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Manual Therapy xxx (2013) 1e6

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The effects of Mobilization with Movement on dorsiflexion range

of motion, dynamic balance, and self-reported function in individuals
with chronic ankle instability
Julie P. Gilbreath a, Stacey L. Gaven c, Bonnie L. Van Lunen b, Matthew C. Hoch b, *
Department of Human Movement Science, College of Education, Old Dominion University, Norfolk, VA, USA
School of Physical Therapy and Athletic Training, College of Heath Sciences, Old Dominion University, Health Sciences Annex, RM 104A, Norfolk, VA 23539,
Department of Kinesiology, Franklin College, Franklin, IN, USA

a r t i c l e i n f o a b s t r a c t

Article history: Previous studies have examined the effectiveness of a manual therapy intervention known as Mobili-
Received 3 December 2012 zation with Movement (MWM) to increase dorsiflexion range of motion (ROM) in individuals with
Received in revised form chronic ankle instability (CAI). While a single talocrural MWM treatment has increased dorsiflexion ROM
26 September 2013
in these individuals, examining the effects of multiple treatments on dorsiflexion ROM, dynamic balance,
Accepted 1 October 2013
and self-reported function would enhance the clinical application of this intervention. This study sought
to determine if three treatment sessions of talocrural MWM would improve dorsiflexion ROM, Star
Excursion Balance Test (SEBT) reach distances, and self-reported function using the Foot and Ankle
Manual therapy
Ankle sprain
Ability Measure (FAAM) in individuals with CAI. Eleven participants with CAI (5 Males, 6 Females, age:
Range of motion 21.5  2.2 years, weight: 83.9  15.6 kg, height: 177.7  10.9 cm, Cumberland Ankle Instability Tool:
Balance 17.5  4.2) volunteered in this repeated-measures study. Subjects received three MWM treatments over
one week. Weight-bearing dorsiflexion ROM (cm), normalized SEBT reach distances (%), and self-
reported function (%) were assessed one week before the intervention (baseline), prior to the first
MWM treatment (pre-intervention), and 24e48 h following the final treatment (post-intervention). No
significant changes were identified in dorsiflexion ROM, SEBT reach distances, or the FAAM-Activities of
Daily Living scale (p > 0.05). Significant changes were identified on the FAAM-Sport (p ¼ 0.01). FAAM-
Sport scores were significantly greater post-intervention (86.82  9.18%) compared to baseline
(77.27  11.09%; p ¼ 0.01) and pre-intervention (79.82  13.45%; p ¼ 0.04). These results indicate the
MWM intervention did not improve dorsiflexion ROM, dynamic balance, or patient-centered measures of
activities of daily living. However, MWM did improve patient-centered measures of sport-related ac-
tivities in individuals with CAI.
Ó 2013 Published by Elsevier Ltd.

1. Introduction sustain an ankle sprain experience residual symptoms for several

years and many develop chronic ankle instability (CAI) which is
Ankle sprains are common injuries occurring among the general characterized by additional ankle sprains, residual ankle sprain
population with an incidence rate of approximately two per 1000 symptoms, and the sensation of recurrent instability (Hertel, 2002;
people per year in the United States (Waterman et al., 2010). While Anandocoomarasary and Barnsley, 2005). CAI is associated with
ankle sprains are often considered innocuous injuries, up to 21% of deficits in health-related quality of life and is a common precon-
ankle sprain patients discontinue or modify occupational activities dition for developing ankle osteoarthritis (Valderrabano et al.,
and nearly 65% modify their level of physical activity for several 2006; Arnold et al., 2011b). Therefore, developing effective inter-
years following their initial ankle sprain (Verhagen et al., 1995; vention strategies to address the long-term consequences of CAI is
Hiller et al., 2012). Further, as many as 70% of individuals that important for maintaining levels of activity and participation which
are meaningful to patients.
CAI develops from multiple contributing factors which are often
* Corresponding author. Tel.: þ1 757 683 4351; fax: þ1 757 683 4410. characterized as either mechanical or functional impairments.
E-mail address: mhoch@odu.edu (M.C. Hoch). Mechanical impairments encompass joint laxity, altered

1356-689X/$ e see front matter Ó 2013 Published by Elsevier Ltd.


Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/
2 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6

arthrokinematics, degenerative changes to the cartilage of the function in individuals with CAI. We hypothesized that there will
talocrural joint, and synovial changes. Functional impairments be significant increases in weight-bearing dorsiflexion ROM, SEBT
consist of insufficiencies in proprioception, strength, neuromus- reach distances, and self-reported function following the
cular control, and postural control (Hertel, 2002). It is likely that a intervention.
combination of mechanical and functional impairments result in
the decreased health-related quality of life, repetitive incidents of 2. Methods
the ankle giving way, and recurrent ankle sprains experienced by
individuals with CAI (Hertel, 2002; Arnold et al., 2011b). Exploring This study was a within-subjects repeated measures design
the connection between mechanical and functional impairments consisting of a single cohort of individuals with chronic ankle
while evaluating the effects of clinical interventions may enhance instability (CAI). Outcome measures were taken prior to and
the current rehabilitation strategies for CAI. following a 1-week talocrural MWM intervention. The independent
Decreased dorsiflexion ROM is a common mechanical impair- variable was time (baseline, pre-intervention, and post-
ment in individuals with CAI based on reports that 30e74% of in- intervention measures) and the dependent variables included
dividuals have at least a 5 deficit based on the contralateral limb weight-bearing dorsiflexion ROM, normalized SEBT reach dis-
(Beazell et al., 2012; Wheeler et al., 2013). This ROM deficit is tances, and self-reported function using the Foot and Ankle Ability
thought to be linked to an anterior positional fault of the talus Measure (FAAM).
(Wilkstrom and Hubbard, 2010), and/or restrictions in posterior
talar glide, which alter the arthrokinematic motions required to 2.1. Participants
achieve maximal dorsiflexion ROM (Denegar et al., 2002; Hoch and
Grindstaff, 2012). Individuals with CAI have demonstrated dorsi- Eleven physically active participants, including five males and
flexion deficits during jogging gait (Drewes et al., 2009) and deficits six females volunteered to participate in this study (Table 1). Par-
in dynamic balance which were correlated to dorsiflexion ROM ticipants were recruited from the University and surrounding
impairments (Hoch et al., 2012b) which suggests ankle dorsiflexion community by recruitment flyers and word of mouth. Participants
ROM impairments may have an impact on functional activity. were included in the study if they had self-reported CAI, which was
Therefore, dorsiflexion ROM should be a consideration when defined as having a history of at least one ankle sprain, at least one
treating patients with CAI. episode of giving away in the past three months, and a score of 25
To address impairments in dorsiflexion ROM which are arthro- or less on the Cumberland Ankle Instability Tool (CAIT) (Arnold
genic in nature, a manual therapy technique known as joint et al., 2011a) (Table 1). Participants also had to be physically
mobilization has been utilized to increase the extensibility of active which was defined as participating in vigorous physical ac-
noncontractile joint structures (Vicenzino et al., 2006; Reid et al., tivity at least 20 min a day, three times a week (Haskell et al., 2007).
2007; Hoch and McKeon, 2011). A joint mobilization technique of Participants were excluded if they had an injury to the lower ex-
interest is Mobilization with Movement (MWM) described by tremity (ankle, knee, hip, or back) within the past three months or a
Mulligan (1995). This technique is of interest because it attempts to history of intra-articular surgery to the lower extremity within the
address arthrokinematic positional faults, which occur following past year. Participants were also excluded if they had an ankle
injury (Mulligan, 1995) by correcting the misaligned joint surfaces sprain in the previous six weeks or any history of ankle surgery.
using a passive mobilization combined with an active movement Episodes of “giving way” were not considered an injury for the
which is a different theoretical approach compared to other joint purposes of inclusion and exclusion criteria. In the event of bilateral
mobilization systems. Talocrural MWM for the purpose of CAI, the limb with the lower CAIT score was considered the
increasing dorsiflexion ROM is performed by applying a poster- involved limb for the purposes of this study. All participants read
oanterior tibial glide over a weight-bearing fixed foot while the and signed an informed consent document approved by the Uni-
patient actively moves into a dorsiflexed position to address an versity’s Institutional Review Board. A power analysis was con-
anterior talar positional fault or restricted posterior talar glide ducted on the mean differences between pre- and post-ankle
(Vicenzino et al., 2006). Increases in ankle dorsiflexion ROM have dorsiflexion measurement following a single MWM treatment,
been observed immediately following a single MWM treatment in resulting in at least 8 participants needed for a statistical power of
individuals with CAI (Vicenzino et al., 2006; Reid et al., 2007); 0.50 with a 0.05 significance level (Reid et al., 2007). No dropouts
however, the effects of multiple treatments have not been were experienced throughout the study.
A review of the evidence concluded that a single MWM treat-
2.2. Procedures
ment was able to improve dorsiflexion ROM in individuals with a
history of ankle sprain (Hoch and McKeon, 2010). This review
Participants reported to the laboratory on five separate occa-
recommended future studies should investigate interventions
sions over a two-week period. After being included into the study,
performed over a number of sessions and use patient-centered
participants completed the first data collection session (baseline).
outcome assessments to evaluate the effectiveness of MWM
Following the baseline session, participants were instructed to
(Hoch and McKeon, 2010). Additionally, previous studies (Hoch and
maintain normal physical activity and activities of daily living and
McKeon, 2011; Hoch et al., 2012a) have determined Maitland Grade
III anterior-to-posterior talocrural joint mobilizations can enhance
static and dynamic balance as well as patient-reported function in Table 1
individuals with CAI. Exploring the effects of MWM on dorsiflexion Participant demographics.
ROM, dynamic balance, and self-reported function would further Means  SD
elucidate the possible interaction between mechanical impair-
Age (years) 21.5  2.2
ments, functional impairments, and disability in those with CAI and Weight (kg) 83.9  15.6
broaden the clinical implications for using MWM for individuals Height (cm) 177.7  10.9
with this condition. Therefore, the purpose of this study was to # Of ankle sprains 3.3  2.1
examine the effect of three MWM treatment sessions on weight- Episodes of giving away in previous 3 months 2.5  1.2
Cumberland Ankle Instability Tool score 17.5  4.2
bearing dorsiflexion ROM, SEBT reach distance, and self-reported

Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/
J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6 3

report back to the laboratory in one week for the second data The FAAM-ADL consists of 21 items pertaining to ADL, whereas the
collection session (pre-intervention). Immediately following the FAAM-Sport consists of 8-items pertaining to sport-specific tasks.
pre-intervention session, participants received their first MWM Each item is scored on a 0e4 point Likert scale which ranges from
treatment and returned to the laboratory for two additional treat- “no difficulty” to “unable to do”. The score for these instruments
ments over the next week. Participants completed the third data can range from 0 to 84 and 0e32 for the FAAM-ADL and FAAM-
collection session (post-intervention) within 24e48 h following Sport, respectively. For both subscales, lower scores are indicative
the final MWM treatment. At each data collection session, each of greater levels of self-perceived functional loss. Both the FAAM-
participant’s self-reported function, dorsiflexion ROM, and dy- ADL and Sport subscales have demonstrated good reliability
namic balance were assessed in the aforementioned order on the (Martin et al., 2005) and have successfully detected functional loss
involved limb using the outcome assessments described below. in collegiate athletes with CAI (Carcia et al., 2008). The minimal
detectable change (MDC) and minimal clinically important differ-
2.2.1. Dorsiflexion range of motion ence (MCID) for the FAAM-ADL are reported as 5.7 and 8 points,
Weight-bearing dorsiflexion ROM was measured using the with 12.3 and 9 points for the FAAM-Sport (Martin et al., 2005). The
weight-bearing lunge test (WBLT). This assessment of dorsiflexion FAAM-ADL and FAAM-Sport score obtained from each data collec-
ROM was used because it has demonstrated excellent reliability tion were used for statistical analysis.
(Bennell et al., 1998; Konor et al., 2012) and has been responsive to
change following joint mobilization (Vicenzino et al., 2006; Hoch
et al., 2012a). This method of assessing weight-bearing dorsi- 2.3. Mobilization with Movement intervention
flexion ROM has been reported to have a minimal detectable
change (MDC) value ranging from 0.3 to 1.5 cm (Konor et al., 2012; The MWM intervention was administered by an athletic trainer
Hoch et al., 2012a). Using this technique, the participant was with 2 years of experience (JPG). To administer the MWM treat-
barefoot and positioned with the great toe and heel on a tape ment, the participant assumed a kneeling lunge position on a
measure perpendicular to a wall. The participant was instructed to treatment plinth with the involved limb in a weight-bearing stance
lunge towards the wall, touch their knee to the wall, and keep their and the foot in a neutral position (Fig. 1). A non-elastic nylon belt
heel in contact with the floor. The participant then moved away with padding was placed around the distal aspect of the tibia and
from the wall in 1 cm increments until the heel no longer main- fibula, level with the inferior margin of the medial malleolus, and
tained contact with the floor or the knee was no longer able to around the waist of the clinician (Reid et al., 2007). The clinician
contact the wall. Maximal dorsiflexion was considered the greatest stabilized the talus and forefoot by applying pressure with the web
distance between the great toe and wall (measured in centimeters) space of the hands on the anterior talus and forefoot. The clinician
when all conditions were satisfied (Hoch et al., 2012a). Past studies applied anterior-to-posterior pressure on the talus and a posterior-
