Effectiveness of MWM on pain and range of movement in patients with lateral ankle

sprain

1 Introduction : This systematised review aimed to investigate the efficacy of Mulligan

Mobilization with Movement (MWM) in improving pain and range of motion in patients
diagnosed with lateral ankle sprain. The main aim is to review the existing literature critically
in order to make recommendations for practice and recommendations for further research.

1.1 Background about lateral ankle sprains

The most common mode of occurrence of lateral ankle sprains (LAS)is when the rearfoot
undergoes excessive supination on an externally rotated lower leg.(
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164367/#:~:text=Lateral%20ankle
%20sprains%20typically%20occur,suffered%20a%20previous%20ankle%20sprain.)LAS is
also known as supination ankle sprains and inversion ankle sprains.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164367/#:~:text=Lateral%20ankle
%20sprains%20typically%20occur,suffered%20a%20previous%20ankle%20sprain.)
Repeated episodes of LAS has been reported to result in chronic ankle instability,(
https://pubmed.ncbi.nlm.nih.gov/9132202) functional instability
(https://pubmed.ncbi.nlm.nih.gov/5846766) and residual instability
(https://pubmed.ncbi.nlm.nih.gov/13271470). LAS are among the most common athletic
injuries (https://pubmed.ncbi.nlm.nih.gov/563179) with some authors reporting no gender
differences (https://pubmed.ncbi.nlm.nih.gov/16009979) and others suggesting that men have
a higher incidence of LAS (https://pubmed.ncbi.nlm.nih.gov/10738413) .
Sustaining one incident of LAS predisposes the person to further incidences
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724316/,
https://pubmed.ncbi.nlm.nih.gov/3099587, and can often lead to chronic ankle instability.
Moreover, residual symptoms have been reported to affect more than 50% of athletes who
have had a LAS lasting for as much as 18 months according some reports
(https://pubmed.ncbi.nlm.nih.gov/9801078, https://pubmed.ncbi.nlm.nih.gov/10101985).
Chronic ankle instability has been linked to two reasons namely functional ankle instability
and mechanical instability. Mechanical instability has been attributed to pathological laxity of
the ligaments (https://pubmed.ncbi.nlm.nih.gov/4030196) and functional instability due to
alterations in proprioception (https://pubmed.ncbi.nlm.nih.gov/5846767), muscle strength
deficits ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164371/) and neuromuscular
control (https://pubmed.ncbi.nlm.nih.gov/11924686/#:~:text=Functional%20instability%20of
%20the%20ankle%20results%20from%20a%20loss%20of,to%20be%20a%20peripheral
%20reflex.). Mechanical instability results from various reasons including pathologic laxity,(
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164367/#:~:text=Pathologic%20laxity
%20may%20be%20assessed,69%2C70%20or%20instrumented%20arthrometry.&text=After
%20lateral%20ankle%20sprain%2C%20pathologic,the%20talocrural%20and%20subtalar
%20joints.&text=Talocrural%20instability%20is%20caused%20primarily%20by%20injury
%20to%20the%20ATFL%20and%20CFL.) impaired arthrokinematics,(
https://www.researchgate.net/publication/7221715_The_Foot_and_Ankle_An_Overview_of_
Arthrokinematics_and_Selected_Joint_Techniques) synovial inflammation and
impingement,( https://pubmed.ncbi.nlm.nih.gov/2750511/) and degenerative changes
(https://pubmed.ncbi.nlm.nih.gov/429402/) .
Functional instability is defined as “ the subjective feeling of ankle instability or recurrent,
symptomatic ankle sprains (or both) due to proprioceptive and neuromuscular deficits”
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164386/#:~:text=Functional%20instability
%20(FI)%20is%20defined,to%20proprioceptive%20and%20neuromuscular%20deficits.) .
Freeman et al (1965) were the first to suggest that ankle instability may occur due to
alterations in sensory information arising from the injured ankle ligaments.
(https://pubmed.ncbi.nlm.nih.gov/5846767)
Therefore it is clear that LAS can cause various dysfunctions and must be treated
appropriately. Rehabilitation of the ankle is based on the anatomical and functional
understanding of the joint.

