PROFESSIONAL ASSIGNMENT PROJECT (PAP2) › 2016 › 01 › ... · PROFESSIONAL ASSIGNMENT PROJECT...

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PROFESSIONAL ASSIGNMENT PROJECT (PAP2) EUROPEAN SCHOOL OF PHYSIOTHERAPY SEMESTER 6,7 AND 8 2015-2016

ANKLE SPRAIN PROTOCOL – WEBSITE Nicholas Bourrier - 500660539 Jessica Boer - 500659440 Sven Faber - 500667356 Coach: Bas Moed Version: 2 Admission date: 19-01-2016

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Acknowledgement We, Nicholas Bourrier, Jessica Boer, and Sven Faber, would like to extend our sincere gratitude to all those who lent us their time and assistance in the creation of this product. Firstly we would like to thank our client, Kusal Goonewardena; our coach, Bas Moed; our PAP supervisor, Bob van den Berg; and school, The European School of Physiotherapy at the Amsterdam University of Applied Sciences; for allowing us to research this project and create our product. Next we would like to thank our expert contacts: once again Kusal Goonewardena for his expertise regarding the field of physiotherapy, Robert Bourrier as medical specialist, Eleftherios Pappas for insight on Pilates exercises, Esther Verloop for academic research skills, and Andreas Heck and Jeroen Klaassen for guidance on web design; they helped us to ensure the quality of our project. Finally, we would like to thank all those who provided the support and feedback that assisted us in producing a tool that can help all those suffering from this widespread injury.

Preface This thesis was written to justify the content selection for the website: https://anklepro.wordpress.com

The professional assignment project (PAP) is part of the curriculum of the European School of Physiotherapy, Amsterdam University of Applied Sciences and takes place throughout the sixth, seventh and eighth semester. Students are expected to translate scientific results and recent knowledge to the professional context. Therefore, this project should not be seen as a classical thesis, but rather as a translation from theory to practice. The client has an active role in this process. Students are expected to improve their skills and knowledge according to the KNGF competence profile (2014). The main, but not only, competence targeted by this project is “knowledge sharing and scientific research.”

The students have created an up-to-date and scientifically based protocol for the treatment of acute ankle sprains. The client's wish was to create an easy to follow online exercise protocol for patients to follow independently; as an adjunct to the care they receive in clinic.

The client is Kusal Goonewardena, an Australian trained physiotherapist with a master’s degree in sports physiotherapy. He is owner of the Elite Akademy Sports Medicine, located on the University of the Melbourne campus.

The website consists of educational information on the pathology, as well as filmed instructions for the prescribed exercise techniques.

Contact details

Nicholas Bourrier

[email protected]

Jessica Boer

[email protected]

Sven Faber

[email protected]

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Table of content ACKNOWLEDGEMENT...................................................................................................................................2

PREFACE............................................................................................................................................................2

ABSTRACT.........................................................................................................................................................6PART1–REVIEWOFEVIDENCE................................................................................................................7

INTRODUCTION...............................................................................................................................................7METHODS..........................................................................................................................................................9DEFINITIONS........................................................................................................................................................................9Function...............................................................................................................................................................................9Modifiableintrinsicriskfactors................................................................................................................................9Exercises..............................................................................................................................................................................9

SEARCHSTRATEGY..............................................................................................................................................................9INCLUSION/EXCLUSIONCRITERIA....................................................................................................................................9GRADING............................................................................................................................................................................10

RESULTS..........................................................................................................................................................11FUNCTION..........................................................................................................................................................................13Objectivemeasures......................................................................................................................................................13Subjectivemeasures....................................................................................................................................................13

MODIFIABLEINTRINSICRISKFACTORS........................................................................................................................14RangeofMotion............................................................................................................................................................14MuscleStrength.............................................................................................................................................................14Balance..............................................................................................................................................................................14

RECURRENCE.....................................................................................................................................................................15

DISCUSSION...................................................................................................................................................21PRIMARYRESEARCHQUESTION....................................................................................................................................21ExercisesIncluded........................................................................................................................................................21Duration...........................................................................................................................................................................23

SECONDARYRESEARCHQUESTION...............................................................................................................................23AcceleratedHomeExercisevs.RICE.....................................................................................................................23HomeExercisevs.SupervisedExercise...............................................................................................................24HomeExercisevsManualTherapyandHomeExercise..............................................................................24Attentionbias.................................................................................................................................................................25

LIMITATIONS.....................................................................................................................................................................25

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CONCLUSION..................................................................................................................................................26

PART2:PRODUCTCREATION.................................................................................................................27INTRODUCTION............................................................................................................................................27

REHABILITATIONOVERVIEW.................................................................................................................28

PRODUCTVALIDATION.............................................................................................................................29BUILDINGBLOCKSTRUCTURE........................................................................................................................................29

PROTOCOL.....................................................................................................................................................30INTENSITYVALIDATION..................................................................................................................................................34SESSIONBUILDUP............................................................................................................................................................35CHECKPOINTVALIDATION..............................................................................................................................................35Kneetowalltest............................................................................................................................................................35Singlelegstancetest...................................................................................................................................................35Singlelegsquat..............................................................................................................................................................36

EXERCISE/INTERVENTIONVALIDATION......................................................................................................................37RICE(rest,ice,compression,elevation)..............................................................................................................37Activerangeofmotionexercises...........................................................................................................................37Tripleflexionandextension.....................................................................................................................................37Circularweightshifting/walking........................................................................................................................37Calfstretch(sitting/standing)................................................................................................................................37Towelscrunch/pickingupobjectswithtoes..................................................................................................37EversionSelf-mobilization........................................................................................................................................38Pilatesexercises.............................................................................................................................................................38Elasticbandexercises.................................................................................................................................................38In-linewalking...............................................................................................................................................................38Singlelegstance............................................................................................................................................................38STARexcursion..............................................................................................................................................................39Bilateralbalancetraining........................................................................................................................................39Squats................................................................................................................................................................................39Toeraises.........................................................................................................................................................................40Lunges...............................................................................................................................................................................40Heelandtoewalking..................................................................................................................................................40Plyometrics......................................................................................................................................................................40

OVERVIEWOFTHEWEBSITECONTENT..............................................................................................41

DESIGN............................................................................................................................................................43

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AESTHETICSANDWEBSITECREATION........................................................................................................................43DESIGNBRIEF...................................................................................................................................................................43LOGO...................................................................................................................................................................................43Inspiration.......................................................................................................................................................................43ColourScheme...............................................................................................................................................................44Rendering.........................................................................................................................................................................44Typeface............................................................................................................................................................................44

WEB-HOSTING..................................................................................................................................................................45BUILDINGBLOCKS............................................................................................................................................................45LANGUAGE.........................................................................................................................................................................46FILMING..............................................................................................................................................................................46

FEEDBACK......................................................................................................................................................47RESULTS.............................................................................................................................................................................47

LIMITATIONSOFTHEANKLEPROWEBSITE......................................................................................49PROTOCOL.........................................................................................................................................................................49CONTENTPRODUCTION..................................................................................................................................................49

CONCLUSION..................................................................................................................................................51REFERENCES..................................................................................................................................................52

APPENDIX1:PEDROSCALE......................................................................................................................56

APPENDIX2:FEEDBACKWEBSITE........................................................................................................57

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Abstract Introduction: As ankle sprains are one of the most common injuries physiotherapists encounter, effective treatment is important to return patients to normal function, and prevent re-injury. It was decided to create a web-based exercise program that patients can use to supplement the care their receive in clinic. To guide the creation of this website, a systematic review was conducted to find out: “What is the most effective rehabilitative exercise program that can be performed at home, that will return grade one and two ankle sprain patients to normal function, and target modifiable intrinsic risk factors?” A sub-question while analyzing the findings of the primary research question was: “Are rehabilitative exercises for ankle sprains effective when performed in a home setting?” Methods: A systematic search of Pubmed and the Cochrane Library was executed to find RCTs exploring the effectiveness of exercise programs on grade 1 or 2 ankle sprains. Exercises could be executed in a supervised or unsupervised setting, provided they used equipment that is easily accessible to the patient. Articles were graded using the PEDro scale. General exercise modality recommendations, as well as specific exercises used in the studies, were extracted and then adapted, based on exercise theory and practitioner input. These were filmed and uploaded to a dedicated website.’ Results: Eight articles were deemed of sufficient quality to be included in the review. From the articles, multiple exercises were identified and adapted to create a 9-week plan that starts within the first week post-injury; includes stretches to increase range of motion; and incorporates prolonged periods of dynamic balance and plyometric components to target neuromuscular improvement. Conclusion: It was found that patients are not disadvantaged when exercise prescriptions are implemented at home instead of when these are performed under supervision of their therapist in clinic. This allows therapists to maximize the amount of time patients receive therapeutic modalities requiring their skills or special equipment. An online home-based exercise plan was created, which is aimed at promoting an early return to normal function, and decrease risk factors of re-injury. Keywords: Ankle sprain, home-exercise, risk factors, functional activity, website, protocol Link to Website: https://anklepro.wordpress.com/

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Part 1 – Review of Evidence Introduction The currently existing guidelines for acute ankle sprains (Van der Wees et al. 2006; Martin et al. 2013) provide general recommendations on relevant intervention modalities. Though they lack a concise protocol that lays out an easy-to-use and step-by-step treatment plan, that can be followed by beginner/novice physiotherapists as well as patients themselves. Exercises are given, but they typically do not include prescriptive parameters and/or progressions. In addition to this, these guidelines do not have adequate media to instruct said interventions. That being said, the currently existing guidelines are a good starting point for the creation of a protocol. An acute lateral ankle sprain can be defined as a traumatic injury of the lateral capsular ligamentous complex, resulting from an excessive supination and adduction (inversion) in combination with a plantar flexed foot. The most common structures involved are the anterior talofibular ligament (ATFL), calcaneofibular ligament and posterior talofibular ligament (Golano et al, 2010). Up to 73% of the ankle sprains involve isolated ATFL injuries. The injury arises most commonly from landing after a jump, stepping into a hole or by landing on a competitor’s foot during sports (Martin et al. 2013). The sprains are split into three grades, depending on the severity of the damage, whereby a grade III sprain indicates a complete tear of a ligament (Petersen et al. 2013). Grade III sprain may require additional treatment, therefore the focus of this PAP will only be on ankle sprain I and II. Risk factors include impaired balance, decreased muscle strength, limitations in dorsiflexion, and previous sprains (van der Wees 2006, Martin et al 2013). According to a review of the American emergency department records between 2002 and 2006 the incidence rate of ankle sprains is estimated to be 2.15 in every 1000 people/year in the general population (Waterman et al. 2010). The National Health Survey that is conducted in Australia in 2001, estimated that approximately 367.000 people reported a recent injury from participating in an organised sport. A total of 32% suffered from an ankle injury (Edwards. 2001), which is the leading number. Thus, ankle sprains are also common throughout the athletic community, with high rates of occurrence in a variety of sports such as: basketball, dance (van den Bekerom et al. 2014) and one of the four most popular sports in Australia, Australian Rules Football (ARF) (Hrysomallis 2013). The annual costs associated with ankle sprains in The Netherlands is around €84m(£73m; $113m) (Verhagen et al. 2005). Proper rehabilitation and prevention of this pathology could help to ease this. This suggest that not only this is a widespread problem that physiotherapist may encounter, but that the current treatment should be improved and that there should come more information about prevention and recurrence. Currently, Mailuhu et al. (2015) are conducting a multi-center, open-label randomized controlled trial. They examine the (cost)-effectiveness of an unsupervised e-health supported neuromuscular training program in combination with usual care in general practice compared to usual care alone in patients with acute ankle sprains in general practice (Mailuhu et al. 2015), this study is carried out in the Netherlands. With the existing guidelines and protocols we still do not have a clear picture of which specific treatment techniques and exercises are the most appropriate for ankle sprains in the different healing phases. Most guidelines are too general and are not as helpful as we wish them to be when it comes to implementation. The protocol created for this PAP includes a step-by-step evidence based intervention program. The protocol can be beneficial for beginner/novice physiotherapists, physiotherapy students, as they may not have yet the experience to comfortably decide on treatment, exercises and their progressions. In addition to that, it is beneficial for the patients, as they will be able to carry out their exercises at home with visual instructions on how to perform them correctly.

