Rajiv Gandhi University of Health Sciences, Karnataka



Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore

Annexure II

| | |KRISHNA PD NEPAL |

|1. |Name of the Candidate and Address (in block letters) |DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY, VIDYANAGAR, KULOOR , |

| | |MANGALORE-575013 |

| | | |

|2. |Name of the Institution |DR.M.V.SHETTY COLLEGE OF |

| | |PHYSIOTHERAPY |

| | | |

|3. |Course of Study and Subject |MASTERS OF PHYSIOTHERAPY (MPT) |

| | |MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY |

| | | |

|4. |Date of Admission to Course |18th JUNE 2009 |

| | |“COMPARATIVE STUDY ON EFFECTIVENESS OF MULLIGAN’S MOBILISATION WITH MOVEMENT |

|5. |Title of the Topic |WITH LOW LEVEL LASER THERAPY AND MULLIGAN’S MOBILISATION WITH MOVEMENT ALONE |

| | |IN PATIENT WITH CHRONIC ANKLE SPRAIN” |

|6. |BRIEF RESUME OF THE INTENDED WORK |

| | |

| |6.1) Introduction and Need of the Study: |

| | |

| |It is estimated that there is one inversion injury occurring per 10,000 persons per day1. Ankle inversion sprains occur frequently in sports, |

| |predominantly in athletes participating in running and jumping sports. The acute injury consists of damage to the lateral ligament and results |

| |in pain, swelling, and limitation of movement. The inability to dorsiflex is thought to be indicative of a severe injury and is often a |

| |complication of these injuries on follow-up. Restriction of dorsiflexion would normally be expected to limit gait and other functional |

| |activities. People with acute ankle sprains walk slowly and take smaller steps2. |

| | |

| | |

| |The lateral ligament complex of the ankle, described as the body’s ‘‘most frequently injured single structure’’ is mechanically vulnerable to |

| |sprain injury. At extremes of plantarflexion and inversion, influenced by the shorter medial aspect of the ankle mortise, the relatively weak |

| |anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are prone to varying grades of rupture, often via minimal force. The |

| |presence of a dorsiflexion deficit not only in the acute stage, but also in the subacute stage3. |

| |A non-operative 'functional treatment' program includes immediate use of RICE (rest, ice, compression, elevation), a short period of |

| |immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. |

| |Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle4. |

| | |

| |Manipulative technique like MULLIGAN’S Movement With Mobilisation and modality like laser proved effective in the treatment of ankle sprain. |

| | |

| |Need of the study: |

| |Many researchers have used different modalities like ultrasound, TENS, Low frequency Stimulator, IFT, SWD along with mulligan’s mobilization |

| |has been used at various stages of ankle sprain. The recent evidence available in the literature shows laser to be a very effective form of |

| |electrotherapeutic intervention in relieving pain when compared to other form of modalities in the treatment of ankle sprain. There is lack of |

| |evidence on treatment of ankle by low level laser combined with Mulligan’s Mobilisation, therefore the present study is done to check the |

| |efficacy of combined effect of Mulligan’s mobilization with low level laser therapy in treatment of chronic ankle sprain. |

| | |

| |Research Question: |

| | |

| |Will there be any significant difference between the subjects treated with Mulligan’s Mobilization with Low Level Laser Therapy and Mulligan’s |

| |Mobilization alone in the treatment of chronic ankle sprain. |

| | |

| |Hypothesis: |

| | |

| |Null hypothesis: |

| | |

| |There will be no significant difference between the subjects treated with Mulligan’s Mobilization with Low Level Laser Therapy and Mulligan’s |

| |Mobilization alone in the treatment of chronic ankle sprain. |

| | |

| |Alternate hypothesis: |

| | |

| |There will be significant difference between the subjects treated with Mulligan’s Mobilization with Low Level Laser Therapy and Mulligan’s |

| |Mobilization alone in the treatment of chronic ankle sprain. |

| | |

| | |

| |6.2) REVIEW OF LITERATURE: |

| | |

| |Natalie Collins, Pamela Teys, Bill Vicenzino(2004) examined subjects with subacute grade II lateral ankle spains in order to check whether |

