Original Article
The Mulligan ankle taping does not affect balance performance in healthy subjects: a prospective, randomized blinded trial
J. Phys. Ther. Sci. 27: 1597–1602, 2015
Jose Maria Delfa-de-la-Morena, PT, MSc1), Isabel Maria Alguacil-Diego, MD, PhD1), Francisco Molina-Rueda, PT, PhD1), Maria R amiro-González, MD, PhD1), Jorge Hugo Villafañe, PT, MSc, PhD2)*, Josué Fernández-Carnero, PT, MSc, PhD1) 1) Department
of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, Faculty of Health Sciences, University of Rey Juan Carlos, Spain 2) IRCCS Don Gnocchi Foundation: Milan, Italy
Abstract. [Purpose] The aim of this study was to evaluate the immediate effects of Mulligan fibular taping on static and dynamic postural balance in healthy subjects using computerized dynamic posturography (CDP). [Subjects and Methods] Forty-four volunteers (26 males and 18 females) aged 21 ±2 years participated in the study. The Mulligan tape was applied by a specialist in this technique. The placebo group received a treatment with a similar tape but with several cuts to avoid the fibular repositioning effect produced by Mulligan tape. Main outcome measures: The Sensory Organization Test (SOT) and the Motor Control Test (MCT) were performed by each subject at baseline and after the interventions. Outcome measures included equilibrium and strategy scores from each trial and condition of the SOT, and speed of reaction (latency period) from the MCT. [Results] Mulligan ankle taping did not have an impact on postural control during static and dynamic balance in subjects with healthy ankles when compared with placebo taping. [Conclusion] There was no difference in, equilibrium and strategy (SOT) and speed of reaction (MCT) in any of the subjects in this study. Therefore, this study suggests that Mulligan ankle taping does not have an impact on balance in healthy subjects. Key words: Ankle, Balance, Dynamic posturography (This article was submitted Jan. 6, 2015, and was accepted Jan. 31, 2015)
INTRODUCTION Ankle sprains are one of the most common musculoskeletal injuries, accounting for 15% of all sport injuries. Although the prognosis of ankle injuries is good, almost 80% of all athletes suffer from recurrent ankle sprains1), and up to 40% may develop ankle instability2). Many theories have been postulated to explain the pathophysiology of an ankle sprain: muscular weakness3), increased postural sway4), and proprioceptive and positional deficits5, 6). In order to correct these fibular misalignments, Mulligan developed a fibular taping technique in the nineties7). Other ankle taping techniques are used to treat patients with ankle sprains in order to improve mechanical stability and proprioceptive activity8). Moiler et al.9) demonstrated that fibular taping decreases the number of ankle injuries in basketball players. More recently, Delahunt et al.10) did not find any postural balance
*Corresponding author. Jorge Hugo Villafañe (E-mail: mail@ villafane.it) ©2015 The Society of Physical Therapy Science. Published by IPEC Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-ncnd) License .
improvement with the Star Excursion Balance Test (SEBT) when using fibular taping compared with another type of taping. In a recent study, Hopper et al.11) showed that Mulligan tape did not improve static and dynamic balance in patients with unilateral chronic ankle instability when compared with the same taping in healthy subjects. A drawback of their study is that balance was not evaluated with computerized dynamic posturography, which is considered the gold standard method. Computerized dynamic posturography (CDP) is a quantitative method of assessing and treating balance disorders12–14). The Sensory Organization Test (SOT) is included in the CDP. With a sensitivity of 95%, a specificity of 92%, and a 5% false positive rate, it is considered the gold standard for