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As the KNGF guideline suggests merely one treatment session with the physiotherapist per week (Van der Wees et al. 2006), the most important aspect of the protocol will be the home-exercises for the patients. As patients cannot constantly be in a clinic or gym, home programs are an integral part of the physiotherapeutic rehabilitation approach. An example of such a home exercise regime was explored in a study by Hupperets et al. (2009), which shows the risk of self reported recurrences of ankle sprains was significantly lower in the intervention group that followed an unsupervised proprioceptive intervention training program in addition to usual care for eight weeks, compared to the control group that only received usual care. When prescribing such an exercise regime, therapists need to provide a take home set of instructions that are easily followed for the period between sessions. Hard copies of these routines may be misplaced; and the written, drawn or photographic instructions could be misunderstood. In the study that is currently conducted by Mailuhu et al. (2015), the intervention group receives, in addition to usual care, a standardized eight-week neuromuscular training program guided by an App. For this PAP it is chosen to make use of a website. Although, many people have smartphones nowadays, the protocol should be accessible by anyone. The Internet offers the opportunity to share content that is stored centrally, and can be accessed from multiple locations. This also opens the door for more visually dynamic instructional tools. Video-based instructions were shown to improve quality of patient exercise execution compared to pamphlets with pictures and written descriptions (Weeks et al. 2002; Reo et al. 2004). This can help ensure patients are effectively targeting the desired structures when performing unsupervised exercises. However, video-based exercise programs have been shown to be no more effective for exercise prescription compliance than a regular program (Lysack et al. 2005). Therefore the primary aim of using this medium would not be to improve compliance, but rather to improve the quality of the education and execution of unsupervised interventions by patients. A total of 80% of the client's patient population is athletic or participates in sporting activities in some way. Of that, about 30% are on an elite level, competing in clubs or in the international scene, some even in the Olympics. However, he is an avid promoter of an active lifestyles for all. His vision is to inspire everyone regardless of his or her background, to strive for physical excellence. Thereby, increasing their capacity to function within their lives to their highest potential, whether this is needed at work, when going for a morning run, or winning a gold medal. With this in mind, although he wanted the product to be able to assist the recovery of his athletes, it should also be able to cater to his less active patients. Therefore only the pathology would be targeted, not a specific demographic. Thus, in order to create an evidence-based home exercise protocol for ankle sprains, a primary research question was devised for the systematic review: “What is the most effective rehabilitative exercise program that can be performed at home, that will return grade one and two ankle sprain patients to normal function, and target modifiable intrinsic risk factors?” The outcomes of the collected articles were meant to guide the amalgamation of exercises that had been proven effective across the studies. In order to confirm the practical usefulness of the resulting product, a sub-question while analyzing the findings of the primary research question was: “Are rehabilitative exercises for ankle sprains effective when performed in a home setting?”

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Methods

Definitions

Function The definition of the term “function” that was used while designing the research question and search strategy was: “to perform the duties of a particular person” (Cambridge 2016b). General measures of functional activity would be used for this category, as these are important factors that allow a person to perform the duties required of them in their daily life. Additionally, given the client’s area of expertise; the duties in question for many of his patients are those of an athlete (professional or recreational). Walking, running, and jumping were thought of as additional keywords to add client relevance to this outcome.

Modifiable intrinsic risk factors The modifiable intrinsic risk factors to be targeted were: balance; muscle strength; and range of motion, particularly dorsiflexion (Fong et al. 2009).

Exercises These were defined as a “physical action performed to make or keep your body healthy” (Cambridge 2016a). Therefore interventions explored in the articles collected had to be actively performed by their body. As one of the risk factors selected was a decreased range of motion (Fong et al. 2009), self-mobilizations were included in this category. Although not strictly an exercise, this form of intervention involves physical actions performed by the patient themselves. Only self-mobilizations that did not require the assistance of a practitioner during execution could be considered.

Search strategy A systematic search of available literature was conducted by all three researchers between 01/09/2015 - 31/10/2015. Keywords were established to reflect the targeted population, outcome measures, and intervention modalities. Spelling differences, and potentially relevant terms, were taken into account; and asterix (*) and quotation marks (“ “) were used to include alternate suffixes, or specify exact wording respectively. An overview of the keywords and MeSH terms used can be seen in table 1. Keyword blocks were first created by combining words within a given column with the Boolean operator “OR”. These blocks were then combined with “AND” to create a full search string. The search was executed on the Pubmed, and Cochrane Library databases, with a year filter of 1995 - 2015.

Inclusion/Exclusion criteria Results of the search were first screened for inclusion by their title and abstract. Only RCTs written in English were collected for inclusion in the review, however systematic reviews were also examined to ensure potentially relevant RCTs were not missed. Full versions of the articles found had to be accessible. The Amsterdam University of Applied Sciences, Universiteit van Amsterdam, University of Ottawa, and Queen’s University library databases were used to double check accessibility. Articles were only included if they focused on participants who were suffering from current episodes of grade 1 and 2 “(inversion/lateral) ankle sprains”. Due to potential lack of specificity within titles and abstracts, this exclusion criteria was performed by the researchers, and not specified within the keywords. In addition

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to this, studies had to include exercises, stretches, or self-mobilization techniques. In order to increase the yield of articles, the setting in which the interventions were performed was not used as an exclusion criteria. Rather, the use of materials that are readily available outside of a clinical setting or easily provided by a physiotherapist (ex: elastic bands) was selected to aid transferability to a home-based setting.

Grading Screened articles were then assessed for quality using the Pedro scale (see appendix 1) (PEDro, 1999). Each article was graded by at least 2 of the authors individually, and then discussed within the whole group to ensure a consensus on all grades assigned. Due to the nature of the interventions examined, the research team considered it unlikely that Items 5 and 6 concerning blinding of the patients and therapists would be possible. As a result, the maximum possible score would be 9/11. Although the absence of affirmative outcomes for criteria does lower the quality of the experiments, an inclusion cut-off score of 5/11 was selected to mitigate the issue. A breakdown of the Pedro score per article included in the review can be seen in table 1. Table 1. Keywords used in the systematic literature search. Terms within a column combined with “OR”, and with “AND” between columns. Population Outcome Intervention

Ankle sprain* “Ankle sprain”

“Range of motion” “Range-of-motion” "Range of Motion, Articular"[Mesh] ROM Mobility Dorsiflexion Balance Proprioception "Proprioception"[Mesh] “Co ordination” “Co-ordination” Coordination Stability Stabilization Strength "Muscle Strength"[Mesh:NoExp]) Function Functional “Return to sport” “Return-to-sport” Walking Running Jumping Gait "Gait"[Mesh] "Mobility Limitation"[Mesh]

Stretch Stretches Stretching Exercise Exercises Exercising "Exercise"[Mesh] Training “Self-mobilisation” Mobilisation “Self-mobilization” Mobilization Plyometric Plyometrics “Home exercise” “home-exercise” “Self care“ Self-care "Home based" “Home-based”

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Results The outcome of the search can be found in figure 1. The initial search resulted in 485 articles. These articles were firstly screened by title and secondly by abstract. A total of 21 were seen as potentially useful based on exclusion criteria and removal of duplicates. Finally, 12 articles were read in their entirety and graded and all articles with at least a 5 on the Pedro scale were included in the research. The methodologic quality of the included articles can be found in table 2. An overview of the effectiveness of home exercise per study, can be found in article 3. A full overview of the interventions used in the eight included studies can be found in table 4. Table 2: Methodologic quality scores

Item # Basset et al. 2007

Bleakley et al. 2010

Chaiwanichsiri et al. 2005

Cleland et al. 2013

Ismail et al. 2010

Tully et al. 2012

Youdas et al. 2009

van Rijn et al. 2007

1. + + + + + + + +

2. + + + + + + + +

3. + + - + + - - -

4. + + + + + + + +

5. - - - - - - - -

6. - - - - - - - -

7. - + - + + - + +

8. + + - + - + - -

9. + + + + - - - -

10. - - - + + + + +

11. + + + + + + + +

TOTAL 7 8 5 9 7 6 6 6

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Figure 1: search outcome

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Table 3: effectiveness of home setting

Article Setting Effectofsetting

Bassettetal.2007 Homevssupervisedexercise Home=Supervised

Bleakleyetal.2010 Earlyhomeexercisevsothermodality(RICE) Earlyhomeexercise>RICE+Latehomeexercise

Chaiwanichsirietal.2005

Allexercisesperformedinclinic n/a(notathome)

Clelandetal.2013 Homeexercisevs.Homeexercise+othermodality(manualtherapy)

Homeexercise<home+manualtherapy

Ismailetal.2010 Allexercisesperformedinclinic n/a(notathome)

Tullyetal.2012* Earlyhomeexercisevsothermodality(RICE) Earlyhomeexercise>RICE

vanRijnetal.2007 Homevssupervisedexercise

Home=Supervised

Youdasetal.2009 Allexercisesperformedathome n/a(allimproved)

*Measured a cohort of participants from the study by Bleakleyetal.(2010) during the first week of the experiment

Function

Objective measures The study of Ismail et al. (2010) compared a resistive training group (RTG) to a plyometric training group (PTG). Although there was a significant improvement in both the groups at the 6 week follow-up in all measurements (p=<.001), the PTG’s improvements were significantly greater than those of the RTG group (p=<.05). In the study by Bleakley et al. (2010), The participants in the accelerated group walked significantly more (p=.029), made significantly more steps (p=.021) and spent more time in light activities (p=.047). Tully et al. (2012) investigated the physical activity in the first week post ankle sprain of the participants of Bleakley’s study (2010), with the addition of measurements from a healthy control group. A significant decrease was found in the number of steps taken daily (p=.002) in the first week after injury. Moreover, a significant difference was found in the average cadence in advantage of the exercise group (p=.002). The participants that did additional therapeutic exercises accumulated higher walking loads.

Subjective measures Three articles looked at the activity of daily living (ADL) as an outcome measure (Cleland et al, 2013; Bassett et al, 2007; Ismail et al. 2010). In the study by Cleland et al. (2013) the manual therapy and exercise group (MTEX) was superior to the home exercise group (HEP) alone (P=.001). Also the between group differences showed that the MTEX group had statistically significantly greater improvements in the Foot and Ankle Ability Measure (FAAM) ADL subscale at 4 weeks, 11.7(7.4 to 16.1); 95% confidence interval (CI). Moreover, HEP demonstrated minimal clinically important differences (MCID) at 4 weeks in FAAM ADL, as well as between 4 weeks and 6 months. Bassett et al. (2007) compared exercise therapy in clinic (CIG) to a home-based setting (HIG). In this study both groups improved significantly (CIG: p=.0001; HIG: p=.002). The Lower Limb Task Questionnaire ADL (LLTQ-ADL) was used to assess the ADL activities of both groups. There was no significant difference found in ADL between both groups (p=>.05)

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Both Cleland et al. (2013) and Bleakley et al. (2010) used the Lower Extremity Function Scale (LEFS). The MTEX group in Cleland et al. (2013) was significantly in favour when it comes to the LEFS score at both 4 weeks and 6 months follow-up (p<.05). In the study by Bleakley et al. (2010), the accelerated training group was in favour at all measurement dates (baseline, week 1, week 2, week 3 and week 4) (p= .0077) CI: 95%. Three studies also have outcomes on subjective physical activity (Cleland et al, 2013; Bleakley et al, 2010; Bassett et al, 2007). Cleland et al. (2013) comparing MTEX to HEP, showed that MTEX is statistically superior to HEP for the FAAM sports (P=<.001). Although MCID between groups was present at the 4 weeks measurement in all functional outcomes, there was no MCID present between groups for any measurement at the 6 month follow-up. Within the HEP group, there were MCID between the baseline and 4 week follow-up, as well as between 4 weeks and 6 months in all functional measures. In the study of Bleakley et al. 2010, there was no difference at Karlsson’s scores or recurrence between both groups, at the 16-week follow-up. The intervention groups in the study of Basset et al. (2007) improved significantly when it comes to recreational activity (p=.0001) and the motor activity scale (p=.0001). However there was no significant difference between both groups (p=>.05).

Modifiable Intrinsic Risk factors

Range of Motion Youdas et al. (2009) and van Rijn et al. (2007) measured ankle range of motion (ROM). Youdas et al. (2009) had three intervention groups, receiving the same home-stretching regime. The difference was in the length of time the static stretches were held (30sec – 1min – 2min). From baseline to the 6 weeks follow-up, there was a significant improvement of active ankle dorsiflexion range of motion (AADFROM) in all three groups (p=<.05). There was no significant difference found in between the group comparisons (p=.6). Van Rijn et al. (2007) compared conventional therapy (which included home exercises) to conventional therapy plus supervised exercises. The ROM was measured at the 3 month follow-up. There was no significant difference found between groups. Effect size between groups: -0.25 (-0.69 to 0.18) CI: 95%.