| |Mulligan’s mobilization with movement (MWM) technique improves talocrural dorsiflexion and relieves pain. They found significant improvements |

| |in dorsiflexion initially but no significant changes in pressure or thermal pain threshold. They concluded that MWM treatment for ankle |

| |dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains3. |

| | |

| |Stergioulas A (2004) conducted a comparative study of three therapeutic protocols in treating edema in second degree ankle sprain and concluded|

| |that low level laser treatment combined with RICE is effective in treating edema in second degree ankle sprain5. |

| |V. Thoms and K. Rome(1997) did a study to compare the intratester reliability of goniometry for measurements of active ankle joint |

| |dorsiflexion (AJDF) using supine, prone (knee extended) and sitting (knee flexed) position and concluded that there were significant |

| |differences between prone and sitting and supine and sitting positions6 |

| |Price DD, McGrath PA, Rafii A, Buckingham B(1983) did a study regarding the validation of visual analogue scales as ratio scale measures for |

| |chronic and experimental pain. VAS sensory intensity responses to experimental pain, VAS sensory intensity responses to different levels of |

| |chronic pain, and direct temperature (experimental pain) matches to 3 levels of chronic pain were all internally consistent, thereby |

| |demonstrating the valid use of VAS for the measurement of and comparison between chronic pain and experimental heat pain7. |

| |Auvo Kaikkonen, Pekka Kannus, Markku Järvinen, (1994) did a study to introduce and evaluated a standardized test protocol and scoring scale |

| |for evaluation of ankle injuries. 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 injury8. |

| | |

| |Judith F. Baumhauer, Denise M. Alosa, Per A. F. H. Renström,et al (1995) did a study to examine injury risk factors prospectively and |

| |determine if an abnormality in any one or a combination of factors identifies an individual, or an ankle, at risk for subsequent inversion |

| |ankle injury and concluded that individuals with a muscle strength imbalance as measured by an elevated eversion-to-inversion ratio exhibited a|

| |higher incidence of inversion ankle sprains9. |

| | |

| |Boonstra, Anne M.; Schiphorst Preuper, Henrica R.; Reneman, Michiel F et al (2008) did a study to determine the Reliability and validity of |

| |the visual analogue scale for disability in patients with chronic musculoskeletal pain and they concluded that reliability of the VAS for |

| |disability is moderate to good and a strong correlation with the VAS for pain10 |

| | |

| | |

| |Claudia Venturni, Alex André, Bruna Prates Aguilar, Bruno Giacomelli(2006). Conducted a study on the reliability of two evaluation methods of |

| |active range of motion in the ankle of healthy individual and concluded that there is big reliability to the measures of digital inclinometer |

| |when compare with universal goniometry11. |

| | |

| |Mary Paul Clapper and Steven L. Wolf (1988) did a study to determine 1) the reliability of the Orthoranger for assessing active lower extremity|

| |joint range of motion, 2) specific methods for applying the Orthoranger, and 3) whether a correlation exists between the measurements obtained |

| |with the Orthoranger and those obtained with a standard goniometer and they found that both instruments were reliable for assessing active |

| |lower extremity joint ROM12. |

| | |

| |6.3) OBJECTIVES OF STUDY: |

| | |

| |To find out the efficacy of Mulligan Mobilization in reducing pain and improving function in subject with chronic ankle sprain. |

| |To find out the efficacy of Low level laser therapy in reducing pain and improving function in subjects with chronic ankle sprain. |

| |To compare the efficacy of Mulligan Mobilization with Low level laser therapy and Mulligan Mobilization alone in reducing pain and improving |

| |function in subjects with chronic ankle sprain. |

| | |

| |MATERIALS AND METHODOLOGY: |

| | |

| |7.1) STUDY DESIGN: |

| | |

| |Comparative study |

| | |

| |7.2) SOURCE OF DATA: |

| |50 symptomatic patients based on the inclusive criteria aged between 18-45 yrs from Dr. M .V. Shetty Surgical Nursing home and Govt. Wenlock |

