Abstract
BackgroundUp to 40% of individuals who sprain their ankle develop chronic ankle instability (CAI). One treatment option for this debilitating condition is joint mobilisation. There is preliminary evidence that Mulligan’s Mobilisation With Movement (MWM) is effective for treating patients with CAI, but the mechanisms by which it works are unclear, with Mulligan suggesting a repositioning of the fibula. This randomised controlled trial aims to determine the effects of MWM on anatomical and clinical characteristics of CAI.MethodsParticipants 18 years or over with CAI will be accepted into the study if they satisfy the inclusion and exclusion criteria endorsed by the International Ankle Consortium. They will be randomised into the experimental group (MWM) or the placebo group (detuned laser) and will receive the assigned intervention over 4 weeks. General joint hypermobility and the presence of mechanical instability of the ankle will be recorded during the first visit. Further, position of the fibula, self-reported function, ankle dorsiflexion range, pressure pain threshold, pain intensity, and static and dynamic balance will be assessed at baseline, and at the conclusion of course of intervention. Follow-up data will be collected at the twelfth week and at the twelfth month following intervention.DiscussionEffectiveness of MWM on clinically relevant outcomes, including long term benefits will be evaluated. The capacity of MWM to reverse any positional fault of the fibula and the association of any positional fault with other clinically important outcomes for CAI will be explored. Proposed biomechanical mechanisms of fibular positional fault and other neurophysiological mechanisms that may explain the treatment effects of MWM will be further explored. The long term effectiveness of MWM in CAI will also be assessed.Trial registrationAustralian New Zealand Clinical Trials Registry; ACTRN12617001467325 (17/10/2017).
Highlights
One proposed anatomical mechanism underpinning Mobilisation With Movement (MWM) is theorised to be a correction of a minor bony incongruity which is at the source of the patient’s presenting problem [22, 73]
There are limited MRI data supporting Mulligan’s positional fault hypothesis in cases of lateral ankle pain [72], there is no evidence to date that MWM reverses any positional anomaly
The proposed study protocol is designed to determine the presence of any positional fault of the fibula in chronic ankle instability (CAI), and whether MWM can reverse this, and if so, whether this reversal is evident 4 weeks after treatment commences
Summary
Up to 40% of individuals who sprain their ankle develop chronic ankle instability (CAI). There is preliminary evidence that Mulligan’s Mobilisation With Movement (MWM) is effective for treating patients with CAI, but the mechanisms by which it works are unclear, with Mulligan suggesting a repositioning of the fibula. Several ankle joint mobilisation procedures have been developed and described by renowned manual therapists such as Geoffrey Maitland, Freddy Kaltenborn and Brian Mulligan, and are commonly used in rehabilitation [7] These procedures are applied to a joint, either in the form of non-thrust passive joint mobilisations, high velocity thrust manipulation, or Mobilisation With Movement (MWM). The proposed neurophysiological mechanisms are based on animal [11] and human experiments [12] related to pain science and motor systems [8] These have shown that joint manual therapy techniques including MWM, activate a descending pain inhibitory pathway which is non-opioid mediated [8]. One proposed biomechanical mechanism relates to a reduction of an entrapped meniscoid or synovial fringe by a directed MWM glide in those instances where only one repetition is required to bring about a substantial and long lasting effect [8]
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