flaccidity appears during the early stage after stroke ; however , as time passes , it is 
 accompanied by spasticity , which occurs in 90% of stroke patients .
in particular , spasticity of the ankle plantar flexor 
 disrupts static and dynamic balance , as well as the normal gait pattern1 , 2 . shortened calf 
 muscles in individuals with hemiparesis cause ankle joint stiffness , increase its 
 hypomobility and resistance to mobility , and decrease passive joint mobility , which 
 ultimately causes limitation of the ankle joint3 , 
 4 .
abnormal muscle tension and movement 
 limitation due to muscle weakness of the ankle joint cause limitation of functional 
 activities such as changing from a sitting position to standing , locomotion , and climbing 
 stairs5 .
stroke patients have difficulty 
 in standing up without help , and difficulties in negotiating obstacles start to emerge 
 during walking6 .
one of the reasons for 
 the decrease in gait speed and asymmetric gait in hemiplegic patients is the limitation of 
 passive and active movements due to structural changes in the connective tissue and 
 articular capsule around the ankle joint7 . 

the motor function of the ankle joint greatly affects balance and walking abilities . in 
 addition , improvement of walking ability is a major goal in patients undergoing stroke 
 rehabilitation8 . manual therapy is widely used and advocated for many aspects of peripheral joint 
 dysfunction .
mulligan s mobilization with movement ( mwm ) technique is commonly used in 
 musculoskeletal physiotherapy .
the recently developed manual therapy techniques include 
 brian mulligan s widely used mwm for peripheral joint pain , which has been shown to improve 
 range of motion and promote earlier return to function after lateral ankle sprain9 , 10 . 

the clinical efficacy of mulligan s mwm technique is also applicable to the mwm technique 
 for talocrural dorsiflexion , which is frequently used to improve talocrural dorsiflexion 
 deficits that often occur after lateral ankle sprain10 .
the mechanisms behind the 
 effectiveness of mwms are based on mechanical dysfunction and therefore on positional fault 
 correction12 .
thus , the purpose of this study was to verify whether mulligan s mwm technique improve the 
 temporal and spatial variables of the gait of individuals who had a stroke .
the study participants were chosen from among 24 stroke patients who were undergoing 
 physical therapy at a rehabilitation hospital . the participant selection criteria were as 
 follows : those who had hemiparesis due to stroke with onset at > 6 months , the ability to 
 follow verbal instructions , the ability to communicate at a certain level , recovered the 
 motor functions of their paretic lower limbs at brunnstrom stage 24 , and a score of > 24 
 points on the mini - mental state examination - korean .
patients were excluded if they had a 
 neurological condition , orthopedic disease , or visual impairment .
all the patients who 
 participated in this trial provided their written informed consent after receiving a full 
 explanation of the expected results and side effects of the intervention .
the present study 
 was approved by the sahmyook university institutional review board ( syuirb2015 - 114 ) .
the 24 subjects were randomly assigned to either mulligan s mwm group ( mwm ; n=12 ) or a 
  weight - bearing with placebo  mwm group ( control ; n=12 ) .
the general characteristics of the 
 12 subjects in the experimental group were as follows : 6 males and 6 females ; a mean age of 
 41.58  years ; a mean height of 165.67  cm ; a mean weight of 62.42  kg ; and a mean time since 
 stroke onset of 8.87 months ; right- and left - side hemiplegia in 8 and 4 cases , respectively . 

the characteristics of the 12 subjects in the control group were as follows : 6 males and 6 
 females ; a mean age of 53.0  years ; a mean height of 164.58  cm ; a mean weight of 60.67  kg ; 
 and a mean time since stroke onset of 10.46 months ; and right- and left - side hemiplegia in 5 
 and 7 cases , respectively .
the participants in the experimental group performed mulligan s mwm technique at 5 sets of 
 10 glides a day , 5 times a week for 4 weeks .
the participants in the control group performed 
 lunges in the same conditions as the experimental group .
the participants in the control 
 group were trained for 5 sets of 10 lunges a day , 5 times a week for 4 weeks . before the 
 intervention
, all the participants received conventional physical therapy for 30 minutes per 
 day , 5 days per week over a 4-week period .
each gliding involved 10 seconds 
 of posterior talar glide with dorsiflexion and 5 seconds of resting between the gliding .
the therapist applied a sustained 
 posteroanterior glide to the tibia through the belt by leaning backward while the talus and 
 forefoot were fixed in the space between the thumb and the second finger of the right hand . 