| |Hospital will be taken for this study. |

| | |

| |7.2(I) Definition of Study Subjects: |

| | |

| |50 symptomatic subjects in the age group of 18-45 yrs will be divided into two groups of 25 subjects in each groups will be recruited for this |

| |study. |

| | |

| |7.2(II) Inclusion and Exclusion Criteria: |

| | |

| |INCLUSION CRITERIA: |

| | |

| |1) Symptomatic subjects aged 18-45 yrs. |

| |2) Both sexes. |

| |3) Diagnosed cases of grade II lateral ligaments injury of ankle. |

| |4) 1 month duration following ankle sprain. |

| | |

| | |

| | |

| | |

| |EXCLUSION CRITERIA: |

| | |

| |1) Grade III lateral ligament injury of ankle. |

| |2) Recent fracture and deformity eg. Bimalleolar fracture. |

| |3) Patients who are under analgesics or anti inflammatory medicines. |

| |4) Repeated lateral ligament sprain. |

| |5) Bilateral ankle sprain. |

| |6) Presence of severe vascular disease. |

| | |

| |7.2(III) Study, Sampling Design, Method and Size: |

| | |

| |SAMPLE DESIGN |

| | |

| |Purposive random sampling design |

| | |

| |SAMPLE – SIZE: |

| | |

| |50 subjects fulfilling the inclusion and exclusion criteria. |

| | |

| |7.2(IV) Follow Up: |

| | |

| |One time study. (No follow up required) |

| | |

| |7.2(V) Parameters used for comparison and statistical analysis used: |

| | |

| |Collective data will be analyzed by paired and unpaired‘t’ test. |

| | |

| |7.2(VI) Duration of study: |

| | |

| |The study will be conducted over Duration of 10-12 months. |

| | |

| |7.2(VII) Methodology: |

| | |

| |50 symptomatic individual fulfilling the inclusion criteria will be selected and randomly divided into two groups i.e. Group A and Group B each|

| |group consists of 25 members. Informed consent will be obtained from the patients. |

| | |

| |Group A:subject will be receiving Mulligan Mobilization and low level laser therapy |

| |Group B: subject will be receiving Mulligan Mobilization alone |

| | |

| |Pre and post test will be done by using Visual Analog Scale (VAS), Goniometer (Active Ankle Range of motion) and Foot and ankle disability |

| |Index (FADI). |

| |The results will be recorded and analyzed. |

| | |

| | |

| |Group A |

| |Procedure: |

| |After screening of subjects with inclusive and exclusive criteria the participants will be selected for the study and will randomly be divided |

| |into two groups. Subject in group A will receive Mulligan Mobilization with low level laser therapy and in Group B will receive Mulligan |

| |mobilization alone. |

| | |

| |Mulligan Mobilization: |

| | |

| |In Mulligan’ Mobilization with Movement the subjects will be asked to perform the joint movement in the respected direction along with |

| |mobilization force until it reaches the end depend on the joint to be treated. |

| |The following techniques are used: |

| | |

| |Ankle Joint: |

| |Dorsiflexion: |

| | |

| |Mobilizing force |

| |Hand place over the calcaneum, pull downwards the floor. |

| |Hand place over the talus glides it posterierly. |

| | |

| |Plantar flexion: |

| | |

| |Mobilizing force |

| |Tibia & fibula is glided posterierly as far as possible by the hand which is placed over the distal leg through the body (This locks the ankle |

| |joint). |

| |Without releasing the glide –Roll the talus ventrally with other hand. |

| | |

| |Subtalar Joint: |

| |Inversion: |

| | |

| |Mobilizing force |

| |Hand over the calcaneum pushes it towards outward or downward for exerting lateral glide. |

| | |

| |Eversion: |

| | |

| |Mobilizing force: |

| |Hand over the calcaneum pushes it towards down for exerting medial glide. |

| |Subjects will question frequently in an attempt to ensure that no pain will produced, and magnitude of the force applied is based on this |

| |feedback. |

| | |

| |These Mobilization techniques will perform every second day of a week followed by four to six weeks. |

