The Effects of Posterior Talar Glide and Dorsiflexion of the Ankle Plus Mobilization with Movement on Balance and Gait Function in Patient with Chronic Stroke: A Randomized Controlled Trial

INTRODUCTION

Stroke is a disease involving disability caused by blockage of blood flow of cerebral vessel due to cerebrovascular, cardiac diseases, or cerebral tissue hemorrhage[1] and shows motor, cognitive, sensation, and speech dysfunction depending on the lesion site.[2] Among them, motor dysfunctions are skeletal muscle paralysis, spasticity like abnormal muscle tone, movement pattern, postural and equilibrium defect, and weight-shifting ability decrease, and these are caused by motor control ability malfunction.[3]

Ankle spasticity of stoke patient stiffens ankle joint by shortening plantar flexor and causes joint range of motion (ROM) decrease, joint movement resistance increase, and passive joint movement decrease to limit ankle joint movement.[4] Due to ankle movement limitation, weight-bearing of nonparalytic side increase, weight-shifting stability decrease, and postural sway increase as twice as much compared to normal.[5] Furthermore, decreased stable weight shift brings about not only loss of static balance but also dynamic balance problem and causes secondary problem such as fall.[6] Ankle joint movement controls effect of foot on ground to maintain gait and balance;[7] compensation is provoked during gait by balance problem, consequently consume much more energy than normal and become abnormal gait.[8] These balance and gait ability decrease of stroke act as instrumental activities of daily living factors to decrease independence as a result brings participation restriction on local community.[9]

To increase ankle function of stroke patient, ankle muscle strength training, functional electrical stimulation training,[10] elasticity band orthosis training,[11] proprioceptive control training,[12] and joint mobilization[13] are being conducted recently. Among those methods, joint mobilization helps regain motion-limited joints to increase ROM and it is usually applied for limited range of motion from musculoskeletal reasons.[14] However, application of joint mobilization on ankle of stoke patient increased ankle ROM and reduced required time for sit to stand; therefore, it was effective.[13]

Mulligan[15] modified joint mobilization for improvement of ankle joint movement and suggested weight-bearing-based mobilization with movement (WBBMWM); application of the mobilization on ankle sprain patient was effective on ankle ROM,[16] ROM sustainment time,[17] and single support time[18] during gait improvement.

However, only a few studies for clinical effects of WBBMWM have been reported. Therefore, the purpose of this study was to observe the effects of posterior talar glide, dorsiflexion of the ankle, mobilization with movement (MWM) on ROM of ankle joint, balance, and gait function in patients with chronic stroke.

METHODS

RESULTS

General characteristics of the remaining 30 participants with stroke who fulfilled the inclusion criteria for the study are summarized in Table 1. As shown in Table 1, Chi-square's results had no difference between WBBMWM and control group.

Table 1 Demographic data of groups (n=30)

The WBBMWM group showed a significant improvement in the WBLT, which increased from 3.20 cm before training to 5.80 cm after training (P = 0.000), a significant improvement in TUG, which decreased from 27.15 s before training to 21.78 s after training (P = 0.000), and a significant improvement in DGI, which increased from 15.40 score before training to 19.13 score after training (P = 0.000).

Moreover, the control group demonstrated significant improvement in the WBLT, which increased from 2.93 cm before training to 3.80 cm after training (P = 0.01), a significant improvement in TUG, which decreased from 24.60 s before training to 22.01 s after training (P = 0.002), and a significant improvement in DGI, which increased from 17.20 score before training to 19.40 score after training (P = 0.000). The WBBMWM group showed significantly greater improvements in WBLT, TUG, and DGI (P < 0.05) compared to the control group, which suggests that the WBBMWM techniques improves the ROM of ankle joint, balance, and gait function in patients recovering from stroke [Table 2].

Table 2 Comparison of range of motion and gait ability within and between the group (n=30)

The WBBMWM group showed a significant improvement in the postural sway path length with eyes open at the COP, which decreased from 43.42 cm before training to 37.71 cm after training (P = 0.000), a significant improvement in the postural sway speed with eyes open, which decreased from 2.89 cm/s before training to 2.51 cm/s after training (P = 0.000), a significant improvement in the postural sway path length with eyes closed, which decrease from 54.40 cm before training to 46.66 cm after training (P = 0.000), a significant improvement in the postural sway speed with eyes closed, which increased from 3.62 cm/s before training to 3.11 cm/s after training (P = 0.000). Moreover, the control group demonstrated significant improvement in the postural sway path length with eyes opened, which decreased from 41.47 cm to 38.46 cm after training (P = 0.003), a significant improvement in the postural sway speed with eyes open, which decreased from 2.74 cm/s to 2.56 cm/s after training (P = 0.000), a significant improvement in the postural sway path length with eyes closed, which decrease from 46.21 cm to 43.90 cm after training (P = 0.013), and a significant improvement in the postural sway speed with eyes closed, which increased from 3.08 cm/s to 2.92 cm/s after training (P = 0.013) [Table 3].

