Ankle Sprain Physical Therapy Doesn’t Shift the Pain Elsewhere

FORT LAUDERDALE, Fla. – A maneuver to relieve persistent ankle pain caused by sprains appeared to give relief to the area being treated without creating a secondary pain-related problem somewhere else in the body, a study showed.

Static pain sensitivity assessment using pain pressure testing showed significant reduction in scores for the ankle after compared with before thrust manipulation of the ankle (P=0.02 for those with chronic pain and P<0.0001 for controls), reported researchers led by Emily Slaven, PhD, of the Krannert School of Physical Therapy at the University of Indianapolis.

However, “no statistically significant findings were found at the unaffected distal site of the ipsilateral shoulder, suggesting the ankle manipulation has a localized effect on pain perception,” Slaven reported at the annual meeting of the American Academy of Pain Medicine.

The study examined the thrust manipulation, a quick stretch of the ankle and foot performed when the patient is lying supine with the goal of reducing pain to allow the patient, “for example, to complete exercises that might have previously been painful or perhaps walk with less pain,” she told MedPage Today.

“We were concerned about whether performing this maneuver in one area of the body might have an unwanted effect elsewhere,” Slaven said. “The challenge lies in understanding how this mechanism works. For many years, we thought it was a bio-mechanism impulse, but now we realize it is much more [about] tapping into the neurophysiology.”

“There has been debate over the years whether when we perform manual therapy if the impact is seen beyond the location of the application of the manual therapy,” she added. “What we found in our study is that the manual therapy only impacts the nervous system local to where the technique was performed.”

In her oral poster presentation, she noted that manual therapy such as thrust manipulation is commonly used for the patients with persistent pain or even limited range of motion after a sprain often seen at physical therapy clinics.

Ten participants in the study had persistent ankle pain for more than 3 months (average 12-14 months) “and were open to thrust manipulation,” Slaven said. “We measured range of motion of the ankle at baseline, and they underwent sensory testing using pain pressure testing in which pressure is applied until the patient reports discomfort. Following this, we then did dynamic pain sensitivity assessment, using conditioned pain modulation. Following the tests, the patients underwent the thrust manipulation, and then the tests were repeated.”

Another 10 age- and gender-matched controls without persistent pain went through the same testing and maneuver.

“There was a greater response to therapy in the control group at the ankle site, but in both groups there was no change at the shoulder, indicating that the thrust maneuver was very much a localized effect,” Slaven said. “We believe that people with persistent pain don’t respond as well as the controls because the ability to cope with pain may have been somewhat compromised.”

The ankle pain pressure t-scores, equivalent to the number of standard deviations from the mean, dropped by 3.146 in the chronic pain patients and 4.453 in the controls from baseline to post-thrust.

Slaven said the thrust maneuver is part of an overall physical therapy program that can include the ankle thrust maneuver along with stretching and other exercises.

For chronic pain patients, “post-surgery we always advocate that they should receive physical therapy, even months after their initial prescription runs out, because there are always very specialized techniques that can help patients,” said session moderator Kellie Marie Jaremko, MD, PhD, an anesthesiologist at Johns Hopkins University in Baltimore.

“We in the post-surgical world may not have that understanding of joints and maneuvers that are used in physical therapy, so I do advocate this for my patients, and I will do so in the future,” she told MedPage Today. “People with ankle sprains who have persistent pain should ask about these things from a physical therapist.”