Muscle Strength Only one study is categorized in this group. Ismail et al. (2010), conducted a research comparing resistive training to plyometrics. Although both groups improved significantly at the 6 week follow-up in all measures (P=<.001), there was no significant difference between the groups for the isokinetic strength measurements. After 6 weeks of training, both groups improved significantly in the peak torque of the e- and invertors compared to body weight (p=<.05).

Balance Two studies included an outcome based on balance (Chaiwanichsiri et al. 2005; Ismail et al. 2010). Both studies tested balance with the single leg stance test. Chaiwanichsiri et al. (2005) compared conventional physiotherapy (CG) to conventional physiotherapy plus a 4-week STAR excursion balance program(IG). Both improved significantly from baseline to the 4-week follow-up, CG: 53.91% (p=.014), IG: 172.42% (p=.000). The PTG (65.9±6.4) in Ismail et al. (2010) was significantly better than the RTG (56.7±3.9) in the single leg stance test (p=.00) after the 6-weeks training program.

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Recurrence Four of the articles compared the rate of recurrence between the groups at follow-ups (Van Rijn et al. 2007; Cleland et al. 2013; Chaiwanichsiri et al. 2005; Bleakley et al. 2010). Though not a part of the research question, reported recurrence rates were seen deemed relevant to goal of targeting risk factors. Van Rijn et al. (2007) reported a recurrence rate of 27% (14/53) in the CT and 23% (10/49) in the CTSE at 3 months follow-up with an odd ratio (OR) of 0.80 with 95% CI (0.31 to 2.03) and an attributable risk (AR) of –4.2 with 95% CI (–21.5 to 13.1%). At 12 month follow-up the re-sprains were 31% (16/53) in the CT and 29% (13/49) in the CTSE with an OR of 0.91 with 95% CI (0.38 to 2.19) and an AR of 2.5 with 95% CI (–16.8 to 22.0%). Cleland et al. (2013) found no significant difference in the reoccurrence of sprains in both groups: MTEX 9,1% (3/33) and HEP 15,6% (5/32) (P= .56) at 6 months. Chaiwanichsiri et al. (2005) recorded no significant difference between groups over the 3 months, with 1 resprain in the intervention group and 2 in the control group. Bleakley et al. (2010) reported 2 resprains in each group over 16 weeks.

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Table 4: overview of the included RCT’s

Article

Participants

Duration

Experimental group

Control group

Measurement tool

Quantitative

Qualitative Condition

Characteristics

Description

Description

Basset et al. 2007

First time or recurrent ankle sprain

N=47 (male=28, female=19); Age: 30.02±12.43. 4 weeks

Home exercise program + educational and cognitive behavioural adjuncts (N=22)

Supervised PT + home program of 4 simple activities (N=25)

LLTQ - recreational activity

Baseline: CIG: 27.92±11.36; HIG: 20.27 ±12.58; 4 weeks: CIG 12.00±10.10 HIG: 8.18±7.24; Between group: p=>.05

Home-based therapy is a viable option for patients who have sustained an ankle sprain

LLTQ - ADL

Baseline: CIG: 13.72±11.29; HIG: 7.18±7.06; 4 weeks: CIG 2.32±3.60 HIG: 1.82±3.58; Between group: p=>.05

Motor activity scale

Baseline: CIG: 1.20±2.00; HIG: 1.77±1.60; 4 weeks: CIG 5.14±1.28 HIG: 5.73±1.08; Between group: p=>.05

Bleakleyetal.2010*

Acute(<7days)anklespraingrade1or2

N=101(male=69,female=32); 4weeks

Acceleratedinterventionwithearlytherapeuticexercises(N=51)

PRICEintervention(N=50) LEFS

Baseline-week1:SG=+16.3(±14.7),EG=+21.7(±14.4);Week2:SG=+9.7(±13.3),EG=+10.7(±8.8);Week3:SG=+7.3(±10.4),EG=+2.9(±8.6);week4:SD=+2.8(±8.0),EG=+2.8(±7.0)

An accelerated exercise protocol in the first week after ankle sprain leads to improved ankle function and a higher rate of activity Karlssonscore

Baseline:SG=50.31(±19.6),EG=45.48(±21.8),week4:SG=95.2(±4.4),EG=90.4(±5.1),week16:SG=98.4(±2.81),EG=97.3(±4.89)

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Physicalactivity(activPAL;PALtechnologies,Glasgow)

Exercisegroupsignificantlymoreactive.Walking(P=0.029);averagenumberofstepstakendaily(P=0.021)andtimespentinlightintensityactivity(P=0.047)

Recurrence16week:standard=2,exercise=2

Chaiwanichsirietal.2005 Grade2anklesprain

N=32(maleathlethes);agedbetween15and22 4weeks

Conventionaltherapy+STARexcursionbalancetraining10min3xpw(N=15)

ConventionalPT(N=17)

SLST

BaselineSLSTeyesopen:TG=74.82(±73.49),CG=58.68(±38.99)(P=.455).Eyesclosed:TG=14.54(±18.43),CG=11.76(±6.25)(P=.547).Month1eyesopen:TG=162.98(±108.50),CG=72.39(±31.47)(P=.007).Eyesclosed:TG=39.91(±22.51),CG=18.10(±8.99)(P=.002)

STAR excursion balance training is more effective than conventional PT alone for the improvement of ankle function after an actute ankle sprain

Recurrence

Month3:3/32(9%),1ofthetraininggroupand2ofthecontrolgroup

Clelandetal.2013 Actuteanklespraingrade1or2.

N=74(male=28,female=38);age35.1±11.0 4weeks

MTEX2xpw(N=37) HEP(N=37) FAAMADL

Baseline-4weeks:HEP=9.6(6.5,12.6);MTEX=21.3(18.2,24.5);BetweenGroup=11.7(7.4,16.1).Baseline-6months:HEP=24.6(20.5,28.7);MTEX=30.8(27.4,34.2);BetweenGroup=6.2(0.98,11.5).

The MTEX treatment is superior to the HEP treatment for patients with acute ankle sprain

FAAMSPORTBaseline-4weeks:HEP=13.8(10.9,16.8);MTEX

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=27.1(22.7,31.6);BetweenGroup=13.3(8.0,18.6).Baseline-6months:HEP=33.5(30.7,36.3);MTEX=40.7(37.0,44.4);BetweenGroup=7.2(2.6,11.8).

LEFS

Baseline-4weeks:HEP=5.6(3.1,8.1);MTEX=18.4(15.5,21.2);BetweenGroup=12.8(9.1,16.5).Baseline-6months:HEP=17.3(14.5,20.0);MTEX=25.3(22.3,28.3);BetweenGroup=8.1(4.1,12.1).

Recurrence

MTEX(3/33,9.1%)andHEP(5/32,15.6%)(P=.56)

Ismailetal.2010

Grade1or2anklesprain,atleast3weeksafteracuteinjury

N=22(male=11,female=11) 6weeks

Plyometrictraining2xpw(N=10)

Resistivetraining2xpw(N=12)

Climbingdownstairs

Baseline:PTG=22.5±5.7;RTG=22.5±3.7.Betweengroups:p=.96;6weeks:PTG=13.7±2.6;RTG=16.6±2.3.Betweengroups:p=.01 Plyometrics exercises

are more effective than resistitve exercises in improving the functional performance of athletes after lateral ankle sprain

Heelraise

Baseline:PTG=25.3±5.5;RTG=24.8±6.6.Betweengroups:p=.86;6weeks:PTG=47.7±3.5;RTG=38.58±4.4.Betweengroups:p=.00

Toeraise

Baseline:PTG=28±5.4;RTG=30±6.3.Betweengroups:p=.44;6weeks:PTG=46.1±4.4;RTG=41.5±6.6.Betweengroups:p=.01

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SLST


Isokineticstrengtheversion30degrees


Isokineticstrengtheversion120degrees


Isokineticstrengthinversion30degrees


Isokineticstrengthinversion120degrees


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Youdasetal.2009 Acuteanklespraingrade1or2

N=22(male=14,female=13) 6weeks

HEP+30secstretching3xpd

HEP+1minand2minstretching3xpd

AROM

Baseline:group1:-4±9;group2:-7±9;group3:-7±8;2weeks:group1:7±7;group2:8±7;group3:5±3;4weeks:group1:11±5;group2:12±8;group3:9±3;6weeks:group1:12±6;group2:12±8;group3:10±4;Betweengroups:p=.6;Baselinetoweek2P=<.001;Baselinetoweek4P=<.001;Baselinetoweek6P=<.001;week2toweek4P=<.001;Week2toweek6P=<.001;Week4toweek6P=<.569

Significantimprovementwasfoundfrombaselinetoweek2andfromweek2toweek4inall3groups.Normaldorsiflexionwasrestored4weeksaftertheanklesprain.

Abbreviations: PT= physiotherapy; LLTQ=Lower limb task questionnaire; CIG=clinical intervention group; HIG=home intervention group; LEFS=Lower extremity functional scale; SLST=Single leg stance test; TG=training group; CG=control group; MTEX= Manual therapy exercise program; HEP=home exercise program; SG=standard group; EG=exercise group; CT=conventional therapy; CTSE=conventional therapy and supervised exercises

*Measured a cohort of participants during the first week of the experiment by Bleakley et al. 2010

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Discussion

Primary Research Question

Exercises Included

Multimodalapproach

The exercise programs used in several of the studies collected (Bassett et al. 2007; van Rijn et al. 2007; Bleakley et al. 2010; Tully et al. 2012; Cleland et al. 2013) followed similar multimodal structures. These incorporated stretches, active mobilization, strengthening, neuromuscular training, and sport-specific functional training. All of the groups using such a program in these studies found significant improvements from baseline in their outcome measures once implemented. This provides some validation that a similar combination of exercise modalities may be a viable approach to treating ankle sprains. However, some more descriptive recommendations can be extracted from the remaining studies.

Stretching

Although several of the aforementioned experiments included static stretches of the calf muscles in their exercise protocols, Youdas et al. (2009) focused their study on them. In the experiment, participants were allocated to one of three groups who were prescribed differing lengths the stretches should be held: 30 sec.; 1 min.; 2 min.. These stretches were to performed at least 5 days per week, in combination with a standardized home-exercise plan. Due to the lack of a control group, the small sample sizes, as well as no in between group differences being found, the authors could not conclude with certainty the effectiveness of the intervention. However, there were clinically important increases in active ankle dorsiflexion range of motion within each group from baseline to 2 weeks, and participants had regained a normal range of 10° by week 4. Static stretching cannot necessarily be recommended as an effective means of increasing dorsiflexion after acute ankle sprain based solely on this article. However, there is some support for it in a systematic review from 2013 by Terada et al., which included the study by Youdas et al. (2009). In the review, 9 articles exploring various intervention modalities (namely manual therapy, therapeutic modalities, therapeutic exercises, and psychological interventions) were compared to examine their effects on dorsiflexion range of motion. Although recommending practitioners to assess for the cause of limitation, they found that static stretching, as described in the experiment by Youdas et al. (2009), led to the the greatest gains in dorsiflexion range of motion.

Plyometrics

The articles by van Rijn et al. (2007), Bassett et al. (2007), and Cleland et al. (2013) used “jumping, hopping, skipping” exercises. The exercise plan used in Bleakley’s experiment included “sport-specific functional training” which may also have incorporated jumping components. However, only the article by Ismail et al. (2010) specifically studied the effectiveness of a plyometric training program (in this case compared to a resistance training program). The programs lasted 6 weeks long and started after the third week of post-injury treatment. Both groups experienced similarly significant strength improvements, but the significantly greater improvements the plyometric group received in the function and balance outcomes demonstrates that this form of training may be the preferred choice. While this may be the case, there are some limitations to the generalizability of these findings. The participants were athletes and in order to be include in the experiment, they needed to be able to perform certain tasks: 1) 5 power squats in 5 seconds at 60% of the individual’s body weight; 2) single-leg stance with eyes open and closed for 30 seconds; and 3) maintain static

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and dynamic control of body weight during a single-leg squat. These requirements may mean the current program is too demanding for the general population. As well, while the study concluded that resistance training was not as effective as plyometrics, it should be noted that the exercises performed by the resistance group were relatively low level (manually resisted isometric exercises, calf raises, etc.), and therefore the comparison may be skewed. On top of this the functional outcomes were largely speed based. As plyometric training directly targets speed, they may have had an unfair advantage. Nevertheless, the neuromuscular improvements afforded by plyometric training (Miller et al. 2006), may account for the greater improvement in single-leg stance performance. Balance being a risk factor for incidence of sprains, in addition to the overall improvements in functional performance, indicate that this is a desirable component of a rehabilitation plan for acute ankle sprain.

