Effects of joint mobilization on chronic ankle instability: a randomized controlled trial

Abstract

Purpose: To evaluate the effects of joint mobilization, in which movement is applied to the ankle's dorsiflexion range of motion, on dynamic postural control and on the self-reported instability of patients with chronic ankle instability (CAI). Methods: A double-blind, placebo-controlled, randomized trial with repeated measures and a follow-up period. Ninety patients with a history of recurrent ankle sprain, self-reported instability, and a limited dorsiflexion range of motion, were randomly assigned to either the intervention group (Joint Mobilizations, 3 weeks, two sessions per week) the placebo group (Sham Mobilizations, same duration as joint mobilization) or the control group, with a 6 months follow-up. Dorsiflexion Range of Motion (DFROM), Star Excursion Balance Test (SEBT) and CAI Tool (CAIT) were outcome measures. A separate 3?×?4 mixed model analysis of variance was performed to examine the effect of treatment conditions and time, and intention-to-treat (ITT) analysis was applied to evaluate the effect of the independent variable. Results: The application of joint mobilization resulted in better scores of DFROM, CAIT, and SEBTs in the intervention group when compared with the placebo or the control groups (p?<?0.001). The effect sizes of group-by-time interaction, measured with eta-squared, oscillated between 0.954 for DFROM and 0.288 for SEBT posteromedial distance. In within-group analysis, the manipulation group showed an improvement at 6 months follow-up in CAIT [mean?=?5.23, CI 95% (4.63–5.84)], DFROM [mean?=?6.77, CI 95% (6.45–7.08)], anterior SEBT [mean?=?7.35, CI 95% (6.59–8.12)], posteromedial SEBT [mean?=?3.32, CI 95% (0.95–5.69)], and posterolateral SEBT [mean?=?2.55, CI 95% (2.20–2.89)]. Conclusion: Joint mobilization techniques applied to subjects suffering from CAI were able to improve ankle DFROM, postural control, and self-reported instability. These results suggest that joint mobilization could be applied to patients with recurrent ankle sprain to help restore their functional stability.

• Implications for Rehabilitation

• Functional instability is a very common sequela in patients with CAI, resulting in reduced quality of living due to the limitations it imposes on daily life activities.

• The mobilization with movement technique presented by Mulligan, and based on the joint mobilization accompanied by active movement, appears as a valuable tool to be employed by physical therapists to restore ankle function after a recurrent ankle sprain history.

• ROM restriction, subjective feeling of instability and dynamic postural control are benefiting from the joint mobilization application.

     

Effect of adding stretching to standardized procedures on cervical range of motion,pain, and disability in patients with non-specific mechanical neck pain: A randomized clinical trial

Objectiveto investigate the benefit of adding stretching exercises to cervical joint mobilization and active rotation exercises for patients with non-specific mechanical neck pain.MethodsThirty-eight subjects with non-specific mechanical neck pain were randomly assigned to a standard procedure group (passive cervical mobilization and active cervical rotation range of motion exercise) or a combined procedure (passive cervical mobilization, active cervical rotation range of motion exercises, and stretching procedures). Mixed factorial analysis of variance was used to compare changes between groups over time in active cervical range of motion, Numeric Pain Rating Scale, Neck Disability Index, Global Rating of Change, and Pressure Pain Threshold.ResultsThere was a significant change in mean active range of motion in all directions, Pressure Pain Threshold, perceived pain, disability levels, and global rating of change over time (p < 0.001). There was a significant group by time interaction in mean active range of motion during extension (p = 0.01), right rotation (p = 0.004), right and left lateral flexion (p = 0.05, and p = 0.02 respectively). However, there was no significant group by time interaction in mean active range of motion during flexion, left rotation, pain intensity (p = 0.09), right and left pressure pain threshold (p = 0.30, 0.47, respectively), and disability (p = 0.07).ConclusionsBoth study groups improved significantly in all subjective and objective outcome measures. However, data from this study suggest that adding stretching to the standard procedures may be more effective than the standard procedure alone at improving cervical extension, right rotation, and lateral flexion active range of motion, but not pain and disability.     

