25.
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