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.

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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