have suggested that each centimeter of lunge distance represents to-anterior glide of the tibia over the talus using the belt. The
approximately 4 of dorsiflexion (Bennell et al., 1998; Konor et al., clinician continued applying pressure as the participant slowly
2012). Each participant performed a practice trial, followed by moved into dorsiflexion until discomfort was reported and/or the
three trials that were recorded, averaged, and used for statistical end ROM occurred (Collins et al., 2004). This position and pressure
analysis. was held for 30 s before returning to the neutral kneeling position.
Each treatment consisted of two sets of four repetitions, separated
2.2.2. Dynamic balance by 1 min of rest, modified from Vicenzino et al. (2006). Therefore, a
Dynamic balance was assessed using the anterior (ANT), post- total of 4 min of MWM was administered at each of the 3 treatment
eromedial (PM) and posterolateral (PL) directions of the SEBT based sessions. The MWM intervention was administered within one
on the recommendation of Hertel (2008). These directions of the week having at least 24 h between each session. No other treat-
SEBT are reported to have a test-retest reliability of 0.84e0.90 ments or interventions were applied by the investigators during
(Munro and Herrington, 2010), and MDC scores of 1.56e6.87% for the study period. Participant compliance was 100% over the course
the anterior (ANT) direction, 3.36e8.15% for the posteromedial of the study.
(PM) direction and 4.28e7.11% for the posterolateral (PL) direction
(Munro and Herrington, 2010; Hoch et al., 2012a). Participants were
instructed to stand in the middle of the SEBT grid with equal halves
of the length of the foot on each side of the instrument (Gribble
et al., 2009). Participants were instructed to perform maximal
reaches followed by a light touch on the tape measure with the
reach leg while maintaining balance and foot placement on the
stance leg (Gribble and Hertel, 2003). If a participant placed sub-
stantial weight on the reach leg, removed the stance leg from the
grid, or lost balance, the trial was disregarded and repeated. Six
practice trials were performed for each direction, followed by 2 min
of rest. Three test trials for each direction were recorded for analysis
with a 30 s rest period between directions. To normalize SEBT
performance, each subject’s reach distances were divided by their
leg length (anterior superior iliac spine to ipsilateral distal aspect of
medial malleolus) and multiplied by 100 (Gribble and Hertel,
2003). The average of the three normalized trials was used for
statistical analysis (Gribble et al., 2012).
Fig. 1. Mobilization with Movement technique. The clinician was positioned with a
non-elastic belt around the hips and hands positioned over the talus to stabilize the
2.2.3. Self-reported function foot to create a posterior-to-anterior glide of the tibia over the talus. The participant
The FAAM is a patient-reported outcome that measures function was positioned in a kneeling-lunge position with the involved limb in a weight-
during activities of daily living (ADL) and sport-related activities. bearing, dorsiflexed stance position.

Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/
4 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6

2.4. Minimal detectable change scores Table 3

Hedges g effect size (95% confidence interval) for all outcome measures. Positive
values represent improvements following the intervention.
Because no control group was used in this study, minimal
detectable change (MDC) scores were calculated to determine the Measure Baseline e post-intervention Pre-intervention e
minimal change required within our dependent variables to ach- post-intervention

