***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: STUDY DESIGN Prospect i ve inception cohort study of 62 consecutive patients seen in 2 orthopaedic clinics following ankle fracture . OBJECTIVES To investigate 4 putative predictors ( age , fracture classification , acute management  [ surgical or nonsurgical ] , and ankle dorsiflexion range of motion measured at the time of cast removal ) of outcome after ankle fracture and to develop simple predictive models of outcome after ankle fracture . BACKGROUND Ankle fracture is a common condition . However , few studies have investigated factors that predict outcome after ankle fracture . METHODS AND MEASURES Sixty-two consecutive subjects aged 17 or older with ankle fractures were recruited from 2 hospital orthopaedic clinics . Outcome measures recorded at 6 weeks and 6 months after cast removal included 2 functional question naires , patients ' ratings of global improvement , and a measure of ankle dorsiflexion . The predictive value of 4 variables selected a priori was analyzed using bivariate and stepwise multiple linear regression . RESULTS Ankle dorsiflexion and fracture classification predicted outcome 6 weeks and 6 months after cast removal for all outcome measures used ( P < .05 , r2 = 0.09 - 0.47 ) . Fracture management ( surgical or nonsurgical ) inconsistently predicted outcome at both 6 weeks and 6 months , and age did not predict outcome at either 6 weeks or 6 months after cast removal . The predictive models explain between 19 % and 58 % of the variance in outcomes 6 weeks after cast removal and 19 % to 52 % of the variance in outcomes 6 months after cast removal . CONCLUSION Ankle dorsiflexion measured at the time of cast removal and fracture classification are clinical ly significant predictors of outcome after ankle fracture ; however , much unexplained variation in outcomes still exists In a prospect i ve study of 321 consecutive cases of dislocation ankle fractures , operatively treated according to the AO ( ASIF ) principles , 306 cases ( 95 % ) were followed up two to six years after surgery . The infection rate was 1.8 % with no septic arthritis . The clinical results were " excellent and good " in 82 % , " acceptable " in 8 % , and " poor " in 10 % . Posttraumatic arthritis occurred in 14 % and was significantly more common among middle-aged women . There was a strong correlation between the degree of arthritis and the clinical result . A computer analysis ( AID ) revealed that the most decisive factors influencing the clinical result were the type of fracture , the accuracy of the reduction , and the sex of the patient . Exact reduction , rigid internal fixation  , early postoperative joint exercises  , and subsequent full weight-bearing  in a below-the-knee walking plaster are essential for a good end result of fracture-dislocations of the ankle joint BACKGROUND AND PURPOSE Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains . A r and omized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization , the anteroposterior glide on the talus , on increasing pain-free dorsiflexion and 3 gait variables : stride speed ( gait speed ) , step length , and single support time . SUBJECTS Forty-one subjects with acute ankle inversion sprains ( < 72 hours ) and no other injury to the lower limb entered the trial . METHODS Subjects were r and omly assigned to 1 of 2 treatment groups . The control group received a protocol of rest , ice , compression , and elevation ( RICE ) . The experimental group received the anteroposterior mobilization , using a force that avoided incurring any increase in pain , in addition to the RICE protocol . Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met , and all subjects were given a home program of continued RICE application . Outcomes were measured before and after each treatment . RESULTS The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion . The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions . The experimental group also had greater increases in stride speed during the first and third treatment sessions . DISCUSSION AND CONCLUSION Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone . Improvement in step length symmetry and single support time was similar in both groups OBJECTIVE To test the efficacy of low-level laser therapy on lateral ankle sprains as an addition to a st and ardized treatment regimen , a trial was conducted in which high-dose laser ( 5J/cm2 ) , low-dose laser ( 0.5J/cm2 ) , and placebo laser therapy ( 0J/cm2 ) at skin level were compared . DESIGN R and omized , double-blind , controlled clinical trial with a follow-up of 1 year . Patients , therapists , assessors , and analysts were blinded to the assigned treatment . SETTING An ambulatory care setting . PATIENTS After informed consent and verification of exclusion criteria , 217 patients with acute lateral ankle sprains were r and omized to three groups from September 1 , 1993 , through December 31 , 1995 . INTERVENTIONS Twelve treatments of 904 nm laser therapy in 4 weeks as an adjunct to a st and ardized treatment regimen of 4 weeks of brace therapy combined with st and ardized home exercises and advice . The laser therapy device used was a 904 nm Ga-As laser , with 25-watt peak power and 5,000 or 500Hz frequency , a pulse duration of 200nsec , and an irradiated area of 1cm2 . PRIMARY OUTCOME MEASURES Pain and function as reported by the patient . RESULTS Intention-to-treat analysis of the short-term results showed no statistically significant difference on the primary outcome measure , pain ( p = .41 ) , although the placebo group showed slightly less pain . Function was significantly better in the placebo group at 10 days ( p = .01 ) and 14 days ( p = .03 ) after r and omization . The placebo group also performed significantly better on days of sick leave ( p = .02 ) and at some points for hindrance in activities in daily life and pressure pain , as well as subjective recovery ( p = .05 ) . Intention-to-treat analysis showed that total days of absenteeism from work and sports were remarkably lower in the placebo group than in the laser groups , ranging from 3.7 to 5.3 and 6 to 8 days , respectively . The total number of relapses at 1 year in the low-dose laser group ( n = 22 ) was significantly higher ( p = .04 ) than in the other two groups ( high laser , n = 13 ; placebo , n = 13 ) . Subgroup analysis to correct for possible confounders did not alter these findings . CONCLUSIONS Neither high- nor low-dose laser therapy is effective in the treatment of lateral  ankle sprains BACKGROUND During the recovery period after acute ankle sprain , it is unclear whether conventional treatment should be supported by supervised exercise . AIM To evaluate the short- and long-term effectiveness of conventional treatment combined with supervised exercises compared with conventional treatment alone in patients with an acute ankle sprain . DESIGN R and omised controlled clinical trial . SETTING A total of 32 Dutch general practice s and the hospital emergency department . METHOD Adults with an acute lateral ankle sprain consulting general practice s or the hospital emergency department were allocated to either conventional treatment combined with supervised exercises or conventional treatment alone . Primary outcomes were subjective recovery ( 0 - 10 point scale ) and the occurrence of a resprain . Measurements were carried out at intake , 4 weeks , 8 weeks , 3 months , and 1 year after injury . Data were analysed using intention-to-treat analyses . RESULTS A total of 102 patients were enrolled and r and omised to either conventional treatment alone or conventional treatment combined with supervised exercise . There was no significant difference between treatment groups concerning subjective recovery or occurrence of resprains after 3 months and 1-year of follow-up . CONCLUSION Conventional treatment combined with supervised exercises compared to conventional treatment alone during the first year after an acute lateral ankle sprain does not lead to differences in the occurrence of resprains or in subjective recovery The sport and leisure industry is one of the fastest growing sectors of the business market . It has been estimated that each year 1–1.5 million people attend accident and emergency ( A&E ) departments in Britain,1 and 3.7 million people present to emergency departments in the USA,2 with an injury related to sport and exercise . With these levels of presentation A&E departments can provide valuable research into the demographics of sports related injuries . There are numerous studies regarding the incidence of sports injuries within a community or defined population , however , there is little modern research investigating specifically the nature of sports injuries presenting to an A&E department in Britain.3–6 Other studies have been published from Irel and , 7,8 Europe,9–11 Australasia,12,13 Asia,14 and more recently North America.2,15 This observational study aim ed to determine the incidence of attendance , types of injuries , nature of the sport involved , and the arrangements for follow up management in patients presenting , with an injury related to sport , to the A&E department of Crosshouse Hospital , Kilmarnock . The study took place prospect ively over