Original articleThe initial effects of a Mulligan's mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains
Introduction
The lateral ligament complex of the ankle, described as the body's “most frequently injured single structure” (Garrick, 1977), is mechanically vulnerable to sprain injury. At extremes of plantarflexion and inversion, influenced by the shorter medial aspect of the ankle mortise, the relatively weak anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are prone to varying grades of rupture, often via minimal force (Hockenbury and Sammarco, 2001).
Immediate inflammatory processes produce acute anterolateral pain and oedema, with avoidance of movement and weight bearing (Wolfe et al., 2001). Subsequent losses of joint range, particularly dorsiflexion, and muscle strength results in significant gait dysfunction. Recent data from our laboratory highlights the presence of a dorsiflexion deficit not only in the acute stage, but also in the subacute stage (Yang and Vicenzino, 2002).
Early physiotherapy intervention consists of rest, ice, compression, elevation (RICE) and electrotherapy modalities to control inflammation, as well as manipulative therapy and therapeutic exercise techniques to address impairments of movement and strength (Wolfe et al., 2001; Hockenbury and Sammarco, 2001). Green et al. (2001) investigated the impact of combining non-weight-bearing talocrural anteroposterior (AP) passive mobilisations, believed to restore dorsiflexion range, with the RICE protocol in the treatment of acute ankle sprains. The experimental group (n=19) demonstrated a more rapid improvement in pain-free dorsiflexion and function than the control group (n=19) who were treated solely with RICE. This provides important evidence substantiating the role of passive joint mobilizations in an acutely injured population.
The mobilization with movement (MWM) treatment approach for improving dorsiflexion post-ankle sprain combines a relative posteroanterior glide of the tibia on talus (or a relative anteroposterior glide of the talus on the tibia) with active dorsiflexion movements, preferentially in weight bearing (Mulligan, 1999). Claims of rapid restoration of pain-free movement are associated with MWM techniques generally (Mulligan (1993), Mulligan (1993); Exelby, 1996). Through examination of the effects of MWM on ankle dorsiflexion in asymptomatic mildly restricted ankle joints, Vicenzino et al. (2001) found that both the weight bearing and non-weight-bearing variations of the dorsiflexion MWM technique produced significant gains in dorsiflexion range. However, weight-bearing treatment techniques are widely believed to be superior to non-weight-bearing techniques, as they replicate aspects of functional activities (Mulligan, 1999). Acute ankle sprains, whilst having marked reduction in dorsiflexion range of motion, are frequently painful in full weight bearing, and weight-bearing techniques are not clinically indicated. The subacute ankle sprain is characterized by significant residual deficits in dorsiflexion (Yang and Vicenzino, 2002) and the capacity to fully weight bear, making it a good model on which to study the initial effects of weight-bearing MWM on dorsiflexion.
The mechanism of action of manipulative therapy has been the focus of several reports in recent times, however spinal manipulative therapy appears to be the common subject of research. A synopsis of current evidence for the initial mechanism of action of manipulative therapy indicates in part a neurophysiological basis (Vicenzino et al (1996), Vicenzino et al (1998), Vicenzino et al. (2001)). Manipulative therapy treatment techniques studied have exhibited non-opioid hypoalgesia to mechanical but not thermal pain stimuli (Vicenzino et al. (1995), Vicenzino et al (1998)).
The primary objective of this study was to test the hypothesis that application of Mulligan's MWM technique for talocrural dorsiflexion to subacute lateral ankle sprains produces an initial dorsiflexion gain, and simultaneously produces a mechanical but not thermal hypoalgesia.
Section snippets
Methods
The double-blind randomized controlled trial incorporated repeated measures into a cross over design, in which each participant served as their own control.
Reliability
Acceptable intrarater reliability was determined through analysis of pre-treatment data from the three testing sessions. The intraclass correlation coefficient (ICC) and standard error of measurement (SEM) data for the pain measures are presented in Table 1. The ICC and SEM for the dorsiflexion measure were 0.99 and 3.50 mm, respectively. The ICC for the pain measures ranged from 0.95 to 0.99. The SEM for pressure pain threshold ranged from 5.57 to 12.00 kPa, and the thermal pain threshold SEM
Data management and analysis
Two independent variables were incorporated into the research design; TREATMENT (MWM, placebo, control), and TIME of application (pre- and post-intervention). Three dependent variables, measures of pressure pain threshold (PPT), thermal pain threshold (TPT) and dorsiflexion (DF), were evaluated. Prior to analysis, triplicate DF, PPT and TPT data were averaged.
Data pertaining to two of the participants were excluded from analysis; subject 4 who had a post-testing MRI that revealed an
Pre-experiment deficits in outcome measures
Pre-experiment values for dorsiflexion and pain measures of the affected and unaffected ankles are displayed in Table 2. Statistical analysis of side-to-side differences revealed a deficit only for dorsiflexion (DF) (t=5.689, P<0.001) and pressure pain threshold over the anterior talofibular ligament (PPT ATFL) (t=2.570, P=0.025). No such deficits in thermal pain threshold (TPT) were found.
Dorsiflexion
A significant interaction time by condition effect for the dorsiflexion outcome measure was detected by
Discussion
Application of the dorsiflexion mobilization with movement (MWM) technique to patients with subacute lateral ankle sprains produced a significant immediate improvement in dorsiflexion, but had no significant initial effect on mechanical and thermal pain threshold measures. This dorsiflexion gain following manipulative therapy parallels findings by Green et al. (2001) in acute ankle injuries, and Vicenzino and colleagues’ (2001) study of asymptomatic minimally restricted ankles.
Current and
Conclusion
Mulligan's dorsiflexion mobilization with movement technique significantly increases talocrural dorsiflexion initially after application in subacute ankle sprains. The absence of hypoalgesia post-application suggests a predominant mechanical rather than hypoalgesic effect behind the technique's success. Further research using a larger sample is required to determine the exact mechanism behind this.
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