StarExcursionBalanceTraining

Dynamic stability exercises were incorporated in the majority of the training programs included in this review, although only the experiment by Chaiwanichsiri et al. (2005) examined a specific form of such training: the star excursion balance training (SEBT). This exercise consists of standing in the middle of a circle around which eight evenly spaced markers are placed. The participant must balance on one foot and reach the suspended leg as far as possible in each of the eight directions. In the study, a random selection of participants receiving conventional care, and who could walk symmetrically without pain, were started on an additional SEBT program. This program was implemented three days per week for four weeks; and consisted of 12 rounds clockwise and 12 rounds counter clockwise, with 3 sec. breaks between directions. Both control and SEBT groups demonstrated significant improvements in single leg balance test (SLBT), though those of the SEBT were roughly 2.2 times greater than those of the control. The two re-sprains in the control group occurred during lower-level activity (jogging) than the one in the SEBT group (contact with another player during a basketball match). This apparent higher tolerance to external perturbations may have been a result of the training in the SEBT, though there is no way of confirming this hypothesis due to the small sample size. While between-group statistical analysis is lacking to confirm the significance of the difference in SLBT performance, it does appear that the SEBT is an effective approach to dynamic stability training. However, it should be noted that the population that was tested was very specific (male athletes between 15-22 years old), and therefore the generalizability of the outcomes is questionable.

Eversionself-mobilization

The only article incorporating a self-mobilization technique that met the inclusion criteria was that of Cleland et al. (2013). The patients in the experimental group that received manual therapy from the therapist were also instructed to perform eversion self-mobilizations as part of their home-exercise regime. This group performed significantly better than the group who did not receive manual therapy in all outcomes. However, the clinic meaningfulness of the differences between groups was brought into question due to the size of the confidence intervals. As a result, while the superior benefits of additional passive mobilizations may have been demonstrated, it could be argued that it is unclear what proportion of the improvements in this group were due to the mobilizations performed by the therapist, vs. those which could be incorporated in a self-treatment plan. Therefore, this home-based intervention could potentially be of merit in rehabilitating acute ankle sprains.

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Duration

Start

The primary focus of the experiment used in the articles by Bleakly et al. (2010) and Tully et al. (2012) was the effect of an accelerated (early) start to rehabilitation exercises. On top of the interventions prescribed to each group, the participants of the study were recommended to walk as much as was tolerable, as soon as possible. The sub-analysis performed by Tully et al. (2012) involved a measurement of the amount of physical activity (as measured by activPAL accelerometer) the participants of the main study undertook during the first week of the experiment. The outcomes were compared to those of a cohort of healthy participants. Both injured groups demonstrated significantly decreased physical activity compared to the healthy control. However, bout length and cadence of walking in the exercise group were significantly greater than the RICE group. Following the first week of the experiment, both groups were prescribed a standardized exercise plan during the next 3 weeks. After the initial short-term functional advantage found in the accelerated exercise group, there were no significant long-term differences between groups. Furthermore, only 2 re-injuries occurred in each group by 16-weeks (Bleakley et al. 2010). This indicates, that while a 1-week delay may not have long-term disadvantages, a faster return to normal function and mobility can be promoted via an early start to exercise based interventions. This can be a very desirable outcome for individuals seeking to return to their sports or activities of daily living as soon as possible. Therefore it is recommended to start ankle sprain therapeutic exercises as soon as possible in the first week post-injury.

End

Favourable effects were shown in the studies by Bassett et al. (2007), Bleakley et al. (2010), and Cleland et al. (2013); all of whom used 4-5 week intervention periods. However, the participants in Cleland’s experiment were encouraged to continue strength and balance training after the main experimental phase, which may have accounted for ongoing improvements. In order to include the neuromuscular enhancement provided by the interventions used in the experiments by Chaiwanichsiri et al. (2005) and Ismail et al. (2010), the delayed starting points need to be taken into consideration. According to the KNGF guideline for acute ankle sprain rehabilitation (van der Wees et al. 2006), the symmetrical walking required to start the SEBT (Chaiwanichsiri et al. 2005) should be reached at the end of the proliferation phase, around day 10. With the 4 weeks of SEBT, that is just over 5 weeks. In Ismail et al.’s experiment (2010), the plyometric training plan started after week 3 and lasted 6 weeks; bringing the length of the exercise plan to 9 weeks.

Secondary Research Question

Accelerated Home Exercise vs. RICE The articles by Bleakley et al. (2010) and Tully et al. (2012) were both analyzing aspects of the same experiment. The main focus of the experiment was during the first week of care: while both groups were instructed to use the RICE method 3 times per day (rest, ice, compression, elevate), one was told to also start immediately with home-exercises. These exercises were instructed with the help of a dvd. The outcomes from Bleakley et al. (2010) demonstrated significantly greater improvements on functional scales in the accelerated exercise group. In the article by Tully et al. (2012), participants from the the accelerated exercise group significantly improved their walking ability. These outcomes indicate that patients provided with instructional materials are capable of effectively improving their return to function via the use of an unsupervised exercise plan.

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The other studies collected compared the effectiveness of different exercise programs against each other; variations in dosage; or using exercise as the control for other intervention modalities. However, none used control groups consisting of no treatment. In the spectrum of treatments possible for this pathology, the RICE method is relatively passive and non-invasive. As a result, the short-term delay in active treatment could be suggested as the nearest control demonstrating the effectiveness of home-exercise as a treatment for ankle sprains.

Home Exercise vs. Supervised Exercise

Van Rijn et al. (2007) conducted an experiment focusing on two groups of ankle sprain patients. Both groups received instructions for home-exercise following assessment from a doctor, while one group received additional supervised exercises with a physiotherapist over 3 months. The outcomes of this study showed no significant differences in any of the measures relevant to this review. That being said, patient appreciation of the treatment they received at the 3-month follow-up was in favour of the group receiving supervised exercises (OR: 4.69 (95% CI = 1.41 to 15.5)). This however, could be a result of an attention bias offered by the additional contact sessions with the physiotherapist. Overall these findings indicate that exercises performed under supervision of a physiotherapist do not offer additional benefits for ankle sprain patients. A self-reported point of note by the researchers would be the size of the confidence intervals regarding recurrence risk difference. Although the difference between groups was insignificant; in combination with the patients’ satisfaction, treatment sessions in the presence of a physiotherapist may be preferable. Bassett et al. (2007) also performed an experiment demonstrating the effect of exercise setting on recovery. The two groups received a standardized 3-phase exercise plan that was progressed according to their recovery. One group (CIG) had their exercises supervised over the course of an average of 8.44 (±4.12) clinical sessions. The other (HIG) received educational material and instructions for exercises to be performed at home. This group had a session booked to match their transition between each phase (4.68, ±1.78). Patient education on the pathology and treatment plan, as well as cognitive behavior techniques were used for both groups; verbally for the CIG, and in the printed booklet given to the HIG. The significant rates of recovery that were found for all measures within groups, but not between them, Supports the conclusions of van Rijn et al (2007) that patients can safely and effectively carry out their prescribed exercises at home. Additionally, they found that significantly more participants from the HIG finished the course of their physiotherapy (p=.004), and attended their sessions (p=.031) than those in the CIG.

Home Exercise vs Manual Therapy and Home Exercise

One of the studies (Cleland et al. 2013) examined the effectiveness of manual therapy and home exercise (MTEX) against a group that only received a home exercise program (HEP). Both groups improved over the course of the study, with the HEP group meeting the minimal clinically important difference in ankle specific functional scales at 4-weeks, despite between group differences being statistically significantly superior in favour of the MTEX group. Although statistically superior, the authors were dubious about stating the difference between groups as clinical important, due to the size of the confidence intervals. These factors in combination with the findings by Bassett et al. (2007), van Rijn. (2007), Bleakley et al. (2010), and Tully et al. (2012), help to support the recommendation that exercises can effectively be allocated for home administration of exercises. To build on this, a limitation in this study is the possibility of an attention bias, as the MTEX group received two sessions per week, while the HEP group only received one. Additionally, a potentially confounding factor in the design of the experiment is the fact that the home-exercise plan prescribed to the MTEX group included a self-mobilization technique. As discussed in the previous section, the presence of this additional component to the MTEX group could bring into question how

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much of a role the patient’s home-based self-mobilization played in the between group differences. Nevertheless, by allocating more of the the exercise instruction and progression to the home setting, the therapist could potentially maximize time spent performing passive manual interventions during clinical appointments. This delegation of tasks could help improve overall recovery of ankle sprain patients.

Attention bias The potential effect of contact time between patients and physiotherapists in the experiments by van Rijn et al. (2007), Bassett et al. (2007), and Cleland et al. (2013) appears to be inconsistent. However, this could be due to the patients’ perceived value of the treatments being offered, the education they were provided, as well as the nature of the modalities used. The two studies from 2007 were predominantly exercise based. As previously discussed, patients have been found to be capable of self-implementing exercise programs. However, in the van Rijn experiment the patients had little follow-up guidance. Therefore those receiving supervised sessions could have felt more reassured; and as a result, more satisfied by the care. In the Bassett experiment, the desired amount of guidance may have been met in the HIG, yet the additional time under supervision may have seemed redundant or burdensome to those in the CIG. Conversely, the education and cognitive behavioral techniques may have been clearer or more effective in the handout format provided to the HIG. This in turn could have helped the patients better understand the role compliance to the prescribed therapy plays in their recovery. This point is also relevant to the Cleland experiment, as the exercise program given to their participants was adapted from the one used by Bassett et al. (2007). However, unlike the HIG from the Bassett experiment, the participants in the Cleland experiment were not provided with educational or instructional materials, or cognitive behavioural techniques. This may have affected their adherence to the prescribed exercises, and subsequently their recovery, though this was not measured in that study. Admittedly, while van Rijn and Bassett’s home-exercise participants displayed similar improvements to their supervised counterparts, Cleland’s MTEX group did statistically significantly better than the HEP group in the actual functional outcomes targeted by this review. However, the questionable certainty of a clinically important difference between said groups (Cleland et al. 2013) highlights the importance of controlling for a potential attention bias. While the manual techniques implemented could have lead to the greater improvements in the MTEX group, it could also be the case that the additional sessions offered the opportunity for more appropriate exercise progression.

Limitations There were several limitations that were encountered during the course of this review. Firstly, The search yielded a small number of quality articles. As a result, there is a lack of homogeneity between the papers with regards to the interventions used (balance training, plyometrics, etc.), and the exact participant demographics (i.e.: sedentary or athletic, age ranges, etc.). This lead to minimal sources being able to validate specific conclusions. Several studies were not included due to their focus on individuals who did not have a current grade 1 or 2 sprain. However, they explored pathologies that are linked or potentially resulting from acute ankle sprains, ex: CAI, etc. These studies, although not directly relevant, often included the targeted training strategies or goals. While they did not fit the set research question, there may be a level of transferability of their conclusions. A next step to this research could be to include their findings; possibly potentiating the effectiveness or supplementing the validation of the current conclusions, or broadening their scope.

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Conclusion Based on the outcomes of this review, it can be concluded that solely relying on exercises for the treatment of ankle sprains is not as effective as when they are combined with manual therapy of a physiotherapist. However, exercise programs do have a place in the improvement of several important factors needed for a quick return to function, and ultimately to decrease risk factors of re-injury. With that in mind, It has been shown that patients provided with education and instructional materials are as capable of effectively implementing rehabilitative exercises at home, as they are when supervised in clinic. This means that by allocating these exercises to a home setting, therapists can maximize the amount of time patients receive other forms of therapeutic modalities requiring their skills or special equipment. In addition to this finding, patients can benefit from an early return to normal function, and decreased risk factors of re-injury, using a multimodal exercise plan. Such a plan should last 9 weeks, starting immediately post-injury; includes stretches to increase range of motion; and incorporates prolonged components of dynamic balance and plyometric training to target neuromuscular improvement.