ieve changes beyond the error of the measurements. MDC scores Dorsiflexion 0.15 (0.69, 0.98) 0.11 (0.73, 0.95)
were determined using intersession reliability (intraclass correla- Anterior reach 0.02 (0.81, 0.86) 0.00 (0.84, 0.83)
Posteromedial reach 0.22 (0.61, 1.06) 0.05 (0.79, 0.89)
tion coefficient (2, 1) and the standard error of measurement
Posterolateral reach 0.12 (0.72, 0.95) 0.16 (0.68, 1.00)
(SEM)) from the data collected during the baseline and pre- Foot And Ankle Ability 0.41 (0.43, 1.26) 0.34 (0.50, 1.19)
intervention sessions. MDC scores were calculated using the Measure Activities
following formula: SEM * O2 (Wyrwich et al., 1999; Beaton et al., Of Daily Living
Foot And Ankle Ability 0.81 (0.06, 1.68) 0.58 (0.27, 1.44)
2001). Each MDC score is provided next to the respective depen-
Measure Sport
dent variable in Table 2.

2.5. Statistical analysis 4. Discussion

Separate one-way ANOVAs were used to determine if changes The results of this study indicate that there were no significant
were observed in weight-bearing dorsiflexion ROM, SEBT reach changes in weight-bearing dorsiflexion ROM, any directions of the
distances (ANT, PM, PL), and FAAM (ADL and Sport) scores over SEBT, or FAAM-ADL scores following three treatments of MWM in
time. In the event of a significant time effect, paired t-tests were individuals with CAI. Despite the lack of significant change in these
calculated for pairwise comparisons. An alpha level of 0.05 was set measures, a significant improvement in FAAM-Sport scores was
to determine significance. Bias-corrected Hedge’s g effect sizes (ES) demonstrated following the intervention. Overall, the MWM
with 95% confidence intervals were also calculated for all pairwise intervention used in this study did not appear to influence any
comparisons. The calculated Hedges g ES is a unit-less measure and clinician-oriented measures of function but the participants did
represents an effect that exists on a parametric distribution. Pooled perceive benefits related to sport activities.
standard deviations were used in the calculation of ES. A positive ES It was hypothesized that the MWM intervention would signifi-
indicated improvement in the dependent measure over time. ES cantly improve dorsiflexion ROM. While this study did observe an
were interpreted as weak if they were less than 0.40, moderate if increase of 0.29 cm from pre- to post-intervention measures, this
between 0.41 and 0.69, or strong if greater than 0.70. All statistical finding was not statistically significant, was associated with a weak
tests were performed using SPSS 19.0 for Windows (SPSS Inc. USA). effect size, and did not surpass the MDC established between the
baseline and pre-intervention measures. Previous studies by
Vicenzino et al. (2006) and Reid et al. (2007) measured dorsiflexion
3. Results
ROM immediately following a single MWM treatment and found
statistically significant improvements in dorsiflexion ROM which
No significant changes were identified in dorsiflexion ROM
were approximately 0.6 cm in both studies. Besides the amount of
(p ¼ 0.69), normalized SEBT reach distances (ANT (p ¼ 0.99), PM
MWM treatment, one of the major differences between the current
(p ¼ 0.15), and PL (p ¼ 0.24)), or for the FAAM-ADL (p ¼ 0.19). A
study and these previous studies is the amount of time following
significant time effect was identified for the FAAM-Sport (p ¼ 0.01).
post-intervention measurement. Vicenzino et al. (2006) and Reid
The post-intervention FAAM-Sport score was greater than baseline
et al. (2007) measured dorsiflexion ROM immediately following
(p ¼ 0.01) and pre-intervention (p ¼ 0.04) measures. No difference
the intervention while the current study waited 24e48 h following
was detected between baseline and pre-intervention measures
the final treatment to assess ROM. Combining the results of these
(p ¼ 0.20). The means  SD for dorsiflexion ROM, normalized SEBT
studies with the current investigation suggests that the effects of
reach distances, FAAM-ADL, and FAAM-Sport scores are presented
MWM on dorsiflexion ROM may not be long lasting.
in Table 2. The ES and 95% CI for all measures are presented in
There are several possible explanations for the inconsistencies
Table 3.
in the reported improvements in dorsiflexion ROM following
MWM. One potential explanation may be the possibility that pre-
Table 2 vious studies examining a single treatment session of MWM
Means  SD and minimal detectable change scores for all outcome measures at acutely stretched the plantar flexor muscle group. This is a possi-
baseline, pre-intervention, and post-intervention assessments.
bility because the patient is placed in a sustained maximal dorsi-
Measure Baseline Pre-intervention Post- Minimal flexion ROM position which may put the gastroesoleus complex on
intervention detectable stretch. While Vicenzino et al. (2006) did identify increases in
posterior talar glide using the posterior glide test, the validity of
Dorsiflexion (cm) 7.39  2.38 7.48  2.54 7.77  2.57 0.85 this assessment technique is unknown. Additionally, Cosby and
Anterior reach (%) 71.36  7.88 71.55  7.19 71.54  7.15 2.81 Hertel (2011) identified a weak correlation between the posterior
Posteromedial 91.21  10.99 93.17  11.85 93.77  11.05 2.79
reach (%)
talar glide test and instrumented measures of posterior glide using
Posterolateral 87.85  13.53 87.39  12.24 89.38  11.97 3.15 an ankle arthrometer. A second explanation is that those with
reach (%) instability may demonstrate transient changes in talar positioning
Foot And Ankle 90.18  6.51 90.45  7.50 92.91  6.19 3.43 that may lead to intermittent and chronic symptoms. This is sup-
Ability Measure
ported by a recent study which determined that simply moving the
Activities Of
Daily Living (%) ankle through the sagittal plane of motion can increase the anterior
Foot And Ankle 78.27  11.09 79.82  13.45 86.82  9.71a 6.02 positioning of the talus in individuals with CAI based on ultraso-
Ability Measure nography (Croy et al., 2013). Under both possibilities, MWM may
Sport (%) create immediate changes in talar positioning or in the length of
Indicates significant difference from baseline and pre-intervention measure. the gastroesoleus complex which may dissipate when examined at

Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/
J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6 5

a later time. Therefore, the underlying arthrokinematic changes be interpreted with caution because although the post-
associated with CAI and following MWM require further intervention change scores did surpass the MDC established in
investigation. this study they did not surpass the minimally clinically important
Another possibility for the inconsistency between the findings difference score previously established for this instrument (Martin
of the current study and previous studies implementing MWM for et al., 2005). This indicates that a change was identified which
individuals with CAI may be in the participant inclusion criteria. surpassed the error associated with the FAAM-Sport instrument
Both Vicenzino et al. (2006) and Reid et al. (2007) used an arbitrary but it might not yet have a meaningful clinical impact. Although
value of a 2 cm dorsiflexion deficit on the weight bearing lunge test caution should be exercised when interpreting these changes in
as part of the inclusion criteria. In the current study, we elected not FAAM-Sport scores, the effect sizes accompanying these changes
to use this inclusion criteria because this was an exploratory study; were moderate-to-strong (0.58e0.90) suggesting these findings
particularly given the pre-experimental design, and the effects of should not be automatically dismissed because changes in sport
joint mobilization have demonstrated implications beyond function may be present. The lack of change in the FAAM-ADL
improving range of motion that may be beneficial for individuals suggests the timeframe of the study may not have been long
with a history of ankle sprain such as improvements in static and enough to impact ADLs, the intervention may not have adequately
dynamic balance, increased self-reported function, increased addressed ADLs, or the level of function exhibited by these partic-
muscle activation, and decreased pain (Cosby et al., 2011; Grindstaff ipants did not enable much improvement to be attained because
et al., 2011; Hoch and McKeon, 2011; Hoch et al., 2012a). The recent FAAM-ADL scores are often greater than FAAM-Sport scores.
investigation by Hoch et al. (2012a) used similar inclusion methods Potentially examining changes in landing, cutting, or other sport-
and study design and detected moderate-to-large treatment effects related activities following MWM in future studies may elucidate
for dorsiflexion ROM, SEBT reach distances, and self-reported some of the improvements reported on the FAAM-Sport. This is
function following six Maitland Grade III treatment sessions in 12 supported by a recent study which incorporated talocrural MWM
individuals with CAI. Furthermore, while a dorsiflexion deficit was along with talar glide and distal tibiofibular mobilizations within a
not used as part of inclusion, the mean weight-bearing lunge dis- single treatment session and identified increases in dorsiflexion
tance for this sample of participants was approximately ROM at initial contact of jump landing in participants with CAI
7.5  2.5 cm. This mean and standard deviation are less than or (Delahunt et al., 2013).
similar to the values reported for CAI participants by Reid et al. This study has several limitations which support the need for
(2007) (13.3  3.5 cm), Hoch et al. (2012a) (10.8  3.8 cm), and additional research in the field. First, the inclusion criteria did not
Plante and Wikstrom (2012) (7.8  4.3 cm) and less than healthy require participants to have specific impairments in dorsiflexion
participant values reported by Bennell et al. (1998) (13.8  3.7 cm), ROM or ankle arthrokinematics. Including participants with a
Hoch et al. (2012b) (12.5  2.5 cm), Konor et al. (2012) dorsiflexion deficit or restricted posterior glide (Vicenzino et al.,
(9.5  3.1 cm), and Plante and Wikstrom (2012) (11.0  2.9 cm). 2006; Reid et al., 2007) may elicit different results. While previ-
Therefore, we believe many of the participants in this study did ous studies have identified individuals with unilateral dorsiflexion
