The 2021 study by Nguyen et.al., “Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial” (HERE) demonstrated that Mobilization with Movement (MWM) can quickly and effectively increase ROM and function for subacute lateral ankle sprains in a little as 3 visits.
MWM manual therapy techniques involve passive accessory forces applied by a therapist, combined with active movement of the patient. MWM’s are always pain-free and are only used on ‘responders’. This means that if the technique is painful, it would not be used and the patient would be considered a ‘non-responder’.
Why is this study design important?
Before diving into the results, let's take a moment to appreciate the significance of this type of study.
The challenge of applying up-to-date evidence-informed care in the clinic is an ongoing struggle for busy clinicians. This topic was highlighted in a recent 2021 open-access editorial in the Journal of Manual and Manipulative Therapy (HERE). Manual therapy thought leaders made 7 recommendations for shaping the 'next steps' in orthopedic manual therapy research. One recommendation was the need for more pragmatic (effectiveness) randomized study designs.
Pragmatic research study designs focus on how an intervention performs under 'real-world' conditions. In other words, how can a busy clinician better apply evidenced-informed care? This is in contrast to interventions/treatments recommended from a traditional efficacy research study in which the trial was performed in an ideal/controlled environment. (HERE)
The pragmatic design of Nguyen et.al. 2021 is at the cutting edge of where research is headed and should be encouraging for all who use manual therapy as part of a multimodal plan of care.
The study examined an individual's response to Mobilization with Movement (MWM) for increasing pain-free dorsiflexion in subacute lateral ankle sprains. Instead of only studying one technique to treat the ankle, the pragmatic design allowed researchers flexibility to look for ‘responders’ to a variety of MWM techniques while determining the effectiveness of MWM’s compared to sham treatment for ROM and function.
The study consisted of 3 treatment sessions with measurements taken before and after each session.
Highlights from this study include:
- 84% of the participants with subacute lateral ankle sprains were ‘responders’ to an MWM technique for immediately improving pain-free dorsiflexion ROM and function on the Y-Balance Test.
- Responders were found with MWM techniques targeting the tibiofibular joint (58%), talocrural joint (33%), and cubometatarsal joint (4%). This suggests not all ankle sprains respond the same to MWM!
- The study further highlighted that being a ‘non-responder’ on the first treatment, did not mean that the individual would not be a responder on the next treatment. Several test subjects became ‘responders’ to MWM on the 2nd and 3rd sessions.
- 16% of all subacute ankle sprains were not appropriate for MWM. This potentially helps sub-group a population who may respond best to exercise and education without MWM manual therapy.
It could be argued that identifying responders to manual therapy, especially manual therapy that is pain-free and provides immediate results in ROM and function, is one of the best methods to treat subacute lateral ankle pain.
Being able to determine who is, and who is not, appropriate for manual therapy is more important than ever. Manual therapy is not for everyone. Though being able to apply hands-on care to ‘responders’ may be an important key to quickly restoring ROM and function for subacute lateral ankle sprains.
Check out an upcoming Lower Quarter Mulligan Concept course if you are interested in learning how to provide MWM safely and effectively for ankle sprains. It will change your practice for the better!