Rajiv Gandhi University of Health Sciences

Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / ANUBHA VERMA
GARDEN CITY COLLEGE OF PHYSIOTHERAPY, 16th KM, OLD MADRAS ROAD,
VIRGONAGAR POST,
BANGALORE-49.
2. / NAME OF THE INSTITIUTION /

GARDEN CITY COLLEGE OF PHYSIOTHERAPY

3. / COURSE OF STUDY AND SUBJECT / MASTERS OF PHYSIOTHERAPY
(MUSCULOSKELETAL AND SPORTS )
4. / DATE OF ADMISSION TO COURSE / 26/09/2011
5. / TITLE OF THE TOPIC:
“ A STUDY TO COMPARE THE EFFECTIVENESS OF CRYOKINETICS AND
MULLIGAN’S MOBILIZATION WITH MOVEMENT (MWM) TECHNIQUE IN
ACUTE ANKLE INVERSION SPRAIN. “
BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY
Ankle sprain, typically ankle inversion injuries, are common orthopaedic conditions
frequently evaluated and treated by health care providers. The ankle is one of the most
common sites for acute musculoskeletal injuries and sprains accounts for 75 percent of ankle
injuries. Acute ankle trauma is responsible for 10 to 30 percent of sports-related injuries in
young athletes.1
Lateral ankle sprains are thought to be suffered by men and women at approximately the
same rates. However, one recent report suggests that female interscholastic and
intercollegiate basketball players have a 25% greater risk of incurring grade I ankle sprains
than their male counterparts. More than 23,000 ankle sprains have been estimated to occur
per day in the United States, which equates to one sprain per 10,000 people daily.2
Lateral ankle sprains most commonly occur due to excessive supination of the rearfoot about
an externally rotated lower leg soon after initial contact of the rearfoot during gait or landing
from a jump.2,3 Excessive inversion and internal rotation of the rearfoot, coupled with
external rotation of the lower leg, results in strain to the lateral ankle ligaments. If the strain
in any of the ligaments exceeds the tensile strength of the tissues, ligamentous damage
occurs. Increased plantar flexion at initial contact appears to increase the likelihood of
suffering a lateral ankle sprain.2
In addition to the immediate onset of pain, swelling and loss of joint motion, it has been
reported that in 15 – 73% of cases, chronic ankle instability (CAI) with recurrent sprains and
residual sensations of giving way may occur following lateral ankle sprain.4
Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II
injuries recover quickly with nonoperative management. There are lots of nonoperative
functional treatment programmes used. One of the conventional protocol includes use of
RICE (rest, ice, compression, elevation), a short period of immobilization and protection with
a tape or bandage. Interventions including early range of motion exercises, weight-bearing
and neuromuscular training exercises and Proprioceptive training exercises on a tilt board
after helps improve balance and neuromuscular control of the ankle.5
Cryokinetics is a combination of cold application and active exercises.6 The cold applications
decrease injury pain so that active exercise within a normal range of motion can begin
quickly after the initial injury, and rehabilitation is completed more quickly.7 Recent
evidence has suggested that the addition of exercise to ice application is more effective than
ice application alone after various soft tissue injuries, including acute ankle sprain.4,8
Mobilization with movement (MWM) is a class of manual therapy techniques that is widely
used in the management of musculoskeletal pain. It involves the manual application of a
sustained force to a joint while a concurrent movement of the joint is actively performed by
the patient (Mulligan, 1999). The success of the technique is contingent upon an immediate
relief of symptoms during its application.9,10
Ultrasound is used in the treatment of a wide variety of musculoskeletal disorders. It has been
used in the treatment of musculoskeletal conditions for many years. Based on these
experimental findings, ultrasound is used in physical therapy to relieve pain, reduce
swelling, and improve joint mobility in a wide variety of musculoskeletal disorders
including ankle sprains.11
Even though recent advances has suggested that cryokinetics is an effective treatment of
acute ankle sprain and clinical benefits such as immediate decrease in pain and an earlier
return to function are claimed to be the result from Mulligan’s mobilization with movement
(MWM) treatment approach but there is little substantial evidences to their effect. Inadequate
treatment of ankle sprains can lead to chronic problems such as decreased range of motion,
pain, and joint instability. The intent of this study is to find the suitable technique to
accelerate the improvement of the functional activity of the subjects with Acute Ankle
Sprain.
