Ankle/Foot

Author Names

Shi, X., Han, J., Witchalls, J., Waddington, G. and Adams, R.

Reviewer Name

Angelo Pata SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Question Can manual therapy improve functional outcomes for individuals with chronic ankle instability?  Design Systematic review with meta-analysis of randomized controlled trials.  Participants Individuals with chronic ankle instability.  Intervention Manual therapy is defined as an intervention that involves joint mobilization, and mobilization with movement.  Outcome measure The primary outcome is patient reported function (PRF) questionnaires scores, the secondary outcomes are ankle dorsiflexion range of motion (DFROM) and balance control.  Results Four studies were included (n = 208, mean age = 24.4) in the meta-analysis, with moderate to high quality on the PEDro scale (range 6–8). For patient reported function (PRF) questionnaires, two studies reported significant improvement after six-session manual therapy measured by foot and ankle ability measures sport subscale (FAAMS) and Cumberland ankle instability tool (CAIT), respectively. For DFROM, one session manual therapy had no significant effect on the weight-bearing lunge test (WBLT) (3 studies, n = 147, SMD = 1.24 (95%CI -0.87 to 3.36), I2 = 96%) or non-weight-bearing inclinometer test (2 studies, n = 47, MD = 3.41° (95%CI -0.26 to 7.09),I2 = 43%), while six-sessions manual therapy showed, a significantly positive effect on WBLT(2 studies, n = 80, SMD = 2.39, (95% CI 0.55, to 4.23), I2 = 93%). For the SEBT, one-session manual therapy had no significant effect on overall star excursion balance test (SEBT) score (3 studies, n = 137,MD = 2.05,95%CI (−0.96,5.05), I2 = 75%), while qualitative analysis of 2 included studies showed significant improvement both on the SEBT score and single limb balance test (SLBT).  Conclusions Six sessions rather than one session of manual therapy improves ankle functional performance for individuals with CAI. 

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Finding #1

Six sessions of manual therapy compared with wait and see or sham intervention proved effective for increasing ankle dorsiflexion range of motion for patients with chronic ankle instability.

Key Finding #2

A single session of manual therapy was proved to be not effective for improving anklle dorsiflexion range of motion for patients with chronic ankle instability.

Key Finding #3

Compared to a single session of manual therapy, six session of manual therapy showed improved results on patient reported function questionnaires and balance control.

Please provide your summary of the paper

With ankle sprains being the most common injury in sport, this article sought to elucidate if the duration of manual therapy treatment would influence functional outcomes for individuals with chronic ankle instability. The authors of this article used a systematic review approach with meta-analysis of randomized control trials. The outcome measures studied were patient reported function (PRF) questionnaires, balance control, and ankle dorsiflexion range of motion. There are limited qualified studies reviewed in this article as the supporting body of research literature is still growing. Also, data was only gathered up to six weeks of treatment session. This means the long-term effects of manual therapy on patients with chronic ankle instability has potential for a future study. All that aside this article confidently proves that six weeks of manual therapy shows improved results in PRF questionnaires and balance control compared to just a single session of manual therapy. It is also worth noting manual therapy for six weeks on patients with chronic ankle instability showed to be effective at increasing dorsiflexion range of motion.

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

This article proves that if manual therapy is done for six weeks, it can help improve ankle dorsiflexion range of motion, PRF questionnaire scores, and balance control for patients with chronic ankle instability. Therapists have been utilizing manual therapy to treat this patient population for some time. However, this is validating research that shows therapists should continue to use manual therapy to supplement their treatment of chronic ankle instability

Author Names

Kim, H.; Cho, J.; Lee, S.

Reviewer Name

Margaret Pohl, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Patellofemoral pain syndrome (PFPS) is defined as pain around the patella while performing activities such as squats, running, and climbing steps. One of the inherent risk factors for PFPS is an excessively pronated foot posture. The aim of this study was to investigate the effect of foot intervention, talonavicular joint mobilization (TJM) and foot core strengthening (FCS), on PFPS.  Methods: Forty‐eight patients with PFPS (mean age, 21.96 ± 2.34 years; BMI, 22.77 ± 2.95 kg/m2) were enrolled in the study. Participants were randomly assigned in a 1:1:1 ratio to three groups, and received 12 sessions of TJM, FCS, and blended intervention at university laboratory for 4 weeks. The primary outcomes were pain while the secondary outcomes were lower extremity function, valgus knee, foot posture, and muscle activity ratio measured at baseline, after 12 sessions, and at the 4‐week follow‐up.  Results: The two‐way repeated‐measures ANOVA revealed significant interactions in all groups (p < 0.05). TJM reduced pain more than the FCS at post‐test (mean difference, − 0.938; 95% Confidence interval [CI], − 1.664 to − 0.211; p < 0.05), and blended intervention improved lower extremity function (mean difference, 6.250; 95% CI, 1.265 to 11.235; p < 0.05) and valgus knee (mean difference, − 11.019; 95% CI, − 17.007 to − 5.031; p < 0.05) more than the TJM at 4 weeks follow‐up. TJM was more effective in post‐test (mean difference, − 1.250; 95% CI, − 2.195 to − 0.305; p < 0.05), and TJM (mean difference, − 1.563; 95% CI, − 2.640 to − 0.485; p < 0.05) and blended intervention (mean difference, − 1.500; 95% CI, − 2.578 to − 0.422; p < 0.05) were more effective in foot posture than the FCS in 4 weeks follow‐up. Blended intervention displayed greater improvement in muscle activity than the TJM (mean difference, 0.284; 95% CI, 0.069 to 0.500; p < 0.05) and the FCS (mean difference, 0.265; 95% CI, 0.050 to 0.481; p < 0.05) at 4 weeks follow‐up.  Conclusions: Our study is a novel approach to the potential impact of foot interventions on patellofemoral pain. Foot intervention including TJM and FCS is effective for pain control and function improvement in individuals with PFPS.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

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

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

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

The results of the study suggest that talonavicular joint mobilization is effective for immediate control of patellofemoral pain and foot posture. 

Key Finding #2

The blended intervention, talonavicular joint mobilization with foot core strengthening, had a positive effect on reduced dynamic knee valgus, increased vastus medialis muscle activity and controlled pain.

Key Finding #3

Key Finding #4

Please provide your summary of the paper

This study looked at the effect of foot interventions, specifically talonavicualr joint mobilizations (TJM) and foot core strengthening (FCS), on patellofemoral pain syndrome (PFPS).  48 patients, with a mean age of 21.96 and history of PFPS, participated in the study and randomly assigned to one of three intervention groups; TJM, FCS or the blended intervention which combined TJM and FCS.  The treatment plan took 4 weeks (12 sessions total) and patients were assessed on the primary outcome of pain and secondary outcomes of lower extremity function, valgus knee, foot posture and muscle activity ratio measured at baseline at the 4 week follow-up.  Overall, the study showed significant interactions in all groups and that TJM reduced pain more than FCS at the 4 week post-test.  It also showed that the blended intervention improved LE function and valgus knee in comparison to TJM alone.  Finally, the study showed that TJM and the blended intervention were more effective in foot posture than FCS.  Overall, the study showed the potential impact of manual therapy of the foot on PFPS and that interventions including TJM and FCS are effective for pain control and functional improvement in this 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 study may impact clinical practice of treating individuals with acute PFPS.  As the study only looked at a treatment period of 4 weeks, talonavicular joint mobilizations may be beneficial in reducing PFPS pain in a short time frame.  In order to determine the long term impacts of TJM, FCS, or the blended intervention, it would be interesting to conduct a study that used a time frame of 8 or 12 weeks.  Overall, this study could be helpful for suggesting interventions to relatively immediately relieve PFPS pain, but a study looking at a longer duration of time would be beneficial to assess at the long term impact that these interventions have on individuals with PFPS pain.  Additionally, the study was conducted on individuals in a university, so looking at a larger population size would be beneficial to the validity of the data and implementation into clinical practice.

Author Names

Zordão, C., Mendonca, E., Valério, P., Perez, C., Ferro, A., Guirro, E.

Reviewer Name

Wes Pritzlaff, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objectives: The objective of this study was to evaluate the immediate effect of manual therapy on ankle joint mobility and static balance in patients with diabetes.  Methods: Forty patients, at a mean age of 59.35 ± 7.85, with type 2 diabetes mellitus and neurologic symptoms according to a Neuropathy Symptom Score protocol with amplitude, were included. The patients were divided into 2 groups: sham group and intervention group, which underwent manual manipulation intervention and 7-day follow-up. Joint range-of-motion analysis was performed using digital goniometry and static discharge of weights assessed by computerized baropodometry with open and closed eyes. The Shapiro-Wilk normality test was used to analyze the distribution. The data showed normal distribution, so the analysis of variance tests followed by Tukey’s tests were used. SAS statistical software was used and the significance level was 5%.  Results: The results of the intervention group showed an increase in the variable ankle goniometry over time compared to the sham group. The dorsiflexion movement on the right side obtained major gains over time; in addition, plantar flexion increased.  Conclusion: Based on the participants evaluated in this study, manual therapy increased the ankle joint amplitude and improved the static balance in individuals with diabetes.  Keywords: Ankle Joint; Diabetes Mellitus; Manipulation; Musculoskeletal Manipulations; Osteopathic; Physical Therapy Modalities.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

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

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

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

There were significant statistical differences between pre-intervention and follow-up (7-days post-intervention) measurements in both plantarflexion and dorsiflexion active range of motion only in the intervention group, as well as an increase in peak plantar pressure during static balance between the immediate post-intervention and follow-up (7-days post-intervention) measurements with eyes open only in the intervention group.

Key Finding #2

There were no significant statistical differences between the intervention and sham groups regarding plantarflexion and dorsiflexion active range of motion, peak plantar pressure, and static postural balance at any time point (pre-intervention, immediately post-intervention, and 7-day follow-up).

Key Finding #3

The sham group received a non-thrust, small mobilization of unspecified grade and duration, and the intervention group received one thrust manipulation at each limited talocrural joint.

Key Finding #4

All participants had a five-year or longer history of type 2 diabetes mellitus, limited talocrural active range of motion, and peripheral neuropathy according to the Neuropathy Symptom Score.

Please provide your summary of the paper

This simple-blind randomized controlled trial sought to evaluate the immediate and lasting effects of talocrural thrust manipulation on dorsiflexion and plantarflexion active range of motion, peak plantar pressure, and static balance in patients with diabetes, peripheral neuropathy and limited dorsiflexion and plantarflexion active range of motion. The data were analyzed utilizing validated measures outlined in the methods section. The only difference between the sham and intervention groups was whether a small non-thrust mobilization or thrust manipulation was applied to the talocrural joint, respectively. The intensity nor duration of non-thurst mobilization received by the sham group was reported. Although there were no intergroup differences in dorsiflexion and plantarflexion active range of motion, peak plantar pressure, nor static balance, the thrust group demonstrated intragroup improvements from pre-intervention to immediately post-intervention or 7-day follow-up in ankle active range of motion, peak plantar pressure, and static balance. This supports that thrust manipulation at the talocrural joint may be beneficial in improving ankle range of motion and static balance in individuals with diabetes, peripheral neuropathy, and limited ankle range of motion; however, this study does not support that thrust manipulation facilitates significant improvement relative to non-thrust mobilization manual therapy at the talocrural joint 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.

The results of this study support the benefit of manual therapy in improving impairments in body structure and function (e.g. limitations in dorsiflexion and plantarflexion active range of motion) and activity limitations (e.g. static balance). As the results from this study do not support any significant differences between non-thrust mobilization and thrust manipulation on ankle active range of motion, peak plantar pressure, and static balance, further research is recommended to better understand any potential differences between types of manual therapy interventions. This research is highly applicable to patients with chronic diabetes and peripheral neuropathy as decreases in proprioceptive sensation at the talocrural joint may lead to limitations in both dorsiflexion and plantarflexion range of motion to promote stability. Therefore, patients who fit this clinical presentation may benefit from manual therapy at the talocrural joint to improve long-term function by improving the available range of motion, plantar distribution of weight, and static balance.