Anatomy of the ankle

The true ankle joint is considered to be the talocrural joint. However, the subtalar joint is
important to ankle stability. The subtalar joint acts as a miter in the weight bearing foot.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164386/#:~:text=Functional%20instability
%20(FI)%20is%20defined,to%20proprioceptive%20and%20neuromuscular%20deficits.)
Stability is also provided by the muscles around the ankle which act to counter the external
forces including the round reaction forces, specifically the plantarflexes and invertors which
counter the external forces which usually acts to dorsiflex and evert the foot(
https://pubmed.ncbi.nlm.nih.gov/7371240)
Anatomically, three ligaments make up the lateral complex namely the anterior talofibular
ligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talofibular ligament
(PTFL). Previous studies have suggested that in 85% of ankle sprain injuries, the ATFL is
injured and the CFL is involved in 35% while the PTFL is injured in 12% of injuries
(http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=23328403).
Reasons for the higher incidence of ATFL injuries have been suggested to be due to its
function being to restrict both plantarflexion and inversion
(http://scholar.google.com/scholar_lookup?&title=The%20anterior%20talofibular
%20ligament%3A%20a%20detailed%20morphological
%20study&journal=Foot&doi=10.1016%2Fj.foot.2015.05.004&volume=25&pages=141-
147&publication_year=2015&author=Khawaji%2CB&author=Soames%2CR) and due to its
low tension threshold to failure.( http://scholar.google.com/scholar_lookup?&title=Ligament
%20force%20and%20joint%20motion%20in%20the%20intact%20ankle%3A%20a
%20cadaveric%20study&journal=Knee%20Surgery%2C%20Sport%20Traumatol
%20Arthrosc&doi=10.1007%2Fs001670050083&volume=6&pages=115-
121&publication_year=1998&author=Bahr%2CR&author=Pena%2CF&author=Shine
%2CJ&author=Lew%2CWD&author=Engebretsen%2CL)
Fig 1: Lateral ligament complex of ankle joint

As can be seen in fig 1 above, The ATFL runs close to the anterior tip of the lateral
malleolus to the anterolateral surface of the talus. The CFL extends from the middle of the
lateral malleolus tip to the peroneal tendons and binds to the calcaneus lateral surface. The
PTFL passes from the posterior section of the lateral malleolus to the posterolateral talar
surface (Bozkurt & Doral, 2006).

Functional anatomy of the ankle:

The talocrural joint, the subtalar joint and the distal tibiofibular syndesmosis work together to
allow controlled movement of the rearfoot. These motions occur in sagittal-plane (plantar
flexion-dorsiflexion), frontal-plane (inversion-eversion), and transverse-plane (internal
rotation-external rotation). (https://pubmed.ncbi.nlm.nih.gov/3453583) always together and
not in isolation allowing the rearfoot to move as a unit in an oblique axis with respect to the
axis of the lower leg. Due to this combined movement, rearfoot motion is best described as
pronation and supination. In non weight bearing positions, combined dorsiflexion, eversion
and external rotation can be called pronation and the opposite movements as supination. In
weight bearing positions, pronation is characterised by plantarflexion, eversion and external
rotation and supination consists of the opposite movements.
(https://pubmed.ncbi.nlm.nih.gov/7655480,.

The anatomical configuration of the ankle joint requires the joints and peri articular structures
to work together along with the sub talar and tibio fibular syndesmosis for weight bearing
function. Injury to any of these structures can affect the stability of the joint. Instability of
the ankle joint has been considered to be of two origins.
Mechanical instability: anatomic changes after an initial ankle sprain may lead to conditions
that predispose the ankle to further injury. These changes may occur in isolation or in
combination. Laxity of the ligaments is one reason for mechanical instability and can occur in
both the talocrural and subtalar joints (https://pubmed.ncbi.nlm.nih.gov/8653951).
Arthrokinematics impairments of one of the three joints that make up the ankle complex in
another reasons for mechanical instability. One such impairment has been suggested as
malalignment of the inferior tibiofibular joint termed as positional fault by Mulligan
(https://scholar.google.com/scholar?q=Mulligan+B+R+Manual+Therapy:+
%E2%80%9CNAGS%E2%80%9D,+%E2%80%9CSNAGS%E2%80%9D,+
%E2%80%9CMWMS%E2%80%9D,+Etc+Plane+View+Services+LTD+Wellington,
+New+Zealand+1995+3rd+ed+).
Hypomobility of the joint has been identified as a risk factor for ankle sprain
(https://pubmed.ncbi.nlm.nih.gov/11132266) and restricted dorsiflexion
(https://pubmed.ncbi.nlm.nih.gov/8536030 , https://pubmed.ncbi.nlm.nih.gov/8947396 ) and
restricted posterior glide of talus (https://pubmed.ncbi.nlm.nih.gov/11949665 ) also been
identified in patients at risk for repeated ankle sprain.
Synovial hypertrophy in the talocrural and subtalar joint capsules leading to impingement
syndrome,( https://pubmed.ncbi.nlm.nih.gov/11128010) osteophytes
(https://pubmed.ncbi.nlm.nih.gov/10966363) and sinus tarsi syndrome
(https://pubmed.ncbi.nlm.nih.gov/868481 ) have all been implicated in recurrent ankle
sprains.
The various pathoanatomical reasons for mechanical instability have been identified in
literature. These factors can result in persistent dysfunction after a LAS.