postural control15–17). During this test, visual and somatosensory inputs are modified (by moving the visual panel and/or the force platform), and the subject’s reactions are recorded and analyzed. Also, the visual panel, force platform, or both may be “sway-referenced”, so they move to follow the subject’s sway, giving inaccurate information to the eyes or feet. The information is collected from six different “conditions” that combine the movement of the panel and the force platform, and the results express the subject’s degree of functional impairment and the ability to maintain equilibrium using different systems involved in balance
1598 J. Phys. Ther. Sci. Vol. 27, No. 5, 2015 Table 1. Baseline demographics for both groups Number of subjects (n) Age (yrs) Gender (M/F) Height (cm) SOT1 (%) SOT2 (%) SOT3 (%) SOT4 (%) SOT5 (%) SOT6 (%) CES (%) SR (%) TSS (%) MCTLF (ms) MCTMF (ms) MCTLB (ms) MCTMB (ms)
Tape group
Placebo group
23 21.7 (2.5) 9/14 168.2 (8.9) 95.4 (1.5) 93.8 (2.4) 90.7 (4.9) 86.1 (9.9) 63.3 (10.4) 58.2 (20.5) 77.3 (7.4) 0.9 (0.0) 90.7 (4.2) 119.6 (28.0) 123.9 (9.4) 104.3 (43.1) 115.6 (37.9)
21 21.7 (3.0) 9/12 171.0 (8.2) 95.1 (1.4) 93.6 (2.1) 90.8 (6.2) 89.8 (2.1) 64.9 (10.5) 66.8 (14.3) 80.2 (4.3) 0.9 (0.0) 91.0 (2.0) 129.0 (9.9) 127.1 (10.0) 104.8 (45.3) 111.4 (45.3)
Values are expressed as the mean (standard deviation). SOT1–6: sensory organization test for conditions 1 to 6; CES: composite equilibrium score; SR: somatosensory ratio (SOT2/SOT1); TSS: total strategy score; MCTLF: motor control test large forward; MCTMF: motor control test medium forward; MCTLB: motor control test large backward; MCTMB: motor control test medium backward *p0.05). There were no dropouts during the different phases of the study. None of the subjects started drug therapy during the study. Descriptive statistics for results are presented in Table 2. The outcome for SOT1, SOT2, and SR demonstrated no significant time factor or group-by-time interactions (p>0.05). However, ANOVA showed significant differences
1600 J. Phys. Ther. Sci. Vol. 27, No. 5, 2015 Table 2. Within-group pre- and post-intervention values for each outcome measure Placebo group
Ankle Tape group Pre-post difference Pre-post difference Pre-intervention Post-intervention Pre-intervention Post-intervention confidence difference confidence difference SOT1 (%) SOT2 (%) SOT3 (%) SOT4 (%) SOT5 (%) SOT6 (%) CES (%) SR (%) EST 1 (%) EST2 (%) EST3 (%) EST4 (%) EST5 (%) EST6 (%) TSS(%) MCT (msec)
95.1±1.4 (94.4/95.7) 93.6±2.1 (92.6/94.6) 90.8±6.2 (88.3/93.3) 89.7±2.1 (86.5/93.0) 64.8±10.4 (60.2/69.4) 66.8±14.2 (58.9/74.6) 80.1±4.3 (77.4/82.8) 0.98±0.02 (1.0/1.0) 97.7±1.1 (97.2/98.3) 97.7±1.1 (97.0/98.5) 95.1±8.0 (92.3/98.0) 91.5±2.1 (90.6/92.4) 79.2±5.7 (75.5/82.9) 82.5±4.8 (79.0/86.1) 91.0±2.0 (89.5/92.4) 114.8±39.2 (98.0/131.5)
95.2±1.5 (94.6/95.8) 93.4±1.9 (92.4/94.4) 93.8±2.7* (92.6/95.0) 90.3±2.8 (88.5/92.2) 74.8±5.2** (71.6/78.0) 74.0±10.5 (68.7/79.3) 84.8±2.9** (83.2/86.4) 0.98±0.02 (1.0/1.0) 97.8±0.7 (97.4/98.2) 97.2±1.3 (96.6/97.8) 97.2±1.5 (96.3/98.1) 91.4±2.5 (90.3/92.4) 82.3±5.6 (79.6/85.0) 86.0±3.6 (83.6/88.4) 92.4±1.7 (91.4/93.4) 115±39.1 (96.8/133.1)
−0.1 (−0.8/0.6) 0.2 (−0.5/0.8) −3.0 (−5.4/−0.5) −0.6 (−3.7/2.4) −10.0 (−14.1/−5.8) −7.2 (−15.5/1.1) −4.7 (−7.0/−2.2) 0.002 (−0.01/0.01) −0.1 (−0.5/0.4) 0.5 (−0.003/1.1) −2.1 (−4.9/0.7) 0.1 (−0.8/1.1) −3.1 (−6.6/0.4) −3.5 (−7.2/0.2) −1.4 (−2.6/−0.1) −0.2 (−19.5/19.1)
95.3±1.5 (94.7/95.9) 93.8±2.3 (92.8/94.7) 90.7±4.9 (88.3/93.0) 86.1±9.9 (83/89.1) 63.2±10.3 (58.9/67.6) 58.1±20.5 (50.6/65.6) 77.2±7.3 (74.6/79.8) 1.0±0.01 (1.0/1.0) 97.9±1.2 (97.4/98.4) 97.8±2.0 (97.1/98.5) 95.9±4.7 (93.2/98.7) 91.2±2.0 (90.3/92.0) 80.4±10.3 (76.9/84.0) 81.8±10.1 (78.4/85.2) 90.6±4.1 (89.2/92.0) 114.7±36.8 (98.6/130.6)