Authors:

Cruz-Díaz, D., Hita-Contreras, F., Martínez-Amat, A., Aibar-Almazán, A., Kim, K.M.

Reviewer: 

Paula Stonehouse, SPT

Affiliation: 

Duke University, School of Medicine, Doctor of Physical Therapy

Study Design:

Randomized controlled trial

Abstract:

Context: Ankle-joint mobilization and neuromuscular and strength training have been deemed beneficial in the management of patients with chronic ankle instability (CAI). CrossFit training is a sport modality that involves these techniques.

Objective: To determine and compare the influence of adding self-mobilization of the ankle joint to CrossFit training versus CrossFit alone or no intervention in patients with CAI.

Design: Randomized controlled clinical trial.

Setting: Research laboratory.

Patients or Other Participants: Seventy recreational athletes with CAI were randomly allocated to either self-mobilization plus CrossFit training, CrossFit training alone, or a control group.

Intervention(s): Participants in the self-mobilization plus CrossFit group and the CrossFit training-alone group pursued a CrossFit training program twice a week for 12 weeks. The self-mobilization plus CrossFit group performed an ankle self-mobilization protocol before their CrossFit training, and the control group received no intervention.

Main Outcome Measure(s): Ankle-dorsiflexion range of motion (DFROM), subjective feeling of instability, and dynamic postural control were assessed via the weight-bearing lunge test, Cumberland Ankle Instability Tool, and Star Excursion Balance Test (SEBT), respectively. Results: After 12 weeks of the intervention, both the self-mobilization plus CrossFit and CrossFit training-alone groups improved compared with the control group (P , .001). The self-mobilization plus CrossFit intervention was superior to the CrossFit training-alone intervention regarding ankle DFROM as well as the posterolateral- and posteromedial-reach distances of the SEBT but not for the anterior-reach distance of the SEBT or the Cumberland Ankle Instability Tool.

Conclusions: Ankle-joint self-mobilization and CrossFit training were effective in improving ankle DFROM, dynamic postural control and self-reported instability in patients with CAI.

Key Words: range of motion, balance, rehabilitation

NIH Risk of Bias Score: 14/14

Key Findings of the Study:

1. Among patients with chronic ankle instability, ankle joint self-mobilization was effective in improving the self-reported instability, ankle dorsiflexion, range of motion, and dynamic postural control.
2. CrossFit training alone also improved ankle dorsiflexion, range of motion, dynamic postural control, and self-reported instability.
3. Adding self-mobilization to CrossFit training produced better results than either intervention alone.

Reviewer Summary:

This article studied the effects of ankle-joint self-mobilization plus CrossFit training compared to CrossFit training alone among individuals with chronic ankle instability (CAI). The control group received no intervention. They assessed changes in ankle-dorsiflexion range of motion (DFROM), subjective feeling of instability, and dynamic postural control.

Three techniques were implemented in the ankle-joint self-mobilization plus CrossFit training group to enhance posterior gliding of the talus: ankle-joint self-mobilization with a resistance band, kettlebell dorsiflexion, and band pull. The CrossFit training program implemented in both intervention groups consisted of a warm-up, a principal training phase (Workout of the Day), and a cool-down phase. The study used 3 methods to compare changes in ankle range of motion, functional performance, and balance: the weight-bearing lunge test, Star Excursion Balance Test (SEBT), and the Cumberland Ankle Instability Tool (CAIT).

The results showed the self-mobilization plus CrossFit training group significantly improved in ankle motion, dynamic balance, and self-reported ankle instability compared to the control group. The CrossFit-alone group also significantly improved in all areas when compared to the control group. The control group did not experience change. The combination of self-mobilization plus CrossFit training appeared to be superior to CrossFit alone for DFROM and SEBT, but not for CAIT. CAIT was greater in the self-mobilization plus CrossFit group, but not significant.

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

Based on the results, it can be concluded that self-mobilization plus CrossFit training appears to be a useful approach in improving DFROM, dynamic postural control, and self-reported instability in patients with CAI. Self-mobilization is a straightforward approach that can be taught by a professional and implemented by most individuals as a tool to gain additional benefits in ankle motion and in turn decrease injury rate in related body structures. It is a simple, cost-effective technique that can be used outside the clinical setting to create significant changes in an individual’s ankle instability. Clinicians can consider implementing ankle-joint self-mobilization techniques in rehabilitation along with strength training as a functional approach to treatment.

Author Names

Yelverton, C., Rama, S., Zipfel, B

Reviewer Name

Megan Saunders

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Plantar fasciitis is one of the common causes of heel pain and a common musculoskeletal problem often observed by clinicians. Numerous options are available in treating plantar fasciitis conservatively, but no previous studies have compared combined conservative management protocols.  Aim: The aim of this study was to compare manipulation of the foot and ankle and cross friction massage of the plantar fascia; cross friction massage of the plantar fascia and gastrocsoleus complex stretching; and a combination of the aforementioned protocols in the treatment of plantar fasciitis.  Setting: This study was conducted at the University of Johannesburg, Chiropractic Day Clinic, and included participants that complied with relevant inclusion criteria.  Methods: Forty-five participants between the ages of 18 and 50 years with heel pain for more than 3 months were divided into three groups and received one of the proposed treatment interventions. The data collected were range of motion (ROM) of the ankle (using a goniometer) and pain perception using the McGill Pain Questionnaire and Functional foot index and algometer.  Results: The results of this study indicate that cross friction massage of the plantar fascia and stretching of the gastrocsoleus complex showed the greatest overall improvement in terms of reducing the pain and disability and ankle dorsiflexion ROM, whereas the combination group showed the greatest increase in plantar flexion.  Conclusion: The results demonstrated that all three protocols had a positive effect on the ROM and pain perception to patients with plantar fasciitis.

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

4. Were study participants and providers blinded to treatment group assignment?

No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

9. Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

12. 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?

No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

14. 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

All three groups showed a statistically significant improvement in the McGill Pain Questionnaire.

Key Finding #2

All three groups showed a statistically significant improvement in the Foot Function Index (FFI), but group 2 (stretching and cross friction) showed the greatest overall improvement in reducing pain and disability.

Key Finding #3

Groups 2 and 3 showed a statistically significant improvement in dorsiflexion measurement. Group 2 (stretching and cross friction) showed the greatest improvement in dorsiflexion. 4.       Group 3 (combination of all three treatments) showed a statistically significant difference for plantarflexion, with the stretching and cross friction (group 2) showing statistically significant improvement compared with the other two approaches.

Key Finding #4

All three groups showed a statistically significant reduced pain threshold with the algometer readings.

Please provide your summary of the paper

Based on the results of this study, all three treatment protocols improved aspects of plantar fasciitis. However, it appears that group 2 (stretching and cross friction) benefited patients more in terms of decreasing pain and increasing ROM, while group 3 (a combination of all 3 treatments) resulted in the most improvement of plantarflexion, indicating the use of manipulations may increase plantarflexion.

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

Depending on which aspects of plantar fasciitis a clinician is looking to improve for a given patient, this paper shows that it may be beneficial to use a combination of therapies. A limitation of this study would be that they did not utilize exercise (other than mobility/stretching) as a variable in any of the treatment groups, making it difficult to gauge how conservative treatment needs to be in the form of activity reduction to improve plantar fasciitis.

Author Names

Alamer, A, Melese, H, Getie, K, Deme, S, Tsega, M, Ayhualem, S, Birhanie, G, Abich, Y, Gelaw, A

Reviewer Name

Lauren Schaeffer, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Ankle joint mobilization with movement has been speculated to be an important intervention for enhancing range of motion, balance, and gait functions in chronic stroke survivors. Nonetheless, there is a scarcity of recent conclusive evidence that evaluates its efficacy in chronic stroke patients. The purpose of this review was to synthesize existing evidence on the efficacy of mobilization with movement therapy on range of motion, balance, and gait performance in subjects after stroke.

Methods: A comprehensive systematic search of literature was performed using the following databases: PubMed/Medline, CINAHL, AMED, PEDro, Cochrane Library, and Scopus. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of included trials. The primary outcome measures of this review were dorsiflexion range of motion (DF-ROM), and Berg balance scale (BBS). This review was reported in accordance with PRISMA statement guidelines. Due to variations in relevant trials, meta-analysis was not carried out.

Results and Conclusions: Seven randomized controlled trials with a total of 224 subjects were analyzed. Evidence of overall quality was graded from moderate to high. This review found that mobilization with movement therapy could be an alternative rehabilitative intervention for subjects with chronic stroke to increase range of motion, balance, and gait ability. However, the evidence remains preliminary due to the small number of participants. Large-scale RCTs in the future are warranted to investigate the efficacy of mobilization with movement in subgroups of chronic stroke subjects.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Were the included studies listed along with important characteristics and results of each study?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Cannot Determine, Not Reported, Not Applicable

Key Finding #1

All 5 studies that investigated range of motion post stroke showed significant improvement with MWM interventions.

Key Finding #2

Balance of stroke survivors was improved with MWM in 6 studies where it was investigated.

Key Finding #3

All seven studies showed improvements in gait spatial parameters with MWM.

Please provide your summary of the paper

This systematic review investigated the efficacy of ankle mobilizations with movement (MWM) to increase ankle dorsiflexion range of motion, improve balance, and enhance gait function post stroke. Seven randomized control trials were analyzed in this review paper including 224 participants with hemiplegia who had chronic strokes (defined as greater than 3 years since injury). The MWM that was investigated is a posterior to anterior tibial glide on the talus while closed-chain active dorsiflexion is performed to increase the accessory motion associated with ankle dorsiflexion. The control group received conventional physical therapy interventions while the experimental group was given MWMs and/or conventional physical therapy. Dorsiflexion range of motion (ROM), the berg balance scale, and gait parameters (velocity, cadence, stride length, single-support time, and step length), in addition to a few other outcome measures, were used in this review. Participants received physical therapy 3-5 times a week for 20-30 minutes each session for a length of 4-5 weeks. The study reviewed randomized control trials in English with relevant data and MWMs. The PEDro scale was performed on the included seven studies to determine the quality. All studies that investigated the effect of MWM on dorsiflexion ROM, gait, and/or balance revealed significant improvements with the interventions compared to the controls. This systematic review reveals the extensive benefits of MWM on chronic stroke patient’s ankle function. Future research should continue to investigate the benefit of MWM with a larger sample size to advance the reliability of the results.

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

This study reflects the importance for performing weight bearing dependent manipulations with movement in post-stroke interventions. The MWM have the potential to increase arthrokinematic accessory motions and capsule extensibility within the joint to improve ROM, enhance weight bearing for gait development, and activate proprioceptive stretch receptors that contribute to improved balance. Clinicians can diversify their interventions by incorporating manipulations with movement when treating patients experiencing dorsiflexion ROM impairments from a chronic stroke.

