Effects of joint mobilization on chronic ankle instability: a randomized controlled trial 指導老師：蔡明倫 報告學生：洪唯博

Outline Introduction Method Data analysis Result Discussion Conclusion

Introduction

Ankle sprain Accounts for 22% of all sports injuries The most common injury in the active population Accounts for 22% of all sports injuries 70~80% of all patients with a previous history of ankle sprain Symptoms : Ligament laxity Pain during activity Loss of proprioception Feelings of “giving way” Decreased range of motion Ankle instability Recurrent swelling

Chronic ankle instability(CAI) Defined: Repetitive bouts of lateral ankle instability resulting in numerous ankle sprains Cause by : Functional instability(FI) Feeling of instability Proprioceptive and neuromuscular dysfunction Feeling of giving away Mechanical instability(MI): Movement of the ankle joint beyond the physiologic ROM More laxity than normal 外側踝關節不穩導致許多腳踝扭傷反覆發作 多半的CAI 都是FI造成

Intrinsic factors Extrinsic factors eversion to inversion strength ratio plantarflexion strength physical activity dorsiflexion to plantarflexion strength ratio limb dominance type of ground lower leg alignment decreased ROM Shoes worn postural control

Posterior talar glide↓ Positional alteration: A lack of DFROM can predispose to re-injury (as a risk factor) Alteration in talar arthokinematics: Posterior talar glide↓ Positional alteration: talas in relation with ankle joint Therapy: Restore DFROM by increasing the extensibility of non-contractile tissues(ex, joint capsule,ligament) Dorsiflexion常是主要被影響因子 Cuff muscle tightness=>影響subtalar joint多 (Johanson in 2008)

Mobilization with movement(MWM) 1. Reducing pain and swelling 4. Improving function 2. Postural control impairment 3. Ankle DFROM in lateral ankle sprain patients Balance: dynamic balance tasks Balance↓is to be a risk factors MWM以上這幾點可以有效的解決re-injury的問題 (posterior talar glide) 增加了sensory output of mechnoreceptors in capsule, ligaments(due to activation of gamma motor neurons by tissue traction →postureal control improvement 大部分的病人照會PT都是因為疼痛及腫的回復狀況。 但是現在大副份的治療像是貼紮，電刺激，熱療，都可以有效減緩疼痛及水腫。 治標不治本，無法根本的解決ankle sprain 的後遺症(像是:CAI,proprioception impairment, muscle weakness, ROM等)提供功能性的恢復及降低復發機率。 所以才想要找一個治療方法來改善上述情況。

B. Method

Participants Randomized double-blind placebo-controlled trial 102 patients Inclusion criteria Exclusion criteria

Inclusion criteria Previous history of ankle sprain (at least two sprains on the same side in the last 2 years) Asymmetry than 2 cm on the weight-bearing lunge test (WBLT) for ankle dorsiflexion No history of lateral ankle sprain on the contralateral side Feeling of “giving way” and instability 這段期間不能接受其他物理治療

Exclusion criteria Acute ankle sprain within the previous 6 months History of bilateral ankle injury Bony injury associated with ankle sprain such as avulsion fracture or ankle osteochondral lesion Previous injury or surgery to the back, hip, or knee

47males, 34 females, age 27.7y/o ,SD=6.8

Outcome measure anterior, posteromedial, posterolateral Ankle DFROM Weight-bearing lunge test(WBLT) Assesses the maximal advancement of tibia over the talus in a weight-bearing position Practice and three analysis trials Self-reported ankle instability Cumberland Ankle Instability Tool (CAIT) Dynamic postural control Star Excursion Balance Test (SEBT) anterior, posteromedial, posterolateral More reliable(ICC=0.93-96) 是dynamic postural control measures Toe 和heel在一直線，踩穩腳跟，instructed to bend the supporting knee so that it touched the wall找出腳可以離強最遠的距離 2)9個item 問卷用來評量CAI的嚴重程度:0(sever instability)~30(normal instability), FI(functional ankle instability):<27 scores，因為這量表可以看出隨著時間的能力改變，所以選擇 3) 單腳站，摸到對側的距離 測三次，量距離

Treatment Manipulation group Placebo group Control group Weight-bearing MWM 10 repetitions/set, 2 minutes rest, 2 set/session, 2 session/week, 3-week Placebo group Control group No treatment 1) 2)Fix talocrural joint, placed a semi-rigid orthosis limited ankle dorsiflexion Supine,passively flexed/extended the knee

Data analysis SPSS 17.0 ANOVA Categorical variable : Chi-squared Continuous variable: One-way analysis P<0.05 Continuous variables: standard deviation (one way ) Categorical variables : frequencies , percentages (Chi-squared test)

C. Result

C. Result(1) Group N= Percentage of males Manipulation group 30 56.7 Total of 81 patients completed the study and were analyzed 47 males, 34 females, mean age of 27.7 years Group N= Percentage of males Manipulation group 30 56.7 Placebo group 31 54.8 Control group 29 58.6

No differences were observed between groups at baseline. 在基準線上是沒有顯著差異的 No differences were observed between groups at baseline.

Discussion

The effectiveness of MWM has been reported in acute and subacute ankle sprain The present study deems joint MWM a useful therapeutic tool that provides good results in DFROM Dynamic postural control Self-reported feelings of instability

It was observed that there is a deficit in DFROM in patients with CAI, which could be associated with functional impairments such as Sensorimotor alterations Subjective feeling of “giving way” Muscle activation DFROM is deemed to be due to the alteration of normal arthrokinematics of the ankle as a consequence of the joint disrupting the normal transmission of afferent information available to the sensorimotor system. DFROM的減少造成正常傳入的sensorymotor路徑被破壞所造成的

Thus, it could be hypothesized that MWM could enhance the subjective feeling of stability. This study has shown the long term effects of WB_MWM joint mobilization on patients with CAI. Conclusion: Weight bearing MWM joint mobilization seems to be effective in the treatment of DFROM Dynamic postural control Self-reported instability 未來可以考量subtalar joint arthokinematics 和sensorimotor system，且更久的follow-up

Conclusion Weight bearing MWM joint mobilization seems to be effective in the treatment of DFROM Dynamic postural control Self-reported instability

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