Manual Therapy xxx (2013) 1e6

Contents lists available at ScienceDirect

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, *
a
Department of Human Movement Science, College of Education, Old Dominion University, Norfolk, VA, USA
b
School of Physical Therapy and Athletic Training, College of Heath Sciences, Old Dominion University, Health Sciences Annex, RM 104A, Norfolk, VA 23539,
USA
c
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
Keywords:
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

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

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

http://dx.doi.org/10.1016/j.math.2013.10.001

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.math.2013.10.001
2 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6
arthrokinematics, degenerative changes to the cartilage of the
talocrural joint, and synovial changes. Functional impairments
consist of insufficiencies in proprioception, strength, neuromus-
cular control, and postural control (Hertel, 2002). It is likely that a
combination of mechanical and functional impairments result in
the decreased health-related quality of life, repetitive incidents of
the ankle giving way, and recurrent ankle sprains experienced by
individuals with CAI (Hertel, 2002; Arnold et al., 2011b). Exploring
the connection between mechanical and functional impairments
while evaluating the effects of clinical interventions may enhance
the current rehabilitation strategies for CAI.
Decreased dorsiflexion ROM is a common mechanical impair-
ment in individuals with CAI based on reports that 30e74% of in-
dividuals have at least a 5 deficit based on the contralateral limb
(Beazell et al., 2012; Wheeler et al., 2013). This ROM deficit is
thought to be linked to an anterior positional fault of the talus
(Wilkstrom and Hubbard, 2010), and/or restrictions in posterior
talar glide, which alter the arthrokinematic motions required to
achieve maximal dorsiflexion ROM (Denegar et al., 2002; Hoch and
Grindstaff, 2012). Individuals with CAI have demonstrated dorsi-
flexion deficits during jogging gait (Drewes et al., 2009) and deficits
in dynamic balance which were correlated to dorsiflexion ROM
impairments (Hoch et al., 2012b) which suggests ankle dorsiflexion
ROM impairments may have an impact on functional activity.
Therefore, dorsiflexion ROM should be a consideration when
treating patients with CAI.
To address impairments in dorsiflexion ROM which are arthro-
genic in nature, a manual therapy technique known as joint
mobilization has been utilized to increase the extensibility of
noncontractile joint structures (Vicenzino et al., 2006; Reid et al.,
2007; Hoch and McKeon, 2011). A joint mobilization technique of
interest is Mobilization with Movement (MWM) described by
Mulligan (1995). This technique is of interest because it attempts to
address arthrokinematic positional faults, which occur following
injury (Mulligan, 1995) by correcting the misaligned joint surfaces
using a passive mobilization combined with an active movement
which is a different theoretical approach compared to other joint
mobilization systems. Talocrural MWM for the purpose of
increasing dorsiflexion ROM is performed by applying a poster-
oanterior tibial glide over a weight-bearing fixed foot while the
patient actively moves into a dorsiflexed position to address an
anterior talar positional fault or restricted posterior talar glide
(Vicenzino et al., 2006). Increases in ankle dorsiflexion ROM have
been observed immediately following a single MWM treatment in
individuals with CAI (Vicenzino et al., 2006; Reid et al., 2007);
however, the effects of multiple treatments have not been
investigated.
A review of the evidence concluded that a single MWM treat-
ment was able to improve dorsiflexion ROM in individuals with a
history of ankle sprain (Hoch and McKeon, 2010). This review
recommended future studies should investigate interventions
performed over a number of sessions and use patient-centered
outcome assessments to evaluate the effectiveness of MWM
(Hoch and McKeon, 2010). Additionally, previous studies (Hoch 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
individuals with CAI. Exploring the effects of MWM on dorsiflexion
ROM, dynamic balance, and self-reported function would further
elucidate the possible interaction between mechanical impair-
ments, functional impairments, and disability in those with CAI and
broaden the clinical implications for using MWM for individuals
with this condition. Therefore, the purpose of this study was to
examine the effect of three MWM treatment sessions on weight-
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.math.2013.10.001
function in individuals with CAI. We hypothesized that there will
be significant increases in weight-bearing dorsiflexion ROM, SEBT
reach distances, and self-reported function following the
intervention.