Author Names

Plaza-Manzano G, Vegara-Vila M, Val-Otero S, Rivera-Prieto C, Pecos-Martin D, Gallego-Izquierdo T, Ferragut-Garcías A, Romero-Franco N

Reviewer Name

Hannah Schauss, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Recurrent ankle sprains often involve residual symptoms for which subjects often perform proprioceptive or/and strengthening exercises. However, the effectiveness of mobilization to influence important nerve structures due to its anatomical distribution like tibial and peroneal nerves is unclear.  Objectives: To analyze the effects of proprioceptive/strengthening exercises versus the same exercises and manual therapy including mobilizations to influence joint and nerve structures in the management of recurrent ankle sprains. Study design: A randomized single-blind controlled clinical trial.  Method: Fifty-six patients with recurrent ankle sprains and regular sports practice were randomly assigned to experimental or control group. The control group performed 4 weeks of proprioceptive/ strengthening exercises; the experimental group performed 4 weeks of the same exercises combined with manual therapy (mobilizations to influence joint and nerve structures). Pain, self-reported functional ankle instability, pressure pain threshold (PPT), ankle muscle strength, and active range of motion (ROM) were evaluated in the ankle joint before, just after and one month after the interventions.  Results: The within-group differences revealed improvements in all of the variables in both groups throughout the time. Between-group differences revealed that the experimental group exhibited lower pain levels and self-reported functional ankle instability and higher PPT, ankle muscle strength and ROM values compared to the control group immediately after the interventions and one month later.  Conclusions: A protocol involving proprioceptive and strengthening exercises and manual therapy (mobilizations to influence joint and nerve structures) resulted in greater improvements in pain, self-reported functional joint stability, strength and ROM compared to exercises alone.

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

4. Were study participants and providers blinded to treatment group assignment?

Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

9. Was there high adherence to the intervention protocols for each treatment group?

Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

12. 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?

No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot Determine, Not Reported, or Not Applicable

14. 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

The manual therapy techniques used in this study demonstrated lower levels of pain, lower functional ankle instability in the ankle joint, greater PPTs, and greater strength of the ankle muscle when used in parallel with proprioceptive and strengthening exercises.

Key Finding #2

Participants who received the combined manual therapy and exercises treatment scored higher on the Cumberland Ankle Instability Test (CAIT) compared to those only receiving exercises.

Key Finding #3

The group receiving only proprioceptive and strengthening exercises exhibited a beneficial effect on all the measure variables, however, the benefits were not to the extent at which the combined treatment group exhibited.

Key Finding #4

Please provide your summary of the paper

This study analyzed the effect of specific manual therapy techniques with proprioceptive and strengthening exercises compared to the use of only proprioceptive and strengthening exercises to manage recurrent ankle sprains. During the study, both groups demonstrated improvements in all measured domains; however, greater improvement was seen in the experimental group which incorporated manual therapy into the treatment. The results suggest that clinicians should supplement their exercise treatment program with manual therapy, specifically joint mobilizations, when treating patients with recurrent ankle sprains. A limitation to this study that must be considered is the criteria that the participant was required to be involved in regular sport practice. Due to this criteria, the results that were produced in the study may not necessarily be translated to a sedentary 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 study offers strong evidence for the use of manual therapy to hep treat and manage recurrent ankle sprains. Clinicians should utilize mobilizations of the talocrural joint and superficial fibular nerve in coordination with proprioceptive and strengthening exercises, when appropriate, to maximize the patient’s rehab potential. Caution should be taken when using the specified manual therapy techniques with sedentary populations as this study focused on participants engaging in regular sports practice. The test-retest principal should be utilized to best gauge the efficacy of the treatment on the patient.

Author Names

Corbett, R; Donner, C; Fraser, J; Hertel, J

Reviewer Name

Dylan Scott, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions.  Methods A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen’s d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups.  Results Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5–21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7–3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions.  Discussion MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF.  Level of Evidence Treatment, level 1a.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

6. Were the included studies listed along with important characteristics and results of each study?

Yes

7. Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Finding #1

“Inclusion of MT (manual therapy) in treatment yielded greater improvement in function and algometry from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities.”

Key Finding #2

“A large and conclusive ES (Effect Size) favoring MT and routine care (consisting of stretching, strengthening, and ultrasound) over routine care alone for the NPRS (Numeric Pain Rating Scale) at 3 and 6 week time points.

Key Finding #3

“When assessed with algometry, patients treated with MT had conclusively better outcomes than controls at 4 weeks and 3 months with large ES in two studies, but were equivalent at 4 weeks in the third study.”

Key Finding #4

“Patients who received a corticosteroid injection to the plantar fascia had improved function with large ES from 3 weeks to 3 months, but no better than those treated with MT at 12 months.”

Please provide your summary of the paper

In this systematic review, seven randomized control trials were selected because they studied manual therapy as a treatment for plantar fasciitis and its effects on pain and function as dependent variables. Manual therapy’s effect on patient reported pain (6 studies), patient reported function (7 studies), and algometry (3 studies), were all extracted from the data. The data found that manual therapy improves patient-pain threshold as well as function when compared to other interventions such as stretching and strengthening exercises or modalities. These manual therapy techniques included various joint mobilizations of the ankle-foot complex, as well as myofascial release to the gastrocnemius, soleus, and plantar fascia. Based on the risk to reward of manual therapy for plantar fasciitis, the researchers recommend manual therapy “be included in a comprehensive rehabilitation program, including stretching and exercise, in the treatment of patients with PF”.

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

This systematic review reinforces the idea that there is a place for manual therapy in rehabilitation, especially when combined with stretching and strengthening. Plantar fasciitis is relatively common and I can appreciate the effectiveness that mobilizations might have to create more dorsiflexion and improve overall ankle mechanics. This, combined with medial arch strengthening and stretching of the plantar fascia and gastroc-soleus complex, seem like a good start to mitigate factors contributing to PF.

Author Names

 Hidalgo, Benjamina; * | Hall, Tobyb | Berwart, Mathildec | Biernaux, Elinorc | Detrembleur, Christinec

Reviewer Name

Gabrielle Stanley, Duke SPT2

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Ankle rigidity is a common musculoskeletal disorder affecting the talocrural joint, which can impair weight-bearing ankle dorsiflexion (WBADF) and daily-life in people with or without history of ankle injuries. The objective of this study was to compare the immediate effects of efficacy of Mulligan Mobilization with Movement (MWM) and Osteopathic Mobilization (OM) for improving ankle dorsiflexion range of motion (ROM) and musculoarticular stiffness (MAS) in people with chronic ankle dorsiflexion rigidity. In a randomized controlled clinical trial with two arms, patients were recruited by word of mouth and via social network as well as posters, and analyzed in the neuro musculoskeletal laboratory of the “Université Catholique de Louvain-la-Neuve”, Brussels, Belgium. A total of 40 men (n=40) ranging in age from 18-40 years presented with nonspecific unilateral ankle mobility deficits during WBDF were randomly assigned to receive either Mobilization with Movement, MWM, (n=20) or Osteopathic Movement, OM (n= 20) manual therapy on their affected ankle. A two way ANOVA revealed a non-significant interaction between either mobilization technique and time with all outcome measures. Outcome measures included Lehmann’s device to measure musculoarticular stiffness, in terms of elastic stiffness (p=.37), viscous stiffness (p=.83), and total stiffness (p=.58) as well as toe-wall distance (p=.58) and angular range of motion to measure limited WBDF (p=.68). A one-way ANOVVA demonstrated non-significant differences with small to moderate effect sizes (d=.003-.580) on all outcome measures before and after intervention. The only time based, significant interaction between groups that existed was viscous stiffness (p=.04. d=-.55).

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

4. Were study participants and providers blinded to treatment group assignment?

Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

No

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

9. Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

12. 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?

No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

No

14. 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

A single session of Mobilization with Movement and Osteopathic Mobilization at the ankle does not immediately improve measures of joint range of motion or joint musculoarticular stiffness.

Key Finding #2

Viscous stiffness increases in people with a history of ankle injury following Mobilization with Movement and Osteopathic Mobilization; however, this may contribute to prevention of future abnormal ankle kinematics.

Key Finding #3

Key Finding #4

Please provide your summary of the paper

Mobilization of the talocrural joint in patients with dorsiflexion rigidity does not appear to improve range of motion immediately. However, the lack of dorsiflexion in the ankle is a direct result of an injury, mobilization may contribute to preventing further abnormal ankle movements. However, it should be noted that this study never clearly defined how many of its participants who possessed “ankle rigidity” acquired said stiffness from an injury. In other words, the concluding key finding may be insignificant if the number of previously injured patients who saw improvements was of an insufficient sample size.

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

 It should be noted that despite being listed as a “randomized controlled trial” in PubMed, the study never explicitly states which manipulation technique is considered the control and why. The study often references its findings in comparison to “control groups” but there is no explicit specification of what the control group would be (i.e. perhaps a group of individuals with ankle sprains who received no mobilization or were given general range of motion exercises as opposed to manual therapy) or what studies these referenced control groups are from. This study may lead practitioners to be more inclined to use manual therapy in patients with rigidity due to ankle injuries.I would be curious to see how this study would compare to a control group of individuals who did not receive manual therapy, to see if there is any benefit to manual therapy over autonomous range of motion exercises in patients with ankle rigidity.

Author Names

Albin, S., Koppenhaver, S., Marcus, R., Dibble, L., Cornwall, M., Fritz, J.

Reviewer Name

Alexis Woywod, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients.  

Objectives: To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. 

Methods: In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling.   

Results: There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (−47.9 N/m; 95% confidence interval: −86.1, −9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%. 

Conclusion: A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation.

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

4. Were study participants and providers blinded to treatment group assignment?

No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

9. Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

No

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

12. 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

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

14. 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

There were no significant differences between the manual therapy and control groups outcomes, except for resting gastrocnemius stiffness. 

Key Finding #2

Participants were already attending physical therapy prior to the start of the study and were instructed to continue their HEP (withholding from new exercises) with the addition of the manual therapy intervention sessions. 

Key Finding #3

The ankle lunge test improved statistically in both groups from baseline to the final follow-up. Although, only the manual therapy group improved greater than the MDC of 1.38 cm.

Key Finding #4

Outcomes were only recorded short-term; at baseline, at 2nd session, and 7 to 10 days after participants final 3rd visit.

Please provide your summary of the paper

Due to the lack of clear guidelines for management, the goal of this study was to observe the short-term effects of manual therapy on individuals with ankle and hindfoot fractures. This study compared two groups that each received manual therapy, the treatment group being a more specific treatment based on the type of fracture and the control group receiving soft tissue and grade I/II proximal tibiofibular mobilizations. Although not significantly different, both groups saw statistical improvements in outcome measures including ROM, gait, and balance. The study also found an increase in stiffness in the control group which indicates the potential for manual therapy to be used for decreasing undesirable neuromotor effects. Limitations included the number of sessions being limited to 3, inadequate blinding of the control group (only 53% guessed they were in the manual therapy group as compared to 90% in the manual therapy group), and not randomizing participants by their fracture type. The manual therapy group included a greater number of total fractures and fixations when compared to the control group, potentially impacting outcomes. 

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

This study suggests that manual therapy may be beneficial for individuals with ankle or hindfoot fractures who are immobilized for 10-16 weeks, but not any more than standard physical therapy treatment alone. It is hard to say if these results came from the additional manual therapy sessions, as the participants all continued their assigned home exercise programs from prior physical therapy. A factor of this study that may impact its clinical use is that both groups received some form of manual therapy. While the two interventions were different, it cannot be said that this study compared manual therapy to treatment without manual therapy. While this study demonstrated some short-term benefits of manual therapy, more research is needed to determine the benefits for those who are immobilized for longer periods of time and if the number of manual therapy treatments impacts the results. 

Author Names

Shashua, A., Flechter, S., Avidan, L., Ofir, D., Melayev, A., Kalichman, L.