Functional instability: LAS can lead to functional difficulties (https://josr-

online.biomedcentral.com/articles/10.1186/s13018-020-01847-8) due to impaired
neuromotor control of the surrounding structures. Impaired balance in individuals with LAS
has been attributed to damaged articular mechanoreceptors leading to impaired
proprioception (https://pubmed.ncbi.nlm.nih.gov/5846767). Although this mechanism
partially explains the symptoms of instability and impaired balance after LAS, the aetiology
is complete only when the impaired dynamic neuromuscular control,(
https://pubmed.ncbi.nlm.nih.gov/9554026) is considered. Thus functional instability can be
explained when various factors are considered namely: impaired kinaesthesia and
proprioception,( https://pubmed.ncbi.nlm.nih.gov/3186791,
https://pubmed.ncbi.nlm.nih.gov/7773272) impairments in neuromuscular recruitment,(
https://pubmed.ncbi.nlm.nih.gov/8602478, https://pubmed.ncbi.nlm.nih.gov/1636854)
postural control dysfunction (https://pubmed.ncbi.nlm.nih.gov/2929827,
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19442581 ) and strength deficits in
the ankle muscles mainly evertors (https://pubmed.ncbi.nlm.nih.gov/10450480,
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19442581 ).

In summary after an index ankle sprain, patients report feelings of instability and this
phenomenon has been explained by two mechanisms namely mechanical instability and
functional instability. Choosing the correct rehabilitation strategy is dependent on identifying
the contribution of the mechanisms underlying symptoms. (https://josr-
online.biomedcentral.com/articles/10.1186/s13018-020-01847-8)
Symptoms and sequalae of lateral ankle sprains : the persistent symptoms of LAS have
been reported to include pain (30.2%), feeling of giving way (20.4%), crepitus (18.3%),
muscle strength deficits (16.5%), range of motion deficits (14.6%) and swelling (13.9%)
(https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/1758-2555-1-14) .
Persistent symptoms have been reported to occur in 72% of people 6-18 months after an
index ankle sprain (https://bjsm.bmj.com/lookup/external-ref?
access_num=10101985&link_type=MED&atom=%2Fbjsports%2F39%2F3%2Fe14.atom ),
pain, swelling or recurrent sprains in 32 % of people at seven years
(https://bjsm.bmj.com/lookup/external-ref?access_num=12135444&link_type=MED&atom=
%2Fbjsports%2F39%2F3%2Fe14.atom ) and in 30% with an unreported follow up time
period
(https://bjsm.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaW
psaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxM
Toiam91cm5hbENvZGUiO3M6ODoiYmpzcG9ydHMiO3M6NToicmVzaWQiO3M6ODoiM
jgvMi8xMTIiO3M6NDoiYXRvbSI7czoyMzoiL2Jqc3BvcnRzLzM5LzMvZTE0LmF0b20iO
31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) and 74% having a combination of persistent
pain, swelling, instability and weakness at 1.5- 4 years after the index injury.
(https://bjsm.bmj.com/content/39/3/e14#ref-8)

Pain : a recent systematic review on the prevalence of pain in persons with chronic ankle
instability following an ankle sprain reviewed 14 articles from a total of 5907 articles
identified at the initial search. The review included various study types such as prospective
cohort, cross sectional, observational and retrospective designs. Follow up periods varied
from 3 months to 6 years across studies and included both young and older participants.
Most studies (11/14) used pain self report whereas two used physical examination to provoke
pain and the remaining two used both self report and objective examination. Notably, all 14
studies identified pain as an important residual symptom of LAS. Taking the studies together
more than 50% of participants reported pain. The reported prevalence of pain was consistent
over time. This systematic review could not find an association between age and pain due to
mixed populations in the included studies. Frequency of pain varied from occasional to
frequent and severity from mild to moderate with high intensity activities being identified as
pain provoking. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602397/#:~:text=Among
%20participants%20with%20CAI%20who,years)%20after%20the%20initial
%20injury.&text=This%20prevalence%20of%20pain%20was%20consistent%20across
%20time.)

Range of motion a recent study compared dorsi flexion ROM between 24 and 72 hours, at 2
to 4 weeks, and at 6 months in participants with grades I-III LAS. The authors reported that
differences in dorsiflexion ROM may be indicative of varying clinical responses after a LAS.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063659/) . However, the study had large
difference sin participants in the three grades with 38% grade I, 49% grade II and 13 % grade
III sprains. A study by Basnett et al (2013) demonstrated the relationship between
dorsiflexion ROM and dynamic balance in participants with chronic ankle instability. The
authors recommended that clinicians must focus on rehabilitation strategies to address ankle
dorsiflexion ROM and dynamic balance.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625791/). Similar findings were reported
by Kosik et al (2019) in middle aged adults. The authors reported that ROM deficits and
concomitant dynamic balance deficits persist long after the index injury to the ankle.
(https://www.sciencedirect.com/science/article/abs/pii/S1440244019301021)
Wenning et al (2020) analysed 43 patients with chronic, unilateral mechanical ankle
instability functionally. They reported that active range of motion of dorsiflexion and
supination were reduced in this population.
(https://josr-online.biomedcentral.com/articles/10.1186/s13018-020-01847-8)
Authors have unanimously concurred that ROM deficits are common in persons with ankle
injury and tend to persist over a period of time. Pain has also been identified as a persistent
dysfunction after LAS.

