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Effect of Thumb Joint Mobilization on Pressure Pain Threshold in Elderly Patients with Thumb Carpometacarpal Osteoarthritis
EFFECT OF THUMB JOINT MOBILIZATION ON PRESSURE PAIN THRESHOLD IN ELDERLY PATIENTS WITH THUMB CARPOMETACARPAL OSTEOARTHRITIS Jorge H. Villafañe, PT, MSc, a, b Guillermo B. Silva, MSc, PhD, c, d and Josue Fernandez-Carnero, PT, MSc, PhD e, f
ABSTRACT Objective: This study evaluated the effects of Maitland's passive accessory mobilization on local hypoalgesia and strength in thumb carpometacarpal osteoarthritis (TCOA). Methods: Twenty-eight patients between 70 and 90 years old with secondary TCOA were randomized into glide mobilization and sham groups. This study was designed as a double-blind, randomized controlled trial. Therapy consisted of Maitland's passive accessory mobilization of the dominant hand during 4 sessions over 2 weeks. We measured pressure pain threshold (PPT) at the trapeziometacarpal joint (TMJ), the tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone by algometry. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU). Results: All values in sham group remained unchanged along the treatment period. In the treated group, the PPT in the TMJ was 3.85 ± 0.35 kg/cm 2, which increased after treatment to 3.99 ± 0.37 and was maintained at the same level during the first FU 3.94 ± 0.39 and second FU 4.74 ± 0.40. In contrast, we found no differences in PPT in the other studied structures after treatment. Similarly, tip, tripod pinch, and grip strength remained without change after treatment. Conclusions: Passive accessory mobilization increased PPT in the TMJ; however, it did not increase motor function in patients with TCOA. (J Manipulative Physiol Ther 2012;35:110-120) Key Indexing Terms: Thumb; Osteoarthritis; Hand Strength
steoarthritis (OA) is the one of the most common joint disorder in the United States and one of the leading causes of disability in the elderly. 1 Osteoarthritis develops relatively frequent at the trapeziometacarpal joint (TMJ), 2 often as a result of athletic injury or cumulative trauma associated with an arduous occupation or hobby. 3,4 Thumb carpometacarpal OA (TCOA) occurs with a disproportionally greater frequency in females and typically in their fifth and sixth decades of age. 5,6
O
Typically, patients report disability during a variety of occupations, domestic tasks, hobbies, and sports. Specific aggravating activities include writing, gardening, turning taps, and opening jars, with pain frequently localized at the volar surface of the joint. 2,4,7,8 Experts suggest that surgery is only indicated if conservative treatment is unsuccessful. 9 However, the more usual options for conservative treatment are exercise, splint therapy, and active daily activities. 10 These treatments
a Physical Therapist, Department of Physical Therapy, Residenze Sanitarie Assistenziali “A. Maritano,” Sangano, Italy and R.S.A “Don Menzio,” Avigliana, Italy. b Doctoral Student, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain. c Principal Investigator, Department of Physiology and Hypertension, Mons. Carlos V. Cruvellier Foundation and J. Robert Cade Foundation, San Juan, Argentina. d Assistant Professor, Department of Research Methods, School of Nutrition, Biochemistry and Pharmacy, Catholic University of Cuyo, San Juan, Argentina.
e Full Professor, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain. f Principal Investigator, Research Group of Musculo-Skeletal Pain and Motor Control, European University of Madrid, Spain. Submit requests for reprints to: Jorge H. Villafañe PT, MSc, Regione Generala 11/16, Piossasco (TO), Italy (e-mail: [email protected]). Paper submitted September 3, 2011; in revised form November 14, 2011; accepted November 14, 2011. 0161-4754/$36.00 Copyright © 2012 by National University of Health Sciences. doi:10.1016/j.jmpt.2011.12.002
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are able to produce improvements at 12 months after treatment; however, no improvement in pain was found at short periods after therapy. 11 Orthopedic manual therapy avoids the risk of joint injury during application of the mobilization. To do that, it usually performed the glide as a passive mobilization of the treated joint. 12,13 It is suggested that passive accessory mobilization decreases articular pain and increases the pain-free range of movement in other articular architectures. 12,13 Despite the numerous manual therapy approaches to the treatment of OA that have been proposed, passive accessory mobilization was never tested in patients with OA. 14-16 In recent studies, we have applied different techniques of manual therapy for treating TCOA to increase strength to the tip and tripod pinch and grip strengths and decrease mechanical hyperalgesia. 17-19 However, we never pursued a passive joint mobilization with distraction in patients with hand OA. On the other hand, it has been published that manual therapy reduces pain and increases physical function in patients with hip OA. 20 In addition, data from animal models of articular pain suggest that joint mobilization may decrease processing of pain, 21 indicating the possibility that joint mobilization with a distraction could benefit patients with OA of the dominant hand. Several studies performed in humans have shown that mobilization of other joints benefits patients in pain perception and motor function, 22-24 but studies focusing on the neurophysiologic effects in patients with TCOA are lacking. 22-24 Therefore, the purpose of the present study was to determine whether posterior-anterior passive accessory mobilization of the TMJ decreases mechanical hyperalgesia and increases strength to the tip and tripod pinch and grip strengths in patients with TCOA in the dominant hand.
METHODS Subjects Twenty-eight subjects, aged 70 to 90 years, with TCOA in the dominant hand with a clinical pathologic history of more than 10 years were recruited by the Department of Physical Therapy, “Residenze Sanitarie Assistenziali” (RR.SS.AA), which depends on Azienda Sanitaria Locale 3, Collegno (Italy). Patients were diagnosed by x-rays and randomly separated into either treated or sham group. The baseline demographic characteristics of the population are listed in Table 1. The inclusion criteria involved those patients with OA of the dominant hand stage III and IV TCOA according to the Eaton-Littler-Burton Classification 6,25 and preserved cognitive capacities according to age, ex-factory workers, and housewives whose use of the dominant hand was common and systematic.
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Table 1. Baseline demographics for Maitland's passive accessory mobilization and sham groups Characteristic Age Sex (M/F)
Passive joint mobilization group (14)
Sham group (14)
P
81.43 ± 5.11 10/14 (71.43% female)
83.71 ± 5.80 10/14 (71.43% female)
.28
3.85 ± 1.26 4.84 ± 1.61 6.32 ± 1.62
3.88 ± 1.29 5.03 ± 1.97 6.41 ± 2.04
.96 .78 .90
2.56 ± 1.78 3.10 ± 1.92 10.64 ± 8.33
.70 .88 .91
PPT (kg/cm2) TMJ Scaphoid bone Hamate bone
Pinch and grip strength (kg) Tip pinch Tripod pinch Grip strength
2,35 ± 0.89 3.01 ± 1.08 10.93 ± 4.50
The exclusion criteria involved those patients with carpal tunnel syndrome, arthritis, surgical interventions on the TMJ, finger spring, or de Quervain tenosynovitis. Patients presenting degenerative or nondegenerative neurologic conditions in which pain perception was altered were also excluded. This study was designed as a double-blind, randomized controlled trial (RCT). Informed consent was obtained from all participants, and all procedures were conducted according to the Declaration of Helsinki. This study was supervised by the Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain. The protocol (N°93571/c) was approved by the Ethical Committee in Azienda Sanitaria Locale 3, Collegno, Italy, and trial registration of the Current Controlled Trials ISRCTN70578774. The complete protocol can be accessed at http://www.controlledtrials.com/ISRCTN70578774. In the randomization procedure, each subject was randomly assigned to either the experimental group or the sham group using simple randomization with a random number generator. Random sequences of 0 or 1 were run through the patient database with a 50% chance of obtaining treatment or sham, respectively. The numbers were randomly assigned to each participant, who was then allocated accordingly. The randomization procedure was facilitated by the online software accessed at http://www.graphpad. com/quickcalcs/randomize1.cfm.
Pain Measurement Patients with TCOA frequently refer pain in the base of the hand. Because the TMJ is the most affected during TCOA, we measured pressure pain threshold (PPT) in the bones linked to the TMJ; those are the unciform apophysis of the hamate bone and the scaphoid bone.