Reviewer Name

Sara Yuen, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

The purpose of this study was to evaluate the efficacy of ankle and midfoot mobilization on pain and function of patients with plantar fasciitis (PF). Plantar fasciitis is a degenerative process of the plantar fascia, with a lifetime prevalence of approximately 10%. Limited ankle dorsiflexion is a common finding and apparently acts as a contributing factor to the development of PF. Fifty patients with PF, aged 23 to 73 years, were randomly assigned to either the intervention or control group. Both groups received 8 treatments, twice a week, consisting of stretching exercises and ultrasound. In addition, the intervention group received mobilization of the ankle and midfoot joints. Dorsiflexion range of motion was measured at the beginning and at the end of treatment. The results were evaluated by 3 outcomes: the numeric pain-rating scale, Lower Extremity Functional Scale, and algometry. No significant difference was found between groups in any of the outcomes. Both groups showed a significant difference in the numeric pain-rating scale and Lower Extremity Functional Scale. Both groups significantly improved in dorsiflexion range of motion, with no difference between groups. The addition of ankle and foot joint mobilization aimed at improving dorsiflexion range of motion is not more effective than stretching and ultrasound alone in treating PF. The association between limited ankle dorsiflexion and PF is most probably due to soft tissue limitations, not the joints.

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

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

4. Were study participants and providers blinded to treatment group assignment?

No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

9. Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

12. 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

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

14. 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

In the analysis of pre and post treatment, outcomes between the control (stretching and therapeutic ultrasound) vs the intervention (ankle and midfoot mobilization, stretching, and therapeutic ultrasound) groups, the NPRS and LEFS showed continuous improvement throughout all measurement points in both groups, with no difference between them.

Key Finding #2

Algometry measures pre and post treatment showed no differences in the treatment vs control groups pain intensity.

Key Finding #3

Conventional treatments alone (stretching and therapeutic ultrasound) may be effective for treating plantar fasciitis.   

Key Finding #4

Please provide your summary of the paper

The authors situated their study in investigations of connections between manual therapy aimed at increasing dorsiflexion range of motion and other plantar fasciitis treatments. This single-blind randomized controlled trial compared conventional plantar fasciitis treatments (stretches for the gastrocnemius, soleus, and plantar fascia and therapeutic ultrasound) to receiving ankle and midfoot mobilizations in addition to those control interventions. This article used 3 methods to compare the outcomes of the 2 groups:  NPRS, LEFS, and algometry.  No measures supported a significant difference in improvements in pain or function with the addition of ankle and midfoot mobilizations. But of the 46 patients that completed the study, 29 improved their pain intensity scores measured by algometry, and 18 participants improved in function based on the outcomes of their LEFS scores. These findings support the effectiveness of conventional stretching and therapeutic ultrasound treatments for plantar fasciitis. The authors suggest that the cause of limited dorsiflexion that presents with heel pain diagnosed as plantar fasciitis is posterior leg tightness and not ankle joint stiffness. Therefore, clinicians should consider techniques focused on soft tissue tightness, and not ankle and midfoot mobilizations. Some limitations of this study include a bias from participants, who were not blinded to their treatment group. The authors disclosed that 2 participants in the control group dropped out of the study due to dissatisfaction. In comparison, the 2 participants that dropped out of the treatment group did so for family and health reasons. The participants also gave their follow up NPRS and LEFS data via phone which may have introduced communication complications. The authors also did not mention how participant adherence to home treatment prescriptions was tracked or how that may have affected participant outcomes.       

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

Clinicians may consider the control groups success in with the conventional treatments used in this study– the seated plantar fascia stretch, standing gastrocnemius and soleus stretches, and therapeutic ultrasound (1 MHz, 1.5 W/cm^2, 50% pulses for 5 minutes)– to treat patients with heel pain diagnosed as plantar fasciitis. However, they should always keep in mind that treatments are ideally patient-specific. Clinicians using manual therapy to increase dorsiflexion range of motion in patient with plantar fasciitis should focus on soft tissue techniques for loosening posterior leg muscle groups instead of techniques that target ankle and midfoot joint stiffness.  

Author Names 

Albin, S.; Koppenhaver, S.; Van Boerum, D.; McPoil, T.; Morgan, J.; Fritz, J. 

Reviewer Name 

Sarah Adamo, MS, SPT 

Reviewer Affiliation(s) 

Duke University Doctor of Physical Therapy Division 

Paper Abstract 

Study design: Randomized clinical trial. 

Background: Patients with fractures to the talus and calcaneus report decreased functional outcomes and develop long-term functional limitations. Although physical therapy is typically not initiated until six weeks after fixation, there’s little research on the optimal time to initiate a formal physical therapy program. 

Objectives: To assess whether initiating physical therapy including range of motion (ROM) and manual therapy two weeks post-operatively (EARLY) vs. six weeks post-operatively (LATE) in patients with fixation for hindfoot fractures results in different clinical outcomes. 

Methods: Fifty consecutive participants undergoing operative fixation of a hindfoot fracture were randomized to either EARLY or LATE physical therapy. Outcomes, including the American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS), the Lower Extremity Functional Scale (LEFS), active ROM, swelling, and pain, were collected at three and six months and analyzed using linear mixed-modeling to examine change over time. Adverse events were tracked for 12 months after surgery. 

Results: The EARLY group demonstrated significantly larger improvements for the AOFAS (p = .01) and the LEFS (p = .01) compared to the LATE group. Pairwise comparison of the LEFS favors the EARLY group at 6 months [7.5 (95%CI −.01 to 15.0), p = .05]. There were no differences between the groups with regard to ROM, pain, and swelling. The LATE group incurred increased adverse events in this study. 

Conclusion: Initiating early physical therapy may improve long-term outcomes and mitigate complications in patients after hindfoot fractures. 

Level of Evidence: Therapy, level 2b.  

NIH Risk of Bias Tool 

Quality Assessment of Controlled Intervention Studies 

Key Finding #1 

Early supervised physical therapy programs (2 weeks post-op vs. 6 weeks post-op) may improve long-term outcomes in patients after hindfoot fractures. 

Key Finding #2 

Early physical therapy intervention may facilitate joint nutrition and mitigate post-surgical complications.  

Key Finding #3 

There was no difference in wound complications between EARLY and LATE groups.  

Summary 

This study used a randomized controlled trial design to compare the patient outcomes after hindfoot fractures with standard-practice-late physical therapy and early physical therapy with joint mobilization and ROM interventions. The results of this study are based on 50 patients who sustained an ORIF of a calcaneal or talar fracture, with 24 patients being randomized into the EARLY group and 26 patients into the LATE group. EARLY group participants began a physical therapy program, including manual therapy and joint mobilization, at 2 weeks post-op, whereas LATE group participants began after the 6-week post-operative appointment with their surgeon. Manual therapy and therapeutic exercise interventions were personalized to the participant’s fracture pattern. Outcome measures included the American Orthopedic Foot and Ankle Score (AOFAS), the Lower Extremity Functional Scale (LEFS), Numeric Pain Rating Scale (NPRS), Beck Anxiety Questionnaire (only collected at baseline), swelling, and AROM, collected at baseline, 3 months, and 6 months. EARLY group participants had significantly greater improvement in the AOFAS and LEFS than the LATE group. No differences were observed between intervention groups in ROM, pain, and swelling. Additionally, the LATE group experienced more adverse events, such as deep vein thrombosis. With further exploration of these findings, more concrete guidance on the timing of physical therapy programs, including manual therapy and therapeutic exercise interventions, can inform the clinical management of patients with hindfoot fractures.  

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

This study provides evidence advocating for earlier physical therapy interventions after hindfoot fractures at 2 weeks post-op, a population in which surgeons’ protocols often recommend waiting until 6-week post-op. While further research is needed to explore and corroborate these findings due to a high drop-out rate in this study, the findings do suggest that there are no adverse effects of beginning an early physical therapy program with personalized joint mobilization and therapeutic exercise interventions. Hindfoot fractures are difficult to manage clinically, with high rates of complications and impaired long-term outcomes in ROM and self-reported functional scales. Minimizing the incidence of post-surgical complications is important and may be promoted by earlier physical therapy program initiation in this patient population. The mechanisms by which earlier physical therapy intervention may improve patient outcomes after hindfoot fractures require deeper exploration, of which joint mobilization and ROM to facilitate joint nutrition was proposed in the study discussion. 

Author Names: Lao Y, Zeng Z, Yu Z, et al.

Reviewer Name: Karla Alvarado

Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Student

Objective: To observe the effect of uphill running and the combined effect of uphill running plus joint mobilizations on dynamic stability and ankle dorsiflexion in young adults with chronic ankle instability (CAI).

Design: Four-arm randomized controlled trial.

Setting: A college rehabilitation center.

Participants: Individuals with CAI (N=73).

Interventions: Participants were randomly assigned to 4 groups: combined uphill running and joint mobilization (URJM), uphill running alone (UR), joint mobilization alone (JM), and control group. The URJM and UR groups received 20-minute running sessions, and the URJM and JM groups received ankle joint mobilizations, all 3 times a week for 4 weeks.

Main outcome measures: Cumberland Ankle Instability Tool (CAIT) and Y-balance test (YBT) in anterior, posteromedial (PM), and posterolateral (PL) directions for dynamic stability; weight-bearing lunge test and non-weight-bearing ankle dorsiflexion degree using a goniometer (NWBG) for dorsiflexion.

Results: The UR group showed significant improvements in CAIT, YBT-PL, YBT-PM, and NWBG compared to the control group. The URJM group demonstrated large treatment effects in NWBG compared to both UR and JM groups. Responder analysis indicated that the UR, JM, and URJM groups had a higher likelihood of achieving clinically significant changes (exceeding minimal detectable change or minimal clinically important difference) in CAIT, YBT-PM, YBT-PL, and NWBG compared with the control group. Additionally, the combination of UR and JM was superior to either intervention alone for NWBG, with success rates 1.55 times greater than UR alone and 2.08 times greater than JM alone.

Conclusions: A 4-week UR program improves the subjective feeling of instability, dynamic postural control, and ankle dorsiflexion in young adults with CAI. Compared to UR or JM alone, their combined application can better improve the non-weight-bearing ankle dorsiflexion range of motion.

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Randomized Controlled Trial

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Not reported.

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. 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

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• No

Key Finding #1 The ankle joints of the participants in the study who underwent both uphill running and joint mobilization showed improvements in ankle dorsiflexion while the joint was non-weight bearing, compared to the participants who were only doing one of the two interventions individually.

Key Finding #2 Participants in the uphill running-only group reported that, as a result of the intervention involving 20-minute treadmill sessions three times per week, they felt their ankle instability had decreased. This was subjectively assessed using the Cumberland Ankle Instability Tool (CAIT).

Key Finding #3 Participants in the uphill running group improved their dynamic postural control in the posterolateral, and posteromedial directions, as it was specifically assessed using the Y-balance test. The Y balance test was consistently used throughout the study to assess balance, ensuring outcomes were reliable in differentiating which group showed improvement.

Please provide your summary of the paper

In the study, they aimed to assess the effectiveness of combining uphill treadmill running(UR) and joint mobilization in a 4 week program to improve ankle dorsiflexion range of motion and dynamic stability in people with chronic ankle instability. To determine the effectiveness of these combined interventions, participants were divided into four groups uphill treadmill running (UR), joint mobilization (JM), and combined uphill treadmill running (UR) and joint mobilization (JM), and control group. Outcomes were collected subjectively using the Cumberland Ankle Instability Tool (CAIT) and objectively with the Y-balance test(YBT).

The study concluded that young adults with chronic ankle instability can benefit from uphill running and joint mobilization to enhance ankle range of motion, particularly dorsiflexion and dynamic stability, and lastly, help individuals feel that their ankle is less unstable than they initially felt when starting the intervention. Combining the interventions resulted in better improvement of outcome measures compared to incorporating only one intervention alone.

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

The study’s findings guide interventions that practicing clinicians can use to help the younger adult population suffering from chronic ankle instability. Since the study found that uphill treadmill running and joint mobilization were more effective in improving ankle dorsiflexion, these interventions can be considered options for young individuals with limited ankle motion. Clinicians might want to consider combining joint mobilization with uphill running for different patient groups, tracking their progress to see how effective the program is. However, the study only involved young adults, so its findings may not fully apply to older populations. Lastly, no follow-up assessment was considered, which can give a better understanding of whether the treatment had long-term effects. Lastly, the relatively small sample size of the study does not provide a broad enough representation to assess its impact on the overall population of young adults with chronic ankle instability.

Author Names

Jaffri A, Fraser J, Koldenhoven R, Hertel J

Reviewer Name

Andrew Aronesty, SPT, CSCS

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

Context: To investigate the effects of midfoot joint mobilization and a 1-week home exercise program, compared with a sham intervention, and home exercise program on pain, patient-reported outcomes, ankle-foot joint mobility, and neuromotor function in young adults with chronic ankle instability. Design: Crossover clinical trial. Methods: Twenty participants with chronic ankle instability were instructed in a stretching, strengthening, and balance home exercise program and were randomized a priori to receive either midfoot joint mobilizations (forefoot supination, cuboid glide, and plantar first tarsometatarsal) or a sham laying of hands on the initial visit. Changes in foot morphology, joint mobility, strength, dynamic balance, and patient-reported outcomes assessing pain, physical, and psychological function were assessed pre to post treatment and 1 week following post treatment. Participants crossed over to receive the alternate treatment and were assessed pre to post treatment and 1 week following. Linear modeling was used to assess changes in outcomes. Results: Participants demonstrated significantly greater perceived improvement immediately following midfoot mobilization in the single assessment numeric evaluation (sham: 5.0% [10.2%]; mobilization: 43.9% [26.2%]; β: 6.8; P < .001; adj R2: .17; Hedge g: 2.09), and global rating of change (sham: -0.1 [1.1]; mobilization: 1.1 [3.0]; β: 1.8; P = .01; adj R2: .12; Hedge g: 0.54), and greater improved 1-week outcomes in rearfoot inversion mobility (sham: 4.4° [8.4°]; mobilization: -1.6° [6.1°]; β: -6.37; P = .01; adj R2: .19; Hedge g: 0.81), plantar flexion mobility (sham: 2.7° [6.4°]; mobilization: -1.7° [4.3°]; β: -4.36; P = .02; adj R2: .07; Hedge g: 0.80), and posteromedial dynamic balance (sham: 2.4% [5.9%]; mobilization: 6.0% [5.4%]; β: 3.88; P = .04; adj R2: .10; Hedge g: 0.59) compared to the sham intervention. Conclusion: Greater perceived improvement and physical signs were observed following midfoot joint mobilization.

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
   • Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
   • Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
   • Yes
4. Were study participants and providers blinded to treatment group assignment?
   • No
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
   • Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
   • Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
   • Yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
   • Yes
9. Was there high adherence to the intervention protocols for each treatment group?
   • Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
    • Yes
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
    • Yes
12. 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
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
    • Yes
14. 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

Participants had greater perceived improvement in their chronic ankle instability after receiving midfoot mobilizations plus a home exercise program (HEP) when compared to sham intervention and the same HEP.

Key Finding #2

After receiving midfoot mobilizations, participants showed decreases in rearfoot inversion mobility and plantar flexion mobility, as well as an improvement in posteromedial reach.

Key Finding #3

N/A

Key Finding #4

N/A

Please provide your summary of the paper

This study investigated the efficacy of midfoot mobilizations in treating chronic ankle instability (CAI). The research team organized a crossover clinical trial consisting of 20 participants with CAI. Participants were “recreationally active” (defined as engaging in at least twenty minutes of physical activity per day, three times a week) and ranged in age from 18 to 35. Subjects were randomized and stratified by sex into two groups, one which would receive midfoot mobilizations first, and one which would receive sham treatment first. The groups received either a single episode of midfoot manual therapy or sham treatment, and each were instructed on a home exercise program. After one week, each group was assessed and then swapped to receive the opposite treatment. The groups were then assessed again one week later. The primary outcome measure of this study was the Foot and Ankle Ability Measure (FAAM). Other key outcome measures were the global rating of change (GROC), single assessment numeric evaluation (SANE), and a variety of mobility measures including range of motion and dynamic balance. The results of the study indicated that individuals with CAI who received midfoot mobilizations had greater improvement as measured by the GROC and SANE, as well as improvements in rearfoot inversion, plantar flexion, and posteromedial dynamic balance. It is unknown whether these positive effects persisted after the trial concluded. The authors suggest that more research into the long-term effects of mobilization in cases of CAI is thus warranted.

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

This study provides evidence in support of using midfoot mobilization when treating patients with chronic ankle instability. As of note, Maitland Grade IV mobilizations were used, and each mobilization was applied only once and for 30 to 60 seconds. This bolsters the idea that mobilization can be efficacious even when used in small doses. Clinicians treating patients with CAI may consider using midfoot manipulations as part of the plan of care, and especially when paired with therapeutic exercise.

Author Names

Stroppa-Marques, Ana E.Z.; Neto, Joao S. Melo; Pedroni, Cristiane R.; Tozim, Beatriz M.; Chagas, Eduardo F.B; Navega, Flavia R.F.; Navega, Marcelo T.

Reviewer Name

Ilene Avalos, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

Paper Abstract

Objective:

The purpose of this study was to evaluate the effects of plantar myofascial mobilization (PMM) on the plantar area, balance, and functional mobility of elderly women.

Methods:

In this randomized, single-blind, placebo-controlled clinical trial, elderly women with maintained independent orthostatism were recruited from the community and randomly separated into a PMM group (MG = 15), a placebo group (PG = 13), or a control group (control group = 14). Vigorous PMM and soft PMM were performed in the MG and PG, respectively, for 5 days with a rest day between each. The measures of plantar area, single leg stance test with open eye and closed eye, and timed up-and-go test were performed pre-PMM, immediately post-PMM, and on the last day of the protocol. The control group only underwent evaluation before and on the last day of the protocol. The sample size was calculated, and, for quantitative variables, a mixed analysis of variance was used for repeated measurements (split plot), followed by the Bonferroni post hoc test. The results were analyzed in 2 ways: 3 groups at 2 moments (pre, last day), and 2 groups at 3 moments (pre, post, last day).

Results:

Forty-two elderly women with mean age of 69.03 § 3.32 years were included in the study. The vigorous MMP showed a statistically signi cant increase in the plantar area of the right foot (3 groups: P = .49) and single leg stance test with open eye time (2 groups: P = .002; 3 groups: P = .001), and a decrease in the timed up-and-go time (2 groups: P = .04; 3 groups: P = .0001).

Conclusion:

The vigorous PMM showed increases of the plantar area and promoted bene cial effects on functional mobility and body balance.

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
   • RCT
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
   • YES
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
   • YES
4. Were study participants and providers blinded to treatment group assignment?
   • YES
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
   • YES
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
   • NOT DISCUSSED
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
   • NOT DISCUSSED
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
   • YES
9. Was there high adherence to the intervention protocols for each treatment group?
   • YES
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
    • NOT DISCUSSED
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
    • YES
12. 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
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
    • NOT DISCUSSED
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
    • NOT DISCUSSED

Key Finding #1

Plantar myofascial mobilization resulted in an increase in the area of plantar contact by 2.6% after treatment.

Key Finding #2

Plantar myofascial mobilization increased the time in single leg stance with eyes open in the intervention group.

Key Finding #3

Plantar myofascial mobilization decreased TUG test time in the intervention group.

Please provide your summary of the paper

This study reported the results of a randomized controlled trial focused on determining the effects of plantar myofascial mobilization on plantar contact area, functional mobility, and balance in elderly women. The hypothesis of this study was the use of deep maneuvers would increase all three variables compared to the placebo and controlled groups. The results of the study supported this hypothesis by showing an increase in plantar contact area, increase in single leg stance time (balance), and decrease in TUG test time (functional mobility).

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

This study provides consideration of manual therapy/myofascial mobilization techniques for clinical application through a low cost method. This study demonstrated the positive responses it can have on balance and functional mobility for elderly women making it all more accessible and attainable for clinicians to implement to their treatment plan when working with this specific population.

Author Names: Yin, Y., Yu, Z., Wang, J., & Sun, J 

Reviewer Name: Megan Broomfield, SPT 

Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Program 

Paper Abstract: 

The study aims to determine whether routine rehabilitation training combined with the Maitland mobilization is more effective than routine rehabilitation training alone in patients with chronic ankle instability, intending to provide a novel rehabilitation strategy for chronic ankle instability. A total of 48 subjects were divided into three groups: EG (Maitland mobilization and routine rehabilitation), CG (routine rehabilitation), and SG (sham mobilization and routine rehabilitation). The intervention was performed three times each week for 4 weeks, for a total of 12 sessions. Before and after the intervention, the muscle strength, star excursion balance test (SEBT), weight-bearing dorsiflexion range of motion (WB-DFROM), ankle range of movement, Cumberland ankle instability tool (CAIT), self-comfort visual analog scale (SCS-VAS), and self-induced stability scale (SISS-VAS) were assessed. The results showed that the improvement of SEBT, WB-DFROM, and active ankle range of movement without the pain in EG was more obvious than CG and SG, but the improvement of the self-report of ankle severity and muscle strength was not. Compared with routine rehabilitation training alone, routine rehabilitation training combined with Maitland mobilization for patients with chronic ankle instability may provide more benefit in terms of balance and ankle range of movement than routine rehabilitation alone, but the improvement in muscle strength was not evident enough. 

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 
   • Yes 
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 
   • Yes 
3. Was the treatment allocation concealed (so that assignments could not be predicted)? 
   • Yes 
4. Were study participants and providers blinded to treatment group assignment? 
   • No 
5. Were the people assessing the outcomes blinded to the participants’ group assignments? 
   • No 
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 
   • Yes 
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 
   • Yes 
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 
   • Yes 
9. Was there high adherence to the intervention protocols for each treatment group? 
   • Yes 
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 
    • Yes  
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 
    • Yes 
12. 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 
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 
    • Yes 
14. 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: Participants in the mobilization group had a larger improvement in the star excursion balance test and weight-bearing dorsiflexion range of motion than the routine rehabilitation group and the sham mobilization and routine rehabilitation group.   

Key Finding #2: Routine rehabilitation training combined with Maitland mobilization did not promote a more obvious difference in improvement in self-report of ankle severity compared to other groups 

Key Finding #3: Compared to the other groups, routine rehabilitation training combined with Maitland mobilization did not promote a more obvious improvement of muscle strength.  

Key Finding #4: After 4 weeks of intervention, participants in all three groups had an improvement in self-perception of ankle stability in daily life scores, self-comfort visual analog scale scores, and self-induced stability scale scores. 

Please provide your summary of the paper: 

Patients who suffer from chronic ankle instability (CAI) typically suffer from restricted ankle range of movement, decreased muscle strength, increased ligament elasticity, decreased proprioceptive control, and decreased neuromuscular control ability. Maitland mobilization has been shown to help with many of these components, which the authors sought out to test in this single-blind, randomized controlled trial. This study measured ankle muscle strength, balance through the star excursion balance test, weight-bearing dorsiflexion range of motion, and self-reports of ankle instability through the Cumberland ankle instability tool, self-comfort visual analog scale, and self-induced stability scale before and after the interventions of either Maitland mobilization and routine rehabilitation, routine rehabilitation, and sham mobilization and routine rehabilitation. Maitland mobilizations included talocrural joint longitudinal traction, subtalar joint forward/backward sliding, and subtalar joint Inside/outside sliding. Regular rehabilitation interventions included ankle muscle strength and balance training. Results showed that all three groups had a positive increase in self-reported ankle instability scores, but no statistical differences. Balance and active ankle range of motion were more obviously increased in the mobilization and rehabilitation group, but self-reports of ankle severity and muscle strength were not. When compared to regular rehabilitation alone, Maitland mobilization combined with regular rehabilitation provides further benefits in balance and ankle ROM compared to routine rehabilitation, but not in ankle strength or self-reports of ankle function. 