2. Methods
This study was a within-subjects repeated measures design
consisting of a single cohort of individuals with chronic ankle
instability (CAI). Outcome measures were taken prior to and
following a 1-week talocrural MWM intervention. The independent
variable was time (baseline, pre-intervention, and post-
intervention measures) and the dependent variables included
weight-bearing dorsiflexion ROM, normalized SEBT reach dis-
tances, and self-reported function using the Foot and Ankle Ability
Measure (FAAM).
2.1. Participants
Eleven physically active participants, including five males and
six females volunteered to participate in this study (Table 1). Par-
ticipants were recruited from the University and surrounding
community by recruitment flyers and word of mouth. Participants
were included in the study if they had self-reported CAI, which was
defined as having a history of at least one ankle sprain, at least one
episode of giving away in the past three months, and a score of 25
or less on the Cumberland Ankle Instability Tool (CAIT) (Arnold
et al., 2011a) (Table 1). Participants also had to be physically
active which was defined as participating in vigorous physical ac-
tivity at least 20 min a day, three times a week (Haskell et al., 2007).
Participants were excluded if they had an injury to the lower ex-
tremity (ankle, knee, hip, or back) within the past three months or a
history of intra-articular surgery to the lower extremity within the
past year. Participants were also excluded if they had an ankle
sprain in the previous six weeks or any history of ankle surgery.
Episodes of “giving way” were not considered an injury for the
purposes of inclusion and exclusion criteria. In the event of bilateral
CAI, the limb with the lower CAIT score was considered the
involved limb for the purposes of this study. All participants read
and signed an informed consent document approved by the Uni-
versity’s Institutional Review Board. A power analysis was con-
ducted on the mean differences between pre- and post-ankle
dorsiflexion measurement following a single MWM treatment,
resulting in at least 8 participants needed for a statistical power of
0.50 with a 0.05 significance level (Reid et al., 2007). No dropouts
were experienced throughout the study.
2.2. Procedures
Participants reported to the laboratory on five separate occa-
sions over a two-week period. After being included into the study,
participants completed the first data collection session (baseline).
Following the baseline session, participants were instructed to
maintain normal physical activity and activities of daily living and
Table 1
Participant demographics.
Means
SD
Age (years) 21.5
2.2
Weight (kg) 83.9
15.6
Height (cm) 177.7
10.9
# Of ankle sprains 3.3
2.1
Episodes of giving away in previous 3 months 2.5
1.2
Cumberland Ankle Instability Tool score 17.5
4.2
 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6
report back to the laboratory in one week for the second data
collection session (pre-intervention). Immediately following the
pre-intervention session, participants received their first MWM
treatment and returned to the laboratory for two additional treat-
ments over the next week. Participants completed the third data
collection session (post-intervention) within 24e48 h following
the final MWM treatment. At each data collection session, each
participant’s self-reported function, dorsiflexion ROM, and dy-
namic balance were assessed in the aforementioned order on the
involved limb using the outcome assessments described below.
2.2.1. Dorsiflexion range of motion
Weight-bearing dorsiflexion ROM was measured using the
weight-bearing lunge test (WBLT). This assessment of dorsiflexion
ROM was used because it has demonstrated excellent reliability
(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-
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;
Hoch et al., 2012a). Using this technique, the participant was
barefoot and positioned with the great toe and heel on a tape
measure perpendicular to a wall. The participant was instructed to
lunge towards the wall, touch their knee to the wall, and keep their
heel in contact with the floor. The participant then moved away
from the wall in 1 cm increments until the heel no longer main-
tained contact with the floor or the knee was no longer able to
contact the wall. Maximal dorsiflexion was considered the greatest
distance between the great toe and wall (measured in centimeters)
when all conditions were satisfied (Hoch et al., 2012a). Past studies
have suggested that each centimeter of lunge distance represents
approximately 4 of dorsiflexion (Bennell et al., 1998; Konor et al.,
2012). Each participant performed a practice trial, followed by
three trials that were recorded, averaged, and used for statistical
analysis.