the other hand was positioned anteriorly over the proximal tibia to direct the knee over the 
 line of the second and third toes .
then , the participant was instructed to perform a slow 
 dorsiflexion movement until the first onset of pain or end of range of motion without the 
 heel lifting off the couch .
gaitrite was used for the measurement of spatiotemporal parameters , 
 including gait velocity , cadence , step length , and stride length13 .
a 
 paired t - test was used to compare pretest and posttest measurements of gait function within 
 the groups , and the independent t - test was used to compare the difference in gait function 
 before and after training between the groups . a p value of < 0.05 was considered 
 statistically significant .
the mwm group showed significant improvements in velocity , which increased from 41.35  cm / s 
 before training to 51.72  cm / s after training ( p<0.001 ) ; cadence , step length , stride 
 length , and single - support time of the affected side ; and step length and stride length of 
 the non - affected side ( p<0.05 ) .
in addition , the control group demonstrated significant 
 improvements in step length and stride length of the non - affected side ( p<0.05 ) .
the mwm 
 group showed significantly greater improvements than the control group in terms of velocity , 
 cadence , and single - support time of the affected side ( p<0.05 ; table 1table 1.comparison of gait ability within and between the groups ( n=24)parametersvalueschange valuesmwm ( n=12)control ( n=12)mwm ( n=12)control ( n=12)beforeafterbeforeafterbefore - afterbefore - aftervelocity ( cm / s)41.35 ( 14.73)51.72 ( 15.42)49.69 ( 23.26)51.55 ( 22.20)10.37 ( 6.63)1.87 ( 7.13)cadence ( step / min)70.25 ( 17.90)78.50 ( 14.59)78.45 ( 21.57)76.50 ( 19.04)8.25 ( 8.50)1.95 ( 7.71)a : step length ( cm)36.35 ( 6.28)41.33 ( 7.04)35.80 ( 8.49)38.36 ( 9.79)4.97 ( 5.53)2.56 ( 5.49)a : stride length ( cm)69.90 ( 13.77)78.14 ( 13.54)73.72 ( 17.52)78.45 ( 17.58)8.23 ( 7.93)4.72 ( 8.77)a : single - support time ( % /gc)20.08 ( 5.81)23.33 ( 4.55)24.00 ( 6.53)23.20 ( 7.19)3.25 ( 4.79)2.51 ( 1.87)na : step length ( cm)33.17 ( 8.60)36.57 ( 7.95)36.31 ( 9.11)39.43 ( 8.33)3.40 ( 3.38)3.11 ( 4.86)na : stride length ( cm)69.60 ( 13.56)77.92 ( 13.32)72.63 ( 15.92)77.64 ( 17.22)8.32 ( 8.03)5.01 ( 7.32)data are presented as means ( sd ) ; * p<0.05 , * * p<0.001 : significant difference 
 within each group ; p<0.05 : significant difference between the groups ; 
 mwm : mulligan s mobilization with movement group ; a : affected side ; na : non - affected 
 side )
. data are presented as means ( sd ) ; * p<0.05 , * * p<0.001 : significant difference 
 within each group ; p<0.05 : significant difference between the groups ; 
 mwm : mulligan s mobilization with movement group ; a : affected side ; na : non - affected 
 side
this study was conducted to assess the effects of mulligan s mwm techniques on the temporal 
 and spatial variables of gait of individuals who had a stroke .
the application of mulligan s 
 mwm techniques effectively improved the gait function of the patients in this study .
the pressure from weight bearing on the affected side of the lower extremity is decreased 
 by up to 43% , which makes stroke patients prone to falls to the affected side because of 
 loss of balance .
they experience difficulty in standing without assistance , which impairs 
 their ambulatory abilities6 . for these 
 reasons , gait and
this training involves 
 exercise of the ankle to improve gait and balance . in particular , problems with the 
 dorsiflexors of the ankle
were reported to be the highest risk factor of falls14 , and tonic paralysis in the plantar 
 flexors of the ankle disrupt the normal gait pattern15 , 16 .
some treatments are 
 available to resolve these problems , including neurodevelopmental techniques , functional 
 electrical stimulation , biofeedback , strength training , and treadmill training . however , in 
 this study , the efficacy of mulligan s mwm technique was verified .
each gliding consisted of 10 seconds of posterior talar glide with 
 dorsiflexion of the ankle joint and 5 seconds of resting between the gliding .
the therapist applied a sustained posteroanterior 
 glide to the tibia through the belt by leaning backward while the talus and forefoot were 
 fixed in the space between the thumb and the second right - hand finger .
the mwm group had 
 significantly greater improvements in velocity , cadence , and single - support time of the 
 affected side ( p<0.05 ) than the control group , which suggests that mulligan s mwm 
 technique could improve the gait ability of patients recovering from stroke .
the symptoms of postural imbalance in stroke patients are evident during standing because 
 of the increased weight bearing toward the non - paretic side . decreased standing balance and 
 loss of the ability to shift weight toward the paretic leg
therefore , limitations in movements can 
 decrease the range and amount of physical activities that can be performed and could lead to 
 further decreases in postural balance , which may ultimately result in the deterioration of 
 physical health18 .
therefore , this study 
 investigated a sustained posteroanterior glide to the tibia for improvement of weight shift 
 in stroke patients .
the mwm group showed a significant improvement in single - support time of 
 the affected side , which increased from 20.08%/gait cycle ( gc ) before training to 23.33%/gc 
 after training ( p<0.05 ) .
for increasing the single - support time of the affected side , 
 mulligan s mwm is more effective than the lunge position .
muscle cooperation in the ankle 
 joint puts the center of gravity on the ankle joint in the standing position .
it requires 
 normal range of motion of the ankle joint and muscular strength19 , 20 .
the normal 
 range of motion of the ankle joint in the standing position improved in the mwm group owing 
 to the posteroanterior glide to the tibia . based on the findings of the present study
, mulligan s mwm could increase the velocity , 
 cadence , step length , stride length , and single - support time of the affected side , and the 
 step length and stride length of the non - affected side .
moreover , increased single - support 
 time of the affected side will positively influence the motivation of patients during gc and 
 weight bearing on the non - paretic side toward maintaining their bodies within the limits of 
 stability .
thus , the positive effect of mulligan s mwm on gait function and its 
 effectiveness as a treatment regimen for improving the gc in stroke patients were 
 confirmed .
this study has limitations , including the lack of diversity in the dependent variables . 