Management of lateral ankle sprains

A case series of ten patients with grade II LAS suggested that treatment must be tailored to
focus on protection of the injured ligament, maintain and restore ankle ROM and provide a
patient centred pathway to functional recovery depending on the patient’s need and sporting
preference. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816301/) . An opinion paper
by McGovern and Martin (2016) suggested that interventions for acute LAS must include
protected weight bearing, manual therapy, exercises and icing. The same authors opined that
for chronic ankle instability, manual therapy and a rehabilitation program were indicated. The
authors based their opinions on the current evidence.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780668/) . Two recent systematic reviews
and an umbrella review have suggested that manual therapy must be considered and there is
evidence of effectiveness in improving pain, ROM and function. MWM specifically was not
mentioned in these reviews and they cited heterogeneity of studies, outcomes and
interventions as limitations (https://pubmed.ncbi.nlm.nih.gov/36281183/,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599579/,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9301067/ ) .
The effectiveness of conservative management including physiotherapeutic methods and
manual therapy have been supported by various authors. Studies have considered manual
therapy as an entity without differentiating between various methods of manual therapy. No
studies were found that reported on MWM in LAS.
Movement with mobilisation in ankle sprains (250): Mulligan proposed that malalignment
between articular surfaces which he termed as positional fault as a potential reasons for pain
and ROM restriction.(
https://www.sciencedirect.com/science/article/pii/S1356689X14000149) This concept has
not been radiologically verified
(https://www.sciencedirect.com/science/article/pii/S1094553914000170) and is verified
through certain clinical examination procedures described by Mulligan.(
https://www.sciencedirect.com/science/article/pii/S1356689X14000149). The Mulligan
concept theorises that symptom alleviation can occur if the positional faults are corrected
(https://www.sciencedirect.com/science/article/pii/S1094553914000170) . Another proposed
reason for symptom alleviation has been reported as sympathetic nervous system excitation
during manual therapy. (
https://www.sciencedirect.com/science/article/pii/S1356689X14000149). The MWM
techniques are utilised on peripheral joints with the theory that if force is applied in a certain
direction during a painful movement the pain is resolved. Multiple repetitions are done
ending with application of overpressure with reported immediate positive results.
(https://www.sciencedirect.com/science/article/pii/S1356689X14000149) No adverse effects
have been reported following this treatment technique. (
https://www.sciencedirect.com/science/article/pii/S1058274609001992)
Stathopoulos et al (2019) in a systematic review and meta analysis on the effect of MWM on
pain and disability in peripheral joints reviewed 16 studies with a total of 572 participants in
four different meta analyses. The review reported short term effectiveness on pain reduction
compared to standard therapy and other manual therapy but no long term effect could be
seen. The authors reported on the high heterogeneity of included studies. No specific
effectiveness in LAS was reported in this review.
(https://www.sciencedirect.com/science/article/abs/pii/S0031940618302918#preview-
section-snippets)
Weerasekara et al., (2020) in a review aimed to find the effect of MWM in isolation for ankle
sprains. The researchers analysed the effects of MWM on 201 people with chronic constant
sprains using data from four studies. The participants included both adults and adolescents
with grade I or grade II ankle sprain who were treated with any MWM approach by a
qualified health professional. The comparator in all included studies was standard
physiotherapy. The review evaluated immediate, short-term, and long-term effects, clinically
significant outcomes including dorsiflexion range, pressure pain threshold (PPT), thermal
pain threshold (TPT), balance, talar stiffness, and self-reported instability. This was the first
meta-analysis to determine if MWM is an effective strategy for improving several clinical
outcomes in patients with a lateral ankle sprain at all phases of chronicity. The review did not
mention the effect of MWM in improving pain in patients with lateral ankle sprain.

1.2 Need for the review

Based on the aim of this systematised review, the research gaps from existing systematic
review was identified. The previous systematic review did not attempt to evaluate the role of
MWM in improving pain and ROM in patients with LAS. As evident from the epidemiology
of LAS, it is necessary to identify treatment methods that are effective in improving the
dysfunctions that are associated with LAS, in order to formulate clinical practice
recommendations.
MWM has been reported to be effective in improving pain and ROM in persons with frozen
shoulder (Sai & Kumar, 2015) and hip osteoarthritis (Beselga et al., 2016)
The two trials conclude that MWM is effective in improving pain and ROM in various
conditions. So, overall MWM can be considered as a good treatment approach, for improving
pain and ROM.

Hence, this systematised review was undertaken to fill the research gap of the effectiveness
of MWM in improving pain and ROM in LAS. The research question has been developed
and presented using the PICO framework, which stands for Population, Intervention,
Comparison, and Outcomes. It is the best approach of question formulation to apply when
performing a quantitative systematic literature review and is currently used by the Cochrane
Collaboration (O'Connor, Green, & Higgins, 2008). Moreover, using this framework enables
the healthcare professional in identifying the key elements of the clinical question that are
most significant to the patient and enhances the search process by identifying the main
concepts for an effective search strategy (Schardt et al., 2007b).