2.2.2. Dynamic balance
Dynamic balance was assessed using the anterior (ANT), post-
eromedial (PM) and posterolateral (PL) directions of the SEBT based
on the recommendation of Hertel (2008). These directions of the
SEBT are reported to have a test-retest reliability of 0.84e0.90
(Munro and Herrington, 2010), and MDC scores of 1.56e6.87% for
the anterior (ANT) direction, 3.36e8.15% for the posteromedial
(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).
2.2.3. Self-reported function
The FAAM is a patient-reported outcome that measures function
during activities of daily living (ADL) and sport-related activities.
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.math.2013.10.001
3
The FAAM-ADL consists of 21 items pertaining to ADL, whereas the
FAAM-Sport consists of 8-items pertaining to sport-specific tasks.
Each item is scored on a 0e4 point Likert scale which ranges from
“no difficulty” to “unable to do”. The score for these instruments
can range from 0 to 84 and 0e32 for the FAAM-ADL and FAAM-
Sport, respectively. For both subscales, lower scores are indicative
of greater levels of self-perceived functional loss. Both the FAAM-
ADL and Sport subscales have demonstrated good reliability
(Martin et al., 2005) and have successfully detected functional loss
in collegiate athletes with CAI (Carcia et al., 2008). The minimal
detectable change (MDC) and minimal clinically important differ-
ence (MCID) for the FAAM-ADL are reported as 5.7 and 8 points,
with 12.3 and 9 points for the FAAM-Sport (Martin et al., 2005). The
FAAM-ADL and FAAM-Sport score obtained from each data collec-
tion were used for statistical analysis.
2.3. Mobilization with Movement intervention
The MWM intervention was administered by an athletic trainer
with 2 years of experience (JPG). To administer the MWM treat-
ment, the participant assumed a kneeling lunge position on a
treatment plinth with the involved limb in a weight-bearing stance
and the foot in a neutral position (Fig. 1). A non-elastic nylon belt
with padding was placed around the distal aspect of the tibia and
fibula, level with the inferior margin of the medial malleolus, and
around the waist of the clinician (Reid et al., 2007). The clinician
stabilized the talus and forefoot by applying pressure with the web
space of the hands on the anterior talus and forefoot. The clinician
applied anterior-to-posterior pressure on the talus and a posterior-
to-anterior glide of the tibia over the talus using the belt. The
clinician continued applying pressure as the participant slowly
moved into dorsiflexion until discomfort was reported and/or the
end ROM occurred (Collins et al., 2004). This position and pressure
was held for 30 s before returning to the neutral kneeling position.
Each treatment consisted of two sets of four repetitions, separated
by 1 min of rest, modified from Vicenzino et al. (2006). Therefore, a
total of 4 min of MWM was administered at each of the 3 treatment
sessions. The MWM intervention was administered within one
week having at least 24 h between each session. No other treat-
ments or interventions were applied by the investigators during
the study period. Participant compliance was 100% over the course
of the study.
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
foot to create a posterior-to-anterior glide of the tibia over the talus. The participant
was positioned in a kneeling-lunge position with the involved limb in a weight-
bearing, dorsiflexed stance position.
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
change
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
a
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.math.2013.10.001
 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6
a later time. Therefore, the underlying arthrokinematic changes
associated with CAI and following MWM require further
investigation.
Another possibility for the inconsistency between the findings
of the current study and previous studies implementing MWM for
individuals with CAI may be in the participant inclusion criteria.