Effects of sling-based manual therapy on cervicothoracic junction in patients with neck pain and forward head posture: A randomized clinical trial

ObjectiveThe purpose of this study was to investigate the effect of 4 weeks of sling-based manual therapy on the cervicothoracic junction (CTJ) area in patients with neck pain and forward head posture.DesignSingle-blind randomized controlled trial.SettingOutpatient, Chonbuk National University hospital, Republic of Korea.SubjectsA total of 22 participants with neck pain (Numeric Pain Rating Scale >3) and forward head posture (craniovertebral angle <51) were randomly assigned to a CTJ group or a control group (n = 11 each).InterventionIn the control group, joint mobilization and motor control training was applied for the upper cervical spine (C0–C1). The CTJ group applied the same intervention to the upper cervical spine and cervicothoracic junction (C7-T3).Main measuresNumeric pain rating scale and neck disability index, craniovertebral angle, active range of motion, and muscle activity were evaluated before and after 4 weeks of intervention.ResultThe CTJ group participants showed significant improvement in the craniovertebral angle and cervical extension range after the intervention than the control group (P = 0.025, P = 0.001). While both groups presented significant differences after the intervention regarding Numeric pain rating scale, neck disability index, and muscle activity (sternocleidomastoid and anterior scalene muscle), there were no statistically significant differences between the groups (P > 0.05).ConclusionOur results suggest that the CTJ and the upper cervical region in patients with neck pain and forward head posture represent an area which if approached by manual therapy, improves cervical mobility and posture.     

Short-term Effects of Mulligan's Mobilization With Movement on Pain,Function, and Emotional Aspects in Individuals With Knee Osteoarthritis: A Prospective Case Series

ObjectiveTo evaluate the short-term effects of Mulligan's mobilization with movement (MWM) on pain, physical function, emotional aspects, and proprioceptive acuity after a 2-week treatment period and throughout a 3-week follow-up period.MethodsA single group of 30 participants (60.96 ± 5.16 years) with symptomatic knee osteoarthritis (KOA) was evaluated. The protocol involved 5 evaluations moments, before (baseline) and after 2 weeks of intervention (24 hours after the last session), and at 3-week follow-up. The intervention included 3 Mulligan's MWM techniques. The variables evaluated were pain (pressure pain threshold and Visual Numeric Scale), physical function (range of motion, proprioceptive acuity, and the Western Ontario and McMaster Universities Osteoarthritis Index) and emotional aspects (Beck Depression Inventory). Analysis of variance for repeated measures was used considering a significance level of 5%.ResultsAt the second evaluation (after intervention), the pressure pain threshold presented higher values for rectus femoris, tibialis anterior, and patellar tendon sites and reduced values for the Visual Numeric Scale, Beck Depression Inventory, and Western Ontario and McMaster Universities Osteoarthritis Index compared with baseline. Also, during the follow-up period, all variables returned close to baseline levels. Proprioceptive acuity and range of motion did not present significant changes.ConclusionScores for pain relief, physical function, and emotional aspects improved after a course of MWM in this single group of individuals with KOA. Mobilization with movement had limited outcome during follow-up. It suggests that future clinical trials on the use of MWM for KOA should be considered.     

Stair descent biomechanics reflect perceived instability in people with unilateral ankle sprain history

BackgroundEfforts have been exerted to establish the correlation between objective variables and subjectively perceived ankle instability. Whether or not biomechanical parameters during stair descent can serve as potential assessment tools for perceived stability in people with unilateral ankle sprain history is unknown.MethodsTwenty-four subjects with unilateral ankle sprain history were categorized into four groups according to the severity of perceived stability during stair descent. Kinematic and kinetic parameters during stair descent were obtained with a motion analysis system. Spearman's correlation coefficient (ρ) was utilized to test the correlation between the score of perceived stability during stair descent and biomechanical variables.FindingsSubjects with increased perceived instability were likely to show increased ankle inversion (ρ = −0.46, p = .025) and increased ankle plantarflexion (ρ = 0.46, p = .025), with increased hip adduction (ρ = −0.43, p = .036), hip flexion (ρ = −0.56, p = .004), knee adduction (ρ = 0.45, p = .027), and knee flexion (ρ = −0.44, p = .031). No significant correlation was detected between kinetic variables and perceived stability.InterpretationSagittal and coronal plane motions of the ankle might require rehabilitative intervention to produce improved self-reported outcomes. Kinematic assessment during stair descent can aid in the quantification of subjective ankle instability.     