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

Maitland mobilizations can be implemented in the clinical setting in addition to regular rehabilitation for a more comprehensive treatment of CAI with the goal of increasing balance and ankle range of motion, but not with a goal of increasing ankle strength. Implementing manual therapy in addition to regular rehabilitation can be a practical, lower cost way for clinicians to improve a ROM and balance when presented with a patient with CAI. Some limitations include a lack of long term follow-ups to clarify the effectiveness of the mobilizations and the lack of a control group with simple manual therapy for effective comparative analysis. Future studies should utilize these follow-ups, use strength testing tools that allow for less human error, and compare the experimental group with a group only utilizing manual therapy to regular rehabilitation to see the full extent of the effectiveness of Maitland mobilizations compared to regular rehabilitation. 

Author Names

de Castro Silva M, de Marche Baldon R, Lins C, de Andrade GM, de Castro GBB, Felicio LR

Reviewer Name

Nayeli Chowdhury, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract:

Background: The range of motion (RoM) of dorsiflexion (DF) plays an important role in human mobility, such as absorption of body weight during gait deceleration, jump landings, balance, and eccentric movements. This limitation can generate potentially damaging movements. This way, evaluating techniques for DF RoM increase could help improve immediate performance in such functional activities. This being the case, the objective of this study will be to verify the sum effect of different joint mobilization techniques for DF gain in persons practicing physical activities and its relationship with functional performance and balance.

Methodology: This is a randomized, controlled, and blind clinical trial. Fifty-four (54) volunteers will be recruited, aged between 18 and 40 years, who have DF limitations. After checking eligibility criteria, the participants will be submitted to a physiotherapeutic evaluation. A researcher, blind to evaluation and treatment, will perform the randomization of patients in groups: (A) Joint Mobilization – Mulligan Concept and (B) Joint Mobilization – Maitland Method. All volunteers will be submitted by two blind evaluators for randomization and treatment groups. They will realize the initial evaluation (A0), immediately after techniques (A1) and after 3-4 days of the technique application (A2). A different researcher, blind for evaluation, will perform the treatment, according to the randomization group.

Discussion: It is already known that DF RoM limitation can lead to compensatory and potentially damaging lower limb movements and that joint mobilizations are effective to treatment. However, there is no consensus whether the application of these techniques would also improve aspects of dynamic postural balance and performance in individuals practicing physical activity, and whether the sum of two joint mobilization techniques could enhance this effect.

Trial registration: Brazilian Registry of Clinical Trials (ReBEC) RBR-93xv9t . Registered on 09 April 2020.

Keywords: Dorsiflexion; Functional tests; Joint mobilization; Postural control.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Cannot Determine

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Cannot Determine

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

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

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

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

Ankle dorsiflexion deficits correlate to reduced postural balance and a decline in functional performance, specifically with dynamic activities.

Key Finding #2

Mobilization with Movement (MWM) of the Mulligan Concept and the Maitland Method are two types of mobilization techniques that are used to improve ankle dorsiflexion. There is not a clear consensus of superiority when comparing both techniques for improving joint mobility.

Key Finding #3

Limited tibial sliding over the talus during closed kinetic chain movements can restrict dorsiflexion and knee flexion, impair eccentric load absorption, and can contribute to movement patterns or compensations that can increase the risk for lower limb injuries.

Please provide your summary of the paper

This paper examines the effects of two manual therapy techniques targeting ankle dorsiflexion range of motion, Mulligan’s Mobilization with Movement (MWM) and Maitland’s Method, through a randomized clinical control trial. Having appropriate ankle dorsiflexion mobility allows for critical functional movements, including walking, balance activities and other weight-bearing activities. Any deficits with dorsiflexion can create compensatory movements of the body that can increase the risk of injuries. To evaluate the two manual therapy techniques, validated assessment tools such as the lunge test, goniometry measurements, and the Y Balance test were used to assess overall ankle ROM, postural stability, and functional performance. The results show that each technique is beneficial in helping restore ankle mobility, but it is unclear whether combining the two methods has additional benefits as compared to using one technique alone. Also, there are no studies identified that evaluate the sustainability of immediate or short-term effects from utilizing the techniques.

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

This paper highlighted potential benefits of combining joint mobilization techniques to improve joint mobility, postural control, and functional performance. In clinical practice, this supports the idea of using different manual therapy approaches to effectively address any range of motion limitations and reduce compensatory movement patterns that may lead to injuries. Physical therapists can incorporate combined techniques to enhance balance, optimize functional outcomes, and prevent any further issues from arising. These interventions can be helpful for rehabilitation by offering non-invasive, targeted interventions for those experiencing limitations or dysfunction in the lower extremities.

Author Names

Hernández-Guillén D., Blasco JM

Reviewer Name

Nathalie Donado De Janon, SPT ’26

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

Background: Ankle range of motion declines with age, affecting mobility and postural control. Objective: The objective of this study was to investigate the effects of a talus mobilization-based intervention among healthy community-dwelling older adults presenting with limited weight-bearing ankle dorsiflexion range of motion and determine how ankle mobility evolved over the treatment. Design: This was a randomized clinical trial. Setting: This study was conducted in an outpatient clinic. Participants: Community-dwelling, older adults over 60 years of age who had limited ankle mobility participated in this study. Interventions: The experimental intervention consisted of 6 sessions of manual therapy applied in the ankle joint. The control group received the same volume of sham treatment. Measurements: The primary outcome was the weight-bearing ankle dorsiflexion range of motion as measured using the lunge test. Data were collected at 9 time points: baseline, after each session, and follow-up. Results: A total of 36 participants were analyzed. A single session of mobilization increased ankle range of motion by 8 degrees (95% confidence interval = 6 to 11). At the end of the sixth session, this effect had increased slightly to 11 degrees (95% confidence interval = 9 to 13). Significant between-group differences were found throughout the intervention. Limitations: Optimal dose and effects from follow-up evaluations for treatment volumes of fewer than 6 sessions remain unknown. Conclusions: Six sessions of a talus mobilization-based intervention in healthy community-dwelling older adults found that the greatest mobility gain in terms of the weight-bearing ankle dorsiflexion range of motion is produced after the first session. Additional sessions produce smaller improvements with a slight upward trend. Importantly, the restoration of joint mobility is enhanced over time after the end of the intervention. Trial registration: ClinicalTrials.gov NCT03600402.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Cannot Determine

Were the people assessing the outcomes blinded to the participants’ group assignments?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

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

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

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

A lunge test showed that talus mobilization interventions effectively produced significant improvements, as opposed to sham ankle mobility interventions.

Key Finding #2

Findings show that the positive effects of talus mobilizations, like increasing ankle ROM, are enhanced over time after the end of a treatment session.

Key Finding #3

Ankle mobility gain was highest after just one intervention session and had subsequently smaller improvements in the following sessions, with a general upward trend.

Key Finding #4

The study found that six sessions of talus mobilizations produce a clinically significant impact on weight-bearing ankle dorsiflexion ROM in healthy, community-active older adults.

Please provide your summary of the paper

This paper examined weight-bearing ankle dorsiflexion range of motion in healthy, community-dwelling older adults. It used a lunge test to measure this clinical outcome between a control and an intervention group. The intervention group received talus mobilization-based interventions and were measured after each treatment session and before and after the first and last session. The control group received a sham ankle treatment. The study found that talus mobilization-based interventions produce significant improvements as compared to the sham treatment. The measurements taken following the treatment sessions showed that the greatest improvement in ankle ROM happened after the first session, with subsequently smaller improvements following other sessions– the trend was still upward in fashion. This suggests that ankle mobilization effects are enhanced after treatment sessions and may increase in magnitude with more sessions.

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

While this trial shows that talus mobilization-based interventions are effective to treat limited ankle dorsiflexion ROM in healthy, community-dwelling older adults, it does not give more information on older adults that are not community-dwelling. This shows that further research is needed to be able to apply these findings and interventions to a different population. However, in clinical practice guidelines, ankle mobilizations are shown to be an effective method of manual therapy to treat ankle ROM and mobility issues. This means that this study and its methods could be implemented into clinical practice for the specific population studied.

Author Names

Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J

Reviewer Name

Autumn Kidd, SPT

Reviewer Affiliation(s)

Duke University’s Doctor of Physical Therapy Division

Paper Abstract

Persistent muscle inhibition of the fibularis longus and soleus muscles and altered joint arthrokinematics may play a role in chronic ankle instability (CAI). Joint mobilization has been shown to improve ankle joint motion, but effects on surrounding musculature is unknown. The purpose of this study was to determine the change in fibularis longus and soleus activation following tibiofibular joint manipulation in individuals with CAI. Forty-three subjects were randomized to one of three groups (proximal tibiofibular manipulation, distal tibiofibular manipulation, or control). A two-way mixed model ANOVA was used to compare changes in the ratio of the maximum H-reflex and maximum M-wave measurements (H/M ratio) of the fibularis longus and soleus between groups over time (pre, post 0, 10, 20, 30 min). The distal tibiofibular joint manipulation group demonstrated a significant increase ( P &lt; .05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention ( P = .48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease ( P &lt; .05) from baseline values in fibularis longus (10–30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Unable to tell

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Unable to tell

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Unable to tell

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

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?

Unable to tell

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

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

Mobilization of the distal tibiofibular joint displays an acute increase in soleus muscle activation compared to mobilization of the proximal tibiofibular joint and no mobilization at all.

Key Finding #2

Since individuals with CAI showed an increase in soleus activation with an ice pack to the joint, which stimulates the sensory receptors, it is hypothesized that joint mobilization stimulates the same sensory receptors.

Key Finding #3

Cryotherapy at the proximal and distal tibiofibular joint helped improve soleus activation in individuals with CIA, however, this was not the focus of the study so there was no control group to test this theory.

Please provide your summary of the paper

While reading this article, the results showed that a distal tibiofibular posterior manipulation can help improve soleus muscle activation. It also showed that cryotherapy (ice pack) on the proximal and distal tibiofibular joint can improve soleus muscle activation as well. While the study aimed to assess the fibular longus muscle as well, no increase in muscle activation was shown through any tested or controlled group. The study used H reflex and M wave reflex activity levels through electrodes to measure the activation of the soleus and fibularis longus muscles. This study used a two-way mixed model ANOVA to compare the rate in changes of the H reflex and M wave activation over time. The time frames included a pre-test, post-test, 10 minutes following, 20 minutes following, and 30 minutes following muscle activation.

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

This study may impact clinical practice because it allows clinicians the ability to see work that has been done previously on patients with chronic ankle instability. It can help influence their approach to providing the best care for these patients. From reading this study, a clinician can decipher that a distal tibiofibular joint posterior manipulation might be the best approach to help improve chronic ankle instability.

Author Names
Wees, P. et al

Reviewer Name
Isha Dixit, SPT

Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division (Class of 2026)

Paper Abstract
This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1 to 7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an (initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited.

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and
described?
Yes.
2. Were eligibility criteria for included and excluded studies predefined and
specified?
Yes.
3. Did the literature search strategy use a comprehensive, systematic approach?
Yes.
4. Were titles, abstracts, and full-text articles dually and independently reviewed
for inclusion and exclusion to minimize bias?
Yes.
5. Was the quality of each included study rated independently by two or more
reviewers using a standard method to appraise its internal validity?
Yes.
6. Were the included studies listed along with important characteristics and
results of each study?
Yes.
7. Was publication bias assessed?
No.
8. Was heterogeneity assessed? (This question applies only to meta-analyses.)
No.