| | |

| |End points of each technique in this mobilization will sustain for 10 seconds and this process will repeat four times in succession followed by|

| |twenty seconds of rest period, constituting one set of the treatment technique. Four sets of each treatment techniques will perform or apply. |

| |Totally these techniques will perform within sixteen minutes per session. |

| | |

| |Low Level Laser Therapy: |

| | |

| |Patient will lie in supine lying position ,identifying the tender area, then LL Laser will be given directly perpendicular over the tender |

| |area for 7-10 minutes twice week for six weeks(infrared Diode laser Ga-As(904nm), 60w maximum power, peak power pulse 27w pulse frequency |

| |1280hz average point region 2-8j;dose/point=3.4j;total energy density 24j/ square cm). |

| | |

| |Group B: |

| |Subjects will be receiving Mulligan Mobilization only and procedure will be the same as in Group A. |

| | |

| |7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly. |

| | |

| |Yes |

| |Clinical method to measure: |

| |Visual Analog Scale(VAS) |

| |Goniometer |

| |Foot and Ankle Disability Index(FADI) |

| | |

| |7.4) Has ethical clearance been obtained from your institution in case of 7.3? |

| | |

| |Yes. |

| | |

| |LIST OF REFERENCES: |

| | |

| |S C Brooks, B T Potter, and J B Rainey Br Med J. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. (Clin |

| |Res Ed). 1981 February 21; 282(6264): 606–607. |

| |Toni Green, Kathryn Refshauge, Jack Crosbie and Roger Adams. A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute |

| |Ankle Inversion Sprains.Vol. 81, No. 4, April 2001, pp. 984-994 |

| | |

| | |

| | |

| |Natalie Collins, Pamela Teys, Bill Vicenzino*The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain |

| |in subacute ankle sprains Manual Therapy 9 (2004) 77–82. |

| | |

| |Lynch SA, Renstrom PA. Treatment of acute lateral ankle ligament rupture in the athelete. conservative versus surgical treatment. Sports |

| |Med.1999 Jan; 27(1) :61-71. |

| | |

| |Stergioulas A Low-level laser treatment can reduce edema in second degree ankle sprains. J Clin Laser Med Surg. 2004 Apr; 22(2):125-8. |

| | |

| | |

| |V. Thoms and K. Rome Effect of subject position on the reliability of measurement of active ankle joint dorsiflexion . |

| | |

| | |

| |References and further reading may be available for this article. To view references and further reading you must purchase this article.The |

| |Foot Volume 7, Issue 3, September 1997, Pages 153-158. |

| | |

| |Price DD,Mc Grath PA,Raffi A,Buckingham B.The validation of visual analogue scale as ratio scale measures for chronic and experimental pain |

| |.September 1983; Volume 17, pages 45-46. |

| | |

| |Kaikkonen, A.P.Kannus, M.Jarvinen. A performance test protocol and scoring scale for the evaluation of ankle injuries. Am J. Sports Med 1994; |

| |22(4):462-469. |

| | |

| |Judith F. Baumhauer, Denise M. Alosa, Per A. F. H. Renström, Saul Trevino, Bruce Beynnon A Prospective Study of Ankle Injury Risk Factors .Am |

| |J Sports Med September 1995 vol. 23 no. 5 564-570. |

| | |

| |Boonstra AM, Schiphorst Preuper HR, Reneman MF. Reliability and validity of the visual analogue scale for disability in patients with chronic |

| |musculoskeletal pain. Int J Rehabil Res. 2008; 31(2): 165-9. |

| | |

| |Claudia Venturni, Alex André, Bruna Prates Aguilar, Bruno Giacomelli. Reliability of two evaluation methods of active range of motion in the |

| |ankle of healthy individuals ACTA FISIATR 2006; 13(1): 39-43 |

| | |

| |Mary Paul Clapper and Steven L. Wolf Comparison of the Reliability of the |

| |Orthoranger ad the Standard Goniometer for assessing active lower extremity Range of |

| |Motion. Volume 68/ number 2, February 1988. |

| | |

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