Both Vicenzino et al. (2006) and Reid et al. (2007) used an arbitrary
value of a 2 cm dorsiflexion deficit on the weight bearing lunge test
as part of the inclusion criteria. In the current study, we elected not
to use this inclusion criteria because this was an exploratory study;
particularly given the pre-experimental design, and the effects of
joint mobilization have demonstrated implications beyond
improving range of motion that may be beneficial for individuals
with a history of ankle sprain such as improvements in static and
dynamic balance, increased self-reported function, increased
muscle activation, and decreased pain (Cosby et al., 2011; Grindstaff
et al., 2011; Hoch and McKeon, 2011; Hoch et al., 2012a). The recent
investigation by Hoch et al. (2012a) used similar inclusion methods
and study design and detected moderate-to-large treatment effects
for dorsiflexion ROM, SEBT reach distances, and self-reported
function following six Maitland Grade III treatment sessions in 12
individuals with CAI. Furthermore, while a dorsiflexion deficit was
not used as part of inclusion, the mean weight-bearing lunge dis-
tance for this sample of participants was approximately
7.5
2.5 cm. This mean and standard deviation are less than or
similar to the values reported for CAI participants by Reid et al.
(2007) (13.3
3.5 cm), Hoch et al. (2012a) (10.8
3.8 cm), and
Plante and Wikstrom (2012) (7.8
4.3 cm) and less than healthy
participant values reported by Bennell et al. (1998) (13.8
3.7 cm),
Hoch et al. (2012b) (12.5
2.5 cm), Konor et al. (2012)
(9.5
3.1 cm), and Plante and Wikstrom (2012) (11.0
2.9 cm).
Therefore, we believe many of the participants in this study did
demonstrate dorsiflexion ROM restrictions when compared to
previously established values. However, from our data we cannot
determine the presence of talar positional faults. The known
presence of talar malpositioning may be a better indicator of who
will benefit from MWM. Currently, it is unclear if patients with CAI
that exhibit certain levels of dorsiflexion deficit or particular
arthrokinematic impairments will benefit most from joint mobili-
zation treatments. Future research is needed to determine if a
subset of individuals with CAI will benefit the most from joint
mobilization treatments.
It was also hypothesized that the MWM intervention would
improve dynamic postural control. However, no significant differ-
ences were detected in the normalized reach distances of the three
directions of the SEBT. The lack of improvement in the SEBT reach
distances especially in the anterior direction was not surprising
because changes in this reach direction are likely related to dorsi-
flexion ROM which did not change in this study (Hoch et al., 2012a).
In comparison to the SEBT MDC scores established in this study as
well as previous studies (Munro and Herrington, 2010; Hoch et al.,
2012a), our observed changes between pre- and post-intervention
measures yielded much lower percentages of change. While a
recent study (Hoch et al., 2012a) which implemented multiple
treatment sessions of Maitland Grade III anterior-to-posterior
talocrural glides has identified improvements in SEBT perfor-
mance, further investigation is required to determine if such im-
provements can be produced following MWM.
Lastly, no significant improvements were reported on the
FAAM-ADL although significant improvements were reported on
the FAAM-Sport following the intervention. This indicates that
MWM may have created perceived functional improvements in
sport activities that were not captured by the clinical measures
included in this study. Although there was a statistically significant
improvement in FAAM-Sport scores, these improvements should
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.math.2013.10.001
5
be interpreted with caution because although the post-
intervention change scores did surpass the MDC established in
this study they did not surpass the minimally clinically important
difference score previously established for this instrument (Martin
et al., 2005). This indicates that a change was identified which
surpassed the error associated with the FAAM-Sport instrument
but it might not yet have a meaningful clinical impact. Although
caution should be exercised when interpreting these changes in
FAAM-Sport scores, the effect sizes accompanying these changes
were moderate-to-strong (0.58e0.90) suggesting these findings
should not be automatically dismissed because changes in sport
function may be present. The lack of change in the FAAM-ADL
suggests the timeframe of the study may not have been long
enough to impact ADLs, the intervention may not have adequately
addressed ADLs, or the level of function exhibited by these partic-
ipants did not enable much improvement to be attained because
FAAM-ADL scores are often greater than FAAM-Sport scores.
