ORIGINAL ARTICLE Effects of Ankle Joint Mobilizations in Adults Poststroke: A Pilot Study Patricia M. Kluding, PT, PhD, Marcio Santos, PT, PhD ABSTRACT. Kluding PM, Santos M. Effects of ankle joint mobilizations in adults poststroke: a pilot study. Arch Phys Med Rehabil 2008;89:449-56. Objective: To compare the effect of 2 interventions on ankle mobility, ankle kinematics, and weight-bearing symmetry dur- ing functional activities in subjects with hemiparesis after a stroke. Design: Randomized trial. Setting: Academic medical center. Participants: A convenience sample of 16 subjects with hemiparesis after stroke (mean age, 55.2y; mean time since stroke, 21.4mo). Intervention: Subjects received 8 sessions over 4 weeks of either functional task practice combined with ankle joint mo- bilizations, or functional task practice only. Main Outcome Measures: Changes in ankle range of mo- tion (ROM) (not blinded), ankle kinematics during sit-to-stand (STS) and gait, and lower-extremity weight-bearing symmetry during STS and static standing. Results: The combined intervention group gained 5.7°3.1° in passive ankle ROM compared with 0.2°2.6° in the func- tional practice only group (95% confidence interval [CI], 2.5– 8.6; P.01). No significant changes in ankle kinematics or weight bearing during static standing were noted in either group. The functional practice group decreased differences in weight bearing during STS by 9.5%6.47%, whereas the com- bined intervention group increased this difference by 3.37% 5.29% (95% CI, 3.26 –19.46; P=.01). Conclusions: The increase in ankle motion did not improve joint kinematics and may have prevented improvement in weight-bearing symmetry. Key Words: Biomechanics; Cerebrovascular accident; Musculoskeletal manipulations; Range of motion, articular; Rehabilitation. © 2008 by the American Congress of Rehabilitation Med- icine and the American Academy of Physical Medicine and Rehabilitation L IMITATIONS IN PASSIVE and active ankle movement are common impairments for people with chronic hemipa- resis secondary to a stroke. 1-3 Subjects with stroke have been found to have only half of dorsiflexion range of motion (ROM) compared with healthy controls. 4 Researchers using careful laboratory measures to distinguish contracture from spasticity in a small sample found that 7 of 16 subjects had a true ankle plantarflexion contracture. 5 Limited motion at the ankle may contribute to functional limitations, which are likely caused by the interaction of several complex factors such as spasticity, immobility, and structural adaptations. Central nervous system pathology may result in spasticity, or a velocity-dependent increase in stretch reflexes, which con- tributes significantly to calf muscle hypertonia or stiffness. 6,7 Non-neural factors, such as immobilization- and aging-induced changes in mechanical properties of muscle and connective tissue, 8-12 are known to increase resistance of joint movement and contribute to the loss of passive movement independent of reflex activity. 2,3,13,14 In the upper extremity, lack of functional limb movement appears to increase the likelihood that wrist flexion contractures develop within 6 to 8 weeks after stroke. 15 Thus, a component of the increased resistance to passive stretch that is commonly attributed to spasticity may be sec- ondary to adaptive muscle changes or passive joint stiffness caused by non-neural factors, and these changes may begin soon after sustaining a stroke. Approximately 30° of ankle ROM is required for normal performance of sit-to-stand (STS) transfers, 16 walking, 17 and climbing stairs. 18 Limited ankle mobility may not only affect the performance of these important functional tasks, but it may also affect the initial foot position for STS, which has been specifically identified as a key determinant in STS perfor- mance. 19 Moderate correlations have been found between an- kle ROM and balance scores in elderly women, 20 and elderly fallers have been found to have significantly less dorsiflexion than elderly nonfallers. 21 Adults with hemiparesis have an asymmetric distribution of body weight away from their hemiparetic leg during STS, 22,23 static standing, 24 and while walking. 25 Limited ankle mobility on the hemiparetic leg may contribute to this asymmetry in weight-bearing positions because of difficulty with placing the foot firmly on the floor. Joint mobilizations, or passive movement of the articular surfaces, are a technique commonly used by physical therapists to help restore normal accessory motion when there is a ROM limitation. 26 Although ankle joint mobilizations are most often used for patients with a primary musculoskeletal pathology such as ankle sprains, 27 mobilizations have been recommended as an appropriate treatment for joint hypomobility in children with cerebral palsy, 28,29 and have been found to effectively increase passive ankle ROM in subjects with diabetic neuro- pathy. 30 However, specific functional practice that targets ac- tive use of the newly gained motion may be necessary for a change in motor strategy. This randomized controlled pilot study compared the effects of a combined intervention (ankle joint mobilizations and structured practice of functional skills) with structured practice alone. The purpose of this project was to compare the effect of these 2 interventions on ankle ROM, ankle kinematics, and weight-bearing symmetry during functional activities in sub- From the Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS. Presented in part as a poster to the Combined Sections Meeting, American Physical Therapy Association, February 1-4, 2006, San Diego, CA, and as a platform to the Kansas Physical Therapy Association, April 1, 2006, Wichita, KS. Supported by the School of Allied Health Research Committee, University of Kansas Medical Center. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Patricia M. Kluding, PT, PhD, Mailstop 3051, 3901 Rainbow Blvd, Kansas City, KS 66160, e-mail: pkluding@kumc.edu. 0003-9993/08/8903-11588$34.00/0 doi:10.1016/j.apmr.2007.12.005 449 Arch Phys Med Rehabil Vol 89, March 2008