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Part 2: Product creation https://anklepro.wordpress.com

Introduction The rehabilitation of a grade 1 and 2 lateral ankle sprain should result in functional recovery without any persisting complaints (van der Wees et al. 2006). Most patients will be able to walk normally within one to two weeks and they will resume their sports activities at the same level as pre ankle sprain within 12 weeks (Van der Wees et al. 2006). Physiotherapy is typically recommended once a week for a duration of at least 6 weeks in order to promote the recovery process, to reduce the risk of reoccurrence and to limit the risk of developing a chronic ankle instability (Van der Wees et al.2006; Holme et al.1999; Hale et al. 2007). However, several studies showed nonetheless multiple benefits of more frequent and/or longer rehabilitation periods (Bleakley et al. 2010; Hupperets et al. 2009). To meet the high frequency of PT treatment sessions, patients could encounter many barriers, such as distance, cost of travel, time away from work and cost of care if under- or not at all insured (Brooks et al. 2014). Bassett et al. (2007) reported, patients can carry out some of their treatment at home in a safe and effective manner. As of this means, home exercises in combination with standard physiotherapy make rehabilitation both accessible and more efficient. For this project, it has been decided to create a website with video instructed media, because it has been proven to be superior to booklets with pictures and written instructions (Weeks et al. 2002; Reo et al. 2004). The website as designed to be used at home and therefore the computer was the main target for this project. Furthermore, website-delivered exercises are available 24hours per day and widely accessible (Vandelanotte et al. 2007). Standard care for ankle sprain rehabilitation involves primary care, exercise programs and information provision (Martin et al. 2013). One frequently used treatment modality is proprioceptive training (also called balance or neuromuscular training). The ability of maintaining balance is ensured by a combination of the visual, vestibular and nervous system. The nervous system is regulated by proprioceptive receptors who are located in the skin, ligaments, muscles, tendons and joint capsule (Karakaya et al. 2015). The information of these receptors will be transferred to different levels of the nervous system. Most remain unconscious such as postural control, while the joint position sense and the joint movement sense are conscious (Riva et al. 2015). Ankle proprioception is closely linked to balance control, hence impaired ankle proprioception after trauma, result in reduced balance capacities (Karakaya et al. 2015). An RCT of Hupperets et al. (2009) reported effectiveness of proprioceptive training in preventing recurrences of ankle sprains in athletes. Another important treatment modality for ankle sprain is strength training. Generally starting with isometric resistive strengthening progressing over concentric and eccentric exercises towards plyometric training. Plyometric training is generally based on different kinds of jumps. Plyometric exercises consist of an eccentric loading (stretch) immediately followed by a concentric contraction (Ismail et al. 2010). Neuromuscular adaptations are taking place; namely the pattern of motor unit recruitment and muscle activities of agonists and antagonists. Plyometric training is supposed to reduce the risk of injury thanks to the enhanced functional joint stability in the lower limbs (Kaitaro et al. 2007). Restoring ankle range of motion is another important treatment goal during the rehabilitation of the ankle sprain. Tightness in the gastrocnemius-soleus complex, as well as capsular adhesions due to immobilization and abnormal gait pattern, are responsible for the limited dorsiflexion after the ankle sprain (Denegar et al. 2002).

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Rehabilitation overview

In the case of normal recovery, an overview of the prescribed frequency of home-exercise sessions per block, as well as the recommended number of clinical appointments within a given phase can be found below in table 5. The recommended number of appointments is specifically based on the client’s clinical approach. A more detailed overview of the protocol’s contents can be found in the chapters below. Table 5: Rehabilitation plan overview

Block Training sessions per block

2 to 3 physiotherapy appointments per week throughout phase 1 and 2

Block 1.1 Every day

Block 2.1 Every day

Block 2.2 Every day

Checkpoint

1 to 2 physiotherapy appointments per week throughout phase 3

Block 3.1 Every day

Block 3.2 Every day

Checkpoint

Block 3.3 Every day

1 to 2 physiotherapy appointments throughout phase 4

Block 4.1 4x per week (2x Alpha, 2x Beta)

Checkpoint



1 to 2 physiotherapy appointments throughout phase 5

Block 5.1 2x per week



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Product validation

Building block structure As different articles used different phase lengths, the KNGF guideline (van der Wees et al. 2006) was used as suggestions for the protocol’s timeframe. This guideline was selected as the other guidelines (McKay and Cook 2006, Martin et al. 2013) did not specify indications of how long phases should last. While the phases guide through general goals, when to progress within them to accomplish these goals was unclear. In Therapeutic Exercise by Brody and Hall (2011), it is stated in the section on home exercise prescription, that when the patient is able to do the same exercise for three consecutive sessions, progression is appropriate. This would mean that in earlier phases when exercises are lower intensity and performed daily (1-3), patients could potentially progress every 3 days if they are recovering at a fast pace. Based on this, it was decided that the protocol should take on a “building block” format. With this in mind, each of the phases 1-3 of the KNGF guideline were divided into blocks of 3 days. As the phase lengths may not be appropriate for every patient, these were not seen as a hard and fast rule. Extra remaining days around these blocks of 3 were seen as opportunities to remain longer or progress faster to the next step, depending on performance within the block. In this way, the opportunity is given to the users of the website to mediate their progress; doing so earlier in less severe cases, or to remain longer in one phase if needed. The users are instructed to progress once they have performed 3 days with ease. However, as certain exercises require baseline requirements to commence, progression between certain blocks can only occur when these requirements (as measure in the Checkpoints via instructed tests) are met. If not, they must remain within the block until they can accomplish the goal. This also provides a set of rules that allow for some flexibility, but still keep the patient within the boundaries of a structured framework. During the last two phases involving more intense workouts, and requiring days of rest to avoid overtraining (Kenney et al. 2012), the blocks were then set to week lengths. The exercises prescribed within these blocks were set to 2x per week. Many exercises within these blocks were set so they would be performed over at least 2 blocks. An offset of which exercises remain, and which are replaced in the next block was applied to continue progression in some respect; all the while solidifying the performance of the other portion of exercises that remained. Whereas other web pages dedicated to ankle sprains may only list a few exercises, the AnklePro website guides patients through several progressions within a given phase all the while maintaining the desired goals and framework. This format was also inspired by input from the client, who requested a “fun/interesting” exercise program to keep his patients motivated. By offering several progressions in a phase, the program is infused with a level of interactivity, whereby patients may feel less stuck in one set of exercises for longer than necessary. Particularly in the early phases when the exercises are less engaging. In addition, the shorter blocks can impart a level of accomplishment and novelty when moving from one block to the next, potentially improving motivation and adherence.

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Protocol

Phase 1: Inflammatory (0-3 days) • Should be done every day

Goals (van der Wees et al. 2006):

1. Reducing pain 2. Improving circulation 3. Promoting partial weightbearing

Block 1.1 • (RICE) Icing Intermittent: 10 min ice - 10 min rest - 10 min ice • (RICE) Compression Throughout inflammatory phase • (RICE) Elevation As long as needed • AROM exercises 3 sets - 20 reps • LE triple flexion/extension 3 sets - 20 reps • Circular weight shifting 3x per day: As much as tolerable up to 15/direction • Walking As much as possible • Calf stretching (sitting) 3x per day: 1 set, 30 sec (beginning at day 2 if no

inflammation)

Crutches should only be used if the pain is not bearable.

Phase 2: Proliferation (4-10 days)

• Should be done every day

Goals (van der Wees et al. 2006): 1. Restoring function and activities 2. Building-up load bearing capacity 3. After 4 to 10 days a symmetrical gait should be possible

Block 2.1 • (RICE) Icing Intermittent: 10 min ice - 10 min rest - 10 min ice • AROM: Alphabet 3 sets (30 sec rest) • Towel scrunch 3 sets - 20 reps (30 sec rest) • Isometric holds 3 sets - 20 reps - 3 sec hold • Calf stretching (sitting) 3x per day: 1set - 30 sec • Eversion self-mobilization 3 sets - 30 reps • Circular weight shifting 3x per day: As much as tolerable up to

15/direction Additional (+Exercises)

• Hip abductor 3 sets - 12 reps (30 sec rest) • Pilates 100 5 pumps per inhale - 5 pumps per exhale (10

pumps x 10 breaths = 100) • Superman (individual limb) 3 sets - 5 reps/side - 5 sec hold (30 sec rest)

Block 2.2 • (RICE) Icing (until day 8) Intermittent: 10min ice - 10min rest - 10min ice • AROM: Alphabet 3 sets (30 sec rest) • Picking-up small objects 3 sets - 20 reps (30 sec rest) • Isometric holds 3 sets - 20 reps - 5 sec hold

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• Calf-stretching (standing) 3x per day: 1 set - 30 sec • Eversion self-mobilization 3 sets - 30 reps • Circular weight shifting 3x per day: As much as tolerable up to

15/direction Additional (+Exercises)

• Hip abductor 3 sets - 10 reps (30 sec rest) • Pilates 100 5 pumps per inhale - 5 pumps per exhale • Superman (diagonal limb) 3 sets - 5 reps/side - 5 sec hold (30 sec rest) • Bridging (standard) 3 sets - 10 reps (30 sec rest)

- CHECKPOINT - Knee to Wall Test: >2-3cm

Phase 3: Early remodeling (11-21 days)

• Should be done every day

Goals (van der Wees et al. 2006) 1. Improving muscle strength 2. Active (functional) stability 3. Range of motion of the ankle 4. Walking, running exercises

Block 3.1 • In-line walking 3 sets - 30 sec • Single leg stance 3 sets - 30 sec • Baby Squats 3 sets - 10 reps (30 sec - 1 min rest) • Toe raises (bilateral) 3 sets - 10 reps (30 sec - 1 min rest) • Elastic band exercises 3 sets - 15 reps (30 sec - 1 min rest) • Calf stretching (standing) 3x per day: 1 set - 30 sec

Additional (+Exercises)

• Hip abductor with circles 3 sets - 10 reps (30 sec rest) • Pilates 100 table top 5 pumps per inhale - 5 pumps per exhale • Superman (cross under) 3 sets - 5 reps/side - 5 sec hold (30 sec - 1

min rest) • Bridging (side-to-side and tilt) 3 sets - 10 reps (30 sec - 1 min rest)

Block 3.2 • Single leg stance eyes closed 3 sets - 30 sec • Squats (full) 3 sets - 10 reps (30 sec - 1 min rest) • Lunges (split squat) 3 sets - 10 reps (30 sec - 1 min rest) • Calf raises (double leg) 3 sets - 10 reps (30 sec - 1 min rest) • Pre-hops 3 sets - 10 reps (30 sec - 1 min rest) • Pre-hops (jog) 3 sets - 10 reps (30 sec - 1 min rest) • Elastic band exercises (not plantar) 3 sets - 15 reps (30 sec - 1 min rest) • Calf stretching (standing) 3x per day: 1 set - 30 sec

-CHECKPOINT- Single Leg Stance: 30sec (eyes open AND closed)

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Phase 4: Late Remodeling (3 - 6 weeks)

• 4x/week (one chunk = 1 week) Goals (van der Wees et al. 2006)

1. Increasing regional load-bearing capacity 2. Walking 3. Stair climbing abilities 4. Skills required for work, domestic and sports-related activities

Block 4.1 A Twice a week

• STAR excursion 2 x 12 rounds 3 sec rest bet. each direction

• Double leg hopping (on the spot) 3 sets - 16 reps (30 sec - 1 min rest) • Double leg hopping (back and forth) 3 sets – 16 reps (30 sec - 1 min rest) • Calf stretching 3x per day: 1 set - 30 sec

B Twice a week:

• Single leg stance uneven surface 3 sets - 30 sec • Walking on heels and toes 3 sets - 10 steps each (30 sec - 1 min rest) • Single leg squat 3 sets - 10 reps (30 sec - 1 min rest) • Lunge (dynamic) 3 sets - 10 reps (30 sec - 1 min rest) • Calf raises (double leg) 3 sets - 10 reps (30 sec - 1 min rest) • Calf stretching 3x per day: 1 set - 30 sec

-CHECKPOINT- Knee to Wall Test: <2cm difference compared to uninjured leg (Norm: 10-12cm)

Single Leg Squat: stable throughout the movement

Block 4.2 A Twice a week:

• STAR excursion 2 x 12 rounds 3 sec rest bet. each direction

• Double leg hopping (side-to-side) 2 sets - 16 reps (30 sec - 1 min rest) • Double leg hopping (4 directions) 2 sets - 16 reps (30 sec - 1 min rest) • Single leg hopping (on the spot) 2 sets - 16 reps (30 sec - 1 min rest) • Single leg hopping (back and forth) 2 sets - 16 reps (30 sec - 1 min rest)

B Twice a week:

• Single leg stance uneven surface eyes closed 3 sets - 30 sec • Side lunges 3 sets - 10 reps (30 sec - 1 min rest) • Single leg squat 3 sets - 10 reps (30 sec - 1 min rest) • Calf raises (single leg) 3 sets - 10 reps (30 sec - 1 min rest)

Block 4.3 A Twice a week:

• Single leg hopping (side-to-side) 2 sets - 16 reps (30 sec - 1 min rest) • Single leg hopping (4 directions) 2 sets - 16 reps (30 sec - 1 min rest) • Squat jumps 4 sets - 6 reps (30 sec - 1 min rest) • Tuck jumps 4 sets - 6 reps (30 sec - 1 min rest)