The initial effects of a Mulligan's mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains

Physiotherapists frequently use manipulative therapy techniques to treat dysfunction and pain resulting from ankle sprain. This study investigated whether a Mulligan's mobilization with movement (MWM) technique improves talocrural dorsiflexion, a major impairment following ankle sprain, and relieves pain in subacute populations. Fourteen subjects with subacute grade II lateral ankle sprains served as their own control in a repeated measures, double-blind randomized controlled trial that measured the initial effects of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in dorsiflexion occurred initially post-MWM ( F(2,26) = 7.82, P = 0.002 ), but no significant changes in pressure or thermal pain threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. The mechanism by which this occurs requires investigation if we are to better understand the role of manipulative therapy in ankle sprain management.     

Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain

Restrictions in ankle dorsiflexion range of motion (ROM) have been associated with decreased posterior talar glide in individuals with an acute lateral ankle sprain. Talocrural joint mobilizations may be used to restore joint arthrokinematics. Our purpose was to examine the effects of a single bout of anterior to posterior (AP) talocrural joint mobilization on self-reported function, dorsiflexion ROM, and posterior talar translation in individuals with an acute lateral ankle sprain. This single-blinded, randomized controlled trial utilized 17 volunteers (nine treatment and eight control) with an acute lateral ankle sprain (grade I/II) who were immobilized for a period of 1–7 days. The treatment group received a single 30-second bout of grade III AP talocrural joint mobilization the day their immobilization device was removed, while the control group did not receive any intervention. Active dorsiflexion ROM and posterior talar translation were assessed before, immediately after, and 24 hours after receipt of the treatment or control interventions. Self-reported function and pain were assessed before and 24 hours after the receipt of the treatment or control interventions using the foot and ankle disability index. Collectively all groups demonstrated improved dorsiflexion ROM and self-reported function. There was a significant decrease in pain perception at 24-hour follow-up for the treatment group. A single bout of AP talocrural joint mobilizations may not have an immediate effect on ankle dorsiflexion ROM, posterior talar translation, or self-reported function; however, they may have an immediate effect on pain perception in individuals with an acute lateral ankle sprain.     

Persistence of long term isokinetic strength deficits in subjects with lateral ankle sprain as measured with a protocol including maximal preloading

BackgroundThe assessment of muscle function is a cornerstone in the management of subjects who have sustained a lateral ankle sprain. The ankle range of motion being relatively small, the use of preloading allows to measure maximal strength throughout the whole amplitude and therefore to better characterize ankle muscles weaknesses. This study aimed to assess muscle strength of the injured and uninjured ankles in subjects with a lateral ankle sprain, to document the timeline of strength recovery, and to determine the influence of sprain grade on strength loss.MethodsMaximal torque of the periarticular muscles of the ankle in a concentric mode using a protocol with maximal preloading was tested in 32 male soldiers at 8 weeks and 6 months post-injury.FindingsThe evertor muscles of the injured ankles were weaker than the uninjured ones at 8 weeks and 6 months post-injury (P < 0.0001, effect size = 0.31–0.42). Muscle weaknesses also persisted in the plantarflexors of the injured ankles at 8 weeks (P = 0.0014, effect size = 0.52–0.58) while at 6 months, only the subjects with a grade II sprain displayed such weaknesses (P < 0.0001, effect size 0.27–0.31). The strength of the invertor and dorsiflexor muscles did not differ between sides.InterpretationThe use of an isokinetic protocol with preloading demonstrates significant but small strength deficits in the evertor and plantarflexor muscles. These impairments may contribute to the high incidence of recurrence of lateral ankle sprain in very active individuals.     

Immediate Effects of Mulligan Mobilization on Elbow Proprioception in Healthy Individuals: A Randomized Placebo-Controlled Single-Blind Study

ObjectiveThe aim of this study was to investigate the immediate effects of Mulligan's mobilization with movement (MWM) on elbow proprioception.MethodsThe study included 26 participants in the intervention group and 30 participants in the control group. The intervention group received MWM, while the control group received a sham application. Proprioception was assessed with joint position sense error at baseline, immediately after mobilization, and 30 minutes after mobilization with 70° and 110° of elbow flexion. The hypothesis of interest was the group × time interaction.ResultsAt 110° of elbow flexion, group × time interaction was significant (F[2, 108] = 11.48, P = .001). In the paired comparisons, there was a statistically significant difference in favor of the control group in the first measurement (P = .003). No difference was detected in other time points (P = 1.00). At 70° of elbow flexion, there was no significant difference between the time point × group interaction (F[2, 108] = 1.37, P = .10). Therefore, no pairwise comparison was made.ConclusionIn this study of healthy participants, no immediate difference was found between MWM and sham application on elbow proprioception.     

Evaluation of scapular mobilization and comparison to pectoralis minor stretching in individuals with rounded shoulder posture: A randomized controlled trial

BackgroundRounded shoulder posture (RSP) is a common postural condition which can alter scapular position. Although, there is no consensus on the relationship between posture and musculoskeletal dysfunction, some evidence suggests a significant relationship between RSP and shoulder dysfunction. Therefore, treatment of this postural condition is important. Various treatment methods are used to correct RSP. However, the effectiveness of scapular mobilization, (SM) as a method which can alter scapular kinematics, has not been investigated.ObjectiveTo evaluate the effects of SM on scapular resting position in individuals with RSP, and to compare this technique to pectoralis minor self-stretching (PMS), and combined SM + PMS.Methods52 healthy students (18 men and 34 women; mean age 23.67 ± 6.73 years) with RSP were randomly assigned to four groups (SM, PMS, combined SM + PMS, control). The mobilization group received SM, the stretching group performed self-PMS, and the combined group received SM + PMS. The control group received no treatment. Kinematics data to measure scapular protraction (cm), anterior tilt (°), internal rotation (°), and downward rotation (°) were captured with a motion analysis system before and after 5 sessions of group intervention.ResultsAll variables decreased significantly post-intervention compared to baseline values (P < 0.05). Internal rotation and downward rotation decreased significantly in the intervention groups compared to the control group (P < 0.05). No significant differences were observed between the intervention groups.ConclusionSM appears to be an effective technique to change scapular resting position in individuals with RSP. However, this technique was not superior to PMS or a combination of SM + PMS.     

Comparison of the effectiveness of proprioceptive neuromuscular facilitation exercises and shoulder mobilization patients with Subacromial Impingement Syndrome: A randomized clinical trial

IntroductionThe aim of this study was to compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) exercises and shoulder mobilization (SM) in addition to conventional physiotherapy on pain, range of motion (ROM), functionality, and muscle strength in patients with Subacromial Impingement Syndrome (SIS).MethodsForty-four patients were randomly allocated into three groups as conventional physiotherapy (control group; n = 14), conventional physiotherapy + PNF exercises (PNF group; n = 15), and conventional physiotherapy + SM techniques (SM group; n = 15). Pain, ROM, muscle strength, and functionality were evaluated by using VAS (Visual Analog Scale), goniometer, push-pull dynamometer, Constant-Murley score and DASH (Disabilities of the Arm, Shoulder and Hand) score. Patients were received 20 sessions (4 weeks) of treatment. Assessments were performed at baseline, and weeks two, four, and sixteen.ResultsAfter treatment, significant improvements in outcome measurements were observed in all groups (all p < 0.05). PNF or SM groups were not superior to each other in terms of improving pain and functionality. SM group was superior to PNF group for improving shoulder flexion ROM at week 4 (p = 0.009). The improvements in shoulder extension muscle strength were greater in PNF group at weeks 2 and 16 compared with other groups (p = 0.030, 0.035).ConclusionPNF or SM, in addition to conventional physiotherapy, might help to improve pain and functionality more in patients with SIS. It is recommended to add SM or PNF to conventional treatment to maintain the ROM increase gained with SIS treatment after treatment, and to apply this treatment for 4 weeks for muscle strength increase.     

The effect of dry needling & muscle energy technique separately and in combination in patients suffering shoulder impingement syndrome and active trigger points of infraspinatus

ObjectiveThe aim of this study was to investigate the effects of a combination of dry needling (DN) and muscle energy technique (MET) on pain intensity (PI), pressure pain threshold (PPT) and shoulder active range of motion (ROM) in patients with shoulder impingement syndrome and active trigger points in the infraspinatus muscle.Methods39 patients, aged 20–50 participated in this study. All the cases were randomly assigned into three groups: group 1 (n = 13) received DN, group 2 (n = 13) received MET, and group 3 (n = 13) received DN & MET. The patients were treated for three sessions in a one-week period with at least a two-day break between sessions.ResultsThe results showed a significant improvement in visual analog scale (VAS), PPT and shoulder ROM over time (P < 0.001) in all three groups. There were no significant differences BETWEEN VAS (P = 0.406) PPT (P = 0.293), external rotation(EXT.ROT) (0.476), internal rotation (INT.ROT)(P = 0.476) and extension(EXT) (P = 0.574) ROMs in the three groups; however, DN group was significantly more effective on abduction(ABD) (P = 0.003) and flexion(FLEX) (0.012) ROM compared with other two groups.ConclusionIn line with previous studies, the present study found that the application of DN, MET and combined of these treatment on active trigger points in the infraspinatus muscle of patients with shoulder impingement syndrome helps reduce pain, increase PPT and enhance the shoulder ROM. Both techniques are effective in the treatment of trigger points. Nevertheless, DN is more effective in enhancing the ROM of flexion & abduction.     

Manual therapy in the treatment of ankle hemophilic arthropathy. A randomized pilot study

Abstract

Purpose: Although physiotherapy has demonstrated effectiveness in preventing ankle arthropathy compared to prophylaxis treatment from early ages, there have been no conclusive studies examining physiotherapy intervention once hemophilic arthropathy of the ankle has been established. The aim of this study was to evaluate the effectiveness of two physiotherapy interventions, in patients with hemophilic arthropathy of the ankle that had not been operated on previously. Method: Nine patients with hemophilia (mean age of 35.7 SD 11.9 years) were randomized to a mobilization group (n?=?5) and manual therapy group (n?=?4). The two physiotherapy interventions were: (1) passive mobilization and stretching; and (2) manual orthopaedic therapy, both with proprioception training. The study lasted for six weeks, with two sessions a week. Ankle mobility and pain perception, lower limb proprioception and quality of life were the outcome measures. Results: Both treatments improved all ankle movements (p?<?0.05). The treatment with passive mobilizations also improved the perception of pain and quality of life. Six months later, both groups still had improved articular movement with the exception of plantar flexion and continued to perceive less pain. Conclusions: Both physiotherapy interventions improved the range of movement and lessened pain in patients with ankle arthropathy. No haemarthrosis was recorded during treatment or during the follow-up period.     