Potentially examining changes in landing, cutting, or other sport-
related activities following MWM in future studies may elucidate
some of the improvements reported on the FAAM-Sport. This is
supported by a recent study which incorporated talocrural MWM
along with talar glide and distal tibiofibular mobilizations within a
single treatment session and identified increases in dorsiflexion
ROM at initial contact of jump landing in participants with CAI
(Delahunt et al., 2013).
This study has several limitations which support the need for
additional research in the field. First, the inclusion criteria did not
require participants to have specific impairments in dorsiflexion
ROM or ankle arthrokinematics. Including participants with a
dorsiflexion deficit or restricted posterior glide (Vicenzino et al.,
2006; Reid et al., 2007) may elicit different results. While previ-
ous studies have identified individuals with unilateral dorsiflexion
ROM deficits, the ROM observed by the participants in the current
study were less than previous joint mobilization studies and
healthy values reported in the literature. This study also included a
small sample size with individuals who were not actively seeking
treatment. It should be taken into consideration that the treatment
effect sizes for dorsiflexion and dynamic balance were weak
(<0.22) and an unfeasible sample size (82e173) would have been
required to achieve statistically significant improvements with a
power of 0.50. While this underscores that this study was under-
powered, it also demonstrates that the MWM intervention did not
generate clinically meaningful changes in dorsiflexion or dynamic
balance. Including the number of subjects needed to achieve sta-
tistical significance would overcome the weak effect sizes but the
clinical relevance of the findings could be questionable. Also, a
previous study (Hoch et al., 2012a) used 12 subjects with similar
inclusion criteria, study design, and dependent variables and ach-
ieved both statistically significant and clinically relevant findings
following a joint mobilization intervention. Future research should
seek to establish a clinical prediction rule to determine the in-
dividuals with CAI who will most likely to benefit from joint
mobilization interventions.
Currently, there is little evidence on the appropriate treatment
parameters for MWM treatments. Hoch et al. (2012a) applied
Maitland Grade III talocrural joint mobilizations during six treat-
ment sessions and found significant increases in ROM, dynamic
balance, and self-reported function while another study by Beazell
et al. (2012) applied high velocity low amplitude thrusts to the
distal fibula during four treatment sessions and found no im-
provements in weight-bearing dorsiflexion ROM or FAAM-Sport
scores. Potentially three MWM treatment sessions were not
enough to produce lasting effects in individuals with CAI. Addi-
tionally, the pressure applied during the MWM should also be
taken into consideration. Reid et al. (2007) used biofeedback in
6 J.P. Gilbreath et al. / Manual Therapy xxx (2013) 1e6
order to gauge the same application across participants. While the
same investigator applied all MWM treatments in this investiga-
tion, the pressure and consistency of pressure is unknown and may
be directly related to treatment outcomes (Silvernail et al., 2011).
Examining the effect of treatment volumes, frequency, and force
application along with comparing the effects of different in-
terventions may provide clearer recommendations for clinically
implementing joint mobilization treatments.
Finally, this study implemented a within-subjects repeated
baseline design rather than including a control group. Also, the
same investigator applied the MWM treatments and recorded the
outcome assessments indicating a lack of blinding. We selected this
pre-experimental design to explore the possible effects of multiple
MWM treatments in generalized group with CAI. Furthermore,
MWM would rarely be used in isolation in the clinical setting.
MWM may prove to be more beneficial when combined with other
manual therapy interventions or rehabilitation activities such as
balance and strength training for optimum treatment of individuals
with CAI and when examined using more rigorous study designs.
Whitman et al. (2009) identified large magnitude improvements in
self-reported function when applying multiple joint mobilization
techniques to acute ankle sprain patients. While this is a prospec-
tive direction for future research it is unclear which aspects of
treatment may be primarily responsible for potential benefits.
These limitations should be taken into context when interpreting
the results of this study.