POPULATION Lateral ankle sprain

INTERVENTION Mobilization with movement

COMPARISON Conventional physiotherapy

 OUTCOME Lower extremity function such as pain,
ROM

PHYLOSOPHICAL ASSUMPTIONS

In research, philosophical assumptions are important perspectives and concepts that influence
how a researcher explores details, reality, and the nature of the universe. The researcher's
decisions about study paradigms, procedures, and methods are supported by these
assumptions (Borislav, 2016). The aim of the study and hypotheses must be carefully
considered to choose the appropriate research paradigm.

RESEARCH PARADIGM
A research paradigm has been defined as “the set of common beliefs and agreements shared
between scientists about how problems should be understood and addressed”(
https://www.lri.fr/~mbl/Stanford/CS477/papers/Kuhn-SSR-2ndEd.pdf)
It has been established that knowledge of research paradigms is important before embarking
on research (https://pubmed.ncbi.nlm.nih.gov/31789841/). Fitzgerald and Howcroft(1998)
reported that there were various paradigms used in social sciences research and the choice
depends on the researcher’s focus of discovery.(
https://link.springer.com/article/10.1057/jit.1998.9) The paradigms reported are positivism
and interpretivism, empirical or qualitative, inductive and deductive methods of hypothesis
testing and explanatory or exploratory research.(
https://oro.open.ac.uk/49591/17/49591ORO.pdf) Four research paradigms have bene
established namely positivism,( https://www.gajrc.com/media/articles/GAJHSS_41_10-
14.pdf, https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9256.2008.01335.x ) realism,
( https://www.jstor.org/stable/24032985) critical theory
(https://www.jstor.org/stable/24032985, https://link.springer.com/chapter/10.1007/978-1-
349-18946-5_6) and interpretivism.( https://www.gajrc.com/media/articles/GAJHSS_41_10-
14.pdf, https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9256.2008.01335.x )
Recently in health science research it has ben suggested that to enforce greater
methodological rigour strong underlying philosophical principles must be understood.(
http://scholar.google.com/scholar_lookup?&title=Shedding%20the%20cobra%20effect%3A
%20problematising%20thematic%20emergence%2C%20triangulation%2C%20saturation
%20and%20member%20checking&journal=Med
%20Educ&doi=10.1111%2Fmedu.13124&volume=51&issue=1&pages=40-
50&publication_year=2017&author=Varpio%2CL&author=Ajjawi
%2CR&author=Monrouxe%2CLV&author=O%27Brien%2CBC&author=Rees%2CCE,
http://scholar.google.com/scholar_lookup?&title=Research%20paradigms%20in%20medical
%20education%20research&journal=Med%20Educ&doi=10.1111%2Fj.1365-
2923.2009.03611.x&volume=44&issue=4&pages=358-
366&publication_year=2010&author=Bunniss%2CS&author=Kelly%2CDR) Traditionally
health has been researched using the positivist or post-positivist paradigm with a reliance on
empirical data.( http://scholar.google.com/scholar_lookup?&title=The%20importance%20of
%20theories%20in%20health
%20care&journal=BMJ.&doi=10.1136%2Fbmj.317.7164.1007&volume=317&issue=7164&
pages=1007-1010&publication_year=1998&author=Alderson%2CP) However, this is
changing with the need to understand explicitly the assumptions made under this paradigm.(
http://scholar.google.com/scholar_lookup?&title=Science%20in%20the%20postmodern
%20era%3A%20postpositivism%20and%20research%20in%20medical
%20education&journal=Teaching%20and%20Learning%20in%20Medicine%3A%20An
%20International
%20Journal&doi=10.1080%2F10401339609539757&volume=8&issue=1&pages=10-
18&publication_year=1996&author=Colliver%2CJA,
http://scholar.google.com/scholar_lookup?&title=Theoretical%20perspectives%20in
%20medical%20education%3A%20past%20experience%20and%20future
%20possibilities&journal=Med%20Educ&doi=10.1111%2Fj.1365-
2923.2010.03757.x&volume=45&issue=1&pages=60-
68&publication_year=2011&author=Mann%2CKV)

Positivist Paradigm

Positivism is related tot eh commonly used hypothetico- deductive model used in clinical
reasoning. This is fundamental to finding cause effect relationships underlaying stated
hypotheses. Thus a study on effectiveness of an intervention relies on this model with the
intention to test the causal links between the intervention and the outcome being
hypothesised based on previously known theory.( https://scholar.google.com/scholar_lookup?
title=Qualitative+research+in+counseling+psychology
%3a+A+primer+on+research+paradigms+and+philosophy+of+science.&publication_year=2
005&author=JG+Ponterotto) Positivist enquiry seeks to find explanations and associations
between intervention and outcome variables with the aim to generate explanations or the
phenomena that can be generalised. This paradigm uses five principles as its basis namely
(https://journals.lww.com/academicmedicine/fulltext/2020/05000/the_positivism_paradigm_
of_research.16.aspx)

1. Focus on discovering laws that can assist in explaining the phenomenon of interest
and prediction in similar phenomenon in the future

