Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial

Abstract

Objective: In a pragmatic and randomized clinical trial, patients with lateral ankle sprains were assessed, under blinded conditions, for their responsiveness and improvements during Mulligan mobilization-with-movement (MWM) therapy. Methods: Overall, 51 participants with subacute lateral ankle sprains (Grade I-II) were recruited. Following an MWM screening procedure, responders were randomized to either an intervention group (MWM) or a sham group. The MWM group received inferior tibiofibular, talocrural, or cubometatarsal MWM. The treatment or sham was administered upon three sessions, each 4 days apart. Changes from baseline were measured and compared between the sessions for dorsiflexion range of motion, pain, stiffness perception, and the Y-balance test. Results: In total, 43 participants were considered responders to MWM. Using a two-way repeated-measure ANOVA, a statistical and clinically meaningful improvement in dorsiflexion range of motion was revealed in the MWM group (p = 0.004, 1^rst = +1.762 cm; 3^rd = +2.714 cm), whereas no improvement following the first session occurred in the sham group (p = 0.454, 1^rsttrial = +1.091 cm; 3^rdtrial = +1.409 cm). Pain and stiffness significantly improved, yet below the clinically meaningful level. The MWM group demonstrated a significant improvement after three sessions for the Y-balance test (p = 0.001, +8.857 cm). Conclusion: More than 80% of participants with subacute lateral ankle sprains responded well to the MWM approach. Three sessions of pragmatically determined MWM provided a significant and clinically meaningful benefit in dorsiflexion range of motion and Y-balance test performance compared to a sham treatment.

Keywords: Ankle sprain; manual therapy; mobilization with movement; mulligan; pragmatic study; weight-bearing lunge test.

Figure 1.

CONSORT Flow diagram Design of the current study divided in three sessions. MWM group represents the intervention group, whereas the sham group received sham therapy. DROM = dorsiflexion range of motion; MWM = mobilization with movement

Figure 2.

The Weight-Bearing Lunge Test (WBLT) against a wall

Figure 3.

Y-balanced test

Figure 4.

MWM intervention Position of the physiotherapist’s hands and participant position for the different mobilization with movement (MWM) techniques. A = inferior tibiofibular MWM, B = talocrural MWM, C = cubometatarsal MWM. White arrows indicate the direction of the therapist’s manual force. For C, the tape and consequent arrow direction can be reversed depending on the patient’s response. The three figures below represent the taping applied at the end of each session: a = inferior tibiofibular taping, b = talocrural taping, c = cubometatarsal taping. Black arrows indicate the direction of applied tension

Figure 5.

Pragmatic trial MWM = Mobilization with movement; PILL effect corresponds to the responsiveness of the participant after application of a define MWM therapy. The PILL effect is positive when the patient described a significant decrease in pain, increase in dorsiflexion range of motion or a functional assessment significantly improved. Responder were randomized while non-responders were excluded from further analysis