I posted three links, and didn't realize they would run together. Here they are separately:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784925/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690789/

http://www.hindawi.com/journals/ecam/aip/462840/

Yes alternate theraphy like acupuncture, cupping ( Hijama) , KT tape will deffinatly help in healing ligaments rupture. The nutrisanal theraphy also additionally help musals and tendants to heal fast and in natural ways.

I have gone through above mention sites. Dr. Khalifa uses all advance testing method to evalute the damage of knees. But if you know reiki or pranic healing you will immidialty sence the damge and impect of it. If you annalised the treatment of Dr. Khalifa for healing he is useing massage and pressure techniques and triger points theraphy. On top of it he is colaborating nurology of nerves and stimilate it to communicate with mind and body faster for healing. This you can do it with acupuncture theraphy. With combination all this theraphies person will ger faster better and natural healing with cost effective budget.

Ambarish,

Thank you for your comments.

Some of my patients seemed to recover completely from old ligament injuries after one session. I wondered, what is happening? When I saw the research on Khalifa, I realized there might be some merit in what I was finding. But to write up my case reports, I know I need to find more published research. Reiki and pranic healing and other energetic modalities have shown no compelling evidence for ligament tears. Khalifa, although he uses intense pressure, does not claim he is doing Trigger Point therapy. TP has different indicators, e.g. referred pain from localized hypertonic or hyperirritable spots in muscles, and is not applied to ligaments which are densely innervated, but have low vascularization.

I totally agree with you that people could get better with manual therapies, and it would be more cost effective than surgery, and possibly have better long term outcomes.

I am still hoping to find published research with other manual therapies for ligament tears. However, in preparing this response to you, I have just found reference to a book Tendon and Ligament Healing by William Weintraub. My experiences are similar to his reports (via Google Books), and to what you wrote. He makes note of the conventional limitations in seeing these tissues as static.

Thank you, again,

Rosi

Hi,

look for "fasziendystorsionsmodell nach typaldos" the evidence is quite weak but they try to do more science at the moment. In my opinion they use, just like khalifa does, the wrong mechanism of action in their thinking models...

Hi, Bernhard,

Thank you for your comments. I found Stephen Typaldos' Fascial Distortion Model (FDM) to be quite interesting, and lacking in basic science. The writing I can access seems to make broad sweeping generalizations about how comprehensive their solutions are. It consequently dismisses other approaches that have been well researched and found to be of value clinically for those injuries. And it fails to have peer reviewed literature to back up its claims. The case reports are impressive as anecdotes, however.

Have you studied FDM? Have you applied it? To what conditions, with what results? What do you find to be incorrect in their thinking? What do you believe to be the correct method of action in what they are accomplishing?

All the best, Rosi

Hi,

actually I know certain parts of it and I made a course at a congress in Salzburg two years ago. Their reasoning processe is oriented rather structural and experience based. They completely forget the massive input into the dorsal horn of the spinal cord you are applying by using such a painful technique. Anyway this might be the reason why it works but in many cases i would never use these techinques. Till now no morphological evidence exists that can prove the model of socalled "hernias" and "triggerbands".

Kind regards,

Bernhard

Before we ask research for the treatment of chronic sprains we need research explaining and describing exactly what a chronic sprain is and how it should be diagnosed. Being someone who treats back and neck problems exclusively for 35 years, I've seen that term used as a junk drawer filled with the unexplainable pains that are not clearly defined by MRIs, or neuralgias. Many of these "sprains" are probably muscle contractures, facet imbrications, spinal misalignments , superior articulating processes invading intervertebral foramina, Iliac or sacral subluxations, etc....In our center, we use different physical modalities and treatments for each of these conditions very effectively. Unfortunately a simple medline search on spinal alignment usually is associated with surgical treatment, not non-surgical physical protocols. Here are a few references describing common structural problems associated with pathology:

Spine (Phila Pa 1976). 2013 Dec 30. [Epub ahead of print]

Three Dimensional Spino-Pelvic Relative Alignment in Adolescent Idiopathic Scoliosis.

Pasha S, Aubin CE, Sangole AP, Labelle H, Parent S, Mac Thiong JM.

Increased pelvic incidence May lead to arthritis and sagittal orientation of the facet joints at the lower lumbar spine.

Jentzsch T, Geiger J, Bouaicha S, Slankamenac K, Nguyen-Kim TD, Werner CL.

Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy.

Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, Patel AA, Traynelis VC, Kim HJ, Shaffrey CI, Smith JS, Lafage V

Unfortunately references like these are infrequent and treatments have focused on surgery rather than physical modalities.

excuse me, let me add the links:

http://www.ncbi.nlm.nih.gov/pubmed/24384650

http://www.ncbi.nlm.nih.gov/pubmed/24113358

http://www.ncbi.nlm.nih.gov/pubmed/?term=Increased+pelvic+incidence+May+lead+to+arthritis+and+sagittal+orientation+of+the+facet+joints+at+the+lower+lumbar+spine.

Bernhard,

Thank you for your comments. Did you mean the massive input to the dorsal horn from so much pressure by the Khalifa Method?

Actually yes, seen from the neurophysiological view you can´t deny such an input and it´s ongoing process in the central nervous system (including descending inhibition and the role of the periaquaductal grey). :-)

Rick,

I actually meant grade 2 or 3 sprain, as in partial or complete tears in ligaments. I rely on patients reporting their doctor's diagnosis. And you are right, what they say may well be vague or inaccurate, so for research reporting, it would be better to obtain a physician's ICD-9 statement if I can.