95.3±1.3 (94.6/95.9) 93.2±2.4 (92.3/94.2) 92.3±2.8 (91.1/93.5) 89.2±5.0* (87.5/91.0) 72.1±8.7** (69.0/75.2) 72.0±13.3** (66.9/77.1) 83.2±4.3** (81.6/84.8) 1.0±0.01 (0.97/0.98) 98.0±1.1 (97.6/98.4) 97.6±1.3 (97/98.2) 96.8±2.3 (96.0/97.7) 91.9±2.0 (90.9/92.9) 84.5±6.5* (81.9/87.1) 85.4±6.7 (83.1/87.8) 92.4±2.5* (91.5/93.3) 107.3±43.1 (89.9/124.6)
0.1 (−0.6/0.7) 0.5 (−0.1/1.2) −1.6 (−3.9/0.8) −3.2 (−6.1/−0.2) −8.8 (−12.8/−4.8) −13.8 (−21.8/−5.8) −6.0 (−8.2/−3.7) 0.01 (−0.01/0.01) −0.05 (−0.5/0.3) 0.2 (−0.3/0.7) −0.9 (−3.6/1.7) −0.7 (−1.6/0.1) −4.1 (−7.4/−0.7) −3.6 (−7.2/−0.1) −1.8 (−2.9/−0.5) 7.3 (−11.1/25.8)
Values are expressed as the mean ± standard deviation (95% confidence interval). SOT1–6: sensory organization test for conditions 1 to 6; CES: composite equilibrium score; SR: somatosensory ratio (SOT2/SOT1); EST: strategy score for conditions 1 to 6; TSS: total strategy score; MCT: motor control test *p
The Mulligan ankle taping does not affect balance performance in healthy subjects: a prospective, randomized blinded trial
J. Phys. Ther. Sci. 27: 1597–1602, 2015
Jose Maria Delfa-de-la-Morena, PT, MSc1), Isabel Maria Alguacil-Diego, MD, PhD1), Francisco Molina-Rueda, PT, PhD1), Maria R amiro-González, MD, PhD1), Jorge Hugo Villafañe, PT, MSc, PhD2)*, Josué Fernández-Carnero, PT, MSc, PhD1) 1) Department
of Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, Faculty of Health Sciences, University of Rey Juan Carlos, Spain 2) IRCCS Don Gnocchi Foundation: Milan, Italy
Abstract. [Purpose] The aim of this study was to evaluate the immediate effects of Mulligan fibular taping on static and dynamic postural balance in healthy subjects using computerized dynamic posturography (CDP). [Subjects and Methods] Forty-four volunteers (26 males and 18 females) aged 21 ±2 years participated in the study. The Mulligan tape was applied by a specialist in this technique. The placebo group received a treatment with a similar tape but with several cuts to avoid the fibular repositioning effect produced by Mulligan tape. Main outcome measures: The Sensory Organization Test (SOT) and the Motor Control Test (MCT) were performed by each subject at baseline and after the interventions. Outcome measures included equilibrium and strategy scores from each trial and condition of the SOT, and speed of reaction (latency period) from the MCT. [Results] Mulligan ankle taping did not have an impact on postural control during static and dynamic balance in subjects with healthy ankles when compared with placebo taping. [Conclusion] There was no difference in, equilibrium and strategy (SOT) and speed of reaction (MCT) in any of the subjects in this study. Therefore, this study suggests that Mulligan ankle taping does not have an impact on balance in healthy subjects. Key words: Ankle, Balance, Dynamic posturography (This article was submitted Jan. 6, 2015, and was accepted Jan. 31, 2015)
INTRODUCTION Ankle sprains are one of the most common musculoskeletal injuries, accounting for 15% of all sport injuries. Although the prognosis of ankle injuries is good, almost 80% of all athletes suffer from recurrent ankle sprains1), and up to 40% may develop ankle instability2). Many theories have been postulated to explain the pathophysiology of an ankle sprain: muscular weakness3), increased postural sway4), and proprioceptive and positional deficits5, 6). In order to correct these fibular misalignments, Mulligan developed a fibular taping technique in the nineties7). Other ankle taping techniques are used to treat patients with ankle sprains in order to improve mechanical stability and proprioceptive activity8). Moiler et al.9) demonstrated that fibular taping decreases the number of ankle injuries in basketball players. More recently, Delahunt et al.10) did not find any postural balance
*Corresponding author. Jorge Hugo Villafañe (E-mail: mail@ villafane.it) ©2015 The Society of Physical Therapy Science. Published by IPEC Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-ncnd) License .