In conclusion, three treatments of MWM did not have a signif-
icant effect on dorsiflexion ROM, SEBT reach distances, or FAAM-
ADL scores. Despite these findings, statistically significant im-
provements were identified in FAAM-Sport scores; however, a level
of caution should be used when interpreting these changes as they
did not surpass the previously established minimally clinically
important difference score for this measure. Further research is
needed to determine the effects of MWM, the effects of MWM in
combination with other interventions, and individuals with CAI
who may respond more favorably to this intervention.
References
Anandocoomarasary A, Barnsley L. Long term outcomes of inversion ankle injuries.
Br J Sports Med 2005;39:e14.
Arnold BL, Wright CJ, Linens SW, Ross SE. Recalibration of the CAIT cutoff score for
chronic ankle instability. Med Sci Sports Exerc 2011a;43(5):497.
Arnold BL, Wright CJ, Ross SE. Functional ankle instability and health-related quality
of life. J Athletic Train 2011b;46(6):634e41.
Beaton DE, Bombardier C, Katz JN, Wright JG. A taxonomy for responsiveness. J Clin
Epidemiol 2001;54(12):1204e17.
Beazell JR, Grindstaff TL, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Effects of a
proximal or distal tibiofibular joint manipulation on ankle range of motion and
functional outcomes in individuals with chronic ankle instability. J Orthopaedic
Sports Phys Ther 2012;42(2):125e34.
Bennell K, Talbot R, Wajswelner H, Techovanich W, Kelly D, Hall A. Intra-rater and
inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion.
Aust J Physiother 1998;44(3):175e80.
Carcia CR, Martin RL, Drouin JM. Validity of the foot and ankle ability measure in
athletes with chronic ankle instability. J Athletic Train 2008;43(2):179e83.
Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with
movement technique of dorsiflexion and pain in subacute ankle sprains. Man
Ther 2004;9(2):77e82.
Cosby NL, Hertel J. Relationships between measures of posterior talar glide and
ankle dorsiflexion range of motion. Athletic Train Sports Health Care 2011;3(2):
76e85.
Cosby NL, Koroch M, Grindstaff TL, Parente W, Hertel J. Immediate effects of pos-
terior talocrural joint mobilizations following acute lateral ankle sprain. J Man
Manipulative Ther 2011;19(2):76e83.
Croy T, Cosby N, Hertel J. Active ankle motion may result in an anterior talar po-
sition fault in ankle injury subjects: a preliminary study. J Orthopaedic Sports
Phys Ther 2013;43(3):A19.
Delahunt E, Cusack K, Wilson L, Doherty C. Joint mobilization acutely improves
landing kinematics in chronic ankle instability. Med Sci Sports Exerc
2013;45(3):514e9.
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.math.2013.10.001
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
Ther 2002;32(4):166e73.
Drewes LK, McKeon PO, Kerrigan DC, Hertel J. Dorsiflexion deficit during jogging
with chronic ankle instability. J Sci Med Sport 2009;12(6):685e7.
Gribble PA, Hertel J. Considerations for normalizing measures of the star excursion
balance test. Meas Phys Education Exerc Sci 2003;7(2):89e100.
Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dy-
namic postural-control deficits and outcomes in lower extremity injury: a
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
dynamic postural control. J Sports Rehabil 2009;18(2):240e57.
Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. Immediate
effects of a tibiofibular joint manipulation on lower extremity H-reflex mea-
surements in individuals with chronic ankle instability. J Electromyogr Kinesiol
2011;21(4):652e8.
Haskell WM, Lee I, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity
and public health: updated recommendation for adults from the American
College of Sports Medicine and the American Heart Association. Med Sci Sports
Exerc 2007;39(8):1423e34.
Hertel J. Functional anatomy, pathomechanics, 30 and pathophysiology of lateral
ankle instability. J Athletic Train 2002;37(4):364e75.
Hertel J. Sensorimotor deficits with ankle sprains and chronic ankle instability. Clin
Sports Med 2008;27(3):353e70.
Hiller CE, Nightingale EJ, Raymond J, Kilbreath SL, Burns J, Black DA, et al. Prevalence
and impact of chronic musculoskeletal ankle disorders in the community. Arch
Phys Med Rehabil 2012;93(10):1801e7.