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We measured the PPT with a mechanical pressure algometer (Wagner Instruments, Greenwich, CT) with a 1-cm 2 rubber-tipped plunger mounted on a force transducer. 26,27 This method has been used in the past by us 17-19 and others 28,29 with positive results. The PPT is defined as the minimum amount of pressure that results in the sense of pressure changing to pain. 30,31 The mean of 3 measurements (intraexaminer reliability) was calculated and used for the main analysis. The range of values of the pressure algometer was 0 to 10 kg, with a minimal sensibility of 0.1 kg. For these specific cases, the algometry has higher reliability (intraclass correlation coefficient [ICC], 0.91; 95% confidence interval, 0.82-0.97) for PPT measurements in older patients. 30 In addition, previous studies have reported an intraexaminer reliability for this procedure ranging from 0.6 to 0.97, and the interexaminer reliability ranged from 0.4 to 0.98. 32 Pressure pain threshold measurements were collected at both the TMJ at the bottom of the anatomical snuffbox, tubercle of the scaphoid bone, and unciform apophysis of the hamate bone.
Strength Measurements Pinch Strength. The pinch strength was measured by a mechanical pinch gauge (Baseline, Irvington, NY), while the patient was in the sitting position with the shoulder adducted and neutrally rotated and the elbow flexed at 90°. 33-35 Two different measurements were taken: first, the tip pinch between the index finger and thumb and second, the tripod pinch between the index and medial fingers and the thumb. The reliability of this procedure to measure the pinch strength has been found to be on the order of 0.93. 36 Likewise, this method has been used in the past by us 17-19 and others 34,37 with positive results. Grip Strength Measurements. Grip strength measurements were taken with a grip dynamometer (Baseline, Irvington, NY), while the patient was also in the sitting position, which has a precision and reliability of ±3% for grip strength measurements. 38-40 We have used in this method in the past 17,18 as others 34,37 finding it as a popper method to measure this variable. The reliability of the measurements was expressed by ICC between 0.82 and 0.97 for grip strength measurements. 36 Pinch and grip strength measurements were expressed in kilograms. The instrument was calibrated before and after treatment of each subject. The reliability of these measurements and instruments has been shown by the Australian/Canadian Osteoarthritis Hand Index. 41,42 We 17-19 and others 28,29,34,37 have used this method in the past to measure the pinch and grip strength in patients with TCOA finding positive results.
Intervention The treatment was delivered in 4 sessions that were distributed over 2 weeks. These patients received 4 sessions
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Fig 1. Maitland's passive accessory mobilization technique: mobilization of posterior-anterior gliding of the TMJ.
of Maitland's passive accessory mobilization or sham, with the treatment being applied to the dominant hand.
Passive Accessory Mobilization: Application of Convex/Concave Rule. We performed a passive accessory mobilization also known as mobilization of posterior-anterior gliding of the TMJ (Fig 1). The initial posture involved the subject in sitting pose with his arm in the anatomical position, the elbow flexed at 90°, the forearm and hand with the cubital facing downwards, and the dorsal face against the body of the physiotherapist. The physiotherapist took the right thumb metacarpal bone of the subject with his right thumb and index finger and made a specific passive accessory mobilization with posterior-anterior gliding of the TMJ for 3 minutes with a 1-minute pause. This action was repeated 3 times. Then, the physiotherapist glides the first metacarpal bone and with a gentle oscillatory technique as described by Maitland. 43 The latter was applied in a posterior-anterior direction. To avoid pain or spasm, which may interfere with the study, the force used for the mobilization corresponded to a small-amplitude oscillation. It is important to emphasize at this point that in the posterior-anterior passive accessory mobilization of the first metacarpal bone, the head and body must slide in the same direction. Subjects were frequently questioned in an attempt to ensure that no pain was produced, and the magnitude of the force applied was based on this feedback. The technique was performed as far as possible into range of the accessory-passive mobilization movement without producing pain. Throughout the study, the mobilization technique was performed for 3 minutes and repeated 3 more times with 1-minute rest between repetitions. During the mobilization period, approximately 60 oscillations per minute were performed. This is because the articular surface of the trapezium is convex, and the surface of the first metacarpal bone is concave. 14,44
Sham Technique. Because sham manipulations involve extensive therapist handlings, 22 we chose a technique that would minimize the intervention of the physical therapist. Therefore, participants in the sham group attended the same number of sessions as did those in the passive joint mobilization group, but they received intermittent ultrasound at nontherapeutic doses (0 watts/cm 2) for 10 minutes
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Assessed for eligibility (n = 30)
Enrollment
Excluded (n = 2) ♦ Not meeting inclusion criteria (n = 2)
Randomized (n = 28)
Allocation Allocated to intervention (n = 14) ♦ Received allocated intervention (n = 14) ♦ Did not receive allocated (n = 0)
Allocated to intervention (n = 14) ♦ Received allocated intervention (n = 14) ♦ Did not receive allocated
Follow-Up Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Analysis Analyzed (n = 14) ♦ Excluded from analysis (n = 0)
Analyzed (n = 14) ♦ Excluded from analysis (n = 0)
Fig 2. Flow diagram of criteria in the study.
in the hypothenar area of the dominant hand. Gel was used as required. 45-47
Study Protocol Each subject attended 4 passive accessory mobilization or sham technique sessions, scheduled on separate days, at least 48 hours apart and at the same time of day. Participants were not allowed to take any analgesic or anti-inflammatory drug for approximately 24 hours before each session. After that, pretreatment measurements were assessed by a blinded assessor, with more than 5 years of experience. Three measurements were done with a 1-minute pause period between measurements to avoid temporal summation. The mean of these 3 measurements was used for analysis. The subjects were divided randomly, using the following computer program: http://www.graphpad.com/quickcalcs/ randomize1.cfm, into 2 groups: passive accessory mobilization technique or sham technique. Subjects received 4 sessions, distributed in 2 weeks by a manipulative physio-
therapist blinded to the subjects' condition and with 9 years of experience. Posttreatment data were recorded 5 minutes after finished treatment, the first follow-up data were assessed 1 week after the treatment, and the second followup data were assessed 2 weeks after the treatment according to the sequence mentioned previously. The present document was prepared according to the editorial form of medical publishing and CONSORT publishing rules. 48
Sample Size Determination The sample size and power calculations were performed using Sample Power statistical software version 15 (SPSS, Inc, Chicago, IL). Within-group effect size was calculated using Cohen d coefficient. The calculations were based on detecting differences of 20% in PPT after posttreatment, a 2-tailed test, and an α level equal to .05, and a power of 80%. These variables generated a sample size of 14 subjects per group.
Statistics. The data were analyzed using SPSS version 15.0 (SPSS, Inc, Chicago, IL). The results were expressed as the
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Fig 3. Effect of passive accessory mobilization on PPT in A, TMJ; B, scaphoid bone; and C, apophysis of the hamate bone. mean ± SE. Intraclass correlation coefficient and standard error of measurement (SEM) were calculated to assess intraexaminer reliability of PPT data. Normal distribution of the sample was analyzed using the Kolmogorov-Smirnov test (P N .05). The Student t test was used to analyze the PPT variables and strength measurements, comparing the experimental group to the sham group data. A 2 × 3 repeat measures analysis of variance (ANOVA) was used, and the factors analyzed were time (pre-post) group (treatment and sham) and time × group interaction. The Bonferroni test was used for the post hoc analysis of specific comparisons between variables. When the differences were not significant with ANOVA, the post hoc was not performed, and the statistical analysis, finished. For all data in the study, P b .05 was considered significant. Cohen D was calculated to determine the effect size.
RESULTS Twenty-eight patients (71.43% females) with TCOA, aged 70 to 90 years (mean, 82.57 ± 1.06 years), were included in this study and assigned to 1 of 2 groups who
received either the passive accessory mobilization technique (n = 14) or a sham (n = 14). Figure 2 shows the flow diagram of subject progress through the study and the following criteria. All subjects were right-hand dominant. No significant differences between the groups (P N .05) were found on key demographic variables and baseline levels of PPT, tip pinch, tripod pinch, or grip strength. The demographic and clinical data of each group are detailed in Table 1. A normal distribution was confirmed with the Kolmogorov-Smirnov test (P N .05). No subjects dropped out during the different phases of the study, and no adverse effects were detected after the application of the three treatments. None of the subjects began drug therapy during the course of the study.