2. Decide on the methodology based on the hypothetico-deductive model of clinical

reasoning

3. Laws of nature that help to generalise findings through replication and synthesis to
identify underlying reasons

4. Evidence of the laws of nature derive form empirical data

5. Laws underlying sampling and inference related to samples

Quantitative Paradigm
Quantitative research, relies on positivism. This method is defined by empirical
investigation; every event can be simplified to measurable signs that represent the truth.
According to the ontological position of the quantitative paradigm, holds that there is only
one truth, an objective reality that exists regardless of human perception (Sale et al., 2002).
Moreover, the quantitative research generally applies the confirmatory scientific method, as it
focuses on hypothesis and theory testing. Quantitative researchers consider that it is crucial to
state one's hypotheses and then test those hypotheses with evidence to see if they are
justified.
The positivist paradigm depends on the belief that there is a single physical reality that can be
recognised, discovered, and measured (Park et al., 2020). Given that the quantitative method
is linked to positivism, so, quantitative research must be based on stating and testing
hypotheses (Makombe, 2017).
In general, the positivist researcher thinks that truth is different from human awareness, that
there is a division between the knower from the known, and that cause-and-effect links
between events can be discovered through repeated observation. Positivists think that truth
can be found. The positivist will pose quantifiable research questions (D. Berryman, 2019).

Ontology & Epistemology

Ontology relates to the knowledge of the nature of existence and reality
(https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?
ReferenceID=1216337) , are concerned with questions pertaining to the person in society
(https://methods.sagepub.com/reference/the-sage-dictionary-of-social-research-methods) and
the assumptions we may have about the reality and what is actually the reality.
(https://www.researchgate.net/publication/260244813_Demystifying_Ontology_and_Epistem
ology_in_Research_Methods) Ontological principles have been reported as integral to post
positivist paradigms (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8849373/) and has
been linked to critical realism. Postpositivist critical realism suggests that multiple methods
must be utilised to explain phenomena related to human functioning.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650753/)
Epistemology is the theory of knowledge, which seeks to explain beliefs and opinion and to
define methods to employ in research. Ontology and epistemology provide an understanding
of the researcher's views about the existence of truth, the reality of the world, and the idea of
existing in that universe; they depict the researcher's view of the world. Ontology,
epistemology, and theoretical perspective are important, as all of these constructs have
significant effects on the research process, determining research questions and designing the
methodology to seek answers. The main difference between ontology and epistemology is
that ontology involves what we assume can exist, as well as what we regard to be essential or
basic. Epistemology is the study of how we determine what we know and who can be an
expert (Berryman, 2019). Ontology and epistemology are important for lateral ankle sprain
for determining the nature of the injury, including its underlying mechanisms and
classification, and ensuring that knowledge collected about lateral ankle sprain is based on
rigorous and valid research methodologies.
There are various studies that evaluate the efficiency of MWM in improving overall lower
extremity function in patients with lateral ankle sprain
This study is conducted with the aim to explore the effectiveness of MWM in ankle sprain by
reviewing studies published in the area. The study will consider empirical data to interpret
and inform clinical practice. Therefore, a positivist and post positivist approach will be
employed in this study.
This study adopted a systematised review approach. This is a post graduate dissertation
research, due to a shortage of both time and funds to conduct a comprehensive systematic
review, a systematised literature review was done in place of a systematic review.

4. METHODS
4.1: Ethics

This study has obtained ethical approval from the Coventry University Ethics Committee,
with the assigned project number being P151781. The certificate confirming ethical
compliance can be located in Appendix A of this document. It is pertinent to note that this
research project carries a minimal level of risk, primarily owing to its foundation in
secondary research methods. Importantly, there is no direct engagement with other
individuals, nor is there a need for the collection of physical samples.

4.2: Eligibility criteria

A.
The establishment of precise inclusion and exclusion criteria constitutes a pivotal
phase in the research process, as it serves the fundamental purpose of orchestrating a
comprehensive yet discerning approach to study selection. These eligibility
parameters are initially cast with a wide net, intended to encompass a broad spectrum
of potential studies, safeguarding against premature exclusions. Subsequently, in
adherence to methodological rigor, studies are subjected to exclusion only when they
conspicuously align with one or more of the predetermined exclusion criteria, thereby
ensuring a judicious and considered approach to the curation of the final study cohort.

inclusion and exclusion criteria is given in table A

Table A: The table shows the included, excluded studies and the main
focus

INCLUDED EXCLUDED RATIONALE OF

FOCUS
Study type *Randomized * Pseudo- * This criterion
controlled trials randomised ensures that
(RCTs), quasi- studies. studies included in
experimental * RCTs with this systematic
studies, cohort sample sizes less review are
studies, and than 10 designed to
crossover studies participants per provide the highest
* Studies not group. level of evidence
published in and minimize bias.
English language * Excluding studies
 with small sample
sizes ensures that
the results are
more robust and
generalizable to
the larger
population.
participants Adults (18 and *Studies with This criterion
above) with a mixed population ensures that only
clinical diagnosis (adults and studies with ankle
of lateral ankle children) sprain patients are
sprain, with a * Studies that included as this
duration of last 3 include can impact the
months participants with effectiveness of
comorbidities that interventions.
may affect lower * comorbidities can
extremity function affect lower
extremity function
and bias the
results.
Intervention Studies comparing Complicated Complicated
the effectiveness additions to MWM additions such as
of Mobilization with Cognitive
Movement (MWM) Behaviour Therapy
as an intervention (CBT)may affect
to conventional the treatment
physiotherapy (PT) outcome and one
for treating ankle cannot claim that
sprain. the effect is from
CBT or MWM.
Comparison Any alternative Studies which do To find which
treatment methods not have control or intervention is
or other comparator group more effective in
physiotherapy treating the
techniques condition

