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Manipulation of the ankle joint

Manipulation of the Ankle Joint.
 
Now this will be a learning experience for all of us, except for maybe some chiros that follow the research or some professors that teach manipulation. For those of us that aren’t doing manipulations (or grade V mobilizations depending on the state that you live in) on a daily basis, this information is interesting. It will be a learning experience for me to type about it and I may not be able to give a strong background on the information, as I continue to learn about this type of information over time.
 
“Joint mobilization is delivered as a low-velocity sustained or oscillatory force, while joint manipulation is often defined as a hight-velocity thrust.”

 
For the most part this is true. Joint mobilizations are graded from I-V (Roman numerals like in Star Wars seems to provide more credibility than simply writing 1-5). Grade five is defined as the rapid thrust that is described in the manipulation aspect.
 
RANT: The APTA, in its white paper on mobilizations and manipulations, prefers that only PT’s perform these movements because students will become proficient in these movements through schooling. I call BS! I have only met one student in 8 years as a clinical instructor that could walk into the clinic and perform all of the manipulations without error. Most students have difficulty performing basic mobilizations. That’s okay, I am not judging the students (well really I am, as the CI, but I won’t knock the grade because they can’t perform the manipulations). The point is…most PT’s become proficient at the manual aspect of the profession outside of schooling. With all of that said, I don’t agree that PTA’s can’t perform mobilizations as a treatment, assuming the PT is there to assess prior and post manipulation. It is really arguing semantics, as it is not applicable in most situations.
 
“A number of researchers have demonstrated changes in the excitability of motor pathways following manipulation of the spine”.

 
When the article speaks of manipulations, the authors are describing the high velocity thrust technique. Performing these techniques causes changes in pain pressure threshold in some patients (think that you could tolerate more pain following the manipulation). In real world sense, it would theoretically require a greater stimulus to create the same pain that you felt prior to the manipulation. There is good work by Stephen (sp) George out of Florida regarding this concept.
 
“Existing research utilizing transcranial magnetic stimulation (TMS) has also indicated an increase in corticospinal motor excitability following manipulation to spinal joints, but not following low-velocity end-range positioning.”

 
I’ll be honest, I had to go look this one up. Neuro is not my strong point. I know that we have a brain…the end. Okay…I know a little bit more than that, but not much. I tended to fall asleep during the neuro portion of PT school and would dream about orthopedics. Oh well. Live and learn, it’s actually important.
 
http://bmcneurosci.biomedcentral.com/articles/10.1186/1471-2202-9-51
 
The basic of the article is that the brain dictates the muscle action. There’s that old saying that “if you see it, then you can be it”. It’s something like that. The brain can increase electrical input to a separate muscle group and the brain can shut down the impulse to muscle groups through imagery, but it can also happen through manipulations, as seen in the article that I am quoting.
 
“Measuring modulation of corticospinal excitability with active contraction is important, because such changes would suggest an alteration in voluntary recruitment”

 
This is big for me, as a meathead, because if I can get my brain to send out more electrical impulses, then I, as a meathead can theoretically lift more weight. That’s all that really matters. Unfortunately, there is not a lot of research on this in the PT world, so more to come later when our profession starts to look into athletic performance.
 
“Individuals in the control group received the hand placement used for a caudal talocrural thrust manipulation only…Individuals in the intervention groups received a caudal talocrural mobilization or thrust manipulation.”

 
I won’t describe the technique because… “Kids, don’t try this at home”. Just know that it is fairly easy to perform for someone with experience performing manipulations. The manipulation is performed at the foot/ankle complex.
 
“Our findings indicate that thrust manipulation increased corticospinal motor excitability of the tibialis anterior approximately 30 minutes following thrust manipulation directed at the talocrural joints…there was no significant change in ankle dorsiflexion or dynamic balance following either of the interventions”

 
Big picture…a manipulation may make you stronger at contracting a muscle, but there doesn’t appear to be functional carryover in this report. It is still big news because there may be other manipulations that not only make your stronger, but also has functional carryover. This will be the fountain of youth once found. A stronger person is a more functional person, assuming that the person has adequate ability to move.
 
Quotes from:
 
Fisher BE, Piraino A, Lee Y, et al. The Effect of Velocity of Joint Mobilization on Corticospinal Excitability in Individuals with a History of Ankle Sprain. JOSPT 2016;46(7):562-570.

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Categories: Physical therapy

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