Key Finding #1
Manual therapy mobilizations to the ankle have been found to have a positive initial effect
on increasing ankle dorsiflexion range of motion in patients with acute ankle fractures or
functional instability.

Key Finding #2
Manual therapy mobilizations applied to the ankle joint have been found to not have a
significant effect on return to activity according to this study.

Please provide your summary of the paper

This systematic review looks into the effectiveness of both exercise therapy and manual
therapy in patients that have experienced an acute ankle fracture or functional instability
of the ankle joint. The study looked at exercise therapy and manual therapy as separate
interventions in multiple studies to provide further evidence to support or oppose the
interventions used in physical therapy when treating the ankle.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study shows the need for further research on the use of manual therapy as a long term intervention. Although their initial findings show the benefits of manual therapy when treating the ankle joint, many of the studies they included only followed up in the short term. The study also found no significant effect on the use of manual therapy in return to normal activity. This may lead us to believe that as patients progress along their rehabilitation timeline, they may not require as much manual therapy to help with return to activity as they would have needed towards the beginning of their rehabilitation when dealing with acute ankle fractures and functional instability.

Author Names
Wikstrom, E, Bagherian S, Cordero, N, Song, K
Reviewer Name
Lauren Ciuba
Reviewer Affiliation(s)
Duke DPT Class of ’26

Paper Abstract
Clinical Scenario: Chronic ankle instability (CAI) is a complex musculoskeletal condition that results in sensorimotor and mechanical alterations. Manual therapies, such as ankle joint mobilizations, are known to improve clinician-oriented outcomes like dorsiflexion range of motion, but their impact on patient-reported outcomes remains less clear. Focused Clinical Question: Do anterior-to-posterior ankle joint mobilizations improve patient-reported outcomes in patients with chronic ankle instability? Summary of Key Findings: Three studies (2 randomized controlled trials and 1 prospective cohort) quantified the effect of at least 2 weeks of anterior-to-posterior ankle joint mobilizations on improving patient-reported outcomes immediately after the intervention and at a follow-up assessment. All 3 studies demonstrated significant improvements in at least 1 patient-reported outcome immediately after the intervention and at the follow-up assessment. Clinical Bottom Line: At least 2 weeks of ankle joint mobilization improves patient-reported outcomes in patients with chronic ankle instability, and these benefits are retained for at least a week following the termination of the intervention. Strength of Recommendation: Strength of recommendation is grade A due to consistent good-quality patient-oriented evidence.

NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and
described?
Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?
Yes

3. Did the literature search strategy use a comprehensive, systematic approach?
Cannot Determine, Not Reported, Not Applicable

4. Were titles, abstracts, and full-text articles dually and independently reviewed for
inclusion and exclusion to minimize bias?
Yes

5. Was the quality of each included study rated independently by two or more reviewers
using a standard method to appraise its internal validity?
Cannot Determine, Not Reported, Not Applicable

6. Were the included studies listed along with important characteristics and results of
each study?
Yes

Key Finding #1
There is strong evidence that supports anterior to posterior joint mobilizations in patients who has chronic ankle instability
Key Finding #2
In patients who received anterior to posterior joint mobilizations, their self reported ADL score
increased relative to baseline
Key Finding #3
Changes related to improved function in patients with chronic ankle instability were observed 1 month after intervention
Key Finding #4
It was reported that there were improvements in dorsiflexion range of motion and postural
control after anterior posterior mobilizations

Please provide your summary of the paper
Chronic ankle instability is a condition that can lead to recurrent ankle sprains and decreased functional performance. This study focused on how patient reported outcomes were affected over a 6 week course of anterior to posterior ankle mobilizations were performed in therapy. This study showed an increase in patient reported outcomes after engaging in at least 2 weeks of ankle mobilizations in individuals with chronic ankle instability.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study can positively impact clinical practice in patients with chronic ankle instability. It
shows evidence that anterior to posterior mobilizations can help increase patient reported
outcomes and improve their confidence in ADLs. It described that with only 2 weeks of
mobilizations, there was an increase in patient reported outcome scores which can help to
prevent re-injury of these patients and increase in self efficacy

Author Names: Pathade, V. , Ramteke, S.

Reviewer Name: Brian Santos, SPT, ATC

Reviewer Affiliation(s): Duke Doctor of Physical Therapy

Paper Abstract:

Introduction Muscle tightness is frequently identified as a potential precursor to muscle injuries. Reclaiming flexibility and enhancing range of motion (ROM) is crucial for preventing injuries and achieving improvements in performance. The present study examines the immediate effects of instrument-assisted soft-tissue mobilization (IASTM) and dry needling (DN) in reducing trigger point pain and calf tightness in long-distance runners. Methodology A total of 40 long-distance runners were recruited in the study (30 males and 10 females). The procedure was performed under the author’s surveillance at the sports complex. These recruited players were placed into two groups: the IASTM (n=20) and the DN (n=20) group. The outcome measures used were the pressure algometer for assessing pain pressure threshold and the lunge test. An iPhone Measure app (Measure app, Apple App Store 2023) is used to assess ankle dorsiflexion ROM. The evaluation took place both prior to and immediately following the intervention and 48 hours after the intervention. Result The analysis within each group revealed a significant alteration in pain pressure threshold for both the IASTM and DN groups (p≤0.05), along with a relative enhancement in ankle dorsiflexion ROM observed in the IASTM group (p≤0.05). Between-group analysis revealed a notable difference with an effect size difference of Cohen’s d=1.06 (large difference) in pain pressure threshold, d=0.21 (small difference) in lunge test,

and d=0.57 (medium difference) in ankle dorsiflexion ROM. Conclusion The present study concludes that both groups, IASTM and DN, showed significant effects in improving pain pressure threshold in long-distance runners. However, DN showed better results. IASTM showed significant results in enhancing the ankle dorsiflexion ROM immediately. This implies that it can be used in conjunction with stretching to decrease pain and enhance flexibility, hence improving performance and preventing injuries. Keywords: calf tightness; dry needling; instrument-assisted soft tissue mobilization; pain; runners; trigger point.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT? 

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)? Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment? 

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments? Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

Yes

Was there high adherence to the intervention protocols for each treatment group? 

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes

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? 

Cannot Determine

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

No

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: Both IASTM and dry needling intervention resulted in significant improvements in pain pressure threshold in long-distance runners, however, dry needling generated a larger change.

Key Finding #2: The IASTM treatment group resulted in larger and statistically significant improvements in the lunge test, compared to the dry-needling intervention group, which did not result in statistically significant changes.

Key Finding #3: The IASTM treatment group resulted in larger and statistically significant improvements in the ankle dorsiflexion ROM, compared to the dry needling intervention group, which did not result in statistically significant changes.

Key Finding #4: One limitation of this study was that the window of observation was only a single treatment session with measurements taken immediately following treatment and at 48 hours after treatment. It does not provide any information regarding long-term changes.

Please provide your summary of the paper

This randomized controlled study investigated the impact of instrument-assisted soft tissue mobilization (IASTM) compared to dry needling (DN) on ankle dorsiflexion range of motion, pain pressure threshold, and lunge test performance. The researchers had 40 long-distance runners agree to be participants randomly allocated into 2 similar groups, one that would receive IASTM and one that would receive DN. Ankle dorsiflexion range of motion, pain pressure threshold, and lunge test performance testing were performed prior to intervention, immediately post-treatment, and 48 hours post-treatment. The researchers found that the IASTM treatment group resulted in larger and statistically significant improvements in the lunge test, compared to the dry needling intervention group, which did not result in statistically significant changes. The IASTM treatment group resulted in larger and statistically significant improvements in the lunge test and ankle dorsiflexion ROM, compared to the dry needling intervention group, which did not result in statistically significant changes. It is important to note that there was no long-term follow-up beyond 48 hours post-treatment.

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

This paper investigated the utilization of IASTM and DN for long-distance runners. This study showed that while both IASTM and DN improved pain pressure threshold, IASTM significantly improved ankle dorsiflexion ROM and lunge test performance. Thus, while both therapeutic interventions can be valuable tools for clinical practice, the selection should be geared toward the patient’s restrictions and goals. Thus, these interventions should be utilized in conjunction with exercises to utilize and maintain the improvements and make lasting changes to the patient’s function and range of motion. It is also important to consider that this study only looked at immediate and short-term changes, thus further research should be completed to understand the long-term changes due to these interventions.

Author Names: Han, Y, Kang, X, Hu, A, Yu, H

Reviewer Name: Anna Smith, SPT

Reviewer Affiliation(s): Duke University

Paper Abstract: Background: Patients with chronic ankle instability (CAI) often experience recurrent swelling and pain, which hinder their ability to walk long distances. Emerging evidence suggests that joint mobilization can enhance ankle function in patients with CAI. Objective: The aim of this study is to investigate the effects of subtalar joint mobilization on enhancing ankle stability, alleviating ankle pain, and improving the walking ability of patients diagnosed with CAI. Methods: A retrospective analysis was conducted on 46 patients who were treated between April 2022 and October 2023. They were randomly divided into two groups: a treatment group with 23 cases receiving conventional treatment along with subtalar joint mobilization treatment, and a control group with 23 cases receiving only conventional treatment. The treatment duration was eight weeks. Pain levels and walking ability were assessed before and after the treatment period. Results: After eight weeks of treatment, the treatment group showed significant increases in the number of heel raises on the affected leg (NLHSL), improvements in the star excursion balance test (SEBT), and higher American Orthopedic Foot and Ankle Society (AOFAS) scores compared to the control group. Additionally, resting pain (RVAS) and walking pain (WVAS) scores were significantly lower in the treatment group. However, there was no statistically significant difference in single-leg standing time (SLT) between the two groups. Within the control group, post-treatment assessments indicated significant improvements in dynamic balance and control measures (SLT, NLHSL, SEBT), but no significant changes were observed in pain levels (RVAS, WVAS) or rear foot function (AOFAS). In contrast, the treatment group showed significant improvements across all measured parameters (RVAS, WVAS, SLT, NLHSL, SEBT, and AOFAS) following treatment. Conclusion: Subtalar joint mobilization effectively reduces ankle pain and enhances walking ability among patients with CAI by improving ankle stability. The observed improvements in walking ability may stem from mitigating compensatory mechanisms associated with varus of the calcaneus and ankle instability. Keywords: Calcaneal varus; Chronic ankle instability; Joint mobilization; Pain; Walking ability.

Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies

Was the research question or objective in this paper clearly stated? Yes

Was the study population clearly specified and defined? Yes

Was the participation rate of eligible persons at least 50%? Cannot Determine, Not Reported, Not Applicable

Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? Yes

Was a sample size justification, power description, or variance and effect estimates provided? Cannot Determine, Not Reported, Not Applicable

For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured? Cannot Determine, Not Reported, Not Applicable

Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? Yes

For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? Cannot Determine, Not Reported, Not Applicable

Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Yes

Was the exposure(s) assessed more than once over time? No

Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Yes

Were the outcome assessors blinded to the exposure status of participants? Cannot Determine, Not Reported, Not Applicable

Was loss to follow-up after baseline 20% or less? Cannot Determine, Not Reported, Not Applicable

Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? Yes

Key Finding #1

Walking pain scores were significantly lower for those receiving rehab with subtalar mobilization compared to those receiving only rehab for those with chronic ankle instability.

Key Finding #2

Static balance as measured with single leg stance time demonstrated no significant difference with subtalar mobilization vs without when treating individuals with chronic ankle instability.

