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Indian Journal of Physiotherapy and Occupational Therapy

A comparative study on the efficacy of pulsed electromagnetic field therapy and interferential therapy in the management of ankle sprains

Author(s): Sharma Bhakti, Yadav Vikram Singh, Sandhu Jaspal Singh

Vol. 1, No. 4 (2007-10 - 2007-12)

Print-ISSN: 0973-5666, Electronic - ISSN: 0973-5674

Sharma Bhakti, Yadav Vikram Singh, Sandhu Jaspal Singh

Department of Sports Medicine and Physiotherapy Guru Nanak Dev University, Amritsar, Punjab (India)

ABSTRACT

Aim: The purpose of the study was to compare the efficacy of pulsed electromagnetic field therapy and interferential therapy in treatment of lateral ligament ankle sprains.
Method: 30 patients of age 20-30 years, suffering from Grade I and Grade II ankle sprains in past 2-3 weeks were randomized into 3 equal groups. X-rays were taken to rule out fractures. Group I was treated with pulsed electromagnetic field therapy (PEMF) along with isometric and crepe, Group II was treated with interferential therapy along with isometric and crepe. The modalities were applied for 30 minutes and 12 sessions were given on consecutive days, electrodes were placed on ankle. The outcome was based on self-reported pain using Visual Analogue scale and Manchester foot and ankle disability index. The pain was assessed on 0, 4th, 8th and 12th day using Visual analogue scale. Manchester scores were assessed on 0 and 12th day.
Results: Analyzed by students unpaired ‘t’ test. Intergroup comparison between group I and group II on 12th day of treatment showed significant improvement with p=0.02. Intergroup comparison between group II and group III, and group I and group III on 12th day of treatment showed highly significant improvement with p=0.000 and p=0.001 respectively. There were more significant improvements in PEMF group as compared to interferential group and controls. In between interferential therapy and controls, the former was more beneficial than latter. Conclusion: PEMF proved to be more beneficial than interferential therapy in the management of ankle sprains.

Keywords : Pulsed electromagnetic field therapy, Interferential therapy, Ankle sprains.

INTRODUCTION

Lateral ankle sprain is one of the most common injury among athletes and other active adults. According to Brooks et al (1981) the incidence of lateral ankle sprain is approximately, 1 per 10000 people per day. There are 17-20 % of ankle injuries in sports that involve jumping and cutting movements such as basketball, volleyball and soccer (Fong DT et at, 2007). Approximately 2\3rd of ankle sprains are isolated injuries of anterior talo-fibular ligament (Brostrom et al, 1966). It can be classified into 3 grades of severity, with grade 1 being the least and grade 3 being the most severe. A mild ankle sprain presents with minimal swelling, localized tenderness, and minor functional deficit. This type of injury generally does not require X-ray examination. Moderate and severe ankle sprains encompass a spectrum of significant pain, swelling, haematoma formation, difficulty or inability to weight bear and degree of functional impairment. A radiograph is required to exclude associated fractures (SH Boyce et al, 2005).

The aim of this study was to determine reduction of pain in mild to moderate ankle sprains, comparing the effect of pulsed electromagnetic field therapy with interferential therapy in treatment of ankle sprains. Pulsed electromagnetic field therapy is a combination of low frequency pulsating electromagnetic and electric field, it mainly influences the ions, dipoles and the molecules of insulators. PEMF relieves the chronic discomfort and aids in natural healing process. The pulsed electromagnetic field was produced using ACETRA 3000, DENMARK. The interferential therapy is a form of electrical treatment in which two medium frequency currents are used to produce a low frequency effect. An interference effect is produced when the two currents cross in patient’s tissue. Interferential therapy assists in pain relief and increases the local circulation.

Method

Setting

The study was conducted in Health center of Punjab armed police campus, Jalandhar and Government sports and art college, Jalandhar.

STUDY DESIGN

The sample of the study was confined to a group of 30 athletes who suffered from ankle sprain in past 2-3 weeks and were randomly divided into experimental (n=20) and control (n=10) groups. All the athletes included in the study were in the age group of 20-30 years and they participated in international, national, state and university level competitions. The subjects gave their informed consent before participating in the study. They were divided into following groups:

Group –I: Pulsed electromagnetic field therapy (Isometric and Crepe)

Group-II: Interferential Therapy (Isometric and Crepe)

Group-III: Controls (Isometric and Crepe)

The following inclusion criteria were applied: The subjects included in the study were in the age group of 20-30 years. Only sports persons (both male and female) were included. They must have suffered grade I and grade II lateral ankle sprains. X-ray was done to rule out fractures around ankle joint. The individuals on medications, mental or psychological disorders, peripheral neuropathy, myopathy, neuro-vascular complications, and metal implants were excluded.

