Elsevier

Physical Therapy in Sport

Volume 30, March 2018, Pages 22-28
Physical Therapy in Sport

Original Research
The effect of additional joint mobilization on neuromuscular performance in individuals with functional ankle instability

https://doi.org/10.1016/j.ptsp.2017.12.001Get rights and content

Highlights

  • Combined mobilization and training improved neuromuscular performance for FAI.

  • Training alone only improved self-perceived ankle function in individuals with FAI.

  • Combined joint mobilization and training were recommended for managing FAI.

Abstract

Objectives

To examine the effects of joint mobilization and exercise training on neuromuscular performance in individuals with functional ankle instability (FAI).

Design

A cross-sectional study.

Participants

Forty five subjects with FAI were randomized into three groups: control (CG, n = 15, 27.9 ± 6.6yr), training (TG, n = 15, 26.9 ± 5.8yr) and mobilization with training group (MTG, n = 15, 26.5 ± 4.8yr).

Intervention

Four weeks of neuromuscular training for TG; neuromuscular training and joint mobilization for MTG.

Main outcome measures

Electromyography of the peroneus longus (PL), tibialis anterior (TA), and soleus (SOL) and the reaching distance of the Y balance test (YBT), dorsiflexion range of motion (DFROM), Cumberland ankle instability tool (CAIT), and global rating scale (GRS). Two-way repeated measures MANOVA were used with the significance level p < .05.

Results

MANOVA found significant group by time interactions on posterolateral reaching distance (p = .032), PL activation (p = .006–.03), DFROM (p < .001), CAIT (p < .001) and GRS (p < .001). The post hoc tests indicated significantly improved PL muscle activity and posterolateral reaching distance for MTG compared to TG (p = .004) and CG (p = .006).

Conclusion

Joint mobilization resulted in additional benefits on self-reported ankle instability severity, dorsiflexion mobility, and posterolateral balance performance in individuals with FAI, but its effects on general improvement, muscle activation, and other balance tasks remained uncertain.

Introduction

Functional ankle instability (FAI) is a common lower extremity dysfunction following lateral ankle sprain (Freeman, Dean, & Hanham, 1965). Individuals with FAI often reported feelings of perceived ankle instability or “giving way” during walking or sport activities (Freeman et al., 1965, Hertel, 2002). Previous studies showed that individuals with FAI exhibited altered patterns of muscle activation, including peroneus longus (PL), tibialis anterior (TA), and soleus (SOL) muscles (Delahunt et al., 2006, Eils and Rosenbaum, 2001, Hopkins et al., 2009, Konradsen and Ravn, 1991, Linford et al., 2006, Lin et al., 2011, Lin and Shih, 2014, Palmieri-Smith et al., 2009, Vaes et al., 2002). Some reports demonstrated differences in balance control strategies between individuals with FAI and non-injured people, such as a more proximal control strategy and a larger postural sway during the single leg standing task in FAI population (Levin et al., 2012, Mitchell et al., 2008, VanDeun et al., 2007). These might indicate deficits in joint proprioception and neuromuscular control which might expose people with FAI to a greater risk of recurrent ankle injuries. Other researchers attributed postural control deficits to decreased ankle dorsiflexion range of motion in individuals with functional or chronic ankle instability (Basnett et al., 2013, Drewes et al., 2009, Hoch et al., 2012a, Hubbard et al., 2007).

Clinicians often use neuromuscular or balance training as the treatment intervention for FAI (Eils and Rosenbaum, 2001, Linford et al., 2006, Loudon et al., 2008, O'Driscoll and Delahunt, 2011). However, evidence for the effectiveness of neuromuscular or balance training is limited to moderate regarding muscle performance, posture stability, or self-perceived improvement (Loudon et al., 2008, O'Driscoll and Delahunt, 2011). Despite the fact that deficits in ankle dorsiflexion have been shown to influence the dynamic balance performance in those with chronically unstable ankles, not many investigators addressed this problem when examining the intervention effect of functional ankle instability. Preliminary data support the effectiveness of joint mobilization on the dynamic posture performance and ankle function in people with chronic ankle instability (Delahunt et al., 2013, Hoch et al., 2012b, Hoch and McKeon, 2011). However, these studies have only assessed the immediate effect or the effect of a short intervention period (two weeks) of joint mobilization alone. Whether or not joint mobilization combined with regular neuromuscular training would result in better neuromuscular and posture performance remains unclear.

This study is a randomized controlled trial examining the effects of four-week joint mobilization combined with neuromuscular training on function, range of motion, muscle activity and balance performance of the ankle joint in individuals with FAI.

Section snippets

Study design and participants

This was a cross-sectional study. Participants had to sign the informed consent before entry into the study. This trial was conducted from October 2014 to July 2015. Forty five participants with FAI were included in the study, and randomly assigned into three groups: the control group (CG), the training group (TG) and the mobilization with training group (MTG). This sample size was determined based on the preliminary data of our pilot study which suggested we needed at least nine participants

Results

Fig. 1 shows the flow of the study. Forty five participants with FAI were recruited and randomized into the CG (7 males 8 females, body mass index BMI = 22.2 ± 2.5), the TG (7M8F, BMI = 22.1 ± 2.6), and the MTG (10M5M, BMI = 23.3 ± 3.2) (Table 1). No significant difference was found in any of the demographic characteristics. Most participants reported more than five episodes of ankle sprain, but were unable to recall the actual number of recurrences or the timeframe of their symptoms. Two

Discussion

Insufficient ankle joint mobility has been shown to contribute to impaired balance performance in individuals with chronic ankle instability (Basnett et al., 2013, Drewes et al., 2009, Hoch et al., 2012a, Hubbard et al., 2007). Joint mobilization is a common intervention for joint mobility deficits. Nevertheless, there is a paucity of data on the clinical effects of joint mobilization for functional ankle instability. Hoch and McKeon (2011) and Delahunt et al. (2013) revealed that ankle joint

Conclusion

Through four weeks of intervention, joint mobilization combined with neuromuscular training resulted in additional benefits on self-reported ankle severity, ankle dorsiflexion mobility, and balance performance in the posterolateral direction, as compared to the training only group and control group. The effect of additional joint mobilization on general improvement, muscle activation, and the anterior and posteromedial balance tests were still uncertain. Future research should explore the

Conflict of interest statement

All authors state that they do not keep any commercial, financial or personal relationships which may lead to a conflict of interests that could inappropriately influence their work. No research grant sponsor had any involvement in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.

Ethical approval statement

This study was approved by the Human Research Ethics Committee, National Yang-Ming University, Taiwan (YM103064).

Acknowledgements

The authors would like to thank Dr. Ya-Yun Lee for her valuable suggestions. This study was in part supported by Ministry of Science and Technology, Taiwan (MOST 104-2410-H-010-013).

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