Pressure Pain Threshold in the TMJ The intraexaminer reliability of PPT measurements of the TMJ was determined as ICC of 0.96, and the SEM was 1.26 kg/cm 2. The PPT outcomes for the TMJ demonstrated significant differences for the time factor (F = 5.67; P = .001;
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Table 2. Pressure pain thresholds (kg/cm 2) over the TMJ, the scaphoid bone, and hamate bone PPT (kg/cm2)
Passive joint mobilization group (14)
Sham group (14)
TMJ
Mean ± SD—% changes
Mean ± SD—% changes
Cohen's D
Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
3.85 ± 1.26 3.99 ± 1.35 3.94 ± 1.36 4.75 ± 1.45 −0.14 ± 0.28 —3.61 −0.09 ± 0.25 —2.22 −0.89 ⁎ ± 0.24 —22.98
3.88 ± 1.29 3.34 ± 1.53 4.01 ± 1.48 3.94 ± 1.61 0.54 ± 0.28 —13.81 −0.13 ± 0.25 —3.31 −0.06 ± 0.24 —1.66
0.81 1.67 0.15 2.16
4.84 ± 1.61 4.71 ± 1.94 4.59 ± 1.97 5.27 ± 1.76 0.13 ± 0.48 —2.73 0.25 ± 0.42 —5.17 −0.43 ± 0.32 —8.86
5.03 ± 1.97 5.18 ± 2.39 5.54 ± 2.52 4.96 ± 2.39 −0.15 ± 0.48 —3.05 −0.51 ± 0.42 —10.09 0.07 ± 0.32 —1.35
2.03 2.31 2.13 2.88
6.32 ± 1.62 5.93 ± 2.00 5.81 ± 2.06 6.58 ± 1.51 0.39 ± 0.47 —6.16 0.51 ± 0.44 —8.14 −0.25 ± 0.34 —4.01
6.41 ± 2.04 6.67 ± 2.26 7.17 ± 2.69 6.16 ± 2.83 −0.26 ± 0.47 —4.12 −0.76 ± 0.44 —11.93 0.24 ± 0.34 —3.79
2.82 2.8 2.79 3.74
Effect size calculations
Scaphoid bone Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference Hamate bone Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
⁎ The mean difference is significant at P b .05 level.
partial eta = 0.18) and for the group × time interaction (F = 3.57; P = .018; partial eta = 0.12). We found significant differences between the pretreatment (3.85 ± 1.26 kg/cm 2) and second follow-up periods in the passive accessory mobilization group (4.75 ± 1.45 kg/cm 2; P b .007) but did not find statistical differences in the first follow-up period postintervention for mechanical hypoalgesia on the TMJ (3.99 ± 1.35 kg/cm 2; P N .05). However, no significant difference was identified between the pretreatment and second follow-up periods (3.94 ± 1.36 kg/cm 2; P N .05). No significant differences were identified in the sham group (P N .05) (Fig 3A). The data are summarized in Table 2.
Pressure Pain Threshold in the Scaphoid Bone The intraexaminer reliability of PPT measurements of the scaphoid bone was determined as ICC of 0.77, and the SEM was 4.40 kg/cm 2. The ANOVA detected no interaction effects; however, a significant effect for time (F = 0.22; P = .88; partial eta = 0.0009) or for the group × time interaction (F = 1.93; P = .12; partial eta = 0.07) was noted. See Figure 3B. The data are summarized in Table 2.
Pressure Pain Threshold in the Hamate Bone The intraexaminer reliability of PPT measurements of the hamate bone was determined as ICC of 0.72, and the SEM was 3.81 kg/cm 2.
The ANOVA revealed significant differences for the group × time interaction (F = 3.76; P = .014; partial eta = 0.13) but not for the time interaction (F = 0.155; P = .93; partial eta = 0.006) regarding data of PPT over the hamate bone. We found that the passive accessory mobilization group caused no significant differences between pretreatment (6.32 ± 1.62 kg/cm 2) and posttreatment and follow-up periods (P N .05; Fig 3C). The data are summarized in Table 2.
Tip and Tripod Pinch and Grip Strength The intraexaminer reliability of strength measurements with tip pinch, tripod pinch, and grip strength was determined as ICC of 0.72, 0.89, and 0.90, respectively. The SEM was 3.81 kg for tip pinch, 2.68 kg for tripod pinch, and 10.79 kg for grip strength. The ANOVA revealed significant differences between times but not between groups × times for force levels over the tip pinch (time: F = 3.37; P = .02; partial eta = 0.11 and group × time: F = 0.16; P = .92; partial eta = 0.006), tripod pinch (time: F = 2.20; P = .095; partial eta = 0.078 and group × time: F = 0.39; P = .76; partial eta = 0.015), and grip pinch (time: F = 0.74; P = .53; partial eta = 0.028 and group × time: F = 2.73; P = .05; partial eta = 0.095). We found that passive accessory mobilization does not produced significant differences among pretreatment, posttreatment, and follow-up periods (P N .05). Finally, no significant differences among pretreatment, posttreatment,
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Fig 4. Effect of passive accessory mobilization on A, tip pinch; B, tripod pinch; and C, grip strength. and follow-up periods were detected in the sham group (P N .05) (Fig 4A, B, and C). All data are summarized in Table 3.
DISCUSSION We found that specific passive accessory mobilization with posterior-anterior gliding of the TMJ increases PPT but does not increases pinch or grip strength in patients with TCOA. We found no significant changes in PPT in the scaphoid bone or the hamate bone of the dominant hand before or after the treatment. Our findings suggest that intermittent ultrasound at nontherapeutic of the TMJ does not provide benefit to the patients. To our knowledge, this is the first report in which the TCOA is treated using this technique, which is in contrast to other studies in patients with TCOA.
Hypoalgesic Effects This study established that 4 sessions of 9 minutes each with posterior-anterior passive accessory mobilization of the TMJ of the thumb increased the PPT of the TMJ more significantly than did the sham procedure, in patients with TCOA.
