Clinical trial NCT04178369: The Effects of Proximal And Distal Tibiofibular Joint Manipulations on Foot Posture, Ankle Range of Motion, and Balance
Official title: The Effects of Proximal And Distal Tibiofibular Joint Manipulations on Foot Posture, Ankle Range of Motion, and Balance in Chronic Hemiplegic Individuals
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Hemiplegia
Gait, Hemiplegic
Mobility Limitation
Lead sponsor: Hacettepe University
Sponsor class: OTHER
First posted: 2019-11-26
Enrollment: 28
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Randomized
Primary purpose: TREATMENT

Brief summary: Limited ankle dorsiflexion adversely affects the weight bearing capacity, increases the knee extensor moment and causes insufficient maneuvers to change the center of gravity of the body in patients with hemiplegia. While biomechanical studies emphasized the importance of proximal tibiofibular joint and distal tibiofibular joint manipulations for ankle dorsiflexion, no studies examining the effect of corrective manipulation techniques applied to these two joints on foot posture, range of motion and balance were observed.

Detailed description: In chronic hemiplegic individuals, gait loss due to biomechanical disorders of the talocrural joint (TCJ) and subtalar joint (STJ) affects 50% of the population. Although foot posture is seen at the same rate in pronation and supination, approximately 30% of individuals have abnormal and asymmetric foot posture. In particular, foot posture in the direction of plantar flexion and inversion leads to limited ankle mobility. Loss of mobility can be caused by non-neural factors as well as neural factors such as spasticity and increased myostatic reflex. Due to long-term immobilization, negative changes are seen in the tissues such as bone, muscle, tendon and ligament and especially ankle dorsiflexion is limited. Limited ankle dorsiflexion adversely affects the weight bearing capacity, increases the knee extensor moment and causes insufficient maneuvers to change the center of gravity of the body in patients with hemiplegia. The main problem is the timing of the posterior foot plantar flexion after the first contact at the beginning of the posture phase; in the late phase, defective heel and forefoot rocker roll mechanism due to the failure of forward weight transfer. For these reasons, foot posture, ankle joint range of motion and balance are adversely affected in hemiplegic individuals. Biomechanical problems related to foot deformities in chronic hemiplegic individuals have been frequently associated with TCJ and STJ anomalies. However, in biomechanical studies, it is emphasized that proximal tibiofibular joint (PTFJ) and distal tibiofibular joint (DTFJ) have important roles in optimal ankle dorsiflexion. Although PTFJ is anatomically belonging to the knee, it is evaluated within the foot-ankle complex as a function. PTFJ makes slip movements during movement in TCJ. Limitations in PTFJ movement result in limitation of the endpoints of normal ankle joint movement and anterior pain in the ankle during weight bearing. Increased tension in the lateral ligaments due to plantar flexion and inversion anomalies and traumas of the ankle applies inferior directional traction force to the distal fibula.This leads to fibular rotation in the parasagittal plane. Anterior and inferior movement of the distal fibula causes inferior and posterior shifting of the PTFJ and the PTFJ locks. This locking restricts the movement of the entire fibula during ankle movements and leads to a limitation of dorsiflexion of TCJ. It is emphasized that ankle posture significantly affects DTFJ in addition to PTFJ. The anterior ligament of DTFJ is closely related to the anterior talofibular ligament (ATFL). Plantar flexion and inversion of the trauma or supination of the foot posture, etc. conditions increase the tension in the lateral ligaments and cause pathologies in ATFL. This situation adversely affects the anterior ligament of DTFJ, leading to instability risk in this joint and loss of dorsiflexion in TCJ. While biomechanical studies emphasized the importance of proximal tibiofibular joint and distal tibiofibular joint manipulations for ankle dorsiflexion, no studies examining the effect of corrective manipulation techniques applied to these two joints on foot posture, range of motion and balance were observed. It is thought that PTFJ and DTFJ also have an effect on the above mentioned biomechanical chain in functional deficiencies caused by foot posture in the direction of plantar flexion and inversion. Therefore, we aimed to investigate the effects of PTFJ and DTFJ manipulation techniques on foot posture, range of motion and balance parameters in chronic hemiplegic subjects.

Eligibility criteria: Inclusion Criteria:

* presence of chronic hemiplegia (˃6 months),
* the ability to stand on the hemiplegic leg on a 30-cm-high step-board,
* the ability to walk at least 10 m without any assistive device,
* presence of limitation in ankle passive dorsiflexion (contracture),
* the ability to understand and follow verbal commands,
* to be volunteer to participate in the study.

Exclusion Criteria:

* presence of any condition that is considered as a contraindication for mobilization (such as hypermobility, trauma, inflammation, etc.),
* presence of any visual, verbal, or cognitive defects (such as aphasia, unilateral neglect, etc.),
* having ankle sprain during the past 6 weeks,
* patients who had undergone foot-ankle surgeries,
* to receive any additional treatment within the time period of our study.

Primary outcomes:
measure: Foot Posture Index
timeFrame: 6 weeks
Secondary outcomes:
measure: Range of Motion
timeFrame: 6 weeks
measure: Berg Balance Scale
timeFrame: 6 weeks
Other outcomes:
Locations:
Study officials:
References:
citation: An CM, Won JI. Effects of ankle joint mobilization with movement and weight-bearing exercise on knee strength, ankle range of motion, and gait velocity in patients with stroke: a pilot study. J Phys Ther Sci. 2016 Jan;28(2):689-94. doi: 10.1589/jpts.28.689. Epub 2016 Feb 29.
citation: An CM, Jo SO. Effects of Talocrural Mobilization with Movement on Ankle Strength, Mobility, and Weight-Bearing Ability in Hemiplegic Patients with Chronic Stroke: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis. 2017 Jan;26(1):169-176. doi: 10.1016/j.jstrokecerebrovasdis.2016.09.005. Epub 2016 Oct 17.
citation: Kluding PM, Santos M. Effects of ankle joint mobilizations in adults poststroke: a pilot study. Arch Phys Med Rehabil. 2008 Mar;89(3):449-56. doi: 10.1016/j.apmr.2007.12.005.