improvement with the Star Excursion Balance Test (SEBT) when using fibular taping compared with another type of taping. In a recent study, Hopper et al.11) showed that Mulligan tape did not improve static and dynamic balance in patients with unilateral chronic ankle instability when compared with the same taping in healthy subjects. A drawback of their study is that balance was not evaluated with computerized dynamic posturography, which is considered the gold standard method. Computerized dynamic posturography (CDP) is a quantitative method of assessing and treating balance disorders12–14). The Sensory Organization Test (SOT) is included in the CDP. With a sensitivity of 95%, a specificity of 92%, and a 5% false positive rate, it is considered the gold standard for postural control15–17). During this test, visual and somatosensory inputs are modified (by moving the visual panel and/or the force platform), and the subject’s reactions are recorded and analyzed. Also, the visual panel, force platform, or both may be “sway-referenced”, so they move to follow the subject’s sway, giving inaccurate information to the eyes or feet. The information is collected from six different “conditions” that combine the movement of the panel and the force platform, and the results express the subject’s degree of functional impairment and the ability to maintain equilibrium using different systems involved in balance
1598 J. Phys. Ther. Sci. Vol. 27, No. 5, 2015 Table 1. Baseline demographics for both groups Number of subjects (n) Age (yrs) Gender (M/F) Height (cm) SOT1 (%) SOT2 (%) SOT3 (%) SOT4 (%) SOT5 (%) SOT6 (%) CES (%) SR (%) TSS (%) MCTLF (ms) MCTMF (ms) MCTLB (ms) MCTMB (ms)
Tape group
Placebo group
23 21.7 (2.5) 9/14 168.2 (8.9) 95.4 (1.5) 93.8 (2.4) 90.7 (4.9) 86.1 (9.9) 63.3 (10.4) 58.2 (20.5) 77.3 (7.4) 0.9 (0.0) 90.7 (4.2) 119.6 (28.0) 123.9 (9.4) 104.3 (43.1) 115.6 (37.9)
21 21.7 (3.0) 9/12 171.0 (8.2) 95.1 (1.4) 93.6 (2.1) 90.8 (6.2) 89.8 (2.1) 64.9 (10.5) 66.8 (14.3) 80.2 (4.3) 0.9 (0.0) 91.0 (2.0) 129.0 (9.9) 127.1 (10.0) 104.8 (45.3) 111.4 (45.3)
Values are expressed as the mean (standard deviation). SOT1–6: sensory organization test for conditions 1 to 6; CES: composite equilibrium score; SR: somatosensory ratio (SOT2/SOT1); TSS: total strategy score; MCTLF: motor control test large forward; MCTMF: motor control test medium forward; MCTLB: motor control test large backward; MCTMB: motor control test medium backward *p0.05). There were no dropouts during the different phases of the study. None of the subjects started drug therapy during the study. Descriptive statistics for results are presented in Table 2. The outcome for SOT1, SOT2, and SR demonstrated no significant time factor or group-by-time interactions (p>0.05). However, ANOVA showed significant differences
