Different Mobilization Techniques on Balance, Gait, Jumping and Foot Plantar Pressure

Study Overview
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Brief Summary
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Adequate ankle dorsiflexion range of motion is important for normal performance of functional activities such as walking, running and climbing stairs. It is important to gain the ankle dorsiflexion range of motion, which affects the functional activities and sports associated with squats and lunges. Stretching and manual therapy are the most frequently used applications to gain range of motion. Manual therapy has been proposed as a possible treatment to improve mobility and restore arthrokinematics of joints. Movement mobilization, which is a manual therapy method, is an active joint mobilization concept. Talocrural mobilization with the movement technique is an extension of traditional joint mobilizations and allows the patient to engage in therapy in an active, partial weight-bearing lunge position. There are variations of this technique that can be applied by the clinician or by the individual himself. Our aim in this study is to compare the effects of movement and mobilization applications, which can be applied by the clinician or by the individual himself, on balance, gait, jumping and plantar pressure. Healthy asymptomatic individuals between the ages of 18-35 whose active ankle dorsiflexion range of motion as measured by the weight-bearing lunge test in the dominant extremity is below 35˚ will be included in the study. According to the inclusion criteria, the individuals to be included in the study will be randomly divided into three groups. Mobilization technique by the clinician will be applied to one group, and the mobilization technique by the individual himself will be applied to another group. The third group will be the control group. Evaluations will be made before and after mobilization applications. Balance will be evaluated with Y balance test, gait and jump will be evaluated with G-Walk, and plantar pressure will be evaluated with pedobarography device.

Detailed Description
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Adequate ankle dorsiflexion range of motion is required for normal performance of functional activities such as walking, running, and climbing stairs. Limited ankle dorsiflexion is a common ankle movement disorder that affects squat and lunge-related functional activities and sports. Soft tissue, myofascial tension or muscle tension in the ankle and foot have been identified as the main etiologic factors causing limited ankle dorsiflexion in asymptomatic populations. Limited dorsiflexion range of motion has been associated with genu recurvatum, excessive subtalar joint pronation, ankle sprains, medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, anterior knee pain, gastrocnemius strains, and anterior cruciate ligament injuries. Therefore, gaining ankle dorsiflexion range of motion seems to be an important goal in the treatment of lower extremity injuries. Manual therapy has been proposed as a possible treatment to improve mobility and restore arthrokinematics of joints. Movement mobilization is the concept of active joint mobilization. The aim is to render painful movement disorder painless and allow the patient to engage in normal functional activity in the progressive recovery process. Talocrural mobilization with the movement technique is an extension of traditional joint mobilizations and allows the patient to engage in therapy in an active, partial weight-bearing lunge position. There are variations of this technique that can be applied by the clinician or by the individual himself. There are studies showing the effect of clinician-applied motion mobilization on range of motion, static balance, gait, and plantar pressure in different populations. In a study conducted by Reid et al. in individuals with ankle sprains, they observed an increase in ankle dorsiflexion joint range of motion immediately after mobilization with motion for the talocrural joint. In their study, Vicenzino et al. demonstrated the curative effect of motion mobilization techniques on posterior talar shift and dorsiflexion range of motion in individuals with recurrent lateral ankle sprains. Based on this result, they stated that this technique should be considered in rehabilitation programs after lateral ankle sprain. Tomruk et al. showed that the application of the motion mobilization technique to the ankle joint significantly improved postural control in the anteroposterior direction compared to the sham group in healthy individuals. However, overall postural control and dorsiflexion range of motion were significantly increased in both groups compared with initial measurements. On the other hand, the stability limit reaction time was significantly shortened in the motion-only group. In their study, Marrón-Gómez et al. stated that the application of motion mobilization technique and manipulation of the talocrural joint significantly improved ankle dorsiflexion in participants with chronic ankle instability. No significant difference was found between these two techniques, but the results of the application of the motion mobilization technique before the application and the evaluation two days after the application showed larger in-group effect sizes than the high speed and low intensity talocrural joint manipulation. When both treatments were compared with the placebo group, both active interventions were more effective in improving dorsiflexion with larger effect sizes. Yoon et al. reported that passive ankle dorsiflexion improved range of motion, heel-rise time, and dynamic plantar loading during 5-minute walking with a modified motion mobilization technique using talus gliding taping in individuals with limited ankle dorsiflexion. An and Won found that motion ankle mobilization was more effective than simple weight bearing in improving walking speed in stroke patients with limited ankle motion. Gilbreath et al., in their study, showed that there was no significant change in weight-bearing dorsiflexion joint range of motion, in any aspect of the Star Excursion Balance Test, or in Foot and Ankle Ability Measurement-Activities of Daily Living scores after three sessions of motion mobilization technique in individuals with chronic ankle instability. . Although there was no significant change in these parameters, they found a significant improvement in Foot and Ankle Ability Measurement-Sports-Related Activities scores after intervention. Despite these studies investigating the effectiveness of movement mobilization applied by the clinician in different pathologies, there is only one study in the literature comparing the movement applied by the clinician and the individual and the mobilization technique. Stanek and Pieczynski, in their study in healthy individuals with dorsiflexion limitation, stated that both the clinician-applied mobilization and self-mobilization showed significant and sudden increases in the active weight-bearing dorsiflexion joint range of motion when compared to the control group, both while kneeling and standing. They found no significant difference between the groups to which the technique was applied. Based on the findings of this study, clinicians can prescribe self-administered mobilization technique to their patients and expect similar results to clinician-administered mobilization. However, only active dorsiflexion range of motion was evaluated in this study. Although there are studies showing the effect of the movement mobilization technique applied by the clinician on the active dorsiflexion range of motion, foot plantar pressure, jumping and balance, no study has been found in the literature comparing the movements applied by the clinician and the individual in terms of foot plantar pressure, jumping and dynamic balance. Therefore, the aim of this study is to compare the effects of these two techniques in terms of active dorsiflexion range of motion, plantar pressure, jump and dynamic balance in individuals with limited dorsiflexion range of motion.