in addition , mulligan s mwm technique is 
 commonly used in musculoskeletal physical therapy ; however , it was used in this study to 
 improve the gc in stroke patients .
hence , further research on the efficacy of mulligan s mwm 
 in stroke rehabilitation should be conducted .
 [ purpose ] we examined the effectiveness of mulligan s mobilization with movement ( mwm ) 
 technique on spatiotemporal variables of gait in individuals who had a stroke . [ subjects 
 and methods ] twenty - four subjects were randomly divided into 2 groups : mulligan s 
 mobilization with movement group ( n=12 ) and  weight - bearing with placebo  mobilization 
 with movement group ( n=12 ) . 
 the subjects in the mobilization with movement group performed 
 5 sets of 10 glides a day , 5 times a week for 4 weeks . the mobilization with movement 
 technique comprised grade iii movements that involved gliding and resting . 
 the control 
 group subjects performed lunges in the same conditions as those of the experimental group . 
 
 gait function was measured in terms of spatiotemporal parameters to determine the effect 
 of mobilization with movement . 
 [ results ] the mobilization with movement group showed 
 significant improvements in velocity , cadence , stride length , single - support time , and 
 step length of the affected side , and step length and stride length of the non - affected 
 side . 
 overall , the mobilization with movement group showed significantly greater 
 improvements than the control group in terms of velocity , cadence , and single - support time 
 of the affected side . [ conclusion ] mobilization with movement can be used to improve the 
 gait function of patients recovering from stroke . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION