Joint Mobilisation and Home-based Rehabilitation for the Treatment of Chronic Ankle Instability: Clinical Investigation and Practitioner Development.
Authors:   , Holland Christopher 
Published: February 2022

Ankle sprains are the most common musculoskeletal disorder, accounting for 22% of all sports injuries (Fong et al., 2007; Gribble et al., 2016a). Despite the high prevalence and severity (Braun, 1999; Fong et al., 2007) up to 70% of those sustaining a single sprain report residual symptoms, including recurrent instability, additional ankle sprains and reduced functional capacity (Wikstrom et al., 2007). These negative antecedents form the primary characteristics of chronic ankle instability (CAI). CAI is linked to several mechanical and functional insufficiencies (Hertel, 2002). These include reduced dorsiflexion range of motion (DF-ROM) (Drewes et al., 2009) and reduced posterior talar glide (Denegar, Hertel and Fonseca, 2002) which may disrupt the transmission of afferent information to the sensorimotor system, contributing to the functional impairments associated with CAI (Hoch and McKeon, 2011a). Joint mobilisations restore arthrokinematic movements that occur between joint surfaces (Green et al., 2001) and consistently demonstrate acute improvements in DF-ROM and posterior talar glide in those with a history of ankle sprains (Green et al., 2001; Reid, Birmingham and Alcock, 2007; Hoch et al., 2014). The use of joint mobilisations to increase afferent input and their effect on dynamic balance and postural control has also been identified (Hoch, Staton and McKeon, 2011b; Hoch, Staton, et al., 2012; Cruz-Díaz et al., 2015). In addition the use of exercise and functional rehabilitation has been seen to be an effective approach to improve ankle function in those with CAI (Webster and Gribble, 2010). However, much of the research into the effective and efficient treatment of CAI is inconclusive. More research is needed to ensure the efficacy of joint mobilisations and functional rehabilitation for those with CAI and to ensure that this knowledge is disseminated effectively to practitioners in order to influence practice. Study 1 (Chapter 4a): Study 1 explored the effects of varying treatment durations of an anterior to posterior talar joint mobilisation on measures of DF-ROM, posterior talar glide, dynamic postural control and self-reported function. Participants completed 6 treatment sessions over a 2-week period with measures taken prior to the first treatment session and directly after the final one, with a one week follow up for self-reported function measures. The findings of the study indicate that joint mobilisations can significantly improve arthrokinematic motion, dynamic postural control and patient reported outcome measures (PROM). The longer treatment durations conferred the greatest improvements in these outcome measures. Study 2 (Chapter 4b): Study 2 built upon the findings of study 1 using the same intervention and outcome measures to explore the within session effects of varying treatment durations. Participants completed 6 treatment sessions over a 2-week period and had measure taken prior to and directly after each treatment. The findings aligned with the conclusion from study 1, however, the greatest effect of the longer treatment duration was observed within the first week of treatment. This suggested that 120s treatment durations are more effective than shorter durations when applied within the first week of treatment. Study 3 (Chapter 5): Study 3 sought to identify whether home-based rehabilitation could be used to augment the improvements elicited from the joint mobilisation recommendations in study 2. Participants completed 3 joint mobilisation treatment interventions in the first week and were then instructed to complete a 4-week home-based rehabilitation programme. The results showed that the combination of joint mobilisation intervention and home-based rehabilitation programmes are effective at treating the deficiencies associated with CAI, and that the application of three, 120s joint mobilisations within the first week of intervention, followed by 2-weeks of daily rehabilitation exercises targeting self-mobilisation and dynamic postural control is an effective treatment strategy. In addition, the improvements elicited by joint mobilisations are lost if additional rehabilitation is not implemented. Study 4 (Chapter 6): Study 4 attempted to disseminate the research information gained from the previous studies to develop practitioner’s knowledge and influence their intended future practice. Participants attended a CPD workshop where the research recommendations were presented and explained. Measures were taken via questionnaire prior to the workshop to ascertain the practitioner’s current knowledge and experience with CAI. Following the workshop an additional questionnaire was completed to identify the impact that the workshop had on the practitioner’s knowledge and understanding, and to ascertain the extent to which the information provided would influence their future practice. The results showed that a CPD workshop is an effective means for knowledge dissemination within manual therapy practitioners, with a clear improvement in knowledge and understanding of CAI and treatment methods. In addition, the practitioner’s behavioural intention to use the information was clear and shows that intended clinical practice can be enhanced through the use of workshop-based research dissemination.