B

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Twice a week: • STAR excursion 2 x 12 rounds 3 sec rest bet. each direction • Single leg stance throwing a ball 3 sets - 10 reps (30 sec - 1 min rest) • Calf raises (single leg) 3 sets - 10 reps (30 sec - 1 min rest) • Single leg squat 3 sets - 10 reps (30 sec - 1 min rest) • Lunges (side lunge) 3 sets - 10 reps (30 sec - 1 min rest)

Phase 5: Transfer

• 2x pw (according to Ismail et al.) in addition to their usual training program Goals (van der Wees et al. 2006):

1. return to sport

Block 5.1 • Star excursion (on pillow) 2 x 12 rounds 3 sec rest between each

direction • Squat jumps 4 sets - 6 reps (30 sec - 1 min rest) • Tuck jumps 4 sets - 6 reps (30 sec - 1 min rest) • Lunge jumps 2 sets - 12 reps* (30 sec - 1 min rest) • Power skips 2 sets - 12 reps* (30 sec - 1 min rest) • Long jumps 2 sets - 6 reps (30 sec - 1 min rest)

Block 5.2 • Lunge jumps 2 sets - 12 reps* (30 sec - 1 min rest) • Side-to-side squat over step 4 sets - 6 reps* (30 sec - 1 min rest) • Power skips 2 sets - 12 reps* (30 sec - 1 min rest) • Long jumps 2 sets - 6 reps (30 sec - 1 min rest) • Jumping over barrier 4 sets - 6 reps* (30 sec - 1 min rest) • Single leg bound 2 sets - 6 reps* (30 sec - 1 min rest)

Block 5.3 • Skaters 4 sets - 6 reps* (30 sec - 1 min rest) • Side-to-side jump over step 4 sets - 6 reps* (30 sec - 1 min rest) • Single leg bound 2 sets - 6 reps* (30 sec - 1 min rest) • Jumping over barrier 4 sets - 6 reps* (30 sec - 1 min rest) • Double leg hopping (4 directions) 2 sets - 16 reps (30 sec - 1 min rest)

* total amount of repetitions of both legs

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Intensity validation A common method in designing a training program is to determine the intensity with the use of the "one repetition maximum" (1RM). However, this principle can't be translated to the rehabilitation protocol, since determining 1RM of the injured body part would be limited by pain and hinder the ongoing healing process by exerting too much force on the healing tissues. Using other methods of determining/estimating 1RM seems inappropriate because it would be too complicated for users. Furthermore the selected exercises are primarily body-weighted exercises in order to guarantee that everyone can perform them at their home. Therefore using the recommendations of Reiman and Lorenz (2011) was the most purposeful for this protocol. Reiman and Lorenz (2011) spread the rehabilitation into different phases, gave training recommendations and goals to reach before proceeding to the next phase. These phases have been matched with the phases being used in this protocol. Although the literature is lacking, the use of non-linear periodization has been recommended by Reiman and Lorenz (2011). It typically introduces the rehabilitation with higher repetitions with lighter weights and endurance before initiating strength-based training. At the end of the rehabilitation, aggressive strength training and power training (e.g. plyometrics) should be included. The characteristics of the first and second phases are tissue repair and regeneration, only AROM and isometric strengthening are in these phases. Therefore it is recommended to train with a low intensity endurance of 20 to 30 repetitions. Of this reason it has been decided to use three sets of 20 repetitions for the exercises in phase one and two. Muscle performance should be improved in the third phase, therefore, body-weighted exercises are implemented. The intensity should be at high intensity endurance of 3 sets of 6 to 12 repetitions. In this protocol the amount of 10 repetitions has been chosen, because it is in the targeted range and the protocol developers believe that it is easier for the user to target one specific amount of repetitions instead of a vague range. Furthermore the exercises are of functional origin and should be rather easy to perform, even for untrained individuals. In phase four, the aim is to restore muscular endurance and strength, high intensity endurance of 6 to 12 repetitions are recommended, transition to power training (e.g. plyometrics) is suggested in this phase. Exercises are progressing in difficulty and this endurance training can be a method of training hypertrophy strengthening which is generally achieved with a range of 8-12 repetitions. Therefore 3 sets of 10 repetitions has been deemed appropriate for this phase. The fifth phase aims to return the athlete to return to full function. It consist exclusively of plyometrics. Piper et al. (1998) recommends to divide the different plyometric exercises into two categories of difficulty. Less difficult exercises (e.g. hopping) are placing high demands on the anaerobic glycolysis system, therefore more than 10 repetitions per set are appropriated. Whereas more difficult exercises (e.g. squat jumps) are placing high demand on the ATP-CP energy system, thus less than 10 repetitions are suitable. All these exercises have to be performed in an explosive and continuous manner. The volume of the plyometric training sessions range from 90 - 140 foot contacts, furthermore intensity and volume have increased during 5 weeks before tapering off during the 6th week as recommended by Piper et al. (1998) and as applied in the study of Ismail et al. (2010). The suggested resting period between the sets is 30 seconds to 1 minute for endurance/hypertrophy strengthening, thus this range has been utilized in this protocol in order to give the less advanced user the possibility to use more time to recover. Piper et al.'s (1998) recommendation for the resting periods between sets in plyometrics is between 10 seconds to 2 minutes depending on the intensity. It has been decided to remain with the 30 seconds to 1 minute resting period, because the exercise sessions are of moderate intensity and for continuity reasons in this protocol.

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Session build up The training session begins with balance/proprioceptive exercises. It continues with strengthening exercises, which have been arranged so that multi-joint exercises (ex: squats), requiring the most coordination, skill, and proper levels of energy precede single joint exercises (Reiman and Lorenz, 2011). Finally stretching and self-mobilization exercises are rounding off the training session.

Checkpoint validation Due to the fact that the website is home-based, it incorporates certain checkpoints for self-assessment of progress. Patients need to meet certain criteria before moving onto the next phase, this is to ensure that patients rehabilitate properly. This also provides the opportunity for users of the site to receive tangible examples of their improvement, potentially increasing their motivation or self-efficacy. In case patients are not yet able to meet a checkpoint, they are required to repeat that specific phase or block as instructed.

Knee to wall test

The knee to wall test is a checkpoint after phase 2.2 and 4.1. The knee to wall test or as found more frequently in literature under weight bearing lunge test (WBLT) is a test to measure ankle dorsiflexion in weight bearing condition. It has an excellent reliability with an Intra-rater intraclass correlation coefficients (ICCs) of 0.97 to 0.98 and an Inter-rater ICC value of 0.99 (Bennell et al. 1998). Novice rater can obtain reliable measures using the WBLT (Konor et al. 2012). Each centimeter in the WBLT corresponds to approximately 3,6 degrees of ankle dorsiflexion (Konor et al. 2012). Symmetrical walking will be altered after sustaining an ankle sprain. First of all, limited ankle dorsiflexion results in reduced step length on the uninjured side. Secondly, pain on weight-bearing reduces the period of single support on the injured leg. A study analysed gait parameters after lateral ankle sprain concluded that 8 degrees of ankle dorsiflexion is needed to see normal single and double support phase proportions. Furthermore, it is known, that healthy persons use 10 degrees of ankle dorsiflexion during level walking (Crosbie et al. 1999). The Dutch guideline indicates, that a symmetrical gait should be possible after 4 to 10 days (Van der Wees et al. 2006). For this reason a WBLT should be performed at the end of phase 2 with an outcome of at least 2-3 cm, in order to ensure that symmetrical gait is not hindered due to restricted ankle dorsiflexion. In the study of Youdas et al. (2009), subjects recovered preinjury active ROM at 4 weeks. As a consequence, ankle dorsiflexion ROM should theoretically be the same in both ankles at 4 week post injury. Since an asymmetry of more than 2 cm in the WBLT relates to clinically relevant impairments (Hoch et al. 2011), testing ankle dorsiflexion in both ankles with the WBLT at 4 weeks is appropriate.

Single leg stance test

The single leg stance test (SLST) is a checkpoint after phase 3.2. The SLST is a test to assess balance. The user of the protocol needs to be able to maintain balance on the injured leg for at least 30 seconds with eyes open and with eyes closed in order to proceed to plyometrics (Ismail et al. 2010). A symmetrical walking is necessary before testing the single leg stance (Van der Wees et al. 2006). Therefore it is started at block 3.1 with the simplest version and progressed to eyes closed in block 3.2.

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Single leg squat

The single leg squat is a checkpoint after phase 4.1. Ismail et al. (2010) used the single leg squat (SLS) with the focus on the ability to maintain static and dynamic control of the body weight as a prerequisite to begin with plyometrics. Only athletes have been recruited for the study of Ismail et al. (2010) this might explain the early start with plyometrics in their study.The user of the protocol should be introduced to SLS before testing their ability. However, the protocol needed to build up squats towards SLS, therefore it wasn't possible to include it earlier. The whole point of altering the plyometric protocol of Ismail et al. (2010) was to provide a guided build up of exercises for a more general population, starting lower than Ismail et al. (2010). Furthermore, this protocol includes prehopping as advised by the client to acclimatize the joint to the loading pattern of plyometrics before really starting. The preparation ensures a better graded activity build up. Plyometric block 4.1 consists of low level exercises with low intensity. But plyometric block 4.2 is already more advanced, so that the indications provided by the ability to perform the SLS are relevant. Phase 5 with it's plyometric is designed for higher level athletic population. However it was the intention to ensure that everyone at least got training of single leg hopping in all directions for transferability to their daily lives.

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Exercise/intervention validation

RICE (rest, ice, compression, elevation) The study of Bleakley et al. (2006), compared the standard RICE application of 20min to a intermittent RICE application following acute ankle sprain. The study showed that the intermittent ice application resulted into a significantly (p<0.05) decreased sensation of pain on activity during the first week. However there was no difference in terms of swelling, function or pain at rest. Due to the fact that exercises in the first week improved ankle function (Bleakley et al. 2010), it has been chosen to include the intermittent ice application protocol. That means, patients were prescribed to ice 10min - 10min rest - 10min ice, three times per day.

Active range of motion exercises Due to the fact that the ankle is the most dependent weight-bearing joint in the body, swelling can become a chronic problem. Early intervention is critical to prevent that from happening (Brody and Hall 2011). Low level dynamic exercise in combination with compression and frequent elevation can be effective in decreasing swelling and pain (Brody and Hall 2011). Therefore the elevation, compression and range of motion ankle exercises are integrated in this protocol. Starting with easy joint movements and progressing to the alphabet-exercise.

Triple flexion and extension The triple flexion and extension exercises targets the hip, knee and ankle joint. After an ankle sprain, patients decrease physical activity (Tully et al. 2012). In order to prevent disuse of other joints (knee and hip), this exercise is integrated in the early phases of this protocol. Moreover this exercise includes a functional movement pattern (Bleakley et al. 2010) and is also a neuromuscular exercise. The ankle is not loaded and can therefore be included early in the protocol.

Circular weight shifting / walking In the study of Tully et al. (2012), the intervention group that did additional exercises in the first week post ankle sprain did also walk significantly more (p=0.02), compared to the standard group that only received PRICE intervention. This finding is in line with the recommendation of the KNGF guideline for ankle sprain, that advise patients to bear as soon as possible weight on the ankle, to the extent that the pain allows (van der Wees et al. 2006). Symmetrical gait should be achieved within 10 days (van der Wees et al. 2006).

Calf stretch (sitting/standing) Reduced dorsiflexion has a major impact on the walking abilities and other physical activities of a patient (Youdas et al. 2009). 10° dorsiflexion is for example needed to walk on a straight surface or to descend stairs (Harris 1991), while 20° to 30° is needed for running and sprinting activities (Pink et al. 1994). The study of Youdas et al. (2009) concluded that normal dorsiflexion is restored after 4 weeks, when stretching lasts at least 30sec three times a day (Bassett et al. 2007; Youdas et al. 2009; Cleland 2013). In case of a bigger difference than 2cm in the knee-to-wall test between both legs, it is recommended to continue stretching (Hoch et al. 2011). Moreover, the professional opinion leaves the authors to recommend stretching throughout all phases, to prevent calf muscle tightness, once started with the heavier and plyometric exercises.

Towel scrunch / picking up objects with toes Intrinsic foot muscles are needed for the maintenance of the longitudinal and transverse arches during functional movements, such as stairwalking and small knee bends. The

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intrinsic foot muscles are also used during gait (Brody and Hall. 2011).Therefore these muscles should be trained following injury. The towel scrunch is the first exercise for the intrinsic foot muscles, followed by picking up small objects.

Eversion Self-mobilization Cleland’s home protocol was based on Bassett’s but included an eversion self-mobilization technique for the group that received manual therapy in clinic. Based on its reproducibility at home, the technique was included in the protocol as the group receiving this intervention recovered significant better than those of the home-exercise group. In addition to this, eversion is a combination of movements that includes dorsiflexion, therefore it was hypothesized that this mobilization could potentially also assist in improving the relevant risk factors. Prescriptive dosage for this maneuver was taken from Cleland et al. (2013).