Hoch MC, Grindstaff TL. The effects of joint mobilization on individuals with chronic
ankle instability: a review of the literature. Athletic Train Sports Health Care
2012;4(5):237e44.
Hoch MC, McKeon PO. The effectiveness of mobilization with movement at
improving dorsiflexion after ankle sprain. J Sport Rehabil 2010;19(2):226e32.
Hoch MC, McKeon PO. Joint mobilization improves spatiotemporal postural control
and range of motion in those with chronic ankle instability. J Orthopaedic Res
2011;29(3):326e32.
Hoch MC, Andreatta RD, Mullineaux DR, English RA, McKeon JM, Mattacola CG,
et al. Two-week joint mobilization intervention improves self-reported func-
tion, range of motion, and dynamic balance in those with chronic ankle
instability. J Orthopaedic Res 2012a;30(11):1798e804.
Hoch MC, Staton GS, McKeon JM, Mattacola CG, McKeon PO. Dorsiflexion and dy-
namic postural control deficits are present in those with chronic ankle insta-
bility. J Sci Med Sport 2012b;15(6):574e9.
Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of
ankle dorsiflexion range of motion. Int J Sports Phys Ther 2012;7(3):279e87.
Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of
validity for the foot and ankle ability measure (FAAM). Foot Ankle Int
2005;26(11):968e83.
Mulligan BR. Manual Therapy: NAGS, SNAGS, MWM, etc. Wellington, New Zealand:
Plane View Services Ltd; 1995.
Munro AG, Herrington LC. Between-session reliability of the star excursion balance
test. Phys Ther Sports 2010;11(4):128e32.
Plante JE, Wikstrom EA. Differences in clinician-oriented outcomes among controls,
copers, and chronic ankle instability groups. Phys Ther Sport. http://dx.doi.org/
10.1016/jptsp.2012.09.005; 2012.
Reid A, Birmingham TB, Alcock G. Efficacy of mobilization with movement for pa-
tients with limited dorsiflexion after ankle sprain: a crossover trial. Physiother
Can 2007;59(3):166e72.
Silvernail JL, Gill NW, Teyhen DS, Allison SC. Biomechanical measures of knee joint
mobilization. J Man Manipulative Ther 2011;19(3):162e71.
Valderrabano V, Hintermann B, Horisberger M, Fung TS. Ligamentous posttraumatic
ankle osteoarthritis. Am J Sports Med 2006;34(4):612e20.
Verhagen RAW, Keizer GD, Dijk CV. Long-term follow-up of inversion trauma of the
ankle. Arch Orthopaedic Trauma Surg 1995;114(2):92e6.
Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar
glide and dorsiflexion of the ankle after mobilization with movement in
individuals with recurrent ankle sprain. J Orthopaedic Sports Phys Ther
2006;36(7):464e71.
Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ. The epidemiology of
ankle sprains in the United States. J Bone Joint Surg 2010;92(13):2279e84.
Wheeler TJ, Basnett CR, Hanish MJ, Miriovsky DJ, Danielson EJ, Barr JB, et al. Fibular
taping does not influence ankle dorsiflexion range of motion or balance mea-
sures in individuals with chronic ankle instability. J Sci Med Sport. http://dx.doi.
org/10.1016/j.jsams.2013.02.012; 2013.
Whitman JM, Cleland JA, Mintken P, Keirns M, Bieniek ML, Albin SR, et al. Predicting
short-term response to thrust and nonthrust manipulation and exercise in
patients post inversion ankle sprain. J Orthopaedic Sports Phys Ther
2009;39(3):188e200.
Wikstrom EA, Hubbard TJ. Talar positional fault in persons with chronic ankle
instability. Arch Phys Med Rehabil 2010;91(8):267e71.
Wyrwich KW, Tierney WM, Wolinsky FD. Further evidence supporting an SEM-
based criterion for identifying meaningful intra-individual changes in health-
related quality of life. J Clin Epidemiol 1999;52(9):861e73.