As for "chronic" I meant unhealed and continuing to be painful after conservative treatment, after the acute phase of an injury has subsided. I cannot diagnose, so cannot make the distinctions you make as a physician. I recognize that surgery is a preferred treatment when people aren't aware of other options.

Regards,

Rosi

We just recently completed an RCT on two different manual therapies (ankle joint mobilizations, plantar massage) and calf stretching on individuals with chronic ankle instability.  We have also done some other massage work in those with chronic ankle instability.  Ankle joint mobilizations have also been used a great deal for acute lateral ankle sprains and chronic ankle instability.  The research consistently shows that joint mobs, are beneficial for a number of different outcomes and the magnitude of the improvements seems to increase over time.  Massage, while less studied also appears effective.

http://www.ncbi.nlm.nih.gov/pubmed/26717498

http://www.ncbi.nlm.nih.gov/pubmed/?term=massage+and+ankle+instability

http://www.ncbi.nlm.nih.gov/pubmed/?term=joint+mobilizations+and+ankle+instability

Dr. Wikstrom,

Thank you for these comments. I have been doing a case study series on manual therapy for ligament injuries. I had read several of your other articles, and cited them in a case report (I recently submitted the abstract), without realizing you were the common author.

I am grateful for your calling attention to"Sensory-Targeted Ankle Rehabilitation Strategies (STARS) for Chronic Ankle Instability." It is both new and directly relevant. I have a few questions.

You did six 5-minute STARS treatments over the course of two weeks. My treatments have mostly been of longer duration, 45-60 min. When symptoms resolve completely, it is usually in one, sometimes two sessions. Do you mind sharing your reasoning for your dosage and frequency? It would not be convenient for my patients. Perhaps it works as a feature of your clinical environment?

I will be rethinking some other questions, especially regarding hypothesis of possible mechanism for the benefits you report and what I have seen.

Thank you for the inspiration.

Regards,

Rosi

Rosi,

I don't mind sharing at all.  The primary rationale for our dosage and frequency were to make the treatments clinically feasible within our primary field of athletic training were providers sometimes have limited time with individual patients.  However, we also wanted to build in multiple treatment sessions so that we could potentially train/improve the sensory system on top of treating the symptoms.  Much of the literature suggests that while a single session, of shorter duration, could be effective, multiple treatments result in a more meaningful response in select outcomes.  This was our first effort to determine if the larger responses were train to altering motor control programs within the patient by improving the degrees of freedom available to them.  Based on these results, we believe that is possible and are now working on the next steps to confirm these results.  I hope this helps

Erik

Dr. Wikstrom,

Your comments and papers have been invaluable to me. I have changed dosage and frequency with attention to increased proprioception, added resisted joint mobilization exercises to build ankle stability, and increase sensorimotor awareness for five of my patients. They have CAI of 5-40 years duration. Some have complications to the CAI-- knees, hips, back, neck. Two have had surgeries with more complications. They are mostly very happy with the new protocol, with pain relief, increased perception of stability, and proximal benefits up to and including relief of neck tension.

The one exception is someone who is pleased after the sessions, but who has difficulty with proprioceptive awareness of her instability. She becomes free of pain, returns to dance, and reinjures. I understand from the research that motor rehabilitation used to be the standard, and you are shifting to sensorimotor training to prevent reinjury. She also has ligamentous laxity. Comments?

In gratitude,

Rosi

Dr. Wikstrom,

Is your hypothesis of mechanism for ATFL and other ligament healing the improvement in sensory feedback and the neurological consequences? Or do you steer clear of mechanism explanations with the emphasis on strategies for functional improvement? I was going to ask this question in lengthy detail in January, but decided to delve into the literature and test out the change of methods you recommended first.

Regards,

Rosi

Hi Rosi,

To your  first post/comment- We are continuing to explore sensory targeted treatments because we believe that traditional rehabilitation (motor based) has been missing something.  Having said that, we are not advocating for sensory only.  Rather, we believe that a combination of the sensory and motor interventions will hopefully be the magic bullet as the treatments will target issues on both sides of the equation. 

We have also been exploring the development of clinical prediction rules (hopefully some of these papers will be out soon) because we have found that while the group means improved after treatment, some patients had much larger responses than others, as one might expect.  So we are hoping to identify characteristics that will allow clinicians to have a higher probability of success for a given treatment.

To your specific patient that has good immediate results but continues to re injure.  They are likely in need of a continual maintenance program that includes motor rehabilitation, such as balance training exercises.  The idea of the sensory targeted treatments is to stimulate the sensory receptors and/or improve ROM so that the CNS has more degrees of freedom to work with while developing motor programs.  But your danced may need practice (balance training) to help her learn how to integrate that new information (more sensory information and/or ROM) into her movement programs.

To your second post/comment:  I have two thoughts on ligament healing.  1) we are generally to quick to return someone to participation after injury.  Unlike the knee or other examples, pain and basic function return relatively quickly at the ankle but much faster than the soft tissue can heal and therefore we may be placing too much stress on a damaged ATFL too soon.  2)  With an ATFL injury (or any other soft tissue injury), we know that there will be a level of deafferentation.  I believe (and we have some preliminary data to support this hypothesis) that ankle sprains/CAI limit an individuals ability to dynamically reweight among sensory and somatosensory inputs.  Sensory targeted treatments may help restore function to damaged receptors and/or improve the ability of these individuals to reweight sensory information (i.e. rely more heavily on sensory input from the plantar aspect of the foot instead of the receptors in the lateral ligaments/capsule).

Ultimately, we want functional improvement.  But we are also interested in the mechanisms so that we can refine our strategies to get more robust functional gains.  I hope this helps

Erik