Key Finding #3

Individuals with chronic ankle instability receiving rehab with subtalar mobilization were able to do more heel raises on the affected leg and saw improvement in their American orthopedic foot and ankle society hindfoot score.

Please provide your summary of the paper

The purpose of this paper was to investigate the relationship between the use subtalar mobilization when treating individuals with chronic ankle stability and walking, balance, and strength outcomes. Two groups of 23 individuals receiving the same treatment regimen with the exception of one additionally receiving subtalar mobilization were followed for 8 weeks. Contrary to other studies, this study found no impact on balance when comparing treatment with and without subtalar mobilizations. Both groups demonstrated improved balance; however, the addition of subtalar mobilization did not significantly change the improvement. Similarly both groups saw approximately the same reduction in resting pain. However, walking pain was significantly less for those that received subtalar mobilization. Additionally, they were able to do more heel raises on the affected leg and saw improvement in their American orthopedic foot and ankle society hindfoot score.

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

This study suggests that performing subtalar mobilization with muscle strengthening and proprioceptive exercises may enhance the desired outcomes when treating individuals with chronic ankle instability. While more research needs to be done to further understand the pathophysiology behind the process, practicing the technique is a safe and affordable method of potentially reducing the number of individuals with chronic ankle instability from needing orthopedic surgery.

Author Names

Stanek, Justin; Brown, Bryce; Barrack, Jessica; Parish, Jake

Reviewer Name

Madison Zaun

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy CO 2026

Paper Abstract

The coupled motions of tibial internal rotation (T-IR) and ankle dorsiflexion (DF) are necessary for proper lower-limb function. Anecdotally, clinicians have been performing techniques to restore T-IR to improve ankle DF, however, no evidence exists to support their efficacy. Therefore, the two objectives were to: (a) determine the effectiveness of a manual therapy technique for improving T-IR range of motion (ROM) and (b) Examine the relationship between ankle DF and T-IR ROM. Twenty-four participants qualified to participate and were randomly allocated to either the control (n=12) or manual therapy (n=12) group. Closed-chain ankle DF and T-IR ROM were assessed at baseline and immediately posttreatment. Control group participants sat quietly for 5 minutes. The experimental group performed 3 sets of 15 repetitions of a manual therapy, mobilization with movement technique. With the patient in a kneeling lunge position, the examiner wrapped an elastic band around the tibia and fibula and was instructed to lunge forward while the examiner simultaneously manually internally rotated the lower leg. T-IR ROM significantly increased following the intervention for the manual therapy group when compared to the control group. There were no significant changes in standing or kneeling DF ROM. No significant correlation was found between T-IR and both standing and kneeling DF ROM. A single mobilization with movement treatment is effective for improving tibial IR ROM in the short-term compared to no treatment. However, active tibial IR and end-range dorsiflexion range of motion do not appear to be correlated based on these methods.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot determine

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

yes

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

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot determine

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot determine

Key Finding #1

There was a statistically significant increase in tibial internal rotation following the intervention for the manual therapy group when compared to the control group

Key Finding #2

There were no significant changes in standing or kneeling DF ROM after the intervention was applied. There was no significant correlation found between tibial internal rotation and both standing and kneeling DF ROM

Please provide your summary of the paper

The article sought to determine the effectiveness of a manual therapy, mobilization with movement technique to improve tibial internal range of motion as well as to examine the relationship between ankle dorsiflexion and tibial internal rotation range of motion. Twenty-seven participants were recruited and screened for inclusion, to which twenty-four met the inclusion criteria. The experimental group and the control group each had 12 participants. Closed chain ankle dorsiflexion and tibial internal rotation was measured at baseline and immediately post-treatment for both groups. While the manual therapy (experimental) group received the manual therapy technique, the control group sat quietly for 5 minutes. The results showed a significant increase in tibial internal rotation range of motion in the manual therapy group compared to the control group. Thus, the single mobilization with movement treatment is effective at improving tibial internal rotation in the short term compared to no treatment. The results also showed that there was no significant change in standing or kneeling dorsiflexion range of motion after treatment. There also was no significant correlation between tibial internal rotation and both standing and kneeling dorsiflexion range of motion. Ultimately, the article found that a single session of manual therapy can increase tibial internal range of motion but did not find that dorsiflexion range of motion would also increase after treatment. This came as a surprise to the researchers since tibial internal rotation and ankle dorsiflexion are coupled in closed kinetic chain movements. The researchers suggest that if they had required participants to also have limited ankle dorsiflexion range of motion in addition to the limited tibial internal rotation, the results may have been different. The researchers also suggest that if maximal tibial internal rotation occurs prior to end range of ankle dorsiflexion range of motion, increasing tibial internal rotation might not have much of an effect on increasing dorsiflexion range of motion as well. Additionally, the researchers suggest that their findings could be different if they had compared to another intervention or a placebo intervention rather than no intervention. The researchers also note that there is not a universal normative value for tibial internal rotation and therefore, their inclusion criteria for tibial internal rotation range of motion may have been too high and otherwise not limited enough. Ultimately, this manual therapy, mobilization with movement intervention if effective in increasing tibial internal rotation in the short term compared to no intervention, but it did not significantly affect closed change dorsiflexion range of motion. Further research on this should be conducted to investigate the effect of manual therapy interventions on tibia internal rotation and ankle dorsiflexion range of motion for functional movement.

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

The article describes the kinematic relationship between tibial internal rotation and ankle dorsiflexion such as their coupled action in closed kinematic chain movements like a squat or in gait. They also mention the association that limited tibial internal rotation has with several lower extremity injuries. They posit that limited tibial internal rotation could contribute to ankle dorsiflexion range of motion limitations. The researchers found that the single session of manual therapy mobilization with movement is effective in improving tibial internal rotation but is not effective in improving ankle dorsiflexion range of motion. Thus, this article can help address patients with marked tibial internal rotation range of motion deficits as this method can increase the range of motion and potentially decrease their risk of lower extremity injury. It would be important to conduct more research such as to see what multiple sessions compared to just the single session of manual therapy could do for patients’ tibial internal rotation range of motion. Additionally, further research should be conducted to determine if there is an intervention that can address both tibial internal rotation and ankle dorsiflexion range of motion as they are coupled in closed kinetic chain movements. The researchers applied this principle to their manual therapy mobilization with movement technique in the study, however it did not effectively increase dorsiflexion range of motion, only tibial internal rotation increased. Therefore, we cannot use this technique to improve ankle dorsiflexion standing of kneeling range motion because the results did not yield significantly improves in the ankle dorsiflexion range of motion. The researchers describe several limitations that could warrant further research studies on this topic. Further research should be conducted on this subject as it could reduce injury risk of both athletic and non-athletic populations and can help them function better in everyday life as closed-kinetic chain movements occur daily and necessitate tibial internal rotation and ankle dorsiflexion range of motion for proper functioning.

Author Names 

Iammarino, K. Marrie, J. Selhorst, M. Lowes, L. 

Reviewer Name 

Julie Wilkerson 

 Reviewer Affiliation(s) 

Duke Doctor of Physical Therapy 

 Paper Abstract 

Background: Ankle injuries account for up to 40% of all sport related injuries. These injuries can result in weeks to months of missed sport or work. The PRICE (Protection, Rest, Ice, Compression, Elevation) treatment is standard care for most acute ankle sprains. Recently, early mobilization in adults has been shown to decrease time off from sport or work, and the likelihood of developing chronic instability. To date, no research has been performed assessing the effectiveness of early mobilization in pediatric patients (&lt;18 years). Purpose: There were two objectives of this study: (1) to determine if early ankle joint mobilization using elastic band traction is effective and (2) assess the occurrence of adverse events with this technique in the pediatric population.  Methods Patients with an acute ankle sprain of &lt;7 days referred to physical therapy were randomly assigned to receive early mobilization or PRICE. Early mobilization was performed using a stretch band ankle traction technique. Both groups received a standardized rehabilitation program. Pain, edema, ankle strength using hand-held dynamometry, and Foot and Ankle Disability Index (FADI) were measured at both initial evaluation and at discharge. The number of days before return to sport and the number of treatment sessions were also variables of interest.  Results Forty-one pediatric patients were recruited for participation (mean age 14.6 + 1.9 years). Both treatment groups had clinically significant improvements in pain, edema, strength, and FADI scores. No significant differences in outcomes were noted between treatment groups. Mean number of days for return to sport for the PRICE group was 26.33 + 7.14 and the early mobilization group was 26.63 + 14.82, the difference between groups was not significant (p = 0.607). The number of total visits for the PRICE group of 8.07 + 2.63 and the early mobilization groups of 8.5 + 1.57, was also not statistically significantly different (p = 0.762). There were no reported adverse events with early mobilization.  Conclusion Early mobilization appears to be a safe intervention in pediatric patients with an acute ankle sprain. Early mobilization resulted in similar outcomes when compared to traditional PRICE treatment. A high drop-out rate in both treatment groups was a limitation of this randomized trial.  Level of evidence 1b  Keywords: Ankle sprain, pediatric, mobilization  

Quality Assessment of Controlled Intervention Studies 

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

Yes – RCT 

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? 

No 

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? 

Not applicable/answered  

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)? 

Not applicable/answered  

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 

The results of this study indicate there is preliminary evidence that early joint mobilization in pediatric patients is safe. 

Key Finding #2 

There are some conflicting findings when assessing the benefit of adding talocrural distraction to supervised PT versus solely following the PRICE recommendations for pediatric patients after an ankle sprain. While the addition of the distraction did not appear  more effective than PRICE, there is research for adult populations that indicate the manual therapy was equally or more effective. There are many reasons this could be, including how pediatric patients recover differently than adults. 

Key Finding #3 

For the participants that were administered elastic band ankle traction mobilization, no adverse events were reported. 

 Key Finding #4 

The results of the finding were not significant and it was limited by a high drop out rate, however due to the preliminary evidence of no adverse events early joint mobilization in pediatric ankle sprains this could be researched further as this was what appears to be the first study done on the topic. 

Please provide your summary of the paper 

The purpose of this study was to obtain information about if early ankle mobilization using elastic band traction is effective and assess adverse events in a pediatric population. Ankle injuries are very common in sports, and for adult populations research suggests early mobilization can decrease return to play time and likelihood of chronic ankle instability, but this had yet to be applied to a population of under 18. A randomized clinical trial for patients that were on average 14.6 years of age with acute ankle sprain (3-7 days) was conducted. One treatment group received early joint mobilization while the other received PRICE (protection, rest, ice, compression, elevation). Results showed no clinically significant differences between groups with no adverse events occurring. The trial was limited by a high drop out rate. The study could serve as preliminary evidence that early joint mobilization is safe for pediatric populations. 

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

Since the findings of the paper are not clinically significant and it was limited by a high drop out rate, I would utilize this paper to gain an understanding for foundational knowledge of the topic and what preliminary evidence there is on the topic that likely needs to be further researched. What may be implemented into clinical practice is the concept that early joint mobilization appears to be safe for a pediatric ankle sprain, but since it has not been heavily researched by a sound study, I would continue using the best clinical reasoning for the patient and rely on typical interventions like PRICE. That being said, if I came across a patient that appeared like a good candidate for a study like this, I would stay up to date with early joint mobilization for pediatric ankle sprains and keep this thought in the back of my mind until research further proves it’s safety and good outcomes. As stated in the paper, joint mobilizations are not eliciting a force greater than what a pediatric patient endures throughout the day (running, jumping, etc.) This study could impact clinical practice by allowing clinicians to utilize more than just the PRICE method and incorporating early joint mobilizations at some point. It can also spark more research projects and questions for researchers to do another study. It will also impact clinical practice by reminding clinicians that pediatric patients may have a different healing process than adults, which is why it is critical to take an in depth history and monitor client response when performing interventions.