a period of three months from February to April 1999 and included people 16 years of age or over . Any patient presenting with an injury attributable to participation in organised sport or recreational activity had their details and A&E number noted by the triage nurse on duty . Only new attendances were included . Relevant A&E cards Background : Lateral ligament ankle sprains are the single most common sports injury . Objective : To determine the functional outcome of the ankle joint after a moderate or severe inversion injury , comparing st and ard treatment with an elastic support b and age against an Aircast ankle brace . Design : Prospect i ve , r and omised controlled trial . Setting : Two accident and emergency departments . Method : Fifty patients presenting consecutively were r and omised into two equal groups : one group was treated with an elastic support b and age and the other with an Aircast ankle brace . All patients were given a st and ardised advice sheet referring to rest , ice , compression , and elevation . Patients were review ed after 48–72 hours , 10 days , and one month . Primary outcome measure : Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method ( maximum score 90 ) . Secondary outcome measure : The difference in ankle girth ( swelling ) and pain score at 10 days . Results : Seventeen patients in the elastic support b and age group ( six defaulted , two excluded ) and 18 patients in the Aircast ankle brace group ( six defaulted , one excluded ) completed the study . There were no significant differences between the two groups at presentation in terms of age ( mean 35.3 and 32.6 years respectively ) , sex , dominant leg , left or right ankle injured , previous injury , time to presentation ( median three and four hours respectively ) , difference in ankle girth ( mean 14.5 and 14.3 mm respectively ) , and pain scores ( mean 6.2 and 5.8 respectively ) . The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic b and age group at 10 days ( mean 50 v 35 , p = 0.028 , 95 % confidence interval ( CI ) 1.7 to 27.7 ) and one month ( mean 68 v 55 , p = 0.029 , 95 % CI 1.4 to 24.8 ) ( Student ’s t test ) . There was no difference between the groups in the secondary outcome measures ( swelling , p = 0.09 ; pain , p = 0.07 ) . When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors , the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days ( p = 0.009 ) and one month ( p = 0.024 ) . Conclusion : The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with st and ard management with an elastic support b and age OBJECTIVE The primary aim of this study was to determine the effectiveness and cost-effectiveness of adding manual therapy to a physiotherapy programme for ankle fracture . DESIGN Assessor-blinded r and omized controlled trial . PARTICIPANTS Ninety-four adults were recruited within one week of cast removal for isolated ankle fracture . Inclusion criteria were : they were able to weight-bear as tolerated or partial weight-bear , were referred for physiotherapy , and experienced pain . Ninety-one participants completed the study . METHODS Participants were r and omly allocated to receive manual therapy ( anterior-posterior joint mobilization over the talus ) plus a st and ard physiotherapy programme ( experimental ) , or the st and ard physiotherapy programme only ( control ) . They were assessed by a blinded assessor at baseline , and at 4 , 12 and 24 weeks . The main outcomes were activity limitation and quality of life . Information on costs and healthcare utilization was collected every 4 weeks up to 24 weeks . RESULTS There were no clinical ly worthwhile differences in activity limitation or quality of life between groups at any time-point . There was also no between-group difference in quality -adjust 
    Output:
    
After ankle sprain , there is evidence for the use of functional support and non-steroidal anti-inflammatory drugs .
There is weak evidence suggesting that the use of manual therapy may lead to positive short-term effects .
Electro-physical agents do not appear to enhance outcomes and are not recommended .
Exercise may reduce the occurrence of recurrent ankle sprains and may be effective in managing chronic ankle instability .
After surgical fixation for ankle fracture , an early introduction of activity , administered via early weight-bearing or exercise during the immobilization period , may lead to better outcomes .
However , the use of a brace or orthosis to enable exercise during the immobilization period may also lead to a higher rate of adverse events , suggesting that this treatment regimen needs to be applied judiciously .