Comparison of Two Manual Therapy Techniques on Ankle Dorsiflexion

Study Overview
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Brief Summary
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Ankle rigidity is a common musculoskeletal disorder affecting the talocrural joint, which can impair weight-bearing ankle dorsiflexion (WBADF). The objective was to compare the efficacy of Mulligan Mobilization with Movement (MWM) and Osteopathic Mobilization (OM) for improving ankle dorsiflexion range of motion (ROM) and musculoarticular stiffness (MAS).

Detailed Description
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Increased musculoarticular stiffness (MAS) of the talocrural joint is a frequently encountered problem, identified during evaluation of weight bearing ankle dorsiflexion (WBADF). Such stiffness may follow ankle injury such as ankle sprain. In such a situation, MAS could be increased and might leads to a lack of joint flexibility as well as decreased dorsiflexion range-of-motion (ROM), however asymmetric rigidity does not necessarily always follow ankle sprain. Nevertheless, MAS is an important and necessary component of normal stability of the talocrural joint and could help to prevent abnormal ankle joint movement and ankle sprains. Measurement of MAS can be determined by a technique known as free-oscillation, which is a comprehensive measure of joint stiffness comprising the stiffness of the muscle-tendon unit, skin, ligaments and joint capsule, along with a number of other mechanical and neuromuscular factors. The assessment of MAS is important when evaluating muscular performance, injury prevention and gender differences in flexibility. For example, men, as well as older people, are known to present with greater MAS than women and young people. MAS of the talocrural joint can be objectively measured using an electromechanical device that imparts a passive oscillatory dorsiflexion movement, but also by means of clinical tests such as toe-wall distance and angular goniometric measurement during the weight bearing lunge test. Electromechanical measurement of ankle MAS has been used in several previous studies of asymptomatic participants and in patients with fibromyalgia syndrome, and spasticity after a stroke. In orthopaedic manual therapy, different methods have been proposed to treat MAS associated with loss of dorsiflexion ROM at the talocrural joint. These include single session of Mulligan's Mobilization with Movement (MWM), anteroposterior mobilization of the talus, high velocity thrust, and Osteopathic Mobilization (OM). These methods have been described in clinical practice manuals, with greater proportion of studies reporting on the effects of MWM in comparison to high velocity thrust for improving ankle dorsiflexion ROM in chronic ankle instability or to study MWM efficacy in isolation for subacute or recurrent ankle sprains and for chronic ankle instability. With the exception of one study the results are generally in favor of MWM. Generally MWM is an increasingly popular form of manual therapy for musculoskeletal disorders, concerning the ankle MWM try to improve talocrural ROM. MWM is a combination of accessory joint glide of the talus combined with active ankle dorsiflexion movement. The patient performs active WBADF while the therapist simultaneously applies an anteroposterior glide of the talus with respective posteroanterior tibial glide with the aid of a manual therapy belt. OM is a purely passive anteroposterior mobilization of the talus with respect to tibia, performed in a non weight-bearing position. To date, there have been no studies comparing the effectiveness of each technique with respect to electromechanically determined ankle MAS or ankle joint ROM determined by the WBADF lunge test. Therefore, the aim of the study was to investigate the relative efficacy of MWM and OM on MAS as the primary outcome measurement and joint ROM during the WBADF lunge test as the secondary outcome measurement. The hypothesis was that MWM would produce significantly greater reduction in MAS and increased ankle joint ROM when compared to OM.

Official Title
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The Immediate Effects of Two Manual Therapy Techniques on Ankle Musculoarticular Stiffness and Dorsiflexion Range of Motion in People With Chronic Ankle Rigidity: A Randomized Clinical Trial

Conditions
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Ankle Stiffness

Intervention / Treatment
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* Other: mobilization with movement
* Other: osteopathic mobilization


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: male gender, aged between 18 to 40 years, with a chronic unilateral mobility deficit of the talocrural joint; i.e. subjective blocking sensation and/or feeling of ankle stiffness together with the presence of ankle region pain/tenderness, during active WBADF while squatting. Subjects were recruited with chronic unilateral mobility deficit of the talocrural joint, which could be following a previous history of ankle injury or without previous history of ankle injury. Exclusion Criteria: a history of ankle joint surgery or injury to the foot, ankle, knee or hip in the previous one-year.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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Male

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: mobilization with movement<br>MWM at the talocrural joint during active weight bearing ankle dorsiflexion with the belt | Other: mobilization with movement<br>* manual therapy intervention<br>|
| Active Comparator: osteopathic mobilization<br>passive mobilization of the talo-crural joint | Other: osteopathic mobilization<br>* manual therapy intervention<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Electromechanical device measurement of MAS (Lehmann device, 1989) | The electromechanical device used to quantify musculoarticular stiffness had been used in previous research studies and has ben shown to have high precision, reliability and accuracy. An oscillating footplate produces passive ankle joint dorsiflexion with 5° amplitude sinusoidal rotary displacements. Thirty trials of 10 different oscillation frequencies, varying from 3 to 12 Hz, were applied on each subject during each session. See Detrembleur and Plaghki (2000) for more details of the process. | Change from baseline until discharge of treatment (same day, single session) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| WBAD lunge test | the weight bearing ankle dorsiflexion lunge test a common clinical test used to evaluate ankle dorsiflexion ROM (Powden et al., 2015) which has been shown to have moderate to excellent intra-rater reliability (ICC = 0,65-0,99) with a minimal detectable change of 1,9 cm and 4,7°. A graduated tape measure was placed on the floor, perpendicular to the wall. The investigator demonstrated the measurement procedure test to the subject providing standardized instructions. The subject placed his symptomatic foot with the big toe aligned on the tape measure and performed ankle dorsiflexion until his knee touched the wall. An iPhone was used to measure the degree of tibial inclination. | Change from baseline until discharge of treatment (same day, single session) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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manual therapy, osteopathy, mobilization with movement, ankle, stiffness