Pilates exercises Advice was taken from the (Brody and Hall 2011) to train the leg joints proximal to the ankle, and core, in order to avoid disuse, and promote proximal control. Advice from the client was combined with those of an experienced pilates instructor (Eleftherios Pappas) to prescribe some pilates exercises. These exercises are included in the protocol as additional exercises (named: +Exercises). Patients are informed about the reasoning behind their inclusion, and are recommended to perform them if they have time, although they are not mandatory. The pilates exercises included in the website are hip abduction, pilates 100, supermans and bridging. Isometric holds Once a patient can tolerate manually resisted ankle motion, the following exercise is isometric strengthening (Youdas et al. 2009). In order to be able to perform this exercise at home, the other foot will be used to give resistance. Isometric strengthening is included in five of the eight included articles (Bassett et al. 2007; Youdas et al. 2009; Ismail et al. 2010; Bleakley et al. 2010; Tully et al. 2012). Isometric strengthening is done in all directions, dorsiflexion, plantar flexion, in- and eversion.

Elastic band exercises This isodynamic exercise helps to improve the muscles around the ankle. The exercise is done in all directions (plantar flexion, dorsiflexion, in- and eversion). Theraband exercises start in the first week of the early remodelling phase (phase 3), once one is able to perform isometric strengthening exercises (Youdas et al. 2009). The goal of this exercise is to achieve muscle fatigue at the end of the third set (Cleland et al. 2013). Increasing intensity of this exercise could be done by either changing colour of the theraband (yellow - red - green - black and grey) (Youdas et al. 2009), or increasing the tension of a theraband. Once one is able to perform 3 sets of 15 reps of resisted plantar flexion, one can proceed to standing calf raises (Youdas et al. 2009).

In-line walking Tight-rope or inline walking is a progression of normal walking (van Rijn et al. 2007), also balance is a component of this exercise. Tight-rope walking is safe to, once one is able to walk symmetrically (van Rijn et al. 2007), therefore it is integrated in this protocol in the early remodelling phase.

Single leg stance The single leg stance is a balance as well as a proprioceptive exercise. The criterium to proceed to the single leg stance is being able to walk symmetrically (van der Wees et al. 2006). It is important for this exercise to master each step before moving on to the next. One

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should be able to stand on one leg for 30sec, before one could continue to closing the eyes. Both variations have to be mastered in order to start with plyometrics (Ismail et al. 2010). To keep improving balance and proprioception, both exercises will be performed on an unstable surface. The last progression includes a dynamic component to increase intensity and transferability to sporting activities; namely standing on an unstable surface while throwing-and-catching a ball.

STAR excursion The STAR excursion improves dynamic stability, control, coordination and proprioception of the lower extremity (Brody and Hall 2011). The study of Chaiwanichsiri et al. (2005) compared two groups, both receiving usual physiotherapy and one group got the STAR excursion balance program as additional therapy. The aim was to improve the functional stability of the subjects measured with the SLST. There was a significant outcome for the intervention group for both the SLST-eyes open (p=0.007) and SLST-eyes closed (p=0.002). The STAR excursion was performed once one could walk without pain and no medication was used. Due to the fact that the intervention was performed under supervision, it has been chosen for this project to include the STAR excursion a bit later in the protocol for safety reasons. The STAR excursion is performed twice a week in combination with other neuromuscular and balance exercises. The Star excursion balance exercise was adapted in Chaiwanichsiri et al. (2005) from a test of the same name (Olmsted et al. 2002) to measure dynamic balance. However, this test is not ideal for self-implementation, and therefore was not included in the protocol.

Bilateral balance training Though not an outcome from evidence search in part one, patients using AnklePro are instructed to perform repetitions of the prescribed balance exercises on both legs. This recommendation was inspired by a systematic review that analysed the possibility of bilateral balance impairments after acute ankle sprain. It has been found, that postural control deficits were also present on the uninvolved limb. Therefore using the uninvolved limb as reference for normal postural control is inaccurate (Wikstrom et al. 2010). Postural control deficits in the uninvolved limb takes approximately 7 days to be restored, although it takes at least 4 weeks for the involved limb (Evans et al. 2004). Balance training is responsible for neural adaptations that occur at multiple sites within the central nervous system. Centrally mediated changes due to bilateral balance deficits might be the cause of chronic ankle instability (CAI). Thus, bilateral balance training should be incorporated in the ankle sprain rehabilitation to make use of the central nervous system's plasticity and likely return the patient to preinjury movement patterns. This in order to reduce the risk of recurrences, and development of CAI (Wikstrom et al. 2010). Therefore, to potentiate balance training neuromuscular and risk reduction capacities, this recommendation has been applied to the prescriptive parameters of the relevant exercises.

Squats The ankle is the most dependent weight-bearing joint in the body (Brody and Hall 2011) and therefore progressive loading of the joint is necessary. The protocol starts with (mini-)squats in the first week of the early remodelling phase. A patient can proceed to the full squat if the mini-squat is mastered. The next progression is the single leg squat, it is one of the prerequisites to start with plyometrics (Ismail et al. 2010). One should be able to maintain static as well as dynamic control of body weight during single leg squat (Ismail et al. 2010). The last progression of the squat is the squat jump, which is a plyometric exercise.

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Toe raises Toe raises are performed to improve the dorsiflexors of the foot. Other than just strength also the active range of motion is trained, which is needed to perform stairwalking, running and eventually sprinting activities (Youdas et al. 2009).

Lunges Lunges are functional exercises for the ankle stabilizers (Brody and Hall 2011). The lunges within this protocol have the same build-up as other exercises. The progression of the normal lunges are dynamic lunges, that in itself will be build-up by first doing for- and backward lunges and the last direction are side-to-side lunges. Calf raises Calf raises is a frequently used exercise in ankle sprain rehabilitation (Basset et al. 2007; Youdas et al. 2009; Hupperets et al. 2009; Ismail et al. 2010; Cleland et al. 2013). Calf raises strengthen multiple muscles around the ankle joint. The main muscles that will be targeted are the gastrocnemius and the soleus. Though, the medial, lateral and intrinsic muscles that stabilize the foot and ankle joint will be strengthened (Brody and Hall 2011). The protocol firstly includes bilateral calf raises, followed by unilateral, once the first step is mastered. Calf raises were also one of the prerequisite to move to plyometrics.

Heel and toe walking Toe walking is a strengthening exercise for the calf muscles, whereas heel walking recruits the dorsiflexor muscles (eg. tibialis anterior) during its performance. Therefore these exercises are also good indicators to assess the functional strength that is required during higher level exercises such as plyometrics (Ismail et al. 2010). Furthermore, These walking exercises demand a level of postural control. As the patient must be able to dynamically sustain positions that diminish their base of support, proprioception and balance can be targeted.

Plyometrics Due to the fact that the study by Ismail et al. (2010) involved a plyometric training program that was directly supervised by a physiotherapist, it was decided that the exercises used should be altered for a safer unsupervised implementation. The exercises that have been included in the web-protocol were based on recommendations from the client. By including a set of similar exercises the client already teaches to his patients, an added level of continuity can be gained for his existing patients. This in turn can help create a more client specific product. Ismail et al. (2010) had a few prerequisites for their athletic population in order to begin 3 weeks after their ankle sprain with plyometric training. Most of these prerequisites can be found in the protocol as exercises being trained before the initiation of plyometrics. According to Chmielewski et al. (2006), there is no validated clinical guideline available for the initiation of plyometric exercise. Chmielewski et al. (2006) found only empirical evidence that advises to begin with plyometrics as soon as the patient is able to tolerate moderate loading during resistance strengthening exercises and if they are able to perform functional movement patterns with proper form. Therefore it has been decided to begin with plyometric exercises in phase 4, since the protocol includes functional weight-bearing strengthening exercises all over phase 3. These exercises in phase 3 need to be mastered with proper form in order to proceed to phase 4.

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Overview of the website content The website is divided in seven categories, that can be seen below (1,2,3 etc). The rehabilitation plan is subdivided in five phases (a,b,c), whereas the references has one subcategory.

1. Home 2. Ankle sprain 101 3. Rehabilitation plan

a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4 e. Phase 5

5. References a. Thesis

6. About us 7. Contact us

The home page of the website includes general information about ankle sprains, the project and some information about how to use the website. The Ankle Sprain 101 page consists of more in-depth information about the ankle sprain and its characteristics (etiology, mechanism of injury, risk factors etc.). Prior to building up the website, a survey about the input has been filled in by 56 people. These responses lead the group to include this webpage. This is also in line with the The rehabilitation plan consists of five phases, suggested by the KNGF guideline for ankle sprains (van der Wees et al. 2006). Each phase consists of information regarding goals specific to that phase and of videos showing and explaining the recommended exercise prescriptions. The reference page contains the references that are directly cited throughout the website. In part 5a. the full thesis in PDF can be downloaded from the website. ‘About us’ contains descriptions of the the client (Kusal Goonewardena) and the research team. Everyone who wishes to contact us, can fill out the form in the ‘contact us’ part. The general layout can be seen in the screenshots below.

Picture 1: Home page

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Picture 2. Information and goals, phase 1

Picture 3: Exercise block

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Design

Aesthetics and Website Creation The aim of the AnklePro website is to guide patients suffering from Grade 1 or 2 ankle sprain injuries back to health. In order to accomplish this goal, they will need to actually follow-through with the prescriptions that have been provided. Trust in the practitioner is an important factor in patient compliance to prescribed rehabilitation exercises for musculoskeletal injuries (Wright et al. 2014). However, this exercise program is being delivered via a self-guided, electronic format. As such, it is important to create a product that encourages patients to feel comfortable entrusting a website with this aspect of their recovery. In another study by Robins and Holmes (2008), visitors were more likely to perceive a website as credible when it had more aesthetic treatment. Furthermore, these judgments were made within the first 3.42 sec. that the visitors saw the page. Even though patients are provided with the evidence based medical documentation used to create this rehabilitation program, they may not stay long enough to learn about it, if they have already dismissed the website as untrustworthy. Therefore, special attention was given to the design of the AnklePro website in order to increase this factor, as well as create a product that satisfied the client.

Design Brief To establish a consistent approach to the look and feel of the website, the clients were asked in an initial meeting how they would describe the ideal branding of this product. This led to the creation of the following list of keywords:

· Sporty/athletic · Elite · Motivating/aspirational · Recovery · Ease of use

These keywords were the basis upon which Nicholas Bourrier designed the website and graphic elements.

Logo A logo was designed as a means to create a brand for this product that was both consistent and professional. This logo was then incorporated throughout the various components of the site (ex: website banner, video watermark).

Inspiration The icon portion of the logo was designed to reflect the subject matter of the website, as well as incorporate symbolic elements to convey the client’s desired brand. The overall approach was to create it in the flat vector style that is often seen in sporting team logos. With this in mind, the starting point was a foot/ankle. It was placed in an active position (i.e: mid-step), to convey the idea of moving forward: forward with life; away from injury; hope for the next step. The Olympics came to mind as the height of elite athletics. Building on this, a search of Greek mythological characters related to athletics led to Hermes, who amongst others was a god of sport, speed, and land travel/running (Atsma, 2015). Some of Hermes’ most recognized symbols are his “Talaria” (winged sandals). This fact loaned itself to the topic due to the location of the symbol (on feet). Compression bandaging was selected as an indicator of sprains due to their widespread use in treating this injury. As well, they bear an abstract resemblance to lace-up sandals. However, in order to maintain the idea of recovery, the end of the bandage was shown floating off of the foot to symbolize moving past the need

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for treatment, and placed in a position that mirrors the wings of the Talaria. Although referenced to Hermes, wings are also associated with Nike/Victoria who is the goddess of victory (Atsma, 2015). Therefore, the reference to wings not only provides a sense of lightness and freedom, but can also be used to motivate visitors of the site to conquer their injury.

Colour Scheme

The colours were selected to reflect the client’s brief association and aspects of the participating institutions. Colour psychology was used to help elicit the desired mood of the site (Column Five, 2015). The following colours and their associated meanings were then selected:

• Orange: fun, motivating, Dutch national colour • Blue: dependable, trustworthy • Purple: elite, colour of the Elite Akademy logo

The blue and purple were combined to keep colour palette to two colours. The resulting shade of indigo also has the advantage of reflecting the ESP logo

Fig 2. Logo colour scheme and associated hexadecimal colour codes.