Table 3 Comparison of static balance ability within and between the group (n=30)

DISCUSSION

Active and passive movement restriction on ankle joint is a common disability for stroke patients.[4] Stroke patients have restricted ankle movement compared to normal.[26] These restrictions affect functional movements.[13] Sit to stand and move, gait, and climbing stairs need approximately 30 degrees of ankle joint ROM.[27]

This study measured WBLT to compare difference between before and after the ankle joint ROM training exercise. Weight-bearing-based joint mobilization were conducted for 4 weeks, 10 repetitions of 5 sets. As a result, experimental group had remarkable increase from 3.20 cm to 5.80 cm and control group had increased from 2.93 cm to 3.80 cm; thus, there was considerable difference between the two groups (P < 0.05).

Decrease of ankle joint dorsiflexion causes restriction of surrounding contractile and noncontractile tissues to interfere with ankle bone gliding.[28] Autonomically combined movement of posterior glide of ankle bone and dorsiflexion of ankle joint affects ankle joint. Ankle joint stretching exercise prevents joint contracture and increases joint ROM,[29] and intermuscle tension. It also stimulates Golgi tendon organs to provoke muscle relaxation, but inhibits muscle spasm; therefore, it is effective on lengthening muscle.[30] Joint mobilization increases flexibility and extensibility of noncontractile tissue surrounding talocrural articulation;[31] this increases additional movements of ankle joint.[13] Vicenzino et al.[21] defines that weight-bearing based joint mobilization is a type of a manual therapy technique which makes joint sliding consistently backward in ankle joint. Therefore, this study lengthens contractile tissues surrounding ankle joint by weight-bearing-based joint mobilization and posteriorly sliding ankle bone consistently through manual therapy. execution to increase additional movements, and ankle joint ROM through improvement of flexibility and extensibility in noncontractile tissues are considered.

In this study, TUG is used to measure difference between before and after the dynamic balance training, as a result of weight-bearing-based joint mobilization for 4 weeks 10 repetitions of 5 sets; experiment group had considerable decrease from 27.15 to 21.78 s which is 5.37 s difference and control group also had considerable decrease from 24.64 to 22.01 s which is 2.63 s; thus, there was remarkable difference between the two groups (P < 0.05).

Wu et al.[32] conducted soleus muscles stretching on standing posture for 12 chronic stroke patients, and experimental group's TUG had decrease from 33.7 to 29.1 s (P < 0.05). Shin and Lee (2014) divided the 22 chronic stroke patients to weight-bearing treadmill group and nonweight-bearing treadmill group. As a result, in weight-bearing treadmill group had considerable decrease from 26.57 to 12 s which is 14.56 s difference (P < 0.05); there was remarkable difference between the two groups (P < 0.05). This matches the results of advanced researches and stands for improvement of dynamic balance.

After stroke due to decrease of postural control and muscle weakness on lesion side body dissymmetry is shown,[33] limited ankle ROM decrease movement of center of gravity within the base of support therefore affects the balance.[34] Thus, ankle joint ROM is important to balance.[35] Joint mobilization on stroke patient shown improve of ankle joint ROM, and then, increase of ankle joint ROM improved speed of movement of tibia in ankle joint while standing up.[13] For these reasons, this study is to conduct weight-bearing-based joint mobilization which improves lesion side ankle joint ROM to decrease standing up time which is initiation; improvement of dynamic balance from improvement of dynamic balance is considered.

Gait improvement of stroke patient during function rehabilitation process is a main goal for both patient and therapist; reason is that gait can be an important matter for functional independence.[36] This study used DGI to measure the difference before and after the gait training. DGI is an assessment tool to measure risk of fall and functional safety.[37] In consequence of 4 weeks of 10 repetitions, 10 sets of weight-bearing-based joint mobilization, experimental group had considerable 3.73 score increase from 15.40 to 19.13, control group had 2.20 score increase from 17.20 to 19.40; thus, there was remarkable difference between the two groups (P < 0.05).

Weight-bearing training improves sensory information of lower extremity to improve stance period duration. Compensation due to restriction of dorsiflexion on ankle joint is especially shown during middle stance period.[3839] This restricted ROM interferes posterior glide of tibia during middle stance period, as a result initial stage of heel off strategy cause forward located body.[40] Furthermore, decrease of dorsiflexion on ankle joint causes reduction of weight load on rear-foot during stance period relatively fore-foot weight load increases which decrease ankle rocker during dorsiflexion of ankle joint,[41] during gait limited ankle joint ROM provoke compensation of fast heel off.[42] Yoon et al.[43] conducted weight-bearing-based joint mobilization and got improved in ankle joint ROM and heel off time which showed effectiveness on ankle rocking; Kang et al.[18] conducted weight-bearing-based joint mobilization and reported improvement of ankle joint ROM, heel off time, and dorsiflexion ROM before heel off during stance period.

For these reasons, it is considered that through weight-bearing trainings such as flatland walking and climbing up and down the stairs provoke activation of neuromuscular control of lower body cause gait improvement. Furthermore, applying joint mobilization improved ankle rocking by creating additional movement during stance period; consequently, it is considered that improvement of dorsiflexion ROM before heel off and ankle joint stability cause improvement of gait movement such as rotating using one foot as a pivot during gait, gait over obstacles, weight-bearing on one side, and pivoting.

CONCLUSION

In this study, WBMWM improved ROM of ankle joint, balance, and gait function in patients with chronic stroke. It is considered that through posterior talar glide and dorsiflexion of the ankle plus MWM improved dorsiflexion, ankle joint stability, and gait movement. Therefore, they are effective training methods for improvement of functional ability and might be used actively in a clinic.