Author Names

Lee, J., Kim, J., Lee, B.

Reviewer Name

Bryan Tanigawa, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

[Purpose] The purpose of this study was to examine the effectiveness of posterior talar glide (PTG) with dorsiflexion of the ankle on stroke patients ankle mobility, muscle strength, and balance ability. [Subjects and Methods] Thirty-four subjects were randomly assigned to either a PTG with dorsiflexion group (PTG; n=17), or a weight-bearing with placebo PTG group (control; n=17). Subjects in the PTG group performed PTG with dorsiflexion, designed to improve ankle mobility, muscle strength and balance ability with proprioceptive control of the ankle, for 10 glides of 5 sets/day, 5 days/week, for 4 weeks. [Results] The experimental group showed significant improvement on the Ankle Dorsiflexion Range of Motion assessment, Ankle Dorsiflexor Manual Muscle Test, Functional Reach Test, Time Up and Go test, and Functional Gait Assessment compared to the control group. However, regarding Ankle Plantarflexion Range of Motion assessment and the Ankle Plantarflexor Manual Muscle Test, no significant differences were found between the two groups. [Conclusion] The results of this study show that PTG with dorsiflexion can improve ankle mobility, muscle strength and balance ability in patients recovering from stroke. This exercise may prove useful in clinical rehabilitation. Further research on the long-term effectiveness of PTG on gait ability is suggested.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • No
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Yes
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • Yes
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

Posterior talar glides appear to improve functional balance ability, as well as passive dorsiflexion range of motion and strength, in patients recovering from a stroke.

Key Finding #2

Posterior talar glides do not appear to have a significant effect on plantar flexion range of motion and strength in patients recovering from a stroke.

 

Please provide your summary of the paper

This paper examined the effects of posterior talar glide (PTG) with dorsiflexion of the ankle on mobility, strength, and balance in patients post-stroke. The study included 34 individuals who were at least 6 months post-stroke. Each patient was randomly assigned to a 4-week treatment regimen that included either PTGs (via Mulligan technique) or a placebo movement (weight bearing dorsiflexion), both prescribed for 5 sets/day, 5 days/week. Both groups also underwent additional standardized physical therapy that included neurodevelopmental treatment. All patients were assessed before and after the 4-week treatments with Passive Range of Motion of the ankle (ROM), Manual Muscle Test (MMT), a Functional Reach Test (FRT), a Time Up and Go test (TUG), and a Functional Gait Assessment (FGA). The results showed that the PTG group had significant improvements in the FRT, TUG, FGA, as well as dorsiflexion ROM and MMT. There appeared to be no effect on plantar flexion ROM and MMT. This demonstrates that a PTG may be an effective treatment for clinicians to implement with patients post-stroke to improve their ankle mobility, strength, and balance ability. More research should be done to observe the long-term effectiveness of posterior talar glides in this patient population.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This randomized control trial demonstrates that posterior talar glides may be a treatment option for patients recovering from a stroke. In clinical practice, joint mobilization techniques are often focused on improving range of motion only. However, this study discusses multiple ways in which strength and balance may also be improved, such as by reducing muscle shortening to optimize tissue function and through the stimulation of afferent pathways of mechanical receptors at the joint. While the results of the study appear to support these hypotheses, there are several variables that were not fully addressed. One flaw of the study was the limited data provided about the patient population. For example, there was no data reported about the participants’ stage of recovery. Qualifying patients only needed to be at least 6-months post-stroke, which was chosen to minimize the effects of natural recovery. However, the amount of time since suffering a stroke would still be useful information when assessing functional outcomes. Further, other factors like spasticity may have an impact on the ankle’s motor function and therefore affect functional balance tests. Future studies could utilize a larger subject group and address these additional variables that may have impacted the results.

Though posterior talar glides with dorsiflexion demonstrated statistical significance in improving mobility, strength, and balance in patients post-stroke, clinicians should implement these results with an understanding of the research’s limitations. In general, there are very few studies that support weight-bearing manual therapy for functional improvements in stroke rehabilitation. As a supplement to a neurorehabilitation program, clinicians may experiment with PTG and other manual techniques to determine effectiveness on stroke recovery, so long as there are no other contraindications for the patient.