OUTCOME MEASURES

The outcome was measured using Visual Analogue Scale and Manchester foot and ankle disability index. The Visual Analogue Scale is a 10 cm horizontal line, which is anchored at each end, with the left end anchor (i.e.1cm) representing minimum score (minimum pain) and right end anchor (i.e.10cm) representing maximum score (maximum pain). The patient was asked to rate his or her pain by means of a vertical mark, which intersects the Visual Analogue Scale line at an appropriate point. It was recorded on 0, 4, 8 and 12th day.

Manchester foot and ankle disability index was designed by Sheri A. Hale to provide a quantitative measure of foot and ankle disability. From a maximum score of 136, points are given for 2 categories (i.e.) scores for activities of daily living (104 points) and scores for sports activities (32 points). Following table 1 outlines the Manchester foot and ankle disability scoring scale.

Foot and Ankle Disability Index Item Foot and Ankle Disability Index Sport Items
• Standing • Running
• Walking on even ground • Jumping
• Walking on even ground without shoes • Landing
• Walking up hills • Squatting and Stopping Quickly
• Walking down hills • Cutting, Lateral Movements
• Going up stairs • Low-Impact Activities
• Going down stairs • Ability to perform activity with your normal technique
• Walking on uneven ground • Ability to participate in your desired sport as long as you would like
• Stepping up and down curves
• Squatting
• Sleeping
• Coming up on your toes
• Walking initially
• Waling 5 minutes or less
• Walking approximately 10 minutes
• Walking 15 minutes or greater
• Home responsibilities
• Activities of daily living
• Personal Care
• Light to moderate work (standing, walking)
• Heavy work (push/pulling, climbing, carrying)
• Recreational activities
• General level of pain
• Pain at rest
• Pain during your normal activity
• Pain first thing in the morning

Patients select the statement, which most closely describes their condition within the past week (i) no difficulty at all (4 points), (ii) Slight difficulty (3 points) (iii) Moderate difficulty (2 points), (iv) Extreme difficulty (1 point), (v) unable to do (0 points), (vi) N/A (not applicable).

DATA ANALYSIS

To analyse changes between each group after the intervention period, the raw data were used and analyzed with the students unpaired ‘t’ test. For statistical analysis, the software SPSS 14.0 was used. The level of significance was set of p0.05 for all comparison.

RESULTS

Of the 30 patients enrolled into the study, 25 (83%) were male and 5(17%) female. The age was 20-30 years. Left and right ankles were injured equally. Twenty five (83%) of the patients were right leg dominant, and 13 (43%) had sustained a previous injury to their ankle. All the injuries were sports related.

Table 1: Comparison of VAS on 0, 4th, 8th and 12th day in 3 groups.

Graph 1: Comparison of VAS (pain scores) on 0,4th, 8th and 12th day in 3 groups.

Intergroup comparison of VAS between group I and group II, group II and group III and group I and group III on 0 day showed no significant differences.

Intergroup comparison of VAS between group I and group II after 8th day of treatment showed significant differences in the mean values of VAS scores with p=0.03

Intergroup comparison between group II and group III, after 4thand12th of treatment showed significant differences in the mean values of VAS scores with p=0.04 and 0.004 respectively.

Intergroup comparison between group I and group III after 4th and 8th day of treatment showed significant differences in the mean values of VAS scores with p=0.002 and 0.002 respectively. Highly significant differences were observed on 12th day of treatment with p=0.000.

Table 2: Comparison of VAS (pain scores) on 0, 4th, 8th and 12th day in 3 groups.

Graph2: Comparison of Machester foot and ankle disability scores on 0 and 12th day in 3 groups.

Intergroup comparison of Manchester scores between group I and group II, group II and group III and group I and group III on 0 day showed no significant differences.

Intergroup comparison of Manchester score between group I and group II on 12th day of treatment showed significant differences in the mean values of Manchester score with p=0.02.

Intergroup comparison between group II and group III on 12th of treatment showed highly significant differences in the mean values of Manchester score with p=0.001

Intergroup comparison between group I and group III on 12th day of treatment showed highly significant differences in the mean values of Manchester score with p=0.000.

Discussion

A sprained ankle is an extremely common injury seen in sports that involve jumping and cutting movements such as basketball, hockey, football, athletics and gymnastics. It affects a wide age group and can result in considerable disability and interference in the everyday lives of sports person. The treatment goal for a competitive athlete will include early and effective return to sport with no residual symptoms of ankle sprain.

However, despite their regular occurrence, management of this injury varies widely between accident and emergency departments and often between therapist working in the same department. There is as yet no “Gold standard” method of management used universally. Instead therapists rely on a combination of personal experience and clinical judgment.

In the present study management strategies were divided into three categories:

  • Pulsed electromagnetic field therapy group
  • Interferential therapy group
  • Controls (Isometrics and crepe).

All the groups showed significant improvement overtime, in pain and disability scores. In the present study, the patients treated with PEMF showed significant improvement in pain and disability scores.