Official Title
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The Effect of Different Mobilization Techniques on Balance, Gait, Jumping and Foot Plantar Pressure in Individuals With Ankle Dorsiflexion Limitation

Conditions
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Dorsiflexion Deformity of Foot

Intervention / Treatment
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* Other: Mobilization with movement for Ankle


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Being between the ages of 18-35 Volunteering to participate in the study Active Dorsiflexion range of motion is below 35˚ Exclusion Criteria: Having a history of ankle pain and injury in the last 6 months Having a Neurological, Rheumatological or Systemic disease Having had any lower extremity surgery

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 35 Years

Sexes Eligible for Study
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All

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
Interventional Model Description: There will be three separate groups in the study. The individuals in the group will be completely different individuals. Each group will receive a different intervention. One of the groups will be the control group
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: The group which mobilization with movement technique applied by clinician<br>13 individuals in this group, after evaluations, mobilization with movement technique applied by clinician and after that same evaluations will be applied | Other: Mobilization with movement for Ankle<br>* The participant will assume a lunge position on a rigid serving table with the relevant extremity in a weight-bearing stance and the foot in a neutral position. An inelastic belt will be placed around the clinician's waist, flush with the lower edge of the medial malleolus, around the distal tibia and fibula. The clinician will stabilize the talus and forefoot with the web spacing of the hands and pressure dimensions on the talus and forefoot, and maintain posterior to anterior sliding of the tibia over the talus using the arch. The clinician will continue to apply pressure while the person is reporting discomfort and/or while the lunge moves, which will continue until the end of the range of motion. Mobilization will be performed as a set of 10 repetitions.<br>|
| Experimental: The group which mobilization with movement technique applied by individual himself<br>13 individuals in this group, after evaluations, mobilization with movement technique applied by individual himself and after that same evaluations will be applied | Other: Mobilization with movement for Ankle<br>* The participant will assume a lunge position on a rigid serving table with the relevant extremity in a weight-bearing stance and the foot in a neutral position. An inelastic belt will be placed around the clinician's waist, flush with the lower edge of the medial malleolus, around the distal tibia and fibula. The clinician will stabilize the talus and forefoot with the web spacing of the hands and pressure dimensions on the talus and forefoot, and maintain posterior to anterior sliding of the tibia over the talus using the arch. The clinician will continue to apply pressure while the person is reporting discomfort and/or while the lunge moves, which will continue until the end of the range of motion. Mobilization will be performed as a set of 10 repetitions.<br>|
| No Intervention: Control Group<br>13 individuals in this control group, Relevant Extremity will assume a lunge position on a firm mattress with the foot in a weight-bearing stance and the foot in a neutral position. The person will feel uncomfortable and/or the parts will suddenly lunge until the end of their range of motion. No mobilization technique will be applied | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Active dorsiflexion range of motion (Degree) | Active dorsiflexion range of motion will be evaluated with the Weight Bearing Lunge test. The Weight Bearing Lunge test will be performed using a digital inclinometer. The inclinometer will be placed 10 cm below the anterior part of the tibia and the maximum tibial inclination will be measured while the participant is standing, knee flexed, while transferring weight without lifting the heel off the ground. | 2 Minutes | 
| Balance (Centimeter) | Y balance test will be used to evaluate the dynamic balance. Participants will be asked to stand barefoot on the weight-bearing platform with their toes positioned back. Then, the participants will be asked to reach anteriorly (ANT), posteromedially (PM), and posterolaterally (PL) three times with their non-weight-bearing extremity. | 10 Minutes | 
| Gait (second, meter) | Gait analysis will be evaluation with BTS G-WALK device. The G-walk will be placed on the Lumbal 5 level of each participant with the help of a belt. Participants will be asked to walk 8 m at their normal walking speed, turn, and return to their starting point. In this process, the spatiotemporal parameters of the gait will be evaluated. | 2 Minutes | 
| Jumping (Centimeter) | Jumping performance will be evaluation with BTS G-WALK device. For evaluation, participants will keep their hands on their hips. Three attempts will be made before proceeding to the test. Individuals will be asked to reach the highest possible vertical length with each jump on the dominant leg. Three attempts will be recorded and the average of the jump height and anaerobic performance values for analysis. | 3 Minutes | 
| Foot Plantar Pressure (centimeter2, contact area %) | Foot plantar pressure will be evaluated using a pedobarographic device. For the measurement, the participants will be asked to stand on the pedobarographic device in a fixed position with bare feet and feet at shoulder level. Participants will be instructed to look across at a fixed point with arms relaxed at both sides. Within the plantar pressure analysis measurements; in static conditions, percentage of contact (%), maximal pressure (N/cm²) and contact area for the dominant foot (cm²), contact surface (%), loads on the fore and hind feet (%) will be determined and recorded. | 3 Minutes | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Ankle mobility, Dorsiflexion Limitation, Mobilization with movement, Manuel Therapy, Plantar pressure, Balance, Gait, Jumping