Effectiveness of joint mobilization techniques in comparison with active

rehabilitation in restoring joint arthro-kinematics in patients with chronic ankle

instability

By Colin Ensminger
Clinical scenario: Chronic ankle instability can be associated with altered gait
mechanics due to injury. Treatments such as joint mobilizations and balance
exercises during rehabilitation have proven effective.
Clinical question: Looking into the effectiveness of joint mobilizations at restoring
normal ankle kinematics in patients with chronic ankle instability when compared to
balance rehabilitation techniques.
Clinical bottom line: Research suggests that both joint mobilization and balance
rehabilitation techniques are effective at returning normal joint kinematics at the
ankle. There is moderate evidence that shows joint mobilizations to be more
effective than balance techniques.
Search strategy: Patients suffering from chronic ankle instability due to altered joint
kinematics from injury (altered neuromuscular control, altered gait mechanics).
Intervention: Joint mobilization. Comparison: Balance rehab techniques. Outcome:
restored kinematics.
Sources of evidence searched: Google scholar, Ebsco, Pubmed
The research articles that were studied were randomized control trials. The
research looked at the effects of different rehabilitation techniques on restoring
normal joint function in patients with chronic ankle instability. The techniques
compared were joint mobilizations and balance in effectiveness of treatment. 4
possible studies were analyzed, 3 RCTs met inclusion criteria (8/11 PEDRO scale).
Study Methodology: (Harkey et al 2014) Participants were included if there was the
presence of chronic ankle instability (CAI). CAI was defined through the Foot and
Ankle Disability Index (FADI) and FADI sport subscale (FADIs). Scores of less than
90% on the FADI and 80% on the FADIs were included. There were 30 total
participants in the study. The participants were allocated randomly into 2 groups:
mobilization and control. Group 1 was treated with Maitland grade III anterior-to-
posterior mobilizations of the talus. Group 2 received no treatment. Two
investigators measured range of motion and the Star Excursion Balance Test. A
single investigator performed the spinal-reflex and corticospinal excitability
measures.
(Green et al 2001) Participants were patients diagnosed with acute ankle sprains. A
total of 41 patients participated in the study. A radiograph of each subjects ankle
was taken in order to screen for abnormalities prior to inclusion. Participants were
assigned to a control group or an experimental group by a random number system.
The experimental group received passive joint mobilizations over the anterior
surface of the talus to mobilize the talocrural joint.
(McKeon 2008) Participants with self-reported chronic ankle instability were
assigned to either a control group or a balance training group. Assignments were
made randomly. The balance training group completed 12 training sessions, while
supervised, over a four-week period. The control group maintained activity levels
from before the study for the duration of the study. Measures of self-reported
values of function, gait, and laxity were assessed prior to and after the study.
Internal Validity: (Harkey et al) Internal validity was good in this article. One strategy
used to reduce the threat to internal validity was to order the groups differently for
the posttest than they were ordered for the pretest. The different groups were
treated for the same amount of time. Some threats that were present were the
instruments used in the testing, however, as long as the same parameters were
used, then that threat could be avoided.
(Green et al) The internal validity in this study was ok. The instrumentation was
tested to ensure validity. One threat to internal validity was that there were
multiple assessors that took part in the study. If one assessor was used and was
blinded to group allocations, then the study would have higher internal validity. The
number of treatment sessions was also very low, which hurt internal validity.
(McKeon) Internal validity was good. It was hurt, though, by the subjects self-
reported symptoms because of the difference in reported factors between subjects.
This could have been helped if one evaluator was used to determine inclusion in the
study. Instrumentation was reliable since three trials were performed to evaluate
arthrometry.
External Validity: (Harkey et al) External validity, in this article, was good. Both
groups completed pretesting and posttesting at the same time as the other. The
study was done recently. One threat to generalization was how the subjects were
gathered, which wasnt specified.
(Green et al) Generalization in this article was hurt by there being multiple
assessors administering treatment. Having one assessor would fix this.
(McKeon) The external validity of this article was hurt due to the fact that the
subjects chronic ankle instability was self-reported.
Results: (Harkey et al) This article showed that when patients with chronic ankle
instability were treated with Maitland Grade 3 joint mobilizations, patients regained
approximately 3 degrees of dorsiflexion.
(Green et al) The study showed that when acute ankle inversion sprains were
treated with mobilization of the talocrural joint and RICE, fewer treatments were
necessary to increase pain free dorsiflexion ROM and stride speed. When RICE
alone was used, more treatments were needed.
(McKeon) This study found that with a 4 week balance training program improved
coordination in patients while walking. However, this improvement in coordination
was not present during jogging. The study also found that lateral ankle ligamentous
laxity didnt prevent restoration of function.
Outcome: (Harkey et al) The results show that joint mobilizations are an effective
treatment for patients with chronic ankle instability.
(Green et al) The results support using passive joint mobilization as an effective
treatment option for patients with instability due to ankle sprains.
(McKeon) The results support using a balance program for restoring normal walking
function in patients with chronic ankle instability.
 References
Green, T., Refshauge, K., Crosbie, J., Adams, R. (2001). A Randomized Controlled
Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion
Sprains. Physical Therapy, 81 (4), 984-994.
Harkey, M., McLeod, M., Van Scoit, A., Terada, M., Tevald, M., Gribble, P.,
Pietrosimone, B. (2014). The Immediate Effects of an Anterior-to-Posterior
Talar Mobilization on Neural Excitability, Dorsiflexion Range of Motion, and
Dynamic Balance in Patients with Chronic Ankle Instability. Journal of Sport
Rehabilitation, 23 (4), 351-359.
McKeon, P., Paolini, G., Ingersoll, C., Kerrigan, C., Saliba, E., Bennett, B., Hertel, J.
(2008). Effects of Balance Training on Gait Parameters in Patients with
Chronic Ankle Instability: A Randomized Controlled Trial. Clinical
Rehabilitation, 23, 609-621.