demonstrate dorsiflexion ROM restrictions when compared to ROM deficits, the ROM observed by the participants in the current
previously established values. However, from our data we cannot study were less than previous joint mobilization studies and
determine the presence of talar positional faults. The known healthy values reported in the literature. This study also included a
presence of talar malpositioning may be a better indicator of who small sample size with individuals who were not actively seeking
will benefit from MWM. Currently, it is unclear if patients with CAI treatment. It should be taken into consideration that the treatment
that exhibit certain levels of dorsiflexion deficit or particular effect sizes for dorsiflexion and dynamic balance were weak
arthrokinematic impairments will benefit most from joint mobili- (<0.22) and an unfeasible sample size (82e173) would have been
zation treatments. Future research is needed to determine if a required to achieve statistically significant improvements with a
subset of individuals with CAI will benefit the most from joint power of 0.50. While this underscores that this study was under-
mobilization treatments. powered, it also demonstrates that the MWM intervention did not
It was also hypothesized that the MWM intervention would generate clinically meaningful changes in dorsiflexion or dynamic
improve dynamic postural control. However, no significant differ- balance. Including the number of subjects needed to achieve sta-
ences were detected in the normalized reach distances of the three tistical significance would overcome the weak effect sizes but the
directions of the SEBT. The lack of improvement in the SEBT reach clinical relevance of the findings could be questionable. Also, a
distances especially in the anterior direction was not surprising previous study (Hoch et al., 2012a) used 12 subjects with similar
because changes in this reach direction are likely related to dorsi- inclusion criteria, study design, and dependent variables and ach-
flexion ROM which did not change in this study (Hoch et al., 2012a). ieved both statistically significant and clinically relevant findings
In comparison to the SEBT MDC scores established in this study as following a joint mobilization intervention. Future research should
well as previous studies (Munro and Herrington, 2010; Hoch et al., seek to establish a clinical prediction rule to determine the in-
2012a), our observed changes between pre- and post-intervention dividuals with CAI who will most likely to benefit from joint
measures yielded much lower percentages of change. While a mobilization interventions.
recent study (Hoch et al., 2012a) which implemented multiple Currently, there is little evidence on the appropriate treatment
treatment sessions of Maitland Grade III anterior-to-posterior parameters for MWM treatments. Hoch et al. (2012a) applied
talocrural glides has identified improvements in SEBT perfor- Maitland Grade III talocrural joint mobilizations during six treat-
mance, further investigation is required to determine if such im- ment sessions and found significant increases in ROM, dynamic
provements can be produced following MWM. balance, and self-reported function while another study by Beazell
Lastly, no significant improvements were reported on the et al. (2012) applied high velocity low amplitude thrusts to the
FAAM-ADL although significant improvements were reported on distal fibula during four treatment sessions and found no im-
the FAAM-Sport following the intervention. This indicates that provements in weight-bearing dorsiflexion ROM or FAAM-Sport
MWM may have created perceived functional improvements in scores. Potentially three MWM treatment sessions were not
sport activities that were not captured by the clinical measures enough to produce lasting effects in individuals with CAI. Addi-
included in this study. Although there was a statistically significant tionally, the pressure applied during the MWM should also be
improvement in FAAM-Sport scores, these improvements should taken into consideration. Reid et al. (2007) used biofeedback in

Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/
6 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6

order to gauge the same application across participants. While the Denegar CR, Hertel JH, Fonseca J. The effect of lateral ankle sprain on dorsiflexion
range of motion, posterior talar glide, and joint laxity. J Orthopaedic Sports Phys
same investigator applied all MWM treatments in this investiga-
Ther 2002;32(4):166e73.
tion, the pressure and consistency of pressure is unknown and may Drewes LK, McKeon PO, Kerrigan DC, Hertel J. Dorsiflexion deficit during jogging
be directly related to treatment outcomes (Silvernail et al., 2011). with chronic ankle instability. J Sci Med Sport 2009;12(6):685e7.
Examining the effect of treatment volumes, frequency, and force Gribble PA, Hertel J. Considerations for normalizing measures of the star excursion
balance test. Meas Phys Education Exerc Sci 2003;7(2):89e100.
application along with comparing the effects of different in- Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dy-
terventions may provide clearer recommendations for clinically namic postural-control deficits and outcomes in lower extremity injury: a
implementing joint mobilization treatments. literature and systematic review. J Athletic Train 2012;47(3):339e57.
Gribble PA, Robinson RH, Hertel J, Denegar CR. The effects of gender and fatigue on
Finally, this study implemented a within-subjects repeated dynamic postural control. J Sports Rehabil 2009;18(2):240e57.
baseline design rather than including a control group. Also, the Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Immediate
same investigator applied the MWM treatments and recorded the effects of a tibiofibular joint manipulation on lower extremity H-reflex mea-
surements in individuals with chronic ankle instability. J Electromyogr Kinesiol
outcome assessments indicating a lack of blinding. We selected this 2011;21(4):652e8.
pre-experimental design to explore the possible effects of multiple Haskell WM, Lee I, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity
MWM treatments in generalized group with CAI. Furthermore, and public health: updated recommendation for adults from the American
College of Sports Medicine and the American Heart Association. Med Sci Sports
MWM would rarely be used in isolation in the clinical setting. Exerc 2007;39(8):1423e34.
MWM may prove to be more beneficial when combined with other Hertel J. Functional anatomy, pathomechanics, 30 and pathophysiology of lateral
manual therapy interventions or rehabilitation activities such as ankle instability. J Athletic Train 2002;37(4):364e75.
Hertel J. Sensorimotor deficits with ankle sprains and chronic ankle instability. Clin
balance and strength training for optimum treatment of individuals
Sports Med 2008;27(3):353e70.
with CAI and when examined using more rigorous study designs. Hiller CE, Nightingale EJ, Raymond J, Kilbreath SL, Burns J, Black DA, et al. Prevalence
Whitman et al. (2009) identified large magnitude improvements in and impact of chronic musculoskeletal ankle disorders in the community. Arch
self-reported function when applying multiple joint mobilization Phys Med Rehabil 2012;93(10):1801e7.
Hoch MC, Grindstaff TL. The effects of joint mobilization on individuals with chronic
techniques to acute ankle sprain patients. While this is a prospec- ankle instability: a review of the literature. Athletic Train Sports Health Care
tive direction for future research it is unclear which aspects of 2012;4(5):237e44.
treatment may be primarily responsible for potential benefits. Hoch MC, McKeon PO. The effectiveness of mobilization with movement at
improving dorsiflexion after ankle sprain. J Sport Rehabil 2010;19(2):226e32.
These limitations should be taken into context when interpreting Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural control
the results of this study. and range of motion in those with chronic ankle instability. J Orthopaedic Res
In conclusion, three treatments of MWM did not have a signif- 2011;29(3):326e32.
Hoch MC, Andreatta RD, Mullineaux DR, English RA, McKeon JM, Mattacola CG,
icant effect on dorsiflexion ROM, SEBT reach distances, or FAAM- et al. Two-week joint mobilization intervention improves self-reported func-
ADL scores. Despite these findings, statistically significant im- tion, range of motion, and dynamic balance in those with chronic ankle
provements were identified in FAAM-Sport scores; however, a level instability. J Orthopaedic Res 2012a;30(11):1798e804.
Hoch MC, Staton GS, McKeon JM, Mattacola CG, McKeon PO. Dorsiflexion and dy-
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did not surpass the previously established minimally clinically bility. J Sci Med Sport 2012b;15(6):574e9.
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Please cite this article in press as: Gilbreath JP, et al., The effects of Mobilization with Movement on dorsiflexion range of motion, dynamic
balance, and self-reported function in individuals with chronic ankle instability, Manual Therapy (2013), http://dx.doi.org/10.1016/