1. 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

2. Outline
Introduction
Method
Data analysis
Result
Discussion
Conclusion

3. Introduction

4. 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

5. 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

6. 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

7. 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)

8. Mobilization with movement(MWM)
1. Reducing pain and swelling 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。

9. B. Method

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

11. 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

12. 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

13. 47males, 34 females, age 27.7y/o ,SD=6.8

14. 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= )
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

15. 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

16. 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)

17. C. Result

18. 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

19. 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.

26. Discussion

27. 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

28. 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

29. 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

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

31. Thank you for your attention 