Letter to Editor on Effect of Aquatic Versus Conventional Physical Therapy Program on Ankle Sprain Grade III in Elite Athletes: Randomized Controlled trial

Dear Editor

We read with great interest the article by Maryam [1]. titled “Effect of aquatic versus conventional physical therapy program on ankle sprain grade III in elite athletes: A randomized controlled trial,” recently published in the esteemed journal Journal of Orthopaedic Surgery and Research [1]. We commend the authors for their effort in conducting this experimental study on elite athletes with grade III ankle sprains, aiming for faster recovery and return to sports. This work is valuable, as most previous studies have focused on grade I and II sprains with similar interventions and outcome measures. However, we have concerns regarding the intervention and rehabilitation aspects, and greater clarity in these areas could have strengthened the study’s findings and contributions to athlete rehabilitation. Firstly, as the authors aimed to compare land-based and aquatic training across several outcome measures-such as pain, balance, functional performance, agility, lower limb muscle strength, and time to return to sport-the title could have been more precise by highlighting these outcome measures according to the PICO (Population, Intervention, Comparison, Outcome), providing a clearer and more informative overview at first glance. Additionally, there is no clear indication of which outcomes are primary or secondary, which could have influenced the study’s results. Secondly, while the authors used the Visual Analog Scale (VAS) to measure pain intensity, there was no mention of baseline inclusion criteria for VAS scores to ensure that a significant change could be detected among participants [2]. Thirdly, while the authors mention using Low-LASER therapy for pain management in the first week, specifying the dosage parameters would have been helpful. Additionally, a clearer description of the type of bracing or external support used-whether below knee cast, rigid brace or tape, as well as details on the occupational training and lymphatic drainage, would provide greater clarity on the intervention.

The authors might consider highlighting the need for protected weight-bearing in severe ankle sprains, and perhaps reconsider the inclusion of towel curls in the first week. In the following weeks of land-based training, which includes resistance exercises, balance, proprioception, and manual therapy, providing more details on the number of sets and repetitions for each exercise would offer clearer guidance [3]. Additionally, further clarification on the progression and type of resistance used in the training would align well with previous studies [3-5]. Lastly, a clearer description or images of the aquatic therapy equipment, along with details on exercise repetitions and sets, would enhance the study’s clarity, as seen in previous pilot studies [4]. Additionally, noticeable baseline differences between the groups in the Single Hop, Triple Hop, Cross-Over Hop, Illinois Agility, and Agility T-tests should have been addressed to clarify their impact on the study’s results. I hope this letter is received as a constructive expression of opinion, highlighting diverse treatment modalities in rehabilitation, offering clinical insights, and suggesting avenues for future research into the ongoing debate of aquatic versus land-based training, with the aim of addressing these concerns and providing more conclusive evidence.

Acknowledgement

None.

Conflict of Interest

None.

References

• Sadaak MM, AbdElMageed SF, Ibrahim MM (2024) Effect of aquatic versus conventional physical therapy program on ankle sprain grade III in elite athletes: randomized controlled trial. J Orthop Surg Res 19(1): 400.
• White IR, Thompson SG (2005) Adjusting for partially missing baseline measurements in randomized trials. Stat Med 24(7): 993-1007.
• Brotzman SB, Manske RC (2011) Clinical orthopaedic rehabilitation e-book: An evidence-based approach-expert consult. Elsevier Health Sciences.
• Kim E, Kim T, Kang H, Lee J, Childers MK (2010) Aquatic versus land-based exercises as early functional rehabilitation for elite athletes with acute lower extremity ligament injury: a pilot study. PM&R 2(8): 703-712.
• Wang H, Yu H, Kim YH, Kan W (2021) Comparison of the effect of resistance and balance training on isokinetic eversion strength, dynamic balance, hop test, and ankle score in ankle sprain. Life 11(4): 307.