The efficacy of massage as a nightly bedtime routine on infant sleep condition and mother sleep quality: A randomized controlled trial

Backgroundand Purpose: Infants' sleep disorders and parents' insufficient sleep are common problems in the infant care. The current study was conducted to assess the effectiveness of infant massage on infants' night-time sleep condition and mothers’ sleep quality.Methods140 number of 15–20 days old infants were randomly put into two different groups, one with bedtime messages and the other with normal infant routine care. For the intervention group, in addition to usual bedtime procedures such as changing diapers and breastfeeding, a 15-min massage was done before sleep for a period of two weeks. For the control group, only the usual above-mentioned bedtime procedures were followed. One week before the intervention, at the end of the first week, and two weeks after the intervention, the information was recorded for both groups. The Brief Infant Sleep Questionnaire, a personal information submission form, and Pittsburgh Sleep Quality Index for the mothers were the tools used to gather data in this study.ResultsInfants in two control and experimental groups showed meaningful differences in variables such as, sleep latency (P = 000, eta = 0.099), number of night waking (P = 0.03, eta = 0.027), and longest continuous sleep period (P = 0.03, eta = 0.026). As for other variables related to the infants' sleep, no meaningful differences were observed. In this study, there was no indication of a meaningful difference in the mother's overall night-time sleep quality between the two groups (P = 0.184, eta = 0.012) except for the duration of the mother's night-time sleep (P = 0.028, eta = 0.026) and the reduction of maternal sleep disorder (P = 0.020 eta = 0.029). As for other sub-factors of maternal sleep quality, no meaningful differences were seen.ConclusionThe findings of this study indicated that infants’ bedtime massages would improve some of the sleep markers of mothers and infants, and therefore, can be suggested as a practical, harmless, and cost-free method to improve sleep.     

Lower extremity thrust and non-thrust joint mobilization for patellofemoral pain syndrome: a case report

A 40-year old female presented to physical therapy with a one-year history of insidious right anteromedial and anterolateral knee pain. Additionally, the patient had a history of multiple lateral ankle sprains bilaterally, the last sprain occurring on the right ankle 1 year prior to the onset of knee pain. The patient was evaluated and given a physical therapy diagnosis of patellofemoral pain syndrome (PFPS), with associated talocrural and tibiofemoral joint hypomobility limiting ankle dorsiflexion and knee extension, respectively. Treatment included a high-velocity low amplitude thrust manipulation to the talocrural joint, which helped restore normal ankle dorsiflexion range of motion. The patient also received tibiofemoral joint non-thrust manual therapy to regain normal knee extension mobility prior to implementing further functional progression exercises to her home program (HEP). This case report highlights the importance of a detailed evaluation of knee and ankle joint mobility in patients presenting with anterior knee pain. Further, manual physical therapy to the lower extremity was found to be successful in restoring normal movement patterns and pain-free function in a patient with chronic anterior knee pain.     

Intersegmental kinematic analysis of lumbar spine by functional radiography between two subgroups of patients with chronic low back pain

IntroductionKinematic deficits such as fault in joint accessory motion is one of the most important contributing factors for developing the movement impairment in the lumbar spine. Functional radiography is accessible method for detecting the artherokinematic disorders. The aim of this study was to compare lumbar spine intersegmental motion between low back pain (LBP) subgroups of movement system impairment (MSI) model by functional radiography.Materials and methods20 subjects with chronic LBP in two subgroups of the MSI model (Rotation with Flexion and Rotation with Extension) participated in this study. Five x-rays were taken in different positions. Intersegmental linear translation and angular rotation of the lumbar segments were calculated.ResultsIn the Rotation with Extension subgroup, the translation and rotation values of the L3-4 segment from full to full position were significantly more than their values in the Rotation with Flexion subgroup ((mean difference = −1.69 (mm) P = 0.01), (mean difference = −3.80 (mm) P = 0.02) respectively). The translation of L2-3 segment from the neutral to the mid-flexion position was significantly greater in the Rotation with Flexion subgroup compared to the Rotation with Extension subgroup (mean difference = 1.12 (mm) P = 0.04). cumulative intersegmental angular rotation of all lumbar segments from mid to mid position was greater in the Rotation with Flexion subgroup compared to the Rotation with Extension subgroup (P = 0.03).ConclusionChanges in intersegmental translation and angular rotation of lumbar segments in subgroups of patients with LBP may be important contributing factors that induce direction specific lumbar spine loads and contribute to the development or persistence of LBP problems.