We found that passive accessory mobilization increased the PPT, compared with the sham procedure in the TMJ (23.4% vs 1.6% in the second week of follow-up), indicating that the chosen therapy could induce a decrease in pain to pressure. These data are consistent with evidence from spinal mobilization studies 22,49 that demonstrated improvement in the PPT by approximately 25% and 30% after treatment. Mobilization in the peripheral joint showed a 15.4% increase of the PPT in conjunction with movement of the elbow. 50 These reports are clinically significant because Bird and Dickson 51 reported that the minimum clinically significant change in PPT could be considered more than 15%. Therefore, both peripheral and spinal mobilizations immediately reduce mechanical hyperalgesia, compared with the sham procedures. 52 Consistent with reports of other measurements, an improvement of more than 15% may be considered to reflect a clinically significant effect. 51,53 That is, the case of passive accessory mobilization in patients with adhesive capsulitis (frozen shoulder). Half of the patients were mobilized anteriorly and the other half posteriorly. They found pain relief in both groups; however, the posterior passive accessory mobilization group had better results in range of motion. 12 In a
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Table 3. Evaluation of pinch tip, tripod pinch, and grip strength Pinch and grip strength (kg)
Passive joint mobilization group (14)
Sham group (14)
Tip pinch
Mean ± SD—% changes
Mean ± SD—% changes
Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
Effect size calculations Cohen's D
2.35 ± 0.89 2.15 ± 0.8 2.03 ± 0.88 2.08 ± 0.99 0.20 ± 0.16 —8.5 0.33 ± 0.14 —13.96 0.28 ± 0.19 —11.84
2.56 ± 1.78 2.50 ± 1.67 2.27 ± 1.54 2.31 ± 1.42 0.06 ± 0.16 —2.37 0.29 ± 0.14 —11.31 0.25 ± 0.19 —9.64
0.44 0.14 0.15 0.16
3.01 ± 1.08 2.89 ± 1.06 2.74 ± 1.17 2.65 ± 1.08 0.12 ± 0.14 —4.15 0.27 ± 0.18 —9.0 0.37 ± 0.14 —12.2
3.10 ± 1.92 3.05 ± 2.06 3.01 ± 1.83 2.94 ± 1.64 0.05 ± 0.14 —1.84 0.09 ± 0.18 —2.88 0.16 ± 0.14 —5.29
0.95 0.94 0.73 0.49
10.64 ± 8.33 11.00 ± 8.17 11.71 ± 8.90 11.64 ± 8.92 −0.36 ± 0.47 —3.36 −1.07 ± 0.60 —10.07 −1.00 ± 0.43 —9.4
9.27 9.5 8.35 9.27
Tripod pinch Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference Grip strength Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
10.93 ± 4.50 11.21 ± 4.64 10.21 ± 3.70 10.96 ± 4.85 −0.29 ± 0.47 —2.61 0.71 ± 0.60 —6.54 −0.04 ± 0.43 —0.33
recent study, the same mobilization technique was applied to patients with ankle sprain and showed a 17.6% increase of the PPT. 54 Similarly, another study 52 using passive accessory mobilization in patients with OA of the knee showed the same results. In other structures such the spine, Sterling et al 22 demonstrated that a posterior-anterior mobilization technique applied to the posterior joint of the C5-6 spinal level resulted in an immediate increase of 25% in PPT on the symptomatic cervical level in patients with idiopathic neck pain. Likewise, others have reported an increase in PPT ranging from 10% to 20% in patients with lateral epicondylalgia. 50 The effect of hand OA on hand function has been investigated by several authors. It has been generally accepted that hand OA has a negative effect on hand function, which is mostly seen in grade III and IV hand OA but does not result in significant disability. 8 If the patient had a grade IV OA or higher, the effect was mild and not a cause of significant disability. Severe grade IV OA, however, leads to major impairment. 8 Although we found significant effects in our study, at the moment, we lack of the information necessary to explain the mechanism involved. In other structures, these types of techniques have caused hypoalgesia by inhibiting thermal temporal summation of pain. 55,56 This is a mechanism
mediated by the C fibers and, therefore, associated with the development of acute into chronic pain and maintenance of the chronic pain. 57 Our results regarding the changes in the PPT of this study may raise a controversy. Because PPT was statistically significant at the TMJ but not at the scaphoid bone and the hamate bone, it is essential that future studies investigate whether the passive accessory mobilization technique has more influence when used to treat a particular anatomical area.
Motor Effects We found no changes in motor activity. Our results differ from those obtained in patients with cubital tunnel syndrome treated with mobilization techniques, in which there was an improvement of grip and pinch strengths. 58 Similarly, hand function was maintained over a period of 12 months after the end of treatment. 58 Other studies using daily home-based exercises for 16 weeks modestly improved grip and pinch strengths, although this benefit was not sufficient to see an improvement in self-reported hand physical function. 2 In the past, passive translatory movements have been used, 12,13 and different results have been obtained with the use of translatory actions plus dynamic movements, whereas passive mobilization is maintained. 59 It is important to emphasize that any of these techniques
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include neurodynamic intervention. Therefore, as shown before, it is quite plausible that, to get increases in strength, neurologic tension might be needed. 17,19
Limitations Although we had positive results, we recognize the limitations of the study. Basically, population-based epidemiological studies with greater sample sizes are needed to permit a more generalized interpretation of these results. We recognize that a restriction in the glide component of a joint motion biomechanically leads to both compression and gapping during end-range movements due to incongruence of the joint surfaces and this may lead to pain. In addition, we did not use the distraction mobilization technique. This, in turn, may cause pain by the contact generated between the articular surfaces during mobilization. Furthermore, it could raise controversy that improvements were not quantified in a disability scale of the hand or upper extremity. Although the improvements were not quantified with a disability scale of hand or upper extremity nor visual analog scales pain intensity, these data might have been relevant to determining the significance clinical results; manual algometry has been shown to be associated with levels of pain similar to the range of values that we obtained in our subjects. 60,61 We used ultrasound as a sham. This was because sham manipulations involve extensive therapist handlings. 22 As we wanted to avoid this parameter completely, we chose a technique that would minimize the intervention of the physical therapist. In addition, it could have been of great interest to compare results linked to sex information; however, the patient availability and sample size calculations made that comparison impossible. Therefore, our result can only refer to the heterogenic group. Finally, based on the limitations, the results of this study should be interpreted with caution.
CONCLUSIONS In conclusion, we found that a specific mobilization of posterior-anterior passive accessory mobilization of the TMJ produces significant decrease of pain to pressure in patients with dominant hand TCOA.
Practical Applications • Maitland's passive accessory mobilization decreases pain sensitivity in the TMJ and increases hand strength. • This study suggests that this conservative intervention has neurophysiologic mechanisms of action and could be used as a supplementary rehabilitation method.
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FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST This work was supported in part by personal funds of JHV and grants from J. Robert Cade Foundation and Mons Carlos V. Cruvellier Foundation to JHV and GBS. The authors report no other conflicts of interest.
REFERENCES 1. Yanow J, Pappagallo M. A patient with osteoarthritis and cardiovascular disease presenting with bilateral hip pain: a case report. Cases J 2009;2:8823. 2. Rogers MW, Wilder FV. Exercise and hand osteoarthritis symptomatology: a controlled crossover trial. J Hand Ther 2009;22:10-7 [discussion 9-20; quiz 18]. 3. Towheed TE. Systematic review of therapies for osteoarthritis of the hand. Osteoarthritis Cartilage 2005;13:455-62. 4. Wajon A, Ada L. No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: a randomised controlled trial. Aust J Physiother 2005;51:245-9. 5. Dias R, Chandrasenan J, Rajaratnam V, Burke FD. Basal thumb arthritis. Postgrad Med J 2007;83:40-3. 6. Batra A, Kanvinde R. Osteoarthritis of the thumb trapeziometacarpal joint. Current Orthopaedics 2007;21:135-44. 7. Neumann DA, Bielefeld T. The carpometacarpal joint of the thumb: stability, deformity, and therapeutic intervention. J Orthop Sports Phys Ther 2003;33:386-99. 8. Bagis S, Sahin G, Yapici Y, Cimen OB, Erdogan C. The effect of hand osteoarthritis on grip and pinch strength and hand function in postmenopausal women. Clin Rheumatol 2003;22: 420-4. 9. Livesey JP, Norris SH, Page RE. First carpometacarpal joint arthritis. A comparison of two arthroplasty techniques. J Hand Surg Br 1996;21:182-8. 10. Egan MY, Brousseau L. Splinting for osteoarthritis of the carpometacarpal joint: a review of the evidence. Am J Occup Ther 2007;61:70-8. 11. Rannou F, Dimet J, Boutron I, Baron G, Fayad F, Mace Y, et al. Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med 2009;150:661-9. 12. Schomacher J. The convex-concave rule and the lever law. Man Ther 2009;14:579-82. 13. Hsu AT, Chiu JF, Chang JH. Biomechanical analysis of axial distraction mobilization of the glenohumeral joint—a cadaver study. Man Ther 2009;14:381-6. 14. Kaltenborn FM, Evjenth O. Manual mobilization of the extremity joints. Basic examination and treatment techniques (i). 4th ed. Oslo: Olaf Norlin Bokhandel; 1989. p. 26-7. 15. Maitland G. Vertebral manipulation. Oxford: ButterworthHeinemann; 1998. p. 3-13. 16. Mulligan B. Manual Therapy: “NAGS”, “SNAGS”, “MWMS”, etc. 4th ed. Wellington: Plane View Services Limited; 1999. 17. Villafañe JH, Silva GB, Fernandez-Carnero J. Short-term effects of the neurodynamic mobilization in patients with secondary thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther 2011;34:449-56. 18. Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis. A randomized, controlled trial. J Manipulative Physiol Ther 2011;34:547-56. 19. Villafañe JH, Silva GB, Bishop MD, Fernandez-Carnero J. Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb
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38. Sayer AA, Syddall HE, Martin HJ, Dennison EM, Roberts HC, Cooper C. Is grip strength associated with health-related quality of life? Findings from the Hertfordshire Cohort Study. Age Ageing 2006;35:409-15. 39. Solanki PV, Mulgaonkar KP, Rao SA. Effect of early mobilisation on grip strength, pinch strength and work of hand muscles in cases of closed diaphyseal fracture radiusulna treated with dynamic compression plating. J Postgrad Med 2000;46:84-7. 40. Schweizer R, Martin DD, Schonau E, Ranke MB. Muscle function improves during growth hormone therapy in short children born small for gestational age: results of a peripheral quantitative computed tomography study on body composition. J Clin Endocrinol Metab 2008;93:2978-83. 41. Dziedzic KS, Thomas E, Myers H, Hill S, Hay EM. The Australian/Canadian osteoarthritis hand index in a community-dwelling population of older adults: reliability and validity. Arthritis Rheum 2007;57:423-8. 42. Allen KD, Jordan JM, Renner JB, Kraus VB. Validity, factor structure, and clinical relevance of the AUSCAN Osteoarthritis Hand Index. Arthritis Rheum 2006;54:551-6. 43. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther 2001;81:984-94. 44. Exelby L. Peripheral mobilisations with movement. Man Ther 1996;1:118-26. 45. Celik D, Atalar AC, Sahinkaya S, Demirhan M. The value of intermittent ultrasound treatment in subacromial impingement syndrome. Acta Orthop Traumatol Turc 2009; 43:243-7. 46. Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH. Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J 2008;17:936-43. 47. Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ 2010;340:c2756. 48. Johnson C, Green B. Submitting manuscripts to biomedical journals: common errors and helpful solutions. J Manipulative Physiol Ther 2009;32:1-12. 49. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapyinduced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther 1998;21:448-53. 50. Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther 2003;83: 374-83. 51. Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emerg Med 2001;38: 639-43. 52. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Man Ther 2007; 12:109-18. 53. Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 2001;38:633-8. 54. Yeo HK, Wright A. Hypoalgesic effect of a passive accessory mobilisation technique in patients with lateral ankle pain. Man Ther 2011;16:373-7. 55. Bialosky JE, Bishop MD, Price DD, Robinson ME, Vincent KR, George SZ. A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome. J Orthop Sports Phys Ther 2009;39:709-23.
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56. Beneciuk JM, Bishop MD, George SZ. Effects of upper extremity neural mobilization on thermal pain sensitivity: a sham-controlled study in asymptomatic participants. J Orthop Sports Phys Ther 2009;39:428-38. 57. Rygh LJ, Svendsen F, Fiska A, Haugan F, Hole K, Tjolsen A. Long-term potentiation in spinal nociceptive systems—how acute pain may become chronic. Psychoneuroendocrinology 2005;30:959-64. 58. Oskay D, Meric A, Kirdi N, Firat T, Ayhan C, Leblebicioglu G. Neurodynamic mobilization in the conservative treatment of cubital tunnel syndrome: long-term follow-up of 7 cases. J Manipulative Physiol Ther 2010;33: 156-63.
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59. Herrero-Gallego P, Tricas-Moreno J, Lucha-Lopez O, Caudevilla-Polo S, Hidalgo-Garcia C, Estebanez-De Miguel E. Indirect influence of specific Kaltenborn glide mobilizations of the carpal joint on a subject with neurological impairments. J Bodyw Mov Ther 2007;11:275-84. 60. Aasvang EK, Brandsborg B, Jensen TS, Kehlet H. Heterogeneous sensory processing in persistent postherniotomy pain. Pain 2010;150:237-42. 61. Farasyn AD, Meeusen R, Nijs J. Validity of cross-friction algometry procedure in referred muscle pain syndromes: preliminary results of a new referred pain provocation technique with the aid of a Fischer pressure algometer in patients with nonspecific low back pain. Clin J Pain 2008;24:456-62.
ABSTRACT Objective: This study evaluated the effects of Maitland's passive accessory mobilization on local hypoalgesia and strength in thumb carpometacarpal osteoarthritis (TCOA). Methods: Twenty-eight patients between 70 and 90 years old with secondary TCOA were randomized into glide mobilization and sham groups. This study was designed as a double-blind, randomized controlled trial. Therapy consisted of Maitland's passive accessory mobilization of the dominant hand during 4 sessions over 2 weeks. We measured pressure pain threshold (PPT) at the trapeziometacarpal joint (TMJ), the tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone by algometry. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU). Results: All values in sham group remained unchanged along the treatment period. In the treated group, the PPT in the TMJ was 3.85 ± 0.35 kg/cm 2, which increased after treatment to 3.99 ± 0.37 and was maintained at the same level during the first FU 3.94 ± 0.39 and second FU 4.74 ± 0.40. In contrast, we found no differences in PPT in the other studied structures after treatment. Similarly, tip, tripod pinch, and grip strength remained without change after treatment. Conclusions: Passive accessory mobilization increased PPT in the TMJ; however, it did not increase motor function in patients with TCOA. (J Manipulative Physiol Ther 2012;35:110-120) Key Indexing Terms: Thumb; Osteoarthritis; Hand Strength
steoarthritis (OA) is the one of the most common joint disorder in the United States and one of the leading causes of disability in the elderly. 1 Osteoarthritis develops relatively frequent at the trapeziometacarpal joint (TMJ), 2 often as a result of athletic injury or cumulative trauma associated with an arduous occupation or hobby. 3,4 Thumb carpometacarpal OA (TCOA) occurs with a disproportionally greater frequency in females and typically in their fifth and sixth decades of age. 5,6
O
Typically, patients report disability during a variety of occupations, domestic tasks, hobbies, and sports. Specific aggravating activities include writing, gardening, turning taps, and opening jars, with pain frequently localized at the volar surface of the joint. 2,4,7,8 Experts suggest that surgery is only indicated if conservative treatment is unsuccessful. 9 However, the more usual options for conservative treatment are exercise, splint therapy, and active daily activities. 10 These treatments
a Physical Therapist, Department of Physical Therapy, Residenze Sanitarie Assistenziali “A. Maritano,” Sangano, Italy and R.S.A “Don Menzio,” Avigliana, Italy. b Doctoral Student, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain. c Principal Investigator, Department of Physiology and Hypertension, Mons. Carlos V. Cruvellier Foundation and J. Robert Cade Foundation, San Juan, Argentina. d Assistant Professor, Department of Research Methods, School of Nutrition, Biochemistry and Pharmacy, Catholic University of Cuyo, San Juan, Argentina.
e Full Professor, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain. f Principal Investigator, Research Group of Musculo-Skeletal Pain and Motor Control, European University of Madrid, Spain. Submit requests for reprints to: Jorge H. Villafañe PT, MSc, Regione Generala 11/16, Piossasco (TO), Italy (e-mail: [email protected]). Paper submitted September 3, 2011; in revised form November 14, 2011; accepted November 14, 2011. 0161-4754/$36.00 Copyright © 2012 by National University of Health Sciences. doi:10.1016/j.jmpt.2011.12.002
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are able to produce improvements at 12 months after treatment; however, no improvement in pain was found at short periods after therapy. 11 Orthopedic manual therapy avoids the risk of joint injury during application of the mobilization. To do that, it usually performed the glide as a passive mobilization of the treated joint. 12,13 It is suggested that passive accessory mobilization decreases articular pain and increases the pain-free range of movement in other articular architectures. 12,13 Despite the numerous manual therapy approaches to the treatment of OA that have been proposed, passive accessory mobilization was never tested in patients with OA. 14-16 In recent studies, we have applied different techniques of manual therapy for treating TCOA to increase strength to the tip and tripod pinch and grip strengths and decrease mechanical hyperalgesia. 17-19 However, we never pursued a passive joint mobilization with distraction in patients with hand OA. On the other hand, it has been published that manual therapy reduces pain and increases physical function in patients with hip OA. 20 In addition, data from animal models of articular pain suggest that joint mobilization may decrease processing of pain, 21 indicating the possibility that joint mobilization with a distraction could benefit patients with OA of the dominant hand. Several studies performed in humans have shown that mobilization of other joints benefits patients in pain perception and motor function, 22-24 but studies focusing on the neurophysiologic effects in patients with TCOA are lacking. 22-24 Therefore, the purpose of the present study was to determine whether posterior-anterior passive accessory mobilization of the TMJ decreases mechanical hyperalgesia and increases strength to the tip and tripod pinch and grip strengths in patients with TCOA in the dominant hand.