Hence, this study is an effort to find out the effectiveness of cryokinetics and Mulligan’s
mobilization with movement (MWM) in subjects with acute ankle sprain in improving their
functional abilities. And the significant difference in the effectiveness of the same.
6.2  REVIEW OF LITERATURE
1.  Joshua C. Dubin DC. et al (2010) have discussed normal anatomy and biomechanics of the foot and ankle, mechanisms that may result in a lateral ankle sprain or syndesmotic “high ankle” sprain, assessment and diagnostic procedures, and presents a treatment algorithm based on normal ligament healing principles.12
2.  Chris M Bleakley. et al (2010) have conducted a randomised controlled study of 120 subjects with an acute grade I or grade II ankle sprain. The Subjects were randomised under strict double-blind conditions to either a standard cryotherapy (intermittent ice applications with compression) or cryokinetic treatment group (intermittent ice applications with compression and therapeutic exercise). Primarily function was, assessed using the Lower Extremity Functional Scale (LEFS), additional outcomes included pain (10 cm Visual Analogue Scale), swelling (modified figure-of-eight method) and activity levels (activPAL™ physical activity monitor, PAL Technologies, Glasgow, UK). After baseline assessment subjects were followed up at 1, 2, 3 & 4 weeks post injury. They found that an accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.4,8
3.  Natalie Collins. et al (2004) have conducted a double-blind randomized controlled trial that
measured the initial effects of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in dorsiflexion occurred initially post-MWM (Fð2;26Þ ¼ 7:82; P ¼ 0:002), but no significant changes in pressure or thermal pain threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains.19
4. Carl G. Mattacola. et al (2002) conducted a study on Rehabilitation of the Ankle after
Acute Sprain or Chronic Instability to outline rehabilitation concepts that are applicable to
acute and chronic injury of the ankle, to provide evidence for current techniques used in the
rehabilitation of the ankle, and to describe a functional rehabilitation program that
progresses from basic to advanced, while taking into consideration empirical data from the
literature and clinical practice. He recommended early functional rehabilitation of the ankle
should include range-of-motion exercises and isometric and isotonic strength-training
exercises. In the intermediate stage of rehabilitation, a progression of proprioception-training
exercises should be incorporated. Although it is important to individualize each
rehabilitation program, this well-structured template for ankle rehabilitation can be adapted
as needed.13
5.  Auvo Kaikkonen. et al (2002) did a study to introduce and evaluate a standardized test protocol and scoring scale i.e. Kaikonnen Functional Scale (KFS) for evaluation of ankle injuries. After evaluation of 11 different functional ankle tests, questionnaire answers, and
results of clinical ankle examination, the final test protocol. The final total test score correlated significantly with the isokinetic strength results of the ankle, subjective opinion about the recovery, and subjective-functional assessment. The scale presented is recommended for studies evaluating functional recovery after ankle injury.14
6.  Toni Green. et al (2001) have conducted a study to investigate the effect of a specific joint
mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and
3 gait variables: stride speed (gait speed), step length, and single support time. Subjects.
Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the
lower limb entered the trial. Subjects were randomly assigned to 1 of 2 treatment groups.