Outcome Studies that report Absence of any This criterion

measures outcomes related validated outcome ensures that
to lower extremity measure studies included in
function, such as Pain,ROM) this systematic
pain Range of review have used
Motion (ROM outcome
measures that are
relevant to the
study

4.3 JUSTIFICATION FOR INCLUSION AND EXCLUSION CRITERIA

POPULATION:
The population groups include people with acute lateral ankle sprain. Age group
includes adults above 18 years of age. This population was taken because this is a
common injury which is mostly seen in athletes. Moreover, the Anterior Talofibular
ligament (ATFL) is the most frequently damaged ligament in the lateral side of the
ankle. Whereas, the medial side ligament, deltoid is less likely to get injured during a
fall.

INTERVENTION:
The studies which include any trials that applied merely MWM or combined it with
additional therapies. Healthcare professionals are increasingly looking at the use of
MWM in Lateral Ankle Sprain to reduce pain and increase range of motion. It has
been demonstrated that MWM can help people with acute lateral ankle sprains
regain their overall lower extremity function. It is worth nothing, that no review of the
literature has been undertaken that is only focused on the efficacy of MWM on pain
and ROM in patients with lateral ankle sprain. In order to fill this gap in the available
literature, this systematic review includes studies applying MWM on pain and ROM
in individuals with acute lateral ankle sprain.

COMPARISON
In the studies MWM is compared with standard physiotherapy treatment. This helps
to know which treatment is more effective. There were no restrictions placed on the
control or comparator groups in order to permit the study of a wide range of research
papers. Likewise, the control group acts as a vital comparison group. The
experimental group follows a regimen that alters their lifestyle or behaviours.
Researchers can measure any differences in the control and experimental groups at
the end of the trial to determine if the new protocol caused an alteration in outcomes
of concern.

OUTCOME
In all the studies one or the other such as pain and ROM were identified as the
outcome. A Visual Analogue Scale was used by practitioners to measure the
musculoskeletal pain of the foot and ankle. Forward Lunge test was used in an RCT
to check the range of motion of the ankle.

Study Design
The studies with a quantitative study design were most suitable for answering the
research question of this systematised literature review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106287/ . Moreover, well-conducted
randomised controlled trials (RCTs) are seen as the 'gold standard' for assessing
different therapies since they are not prone to the same confounding as non-
randomised research. Randomization ensures that, on average, the treatment
populations are adequate for both known and unknown characteristics, resulting in
an unbiased assessment of the treatment impact (when executed appropriately)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136079/ . Thus, this review
attempted to include all relevant papers other than RCTs, such as quasi
experimental and clinical investigations. Studies released before 2010 were not
taken into consideration. The researcher believes that, given the advances in
technology, it may be reasonable to eliminate previous studies to improve the
accuracy of findings, as the most recent studies are likely to be significantly more
technologically improved.
Other criteria
Due to a lack of time and resources for translation, all studies published in any
language other than English were excluded from this systematic review.
Moreover, unpublished research, and clinical trials of studies that were inaccessible
were all removed in this analysis. Most of the publications included in this
systematised review were published after 2010.

4.4 Search Strategy

Systematic literature reviews play a pivotal role in aggregating the best available evidence to
inform decisions in the fields of medical and social care. The systematic review process
commences with the delineation of a research topic and the formulation of a methodological
frameworknhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6670166/#:~:text=Systematic
%20review%2Fmeta%2Danalysis%20steps,%2C%20full%2Dtext%20screening%2C
%20manual . Of paramount importance within this process is the comprehensive search for
pertinent literature, as the quality of this search significantly underpins the overall
effectiveness of the systematic review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037943/ .

In the context of this research, the subject matter pertains to ankle sprains, a topic rich in
available information. To manage the wealth of data, the focus was narrowed to lateral ankle
sprains, thereby curtailing the volume of eligible studies. Consequently, after establishing the
eligibility criteria, a meticulously designed search strategy was developed with the dual
objectives of maximizing the yield of relevant findings and ensuring the repeatability of the
evaluation. The systematic review aims to collate all pertinent research addressing the
effectiveness of Mulligan's Mobilization with Movement (MWM) on pain management and
range of motion (ROM) in cases of lateral ankle sprains.

To achieve this, a comprehensive search was imperative, as only a limited number of studies
directly addressed the impact of MWM on lateral ankle sprains. To this end, a thorough
exploration of several databases was conducted individually to attain a breadth and depth of
investigation. Moreover, the scope of the review was defined from the year 2010 to 2023 to
encompass the most recent developments in the field.