METHODS Subjects Twenty-eight subjects, aged 70 to 90 years, with TCOA in the dominant hand with a clinical pathologic history of more than 10 years were recruited by the Department of Physical Therapy, “Residenze Sanitarie Assistenziali” (RR.SS.AA), which depends on Azienda Sanitaria Locale 3, Collegno (Italy). Patients were diagnosed by x-rays and randomly separated into either treated or sham group. The baseline demographic characteristics of the population are listed in Table 1. The inclusion criteria involved those patients with OA of the dominant hand stage III and IV TCOA according to the Eaton-Littler-Burton Classification 6,25 and preserved cognitive capacities according to age, ex-factory workers, and housewives whose use of the dominant hand was common and systematic.
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Table 1. Baseline demographics for Maitland's passive accessory mobilization and sham groups Characteristic Age Sex (M/F)
Passive joint mobilization group (14)
Sham group (14)
P
81.43 ± 5.11 10/14 (71.43% female)
83.71 ± 5.80 10/14 (71.43% female)
.28
3.85 ± 1.26 4.84 ± 1.61 6.32 ± 1.62
3.88 ± 1.29 5.03 ± 1.97 6.41 ± 2.04
.96 .78 .90
2.56 ± 1.78 3.10 ± 1.92 10.64 ± 8.33
.70 .88 .91
PPT (kg/cm2) TMJ Scaphoid bone Hamate bone
Pinch and grip strength (kg) Tip pinch Tripod pinch Grip strength
2,35 ± 0.89 3.01 ± 1.08 10.93 ± 4.50
The exclusion criteria involved those patients with carpal tunnel syndrome, arthritis, surgical interventions on the TMJ, finger spring, or de Quervain tenosynovitis. Patients presenting degenerative or nondegenerative neurologic conditions in which pain perception was altered were also excluded. This study was designed as a double-blind, randomized controlled trial (RCT). Informed consent was obtained from all participants, and all procedures were conducted according to the Declaration of Helsinki. This study was supervised by the Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain. The protocol (N°93571/c) was approved by the Ethical Committee in Azienda Sanitaria Locale 3, Collegno, Italy, and trial registration of the Current Controlled Trials ISRCTN70578774. The complete protocol can be accessed at http://www.controlledtrials.com/ISRCTN70578774. In the randomization procedure, each subject was randomly assigned to either the experimental group or the sham group using simple randomization with a random number generator. Random sequences of 0 or 1 were run through the patient database with a 50% chance of obtaining treatment or sham, respectively. The numbers were randomly assigned to each participant, who was then allocated accordingly. The randomization procedure was facilitated by the online software accessed at http://www.graphpad. com/quickcalcs/randomize1.cfm.
Pain Measurement Patients with TCOA frequently refer pain in the base of the hand. Because the TMJ is the most affected during TCOA, we measured pressure pain threshold (PPT) in the bones linked to the TMJ; those are the unciform apophysis of the hamate bone and the scaphoid bone.
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We measured the PPT with a mechanical pressure algometer (Wagner Instruments, Greenwich, CT) with a 1-cm 2 rubber-tipped plunger mounted on a force transducer. 26,27 This method has been used in the past by us 17-19 and others 28,29 with positive results. The PPT is defined as the minimum amount of pressure that results in the sense of pressure changing to pain. 30,31 The mean of 3 measurements (intraexaminer reliability) was calculated and used for the main analysis. The range of values of the pressure algometer was 0 to 10 kg, with a minimal sensibility of 0.1 kg. For these specific cases, the algometry has higher reliability (intraclass correlation coefficient [ICC], 0.91; 95% confidence interval, 0.82-0.97) for PPT measurements in older patients. 30 In addition, previous studies have reported an intraexaminer reliability for this procedure ranging from 0.6 to 0.97, and the interexaminer reliability ranged from 0.4 to 0.98. 32 Pressure pain threshold measurements were collected at both the TMJ at the bottom of the anatomical snuffbox, tubercle of the scaphoid bone, and unciform apophysis of the hamate bone.
Strength Measurements Pinch Strength. The pinch strength was measured by a mechanical pinch gauge (Baseline, Irvington, NY), while the patient was in the sitting position with the shoulder adducted and neutrally rotated and the elbow flexed at 90°. 33-35 Two different measurements were taken: first, the tip pinch between the index finger and thumb and second, the tripod pinch between the index and medial fingers and the thumb. The reliability of this procedure to measure the pinch strength has been found to be on the order of 0.93. 36 Likewise, this method has been used in the past by us 17-19 and others 34,37 with positive results. Grip Strength Measurements. Grip strength measurements were taken with a grip dynamometer (Baseline, Irvington, NY), while the patient was also in the sitting position, which has a precision and reliability of ±3% for grip strength measurements. 38-40 We have used in this method in the past 17,18 as others 34,37 finding it as a popper method to measure this variable. The reliability of the measurements was expressed by ICC between 0.82 and 0.97 for grip strength measurements. 36 Pinch and grip strength measurements were expressed in kilograms. The instrument was calibrated before and after treatment of each subject. The reliability of these measurements and instruments has been shown by the Australian/Canadian Osteoarthritis Hand Index. 41,42 We 17-19 and others 28,29,34,37 have used this method in the past to measure the pinch and grip strength in patients with TCOA finding positive results.
Intervention The treatment was delivered in 4 sessions that were distributed over 2 weeks. These patients received 4 sessions
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Fig 1. Maitland's passive accessory mobilization technique: mobilization of posterior-anterior gliding of the TMJ.
of Maitland's passive accessory mobilization or sham, with the treatment being applied to the dominant hand.
Passive Accessory Mobilization: Application of Convex/Concave Rule. We performed a passive accessory mobilization also known as mobilization of posterior-anterior gliding of the TMJ (Fig 1). The initial posture involved the subject in sitting pose with his arm in the anatomical position, the elbow flexed at 90°, the forearm and hand with the cubital facing downwards, and the dorsal face against the body of the physiotherapist. The physiotherapist took the right thumb metacarpal bone of the subject with his right thumb and index finger and made a specific passive accessory mobilization with posterior-anterior gliding of the TMJ for 3 minutes with a 1-minute pause. This action was repeated 3 times. Then, the physiotherapist glides the first metacarpal bone and with a gentle oscillatory technique as described by Maitland. 43 The latter was applied in a posterior-anterior direction. To avoid pain or spasm, which may interfere with the study, the force used for the mobilization corresponded to a small-amplitude oscillation. It is important to emphasize at this point that in the posterior-anterior passive accessory mobilization of the first metacarpal bone, the head and body must slide in the same direction. Subjects were frequently questioned in an attempt to ensure that no pain was produced, and the magnitude of the force applied was based on this feedback. The technique was performed as far as possible into range of the accessory-passive mobilization movement without producing pain. Throughout the study, the mobilization technique was performed for 3 minutes and repeated 3 more times with 1-minute rest between repetitions. During the mobilization period, approximately 60 oscillations per minute were performed. This is because the articular surface of the trapezium is convex, and the surface of the first metacarpal bone is concave. 14,44
Sham Technique. Because sham manipulations involve extensive therapist handlings, 22 we chose a technique that would minimize the intervention of the physical therapist. Therefore, participants in the sham group attended the same number of sessions as did those in the passive joint mobilization group, but they received intermittent ultrasound at nontherapeutic doses (0 watts/cm 2) for 10 minutes
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Assessed for eligibility (n = 30)
Enrollment
Excluded (n = 2) ♦ Not meeting inclusion criteria (n = 2)
Randomized (n = 28)
Allocation Allocated to intervention (n = 14) ♦ Received allocated intervention (n = 14) ♦ Did not receive allocated (n = 0)
Allocated to intervention (n = 14) ♦ Received allocated intervention (n = 14) ♦ Did not receive allocated
Follow-Up Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Lost to follow-up (n = 0) Discontinued intervention (n = 0)
Analysis Analyzed (n = 14) ♦ Excluded from analysis (n = 0)
Analyzed (n = 14) ♦ Excluded from analysis (n = 0)
Fig 2. Flow diagram of criteria in the study.