The control group received a protocol of rest, ice, compression, and elevation (RICE). The
experimental group received the anteroposterior mobilization, using a force that avoided
incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups
were treated every second day for a maximum of 2 weeks and all subjects were given a
home program of continued RICE application. The results showed that the experimental
group required fewer treatment sessions than the control group to achieve full pain-free
dorsiflexion. The experimental group had greater improvement in range of movement before
and after each of the first 3 treatment sessions.15
7.  Katz J,Melzack R. (1999) conducted a study on Measurement of pain he included verbal and numeric self-rating scales, behavioral observation scales, and physiologic responses. The complex nature of the experience of pain suggests that measurements from these domains may not always show high concordance. Because pain is subjective, patients' self-reports provide the most valid measure of the experience. The VAS and the MPQ are probably the most frequently used self-rating instruments for the measurement of pain in clinical and research settings. It has been shown to be a valid and reliable measurement of pain with ratio-scaling properties and has recently been used in a clinical setting. Behavioral approaches to the measurement of pain also provide valuable data. Further development and refinement of pain measurement techniques will lead to increasingly accurate tools with greater predictive powers. 16
8.  O’Brien and Vicenzino. (1998) investigated the effect of a MWM for lateral ankle pain in 2
male patients following acute ankle sprain (2–3 days post-injury) using a single subject
design. Subject I underwent an ABAC protocol while subject II underwent a BABC
protocol, where ‘‘A’’ = no intervention period, ‘‘B’’ = intervention period, and ‘‘C’’ = post-
treatment return to sport period. The MWM treatment technique involved a sustained
posterior glide with cephalad inclination to the distal fibula, while the patient actively
inverted the ankle to the end of pain-free range with overpressure. Following treatment a
strapping tape was applied to replicate the effects of the posterior glide of the fibula. The
MWM produced immediate improvements in pain, range of motion and function within each
Treatment session, which accumulated over several (4) treatment sessions and was far
greater than the natural resolution over time as observed in the ‘‘A’’ phase of subject 1. The
authors speculated that the results may reflect the reduction of a positional fault at the
inferior tibiofibular joint.9
9.  M. Patrice Eiff et al (1994) have conducted a prospective trial at a military medical center to determine which treatment for first-time ankle sprains, early mobilization or immobilization, is more effective. Eighty-two patients with a lateral ankle sprain were randomly selected for one of two treatment groups. The Early Mobilization Group received an elastic wrap for 2 days followed by functional bracing for 8 days. Two days after injury, this group began weight bearing and an ankle rehabilitation program. Patients in the Immobilization Group were placed in a nonweight bearing plaster splint for 10 days followed by weight bearing and the same rehabilitation program. They conclude that in first-time lateral ankle sprains, although both immobilization and early mobilization prevent late residual symptoms and ankle instability, early mobilization allows earlier return to work and may be more comfortable for patients.17
10.  M. S. Yeung. et al (1994) have conducted a epidemiological study among three
categories of Hong Kong Chinese athletes: national teams, competitive athletes and
recreational athletes. This study shows that as much as 73% of all athletes had recurrent ankle sprain and 59% of these athletes had significant disability and residual symptoms which led to impairment of their athletic performance. This study indicates that a proper
approach towards injury prevention and a comprehensive rehabilitation programme are
required.18
6.3  OBJECTIVE OF THE STUDY
1.  To find out the effect of cryokinetics in subjects with acute ankle sprain in improving their functional abilities.
2.  To find out the effect of Mulligan’s Mobilization with Movement in subjects with acute ankle sprain in improving their functional abilities.
3.  To compare the effectiveness of cryokinetics over Mulligan’s Mobilization with Movement in improving the functional abilities of subjects with acute ankle sprain.
6.4 HYPOTHESIS
ALTERNATE HYPOTHESIS: There is a significant difference in the effectiveness of cryokinetics over Mulligan’s Mobilization with Movement techniques in the subjects with acute ankle sprain .
NULL HYPOTHESIS: There is a no significant difference in the effectiveness of cryokinetics over Mulligan’s Mobilization with Movement techniques in the subjects with acute ankle sprain .
MATERIALS AND METHODS:
7.1  SOURCE OF DATA.
Physiotherapy Department of ITI Hospital, Bangalore, Karnataka. And GCC Physio Care,
Virgo Nagar Post Bangalore – 560 049.
7.2. METHOD OF COLLECTING DATA
A routine method of evaluation to collect the pre and post therapy data will be used.
This will involve history, evaluation of pain and range of motion of dorsiflexion,
Inversion and functional activity.
The outcome measures are :
1.  Visual analogue scale[VAS] for pain.
2.  Kaikkonen Functional Scale for ankle functional activity.
Material:
1. Data collection sheet.
2. Ice Bag.
3. Towel.
4. Crepe Bandage 4inches to 6inches as required.
5. 35mm rigid strapping tape.
6. Universal goniometer
7.2.1 STUDY DESIGN:
This study is based on Experimental study design.
7.2.2 DURATION OF STUDY
The duration of the study will be approximately 1 year.
7.2.3 STATISTICAL TOOL
Unpaired t- test.
Chi-Square test
Repeated Measures ANOVA
7.2.4 SAMPLE SIZE
Thirty Subjects.
Group A - 15 subjects.
Group B - 15 subjects.
INCLUSION CRITERIA
1.  Subjects: Age 18 to 50 years of either gender