Rendering Following this brainstorm, several sketches were drawn; at which point the research team and client approved a final version. This was then turned into a vector format using “Adobe Illustrator”; incorporating the selected colour scheme. Adobe Illustrator is a vector graphic editing program used in graphic design (Adobe, 2015). Vector graphics are images that are built using mathematical equations instead of fixed pixels. As a result, they can be resized infinitely without losing quality (i.e.: becoming blurry). Therefore, they are the preferred method of creating design elements such as logos that need to be used in various settings (Olympus Press, 2015).

Typeface The site’s title was written in the royalty-free font: “Squares Bold”, created by Ivan Gladhikh (aka. Jovanny Lemonad) (the font file can be downloaded at: http://www.dafont.com/squares2.font). As the client predominantly treats a university athletic population, this font was selected for its octagonal shape similar to varsity sports lettering, while appearing sleeker than the stereotypical version. The words were then coloured to match the colour scheme. Finally, the icon was placed in the middle of words “ankle” and “pro”, with a slight overlay of the heel over the “P” to create depth of field.

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Fig 3. AnklePro Logo

Web-hosting To develop the AnklePro website, Wordpress was selected as a freely available hosting service based on its adaptability, ease-of-use. In addition to these factors, prior PAP products had been successfully created using this service (Dienemann and Le-Minh, 2015). The theme used as a basic framework upon which the site was built was: “Sela”. This theme was selected because of its clean and adjustable template. As a result of limited access to certain formatting components reserved for the paid version of the Wordpress service, the designer learned and implemented html and css coding. This assisted in designing a site that met the desired layout and appearance.

Building Blocks An important component to the layout of the protocol is the building block format of the progressions. To help distinguish one block from the next, they were framed in boxes that progressed in colour from red in Phase 1 to green in Phase 5. A chart Kusal shows his patients, which is split between a “red zone”, “yellow zone”, and “green zone”, inspired this decision. This chart gives a visual aid to let clients know where they are in their rehabilitation process. In using this as a basis for the appearance of the exercise program, Kusal’s patients may recognize the style of care they have been receiving, thereby infusing the site with an added level of client specificity

Fig 4. Building block colour scheme inspiration: Elite Akademy zones.

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Fig 5. Building block colour scheme and associated hexadecimal colour codes.

Language As requested by the client, the website should be easy to use. An aspect of this specified by Kusal, was that the information should be provided in layman’s terms. This would make it easier for patients to interact with the website, and understand the educational materials and instructions. This decision is also in line with the study by Wright et al (2014), which found that along with trust, effective communication between practitioner and patient helps with adherence. In instances where more scientific terminology were used, they were then explained so the user could still follow the content. In addition to using simple wording, the text is written in a conversational tone to bring a level of humanity and social interaction to the site. In this way, motivational comments and a fun, low-key atmosphere could be incorporated to make the time spent using the product more enjoyable. This tone is much in keeping with the client’s own approach when interacting with his patients.

Filming Filming of the instructional videos took place in the “skills lab” of the European School of Physiotherapy (room c0.33) from November 17 - 20, 2015. The videos to be filmed were scheduled across the week, and general scripting was planned in advance to help with cueing. From the research team, Jessica Boer and Sven Faber acted as models in the videos. With permission from the client, the models wore t-shirts with the ESP logo printed on them. The following equipment was used during filming:

• Camera (x1): Panasonic HC-V750 • Tripod (x1) • Memory card (x1): SanDisc 32GB MicroSD + Adapter • Lighting (2x): Bresser High Power LED Photo Light • 2x White Backdrops

Of the 395 takes filmed across the week, 37 videos were created. After filming, Nicholas Bourrier edited the videos and added the instructional voice-overs. This was accomplished using the film editing software Final Cut Pro X. Exercises that progress to each other were grouped together to diminish the total number of videos. These were then uploaded to youtube. Subsequently, these were embedded into the appropriate building blocks on the AnklePro site.

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Feedback To increase the quality of the AnklePro website, an online survey was sent to a cohort of individuals to get feedback that could be implemented during its creation. The site is predominantly meant for a patient population; however, physiotherapy students and health care providers in various fields, who may recommend the site to future patients, were also approached during this process. The form focused on elements that contribute to the quality and credibility of a website (Fogg 2002, Demers 2014). These included:

• Spelling and grammar • Working links • Means of contact • Logical layout and ease of navigation • Value of content • Transparency of author qualification, publication, and sources • Aesthetics • Media quality • Cross-browser compatibility

The form was mainly designed to collect qualitative feedback that could indicate potentially necessary alterations. Other than a multiple choice question on browser usage, the majority of the questions were stated in a yes/no format, with the affirmative indicative of “no problem”. In some instances, respondents were instructed to select the option “other” when a negative answer would require further clarification (ex: spelling mistakes, locations of broken links, etc.). The only quantitative measure was the concluding question involving a 10 point scale, upon which participants rated their likelihood of utilizing the website in the future (1=unlikely; 10=very likely). As the primary aim of the website is to be consulted as a tool, this was included to give an indication of the site’s overall quality and potential usefulness in practice. An average score of 7 was selected as a cut-off of acceptable quality. A final open comment section was included for general feedback.

Results A total of 32 Responses were collected from 28/12/2015 – 02/01/2016. A summary of the questions and results of the feedback form can be seen in appendix 2. The majority of respondents were using Google Chrome as their browser (62.5%). Of the yes/no questions, all but one remained above 90.6% (3/32) of “yes” answers. Only the question pertaining to the embedded videos did not, and receiving 7 negative answers. The average overall quality score was 8.25 ± 1.57, and one outlier responding with a 2.

Discussion Of the 7 negative responses regarding the embedded videos, 3 individuals specified that they could not see any videos on the page. This does not appear to be a result of cross-browser compatibility, as all three were using different browsers. It should be noted that one of these incidents involved a mobile phone instead of a computer, and the developers previously knew about the site’s lack of mobile-friendliness. It was not indicated what type of phone was being used. However upon investigation, apart from layout problems, the videos do show up on iphones, Android and Windows 8.1 phones. Otherwise, these seem to be isolated incidents unrelated to the central control of the website. The remainder of these responses mentioned that the volume of the audio could be louder (2), or referred to pages in which no video content had yet been uploaded (3). Other claims of broken links or pages, and spelling errors were double checked and fixed when necessary. Two individuals mentioned that the authors qualifications were not readily available, however no feedback was provided in the comment section. Nevertheless, the majority of answers indicated that this was not the case, and the relevant information is present in the “About Us” page, which is accessible through the menu bar.

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The one response stating that information was incorrect was in fact a comment that the individual did not have the educational background to answer the question. Therefore it was dismissed. Generally the outcomes regarding reference accessibility were positive. Of the two who responded negatively, one did not comment, while the other mentioned that they thought the in text citations were supposed to link to the reference page. However, this is not the case; and given the overall positive response, access to the “References” page via the menu appears to be clear. The high score provided to the overall quality question indicates promise for the future application of the website. The single 2 does not seem to indicate that the quality of the website is bad. Although it is possible the individual in question did not like the product, their score could also be due to a misunderstanding of the scale, or a reflection of their preference for a more supervised rehabilitation process. Building on the quality score, was the positive feedback received in the comments section. Overall these included compliments about the site. Feedback that came up repeatedly included: the design looking appealing and professional; the written information being engaging and clear; and positive responses to the short duration of the videos and clarity of instruction.

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Limitations of the AnklePro website Protocol A primary limitation when developing AnklePro’s self-directed exercise protocol was that the prescriptions were not based on a real patient. In order to create a product that was easy to use, and offered enough transferability between patients, some individualization had to be sacrificed. However, a disclaimer has been provided on the home page that stresses the importance for patients to review the AnklePro rehabilitation program with their specific physiotherapist prior to starting the program. This is of course if they were not initially directed to the site by said physiotherapist. In this way, the physiotherapist can veto prescriptions if necessary. Although a goal of the website is to diminish the intra-session time burden involved in exercise selection and education, patients are still expected to attend regular clinical appointments to receive other treatment modalities. Therefore, there is still the opportunity for patients to seek confirmation and guidance in person, should their uncertainties go beyond what is provided in AnklePro. By making the physiotherapist aware of the overall plan at the beginning of the process, they can pre-emptively make alterations to the program if their assessment deems them relevant, removing the need to do so later. At the very least, this can prepare them mentally for the potential roadblocks to come. Furthermore, once the physiotherapist has become aware of the website, their familiarity with the protocol will speed up the process with future patients. This disclaimer additionally has the advantage of instigating word-of-mouth promotion, thus allowing AnklePro to assist a wider population.

Content Production There were resource limitations while filming the content for the videos, in that the equipment and space available offered some unforeseen challenges. Firstly, the size and shape of the filming studio did not allow the camera to be placed far enough back to provide space to freely move while remaining in the frame. The results were instances where the models had to adjust the span of their exercises, sometimes leading to awkward looking execution or backdrop movements. As much as possible, props and camera angles were adjusted to create a forced perspective to maximize the space. Secondly, the two halves of the white backdrop had recently been attached to the wall at an inopportune spacing, creating visible folds and gaping. Angling and fixation of the backdrops was only able to mediate this to an extent, as can be seen in the videos. Lastly, there were not enough lighting fixtures to fully remove shadows from the models and background. While editing the footage, colour and brightness were altered to counteract a portion of this. During the editing process, it was noticed that the acting pace was faster than anticipated while filming. This meant that the instructions in some of the videos ended up faster than initially desired. Nevertheless, if necessary, the time burden of repeated viewings has been minimized by the short duration of the videos. In addition, feedback from the second survey provided several positive comments on the clarity of the instructions. Therefore, this limitation does not appear to be a hindrance to the quality of the product. This was also the first time that the team members had undertaken such a production. As such, the lack of prior experience with relevant skills (i.e.: ideal camera or light placement, film editing, and web design), in addition to the resource limitations mentioned earlier, may have influenced the quality of the final product. As outcomes of the feedback form were generally favourable, AnklePro appears to be a beneficial website offering useful resources for recovery. However, it is uncertain what discrepancies lie between the realized product, and a hypothetical one, where upon an experienced production crew would have been hired.

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A limitation to usability is the fact that the website is not mobile friendly. This was a result of the forced html design process. Though not ideal, the framing issues can be somewhat mitigated by turning the phone into landscape mode. This provides additional horizontal space for the blocks and videos to display more correctly. While ideally the website would be able to display across all platforms, computer and tablet screens are still able to display the content without issue. While unfortunate, the gains in design quality that led to this outcome were widely praised in the feedback. This aided in raising the professional appearance of the website, and thus potentially increased its credibility. Nevertheless, In an attempt to counteract the layout issues on mobile devices, the users are directed to the website’s youtube channel if they will not be using the site from a computer or tablet. The youtube channel has playlists that contain the exercises included within a given block. Additionally, the prescriptive parameters can be filled in to the printable exercise diary. A limitation of the quality control process was that the website was not yet complete when the survey was sent out. However, as the focus of the form was on fixing errors, it was able fulfill its purpose. It did so by bringing attention to aspects of the site that needed to be changed. Furthermore, it provided feedback that could be implemented through the remainder of the process. Through these actions it was able to raise the quality of the site. Although, related to the aspects that were presented online at the time, the overall quality score surpassed the pre-selected cut-off point. In combination with the positive general comments, this outcome may be generalizable to the finished product. A follow-up study of interest could investigate the practical application of the website, and measure improvements in the outcomes targeted by the protocol. This would provide further insight into the quality of the product, and feedback for content amelioration. A printable exercise diary was included to be used in conjunction with the protocol. Users, are instructed to keep notes on their workouts, both for their self-directed implementation, and so the physiotherapist can keep an eye on their progress when they have appointments. Although follow-up research may explore a variety of outcomes related to using the site, this built-in tool could also act as means collecting some of the subjective data.

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Conclusion Although the prescriptions provided in this website lack a degree of individuality, they are well founded on several sources of high-level research and professional experience. Furthermore, by using the selected building block framework that includes opportunities for self-testing, patients can easily follow the rehabilitation program while allowing for a degree of adaptability. Additionally, patients are provided with background information on the pathology, and insight into the reasoning behind prescriptive decisions. This transparent education may deepen patients’ understanding of the importance of proper rehabilitation, and thereby potentially improve their compliance. In combination with the accessible level at which the information is described, and positive feedback from potential users of the site; it is likely that AnklePro will be a good quality adjunct to the physiotherapeutic rehabilitation of grade 1 & 2 acute ankle sprains.

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Appendix 1: Pedro Scale

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Appendix 2: Feedback website

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European School of Physiotherapy

Amsterdam University of Applied Sciences | Hogeschool van Amsterdam

Tafelbergweg 51

1105 BD Amsterdam

The Netherlands

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