in the hypothenar area of the dominant hand. Gel was used as required. 45-47
Study Protocol Each subject attended 4 passive accessory mobilization or sham technique sessions, scheduled on separate days, at least 48 hours apart and at the same time of day. Participants were not allowed to take any analgesic or anti-inflammatory drug for approximately 24 hours before each session. After that, pretreatment measurements were assessed by a blinded assessor, with more than 5 years of experience. Three measurements were done with a 1-minute pause period between measurements to avoid temporal summation. The mean of these 3 measurements was used for analysis. The subjects were divided randomly, using the following computer program: http://www.graphpad.com/quickcalcs/ randomize1.cfm, into 2 groups: passive accessory mobilization technique or sham technique. Subjects received 4 sessions, distributed in 2 weeks by a manipulative physio-
therapist blinded to the subjects' condition and with 9 years of experience. Posttreatment data were recorded 5 minutes after finished treatment, the first follow-up data were assessed 1 week after the treatment, and the second followup data were assessed 2 weeks after the treatment according to the sequence mentioned previously. The present document was prepared according to the editorial form of medical publishing and CONSORT publishing rules. 48
Sample Size Determination The sample size and power calculations were performed using Sample Power statistical software version 15 (SPSS, Inc, Chicago, IL). Within-group effect size was calculated using Cohen d coefficient. The calculations were based on detecting differences of 20% in PPT after posttreatment, a 2-tailed test, and an α level equal to .05, and a power of 80%. These variables generated a sample size of 14 subjects per group.
Statistics. The data were analyzed using SPSS version 15.0 (SPSS, Inc, Chicago, IL). The results were expressed as the
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Fig 3. Effect of passive accessory mobilization on PPT in A, TMJ; B, scaphoid bone; and C, apophysis of the hamate bone. mean ± SE. Intraclass correlation coefficient and standard error of measurement (SEM) were calculated to assess intraexaminer reliability of PPT data. Normal distribution of the sample was analyzed using the Kolmogorov-Smirnov test (P N .05). The Student t test was used to analyze the PPT variables and strength measurements, comparing the experimental group to the sham group data. A 2 × 3 repeat measures analysis of variance (ANOVA) was used, and the factors analyzed were time (pre-post) group (treatment and sham) and time × group interaction. The Bonferroni test was used for the post hoc analysis of specific comparisons between variables. When the differences were not significant with ANOVA, the post hoc was not performed, and the statistical analysis, finished. For all data in the study, P b .05 was considered significant. Cohen D was calculated to determine the effect size.
RESULTS Twenty-eight patients (71.43% females) with TCOA, aged 70 to 90 years (mean, 82.57 ± 1.06 years), were included in this study and assigned to 1 of 2 groups who
received either the passive accessory mobilization technique (n = 14) or a sham (n = 14). Figure 2 shows the flow diagram of subject progress through the study and the following criteria. All subjects were right-hand dominant. No significant differences between the groups (P N .05) were found on key demographic variables and baseline levels of PPT, tip pinch, tripod pinch, or grip strength. The demographic and clinical data of each group are detailed in Table 1. A normal distribution was confirmed with the Kolmogorov-Smirnov test (P N .05). No subjects dropped out during the different phases of the study, and no adverse effects were detected after the application of the three treatments. None of the subjects began drug therapy during the course of the study.
Pressure Pain Threshold in the TMJ The intraexaminer reliability of PPT measurements of the TMJ was determined as ICC of 0.96, and the SEM was 1.26 kg/cm 2. The PPT outcomes for the TMJ demonstrated significant differences for the time factor (F = 5.67; P = .001;
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Table 2. Pressure pain thresholds (kg/cm 2) over the TMJ, the scaphoid bone, and hamate bone PPT (kg/cm2)
Passive joint mobilization group (14)
Sham group (14)
TMJ
Mean ± SD—% changes
Mean ± SD—% changes
Cohen's D
Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
3.85 ± 1.26 3.99 ± 1.35 3.94 ± 1.36 4.75 ± 1.45 −0.14 ± 0.28 —3.61 −0.09 ± 0.25 —2.22 −0.89 ⁎ ± 0.24 —22.98
3.88 ± 1.29 3.34 ± 1.53 4.01 ± 1.48 3.94 ± 1.61 0.54 ± 0.28 —13.81 −0.13 ± 0.25 —3.31 −0.06 ± 0.24 —1.66
0.81 1.67 0.15 2.16
4.84 ± 1.61 4.71 ± 1.94 4.59 ± 1.97 5.27 ± 1.76 0.13 ± 0.48 —2.73 0.25 ± 0.42 —5.17 −0.43 ± 0.32 —8.86
5.03 ± 1.97 5.18 ± 2.39 5.54 ± 2.52 4.96 ± 2.39 −0.15 ± 0.48 —3.05 −0.51 ± 0.42 —10.09 0.07 ± 0.32 —1.35
2.03 2.31 2.13 2.88
6.32 ± 1.62 5.93 ± 2.00 5.81 ± 2.06 6.58 ± 1.51 0.39 ± 0.47 —6.16 0.51 ± 0.44 —8.14 −0.25 ± 0.34 —4.01
6.41 ± 2.04 6.67 ± 2.26 7.17 ± 2.69 6.16 ± 2.83 −0.26 ± 0.47 —4.12 −0.76 ± 0.44 —11.93 0.24 ± 0.34 —3.79
2.82 2.8 2.79 3.74
Effect size calculations
Scaphoid bone Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference Hamate bone Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
⁎ The mean difference is significant at P b .05 level.
partial eta = 0.18) and for the group × time interaction (F = 3.57; P = .018; partial eta = 0.12). We found significant differences between the pretreatment (3.85 ± 1.26 kg/cm 2) and second follow-up periods in the passive accessory mobilization group (4.75 ± 1.45 kg/cm 2; P b .007) but did not find statistical differences in the first follow-up period postintervention for mechanical hypoalgesia on the TMJ (3.99 ± 1.35 kg/cm 2; P N .05). However, no significant difference was identified between the pretreatment and second follow-up periods (3.94 ± 1.36 kg/cm 2; P N .05). No significant differences were identified in the sham group (P N .05) (Fig 3A). The data are summarized in Table 2.
Pressure Pain Threshold in the Scaphoid Bone The intraexaminer reliability of PPT measurements of the scaphoid bone was determined as ICC of 0.77, and the SEM was 4.40 kg/cm 2. The ANOVA detected no interaction effects; however, a significant effect for time (F = 0.22; P = .88; partial eta = 0.0009) or for the group × time interaction (F = 1.93; P = .12; partial eta = 0.07) was noted. See Figure 3B. The data are summarized in Table 2.
Pressure Pain Threshold in the Hamate Bone The intraexaminer reliability of PPT measurements of the hamate bone was determined as ICC of 0.72, and the SEM was 3.81 kg/cm 2.
The ANOVA revealed significant differences for the group × time interaction (F = 3.76; P = .014; partial eta = 0.13) but not for the time interaction (F = 0.155; P = .93; partial eta = 0.006) regarding data of PPT over the hamate bone. We found that the passive accessory mobilization group caused no significant differences between pretreatment (6.32 ± 1.62 kg/cm 2) and posttreatment and follow-up periods (P N .05; Fig 3C). The data are summarized in Table 2.