1600 J. Phys. Ther. Sci. Vol. 27, No. 5, 2015 Table 2. Within-group pre- and post-intervention values for each outcome measure Placebo group
Ankle Tape group Pre-post difference Pre-post difference Pre-intervention Post-intervention Pre-intervention Post-intervention confidence difference confidence difference SOT1 (%) SOT2 (%) SOT3 (%) SOT4 (%) SOT5 (%) SOT6 (%) CES (%) SR (%) EST 1 (%) EST2 (%) EST3 (%) EST4 (%) EST5 (%) EST6 (%) TSS(%) MCT (msec)
95.1±1.4 (94.4/95.7) 93.6±2.1 (92.6/94.6) 90.8±6.2 (88.3/93.3) 89.7±2.1 (86.5/93.0) 64.8±10.4 (60.2/69.4) 66.8±14.2 (58.9/74.6) 80.1±4.3 (77.4/82.8) 0.98±0.02 (1.0/1.0) 97.7±1.1 (97.2/98.3) 97.7±1.1 (97.0/98.5) 95.1±8.0 (92.3/98.0) 91.5±2.1 (90.6/92.4) 79.2±5.7 (75.5/82.9) 82.5±4.8 (79.0/86.1) 91.0±2.0 (89.5/92.4) 114.8±39.2 (98.0/131.5)
95.2±1.5 (94.6/95.8) 93.4±1.9 (92.4/94.4) 93.8±2.7* (92.6/95.0) 90.3±2.8 (88.5/92.2) 74.8±5.2** (71.6/78.0) 74.0±10.5 (68.7/79.3) 84.8±2.9** (83.2/86.4) 0.98±0.02 (1.0/1.0) 97.8±0.7 (97.4/98.2) 97.2±1.3 (96.6/97.8) 97.2±1.5 (96.3/98.1) 91.4±2.5 (90.3/92.4) 82.3±5.6 (79.6/85.0) 86.0±3.6 (83.6/88.4) 92.4±1.7 (91.4/93.4) 115±39.1 (96.8/133.1)
−0.1 (−0.8/0.6) 0.2 (−0.5/0.8) −3.0 (−5.4/−0.5) −0.6 (−3.7/2.4) −10.0 (−14.1/−5.8) −7.2 (−15.5/1.1) −4.7 (−7.0/−2.2) 0.002 (−0.01/0.01) −0.1 (−0.5/0.4) 0.5 (−0.003/1.1) −2.1 (−4.9/0.7) 0.1 (−0.8/1.1) −3.1 (−6.6/0.4) −3.5 (−7.2/0.2) −1.4 (−2.6/−0.1) −0.2 (−19.5/19.1)
95.3±1.5 (94.7/95.9) 93.8±2.3 (92.8/94.7) 90.7±4.9 (88.3/93.0) 86.1±9.9 (83/89.1) 63.2±10.3 (58.9/67.6) 58.1±20.5 (50.6/65.6) 77.2±7.3 (74.6/79.8) 1.0±0.01 (1.0/1.0) 97.9±1.2 (97.4/98.4) 97.8±2.0 (97.1/98.5) 95.9±4.7 (93.2/98.7) 91.2±2.0 (90.3/92.0) 80.4±10.3 (76.9/84.0) 81.8±10.1 (78.4/85.2) 90.6±4.1 (89.2/92.0) 114.7±36.8 (98.6/130.6)
95.3±1.3 (94.6/95.9) 93.2±2.4 (92.3/94.2) 92.3±2.8 (91.1/93.5) 89.2±5.0* (87.5/91.0) 72.1±8.7** (69.0/75.2) 72.0±13.3** (66.9/77.1) 83.2±4.3** (81.6/84.8) 1.0±0.01 (0.97/0.98) 98.0±1.1 (97.6/98.4) 97.6±1.3 (97/98.2) 96.8±2.3 (96.0/97.7) 91.9±2.0 (90.9/92.9) 84.5±6.5* (81.9/87.1) 85.4±6.7 (83.1/87.8) 92.4±2.5* (91.5/93.3) 107.3±43.1 (89.9/124.6)
0.1 (−0.6/0.7) 0.5 (−0.1/1.2) −1.6 (−3.9/0.8) −3.2 (−6.1/−0.2) −8.8 (−12.8/−4.8) −13.8 (−21.8/−5.8) −6.0 (−8.2/−3.7) 0.01 (−0.01/0.01) −0.05 (−0.5/0.3) 0.2 (−0.3/0.7) −0.9 (−3.6/1.7) −0.7 (−1.6/0.1) −4.1 (−7.4/−0.7) −3.6 (−7.2/−0.1) −1.8 (−2.9/−0.5) 7.3 (−11.1/25.8)
Values are expressed as the mean ± standard deviation (95% confidence interval). SOT1–6: sensory organization test for conditions 1 to 6; CES: composite equilibrium score; SR: somatosensory ratio (SOT2/SOT1); EST: strategy score for conditions 1 to 6; TSS: total strategy score; MCT: motor control test *p