Several prominent electronic databases were scrutinized as part of the search strategy, which
included PUBMED, AMED (Association for Management Education and Development),
MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and
SPORT Discuss.
AMED, an invaluable bibliographic resource curated by the British Library's Health Care
Information Service, encompasses complex subject matter, including alternative therapies,
palliative care, and allied healthcare professions. On the other hand, MEDLINE compiles
bibliographic information from scholarly sources spanning nursing, healthcare, pharmacy,
dentistry, veterinary medicine, and broader healthcare domains.

The initial step involved the identification of key terms requisite for efficient electronic
database searches. This process facilitated the identification of potentially relevant titles and
abstracts contained within these databases. In tandem, synonyms were explored to encompass
multiple expressions signifying the same concepts. The PICO (Population, Intervention,
Comparison, Outcome) framework, renowned for its utility, was widely adopted to guide
researchers in defining the research question and subsequently constructing the search
strategy. The Cochrane Collaboration has extensively employed PICO as a standard for
framing research inquiries and identifying critical terms and synonyms
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6148624/ .

In our quest for comprehensiveness, these terms were logically combined using Boolean
operators and truncation symbols. This systematic approach ensured the inclusion of a broad
spectrum of studies relevant to our research question, as depicted below.

Table b: An example of the search strategy used on CINAHL database.

CINAHL

Search no Search terms Results

S1 “Lateral ankle sprain” or “ankle 21,087
sprains” or “ligament injury” or
“ligamentous injury”
S2 “mwm” or “mobilisation with 1,629
movement” or “mobilisation belt”
or “mulligan technique”
S3 “pain measurement” or “pain 141,729

assessment” or “pain scale”

S4 “range of motion” or “rom” or 52,150

“range of movement”

S5 S1 AND S2 AND S3 AND S4 10

AND S5

4.5 DATA EXTRACTION

Data extraction constitutes a pivotal and meticulous phase in the execution of Systematic
Reviews, synergizing with the concurrent process of data collection. This procedure entails
the systematic compilation of information derived from primary research sources into
standardized tabular formats. Its significance cannot be overstated, as it stands as a linchpin
for ensuring the veracity and integrity of the ensuing research findings.

Notably, data extraction operates as an architectural framework upon which the results and
conclusions of Systematic Reviews are constructed
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361807/ . This amalgamated dataset
subsequently undergoes rigorous analysis and interpretation by researchers to distill pertinent
and actionable insights.

Moreover, the utilization of a data extraction or data summary sheet emerges as a valuable
tool within this context. Such a tool serves the dual function of encapsulating the salient
facets of a research paper and facilitating the researcher's discernment of its alignment with
the overarching research inquiry. By proficiently leveraging this instrument, scholars can
circumvent the laborious task of revisiting each individual paper when seeking specific
details, thereby enhancing efficiency.

Furthermore, the adoption of a data extraction form serves the critical function of ascertaining
the degree to which a given paper aligns with the research review's objectives, thereby
streamlining the curation of a document that encapsulates the paper's essence. This practice
proves particularly beneficial for researchers operating at the master's level in enabling a
focused and expeditious distillation of key ideas and insights from the reviewed literature
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574308/ .

4.7 DATA ANALYSIS

The data analysis methodology employed in this study aligns with the fundamental principles
of a systematic review, specifically addressing the synthesis of findings. The overarching
objective was to comprehensively assess the literature on the effectiveness of Mulligan's
Mobilization with Movement (MWM) in managing lateral ankle sprains. Notably, this
systematic review encompassed a diverse array of research studies, each offering distinct
outcomes and study designs.

In light of this diversity, the chosen approach was a descriptive analysis utilizing narrative
synthesis. This method was selected deliberately to accommodate the inherent heterogeneity
across the included studies, thus ensuring a rigorous and transparent process. Several key
justifications underscored this analytical choice:

Heterogeneous Outcome Measures: The studies incorporated in this systematic review

exhibited marked variability in their outcome measures. Pain, range of motion (ROM), and
the Foot and Ankle Ability Measure - Activities of Daily Living (FAAM-ADL) are just a few
examples of the multifaceted parameters under investigation. The comprehensive nature of
narrative synthesis allowed for the systematic consideration of these diverse outcomes
without compromising methodological rigor.
Diverse Study Designs: Another notable aspect was the diversity in study designs. This
encompassed randomized controlled trials, interrupted time series, and various other research
paradigms. Narrative synthesis afforded the flexibility to integrate findings from these
distinct study designs, acknowledging the unique contributions of each while maintaining a
coherent analytical framework.

Transparency and Reproducibility: The narrative synthesis approach enhances the

transparency of the analytical process, a crucial element in systematic reviews. It provides a
clear and systematic framework for organizing and summarizing findings, making it
accessible to both researchers and readers. Moreover, narrative synthesis promotes the
repeatability of the review process, ensuring that the methodology can be applied consistently
in future studies.