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The effectiveness of mobilization with movement on pain, balance and function following acute and sub acute inversion ankle sprain – a randomized, placebo controlled trial

Review written by Robin Kerr info

Key Points

  1. Mobilization with movement (MWM) involves a sustained passive bone glide applied by the therapist in conjunction with active movement by the patient.
  2. This is the first paper investigating the effect of MWM on acute/subacute grade I and II inversion ankle sprains.
  3. MWM along with taping and exercises may be more effective than remedial exercises alone to reduce pain, disability and improve balance in the short-term.

BACKGROUND & OBJECTIVE

Mobilization with movement (MWM) originates from the Mulligan Concept of manual therapy. The techniques involve sustained pain-free force at the involved joint with superimposed active movement by the patient into painful or limited range of movement (ROM) (1).

The purpose of this study was to examine the short and long-term efficacy of MWM in addition to usual care (RICE and remedial exercises) in patients with inversion ankle sprain. The impact on pain, balance and function following inversion injury were examined.

Mobilization with movement techniques involve sustained pain-free force at the involved joint with superimposed active movement by the patient.
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The addition of MWM seems to encourage faster clinically meaningful improvement over exercise alone in the initial stages of ankle sprain management.

METHODS

This randomized placebo-controlled trial was performed in an Indian hospital on patients with acute (4 days) and sub-acute (5-14 days) grade I and II ankle inversion injuries. 32 subjects were randomly assigned in a parallel group, assessor blind, placebo-controlled RCT. Six sessions of therapy were delivered over two weeks.

Interventions for the two groups were as follows:

  • Experimental: MWM involving supero-postero-lateral glide on the lateral malleolus with concurrent plantarflexion/inversion active movement. In addition, “Mulligan taping” to maintain the posterior malleolus, plus usual care (RICE) and remedial exercises.
  • Control/sham MWM: Forceless holding of the ankle with sham taping but the same usual care and remedial exercise regime.

Outcome measures were taken at baseline, two weeks, one and six months. Primary measure was numeric rating scale (NRS) for pain. Secondary measures were Foot and Ankle Disability index (FADI), functional dorsiflexion ROM, the Y balance test (YBT), and pressure pain threshold at the affected ankle and ipsilateral deltoid. Pressure pain thresholds were used to assess local (ankle) and widespread (deltoid) change in pain sensitivity

RESULTS

Within-group analysis: Significant effect of both MWM + exercise and sham + exercise at all follow-up points.

Between-group analysis: Significant effect of MWM in favor of the experimental group at all follow-up points. More than 93% of subjects surpassed the minimal clinical important difference (MCID) for pain, FADI and dorsiflexion ROM in the experimental group, which was greater than in the control group (see Table 2).

Effect size Cohen d (95% CI): Effect sizes were interpreted as trivial < 0.2; small 0.2-0.5; moderate 0.5-0.8; and large > 0.8.

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LIMITATIONS

  • Lack of a pure control group to identify the role of natural healing processes.
  • Sample size was small increasing the risk of false positive findings.
  • Home exercise programme was unsupervised.

CLINICAL IMPLICATIONS

Research on manual therapy is needed to support or dismiss this foundational component of the profession. MWM is a common technique used by clinicians to help reduce pain and restore ROM in patients presenting with ankle sprain. Several studies (albeit by Mulligan associates) on MWM have been performed over the last three years on chronic ankle sprains; this is the first RCT looking at acute injury.

Mulligan’s premise is that a “positional fault” in a bone may occur at the point of injury and result in ongoing pain and dysfunction if permitted to remain. This is in line with the traditional patho-mechanical thinking underlying most manual therapies. It is therefore interesting that pressure point pain thresholds responded in the ipsilateral deltoid indicating a central down-regulation mechanism from MWM at the ankle.

All the non-specific contextual effects of hands being laid on a fresh injury must be considered in these outcomes. It would also be interesting to run a head-to-head comparison with a reversed glide and tape scenario to see if the direction of the bone glide is important.

Mulligan’s technique consists of several components. Tape is routinely used to “reinforce the correctional glide”, the therapist may add manual overpressure to the movement, plus the patient continues with self-treatment at home (2). Several factors would be at play apart from ‘changing the position of a bone’ in this interaction.

In ankle sprain management, the addition of MWM seems to encourage faster clinically meaningful improvement over prescribed exercise alone in the initial stages (see Table 2). Prescribed exercise alone has been shown to provide solid results for ankle sprains at around 6 weeks (3).

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On a practical note, six treatments over two weeks is intensive/expensive therapy and would probably be more a sports medicine scenario rather than everyday hospital outpatient or private practice scheduling.

Talar glide with loaded/weightbearing ankle dorsiflexion is another Mulligan ankle technique used in recurrent chronic ankle sprains. In a recent systematic review and meta-analysis (4), moderate quality evidence found that weight-bearing MWM appears to immediately improve weight-bearing dorsiflexion. Other outcomes such as pain across the included studies had a severe lack of quantitative data, making direct comparisons difficult. Long-term outcomes have not been established.

Finally, clinicians performing manual therapy could view MWM as a pathway to segue patients into active self-management of acute ankle sprains.

+STUDY REFERENCE

Gogate N, Satpute K, Hall T (2021) The effectiveness of mobilization with movement on pain, balance and function following acute and sub acute inversion ankle sprain – A randomized, placebo controlled trial. Physical therapy in sport, 48, 91-100.

SUPPORTING REFERENCE

  1. https://bmulligan.com/mulligan-concept/
  2. https://www.youtube.com/watch?v=iiymeAJRkWY or https://www.youtube.com/watch?v=TEjKhf-qDJU
  3. Lazarou, L., Kofotolis, N., Pafis, G., & Kellis, E. (2018). Effects of two proprioceptive training programs on ankle range of motion, pain, functional and balance performance in individuals with ankle sprain. Journal of Back and Musculoskeletal Rehabilitation, 31(3), 437–446. https://doi.org/10.3233/BMR-170836
  4. Weerasekara, I., Deam, H., Bamborough, N., Brown, S., Donnelly, J., Thorp, N., & Rivett, D. A. (2020). Effect of Mobilisation with Movement (MWM) on clinical outcomes in lateral ankle sprains: A systematic review and meta- analysis. The Foot, 43, 101657.https://doi.org/10.1016/j.foot.2019.101657
The effectiveness of mobilization… By Robin Kerr