It has been suggested that pain may be due to accumulation of waste products and metabolites in the tissues (John Low and Ann Reed, 2000), which includes prostaglandins and bradykinins. It was also suggested that increased blood flow due to the effects of modalities, washes out some of the pain provoking metabolites, resulting from tissue injury. So pain relief due to PEMF could be attributed to the reason that PEMF augments angiogenesis, a process critical for successful healing of various tissues. PEMF augments angiogenesis primarily by stimulating endothelial release of FGF-2, inducing paracine and autocrine changes in the surrounding tissue (Tepper OM et al, 2004). Angiogenesis increases blood flow and promotes healing.

PEMF normalizes the potential across the membrane which is necessary for the cell to perform its metabolic processes and it ‘stirs’ ions, molecules, membranes and perhaps the cell itself, thus accelerating the phagocytic activity, enzymatic activity and the transport across the cell membranes. This accounts for the evident acceleration of anti-inflammatory and healing processes.

Interferential therapy group also showed significant improvement regarding pain and disability. It causes increase in local circulation, which may be produced by either local pumping effect of stimulated muscles or the effect of autonomic nervous system on blood vessels. Increased blood flow may help in removing chemicals from the area, which are stimulating nociceptors as studied by Jorge S et al (2006). It also provides pain relief by ‘Pain gate mechanism’.

The Manchester foot and ankle disability scoring scale was used, as it provided a practical and reproducible method of assessing ankle joint function. The results of Manchester foot and ankle disability index were more significant than VAS (pain scores) because it is a subjective method. All the groups showed significant results, but PEMF proved to be the most effective one in comparison to interferential therapy and controls. Reason for this improvement might be due to better healing of injured site after treatment with PEMF in comparison to interferential therapy. As PEMF promotes healing by angiogenesis, accelerates phagocytic activity, enzymatic activity and treatment across membranes. PEMF works on micro level where as IFT works on macro level.

CONCLUSION

All the groups showed significant improvement overtime in Visual Analogue Scale (pain scores) and Manchester foot and Ankle disability scores. But from the results it can be stated that pulsed electromagnetic field therapy proved to be the most effective in comparison to interferential therapy and controls. In between interferential therapy and controls, the former is more beneficial than the latter. Hence, the present study signifies that because of the beneficial effects of PEMF it can be used for the management of ankle sprains.

Table-1: Comparison of VAS on 0, 4th, 8th and 12th day in 3 group.

VAS Group I Group II Group III ‘t’ value
Mean S.D. Mean S.D. Mean S.D. tI-II tII-III tI-III
0 day 8 2.35 8.9 1.66 8.7 1.64 0.98 0.27 0.77
4th day 4.9 2.28 6.3 1.88 7.9 1.19 1.49 2.26* 3.68**
8th day 2.9 2.18 4.9 1.37 6.5 2.7 2.45* 1.97 3.70**
12th day 1 2.16 2.3 1.70 4.7 1.49 1.52 3.35** 4.52***
* 0.05, ** 0.01, *** 0.001

Table-2: Comparison of Manchester foot and ankle disability scores on 0 and 12th day in 3 groups.

VAS Group I Group II Group III ‘t’ value
Mean S.D. Mean S.D. Mean S.D. tI-II tII-III tI-III
0 day 62.60 20.13 55.30 13.27 56.50 13.06 0.96 0.20 0.80
12th day 120.60 18.81 102.40 12.50 81.70 11.68 2.54* 3.86*** 5.55***
* 0.05, ** 0.01, *** 0.001

Graph 1: Comparison of VAS (pain scores) on 0, 4th, 8th and 12th day in 3 groups.

Comparison of VAS (pain scores) on 0,4th, 8th and 12th day

Graph2: Comparison of Machester foot and ankle disability scores on 0 and 12th day in 3 groups.

Comparison of VAS (pain scores) on 0,4th, 8th and 12th day

REFERENCES

  1. Boyce, SH and Quigley, MA: Management of ankle sprains: a randomized controlled trial of the treatment of inversion injuries using an elastic support bandage or an Air cast ankle brace. British Journal of Sports Medicine, 39: 91-96, 2005.
  2. Brooks, C and Potter, BT: Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. B.M.J., 282: 606-607, 1981.
  3. Brostrom L: Sprained ankle: Treatment and prognosis in recent ligament injuries. Acta. Chin. Scad. , 132: 537-550, 1996.
  4. Fong, DT and Hong, Y: A systemic review on ankle injury and ankle sprain in sports. Sports Med., 37(1): 73-94, (2007)
  5. Hale, SA: Reliability and sensitivity of the foot and ankle disability index in subjects with chronic ankle instability. Journal of Athletic Training, 40(1): 35-40, 2005.
  6. Jorge, S and Parada, CA: Interferential therapy produces anti nociception during application in various models Inflammatory pain. Journal of Physical Therapy, 8: pp 6 ,2006.
  7. John low , Ann reed(2000): Electrotherapy explained, principle and practice. 3rd edition, Butterworth (London),pp233.
  8. Tepper, OM and Callaghem, MJ: Electromagnetic fields increase in vitro and in vivo angiogenesis through endothelial release of FGF-2 . F.A.S.E.B.J., 18(11): 1231-1233, 2004
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