Tip and Tripod Pinch and Grip Strength The intraexaminer reliability of strength measurements with tip pinch, tripod pinch, and grip strength was determined as ICC of 0.72, 0.89, and 0.90, respectively. The SEM was 3.81 kg for tip pinch, 2.68 kg for tripod pinch, and 10.79 kg for grip strength. The ANOVA revealed significant differences between times but not between groups × times for force levels over the tip pinch (time: F = 3.37; P = .02; partial eta = 0.11 and group × time: F = 0.16; P = .92; partial eta = 0.006), tripod pinch (time: F = 2.20; P = .095; partial eta = 0.078 and group × time: F = 0.39; P = .76; partial eta = 0.015), and grip pinch (time: F = 0.74; P = .53; partial eta = 0.028 and group × time: F = 2.73; P = .05; partial eta = 0.095). We found that passive accessory mobilization does not produced significant differences among pretreatment, posttreatment, and follow-up periods (P N .05). Finally, no significant differences among pretreatment, posttreatment,
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Fig 4. Effect of passive accessory mobilization on A, tip pinch; B, tripod pinch; and C, grip strength. and follow-up periods were detected in the sham group (P N .05) (Fig 4A, B, and C). All data are summarized in Table 3.
DISCUSSION We found that specific passive accessory mobilization with posterior-anterior gliding of the TMJ increases PPT but does not increases pinch or grip strength in patients with TCOA. We found no significant changes in PPT in the scaphoid bone or the hamate bone of the dominant hand before or after the treatment. Our findings suggest that intermittent ultrasound at nontherapeutic of the TMJ does not provide benefit to the patients. To our knowledge, this is the first report in which the TCOA is treated using this technique, which is in contrast to other studies in patients with TCOA.
Hypoalgesic Effects This study established that 4 sessions of 9 minutes each with posterior-anterior passive accessory mobilization of the TMJ of the thumb increased the PPT of the TMJ more significantly than did the sham procedure, in patients with TCOA.
We found that passive accessory mobilization increased the PPT, compared with the sham procedure in the TMJ (23.4% vs 1.6% in the second week of follow-up), indicating that the chosen therapy could induce a decrease in pain to pressure. These data are consistent with evidence from spinal mobilization studies 22,49 that demonstrated improvement in the PPT by approximately 25% and 30% after treatment. Mobilization in the peripheral joint showed a 15.4% increase of the PPT in conjunction with movement of the elbow. 50 These reports are clinically significant because Bird and Dickson 51 reported that the minimum clinically significant change in PPT could be considered more than 15%. Therefore, both peripheral and spinal mobilizations immediately reduce mechanical hyperalgesia, compared with the sham procedures. 52 Consistent with reports of other measurements, an improvement of more than 15% may be considered to reflect a clinically significant effect. 51,53 That is, the case of passive accessory mobilization in patients with adhesive capsulitis (frozen shoulder). Half of the patients were mobilized anteriorly and the other half posteriorly. They found pain relief in both groups; however, the posterior passive accessory mobilization group had better results in range of motion. 12 In a
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Table 3. Evaluation of pinch tip, tripod pinch, and grip strength Pinch and grip strength (kg)
Passive joint mobilization group (14)
Sham group (14)
Tip pinch
Mean ± SD—% changes
Mean ± SD—% changes
Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
Effect size calculations Cohen's D
2.35 ± 0.89 2.15 ± 0.8 2.03 ± 0.88 2.08 ± 0.99 0.20 ± 0.16 —8.5 0.33 ± 0.14 —13.96 0.28 ± 0.19 —11.84
2.56 ± 1.78 2.50 ± 1.67 2.27 ± 1.54 2.31 ± 1.42 0.06 ± 0.16 —2.37 0.29 ± 0.14 —11.31 0.25 ± 0.19 —9.64
0.44 0.14 0.15 0.16
3.01 ± 1.08 2.89 ± 1.06 2.74 ± 1.17 2.65 ± 1.08 0.12 ± 0.14 —4.15 0.27 ± 0.18 —9.0 0.37 ± 0.14 —12.2
3.10 ± 1.92 3.05 ± 2.06 3.01 ± 1.83 2.94 ± 1.64 0.05 ± 0.14 —1.84 0.09 ± 0.18 —2.88 0.16 ± 0.14 —5.29
0.95 0.94 0.73 0.49
10.64 ± 8.33 11.00 ± 8.17 11.71 ± 8.90 11.64 ± 8.92 −0.36 ± 0.47 —3.36 −1.07 ± 0.60 —10.07 −1.00 ± 0.43 —9.4
9.27 9.5 8.35 9.27
Tripod pinch Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference Grip strength Pretreatment Posttreatment First follow-up Second follow-up Predifference/postdifference Predifference/first follow-up difference Predifference/second follow-up difference
10.93 ± 4.50 11.21 ± 4.64 10.21 ± 3.70 10.96 ± 4.85 −0.29 ± 0.47 —2.61 0.71 ± 0.60 —6.54 −0.04 ± 0.43 —0.33
recent study, the same mobilization technique was applied to patients with ankle sprain and showed a 17.6% increase of the PPT. 54 Similarly, another study 52 using passive accessory mobilization in patients with OA of the knee showed the same results. In other structures such the spine, Sterling et al 22 demonstrated that a posterior-anterior mobilization technique applied to the posterior joint of the C5-6 spinal level resulted in an immediate increase of 25% in PPT on the symptomatic cervical level in patients with idiopathic neck pain. Likewise, others have reported an increase in PPT ranging from 10% to 20% in patients with lateral epicondylalgia. 50 The effect of hand OA on hand function has been investigated by several authors. It has been generally accepted that hand OA has a negative effect on hand function, which is mostly seen in grade III and IV hand OA but does not result in significant disability. 8 If the patient had a grade IV OA or higher, the effect was mild and not a cause of significant disability. Severe grade IV OA, however, leads to major impairment. 8 Although we found significant effects in our study, at the moment, we lack of the information necessary to explain the mechanism involved. In other structures, these types of techniques have caused hypoalgesia by inhibiting thermal temporal summation of pain. 55,56 This is a mechanism
mediated by the C fibers and, therefore, associated with the development of acute into chronic pain and maintenance of the chronic pain. 57 Our results regarding the changes in the PPT of this study may raise a controversy. Because PPT was statistically significant at the TMJ but not at the scaphoid bone and the hamate bone, it is essential that future studies investigate whether the passive accessory mobilization technique has more influence when used to treat a particular anatomical area.
Motor Effects We found no changes in motor activity. Our results differ from those obtained in patients with cubital tunnel syndrome treated with mobilization techniques, in which there was an improvement of grip and pinch strengths. 58 Similarly, hand function was maintained over a period of 12 months after the end of treatment. 58 Other studies using daily home-based exercises for 16 weeks modestly improved grip and pinch strengths, although this benefit was not sufficient to see an improvement in self-reported hand physical function. 2 In the past, passive translatory movements have been used, 12,13 and different results have been obtained with the use of translatory actions plus dynamic movements, whereas passive mobilization is maintained. 59 It is important to emphasize that any of these techniques
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include neurodynamic intervention. Therefore, as shown before, it is quite plausible that, to get increases in strength, neurologic tension might be needed. 17,19
Limitations Although we had positive results, we recognize the limitations of the study. Basically, population-based epidemiological studies with greater sample sizes are needed to permit a more generalized interpretation of these results. We recognize that a restriction in the glide component of a joint motion biomechanically leads to both compression and gapping during end-range movements due to incongruence of the joint surfaces and this may lead to pain. In addition, we did not use the distraction mobilization technique. This, in turn, may cause pain by the contact generated between the articular surfaces during mobilization. Furthermore, it could raise controversy that improvements were not quantified in a disability scale of the hand or upper extremity. Although the improvements were not quantified with a disability scale of hand or upper extremity nor visual analog scales pain intensity, these data might have been relevant to determining the significance clinical results; manual algometry has been shown to be associated with levels of pain similar to the range of values that we obtained in our subjects. 60,61 We used ultrasound as a sham. This was because sham manipulations involve extensive therapist handlings. 22 As we wanted to avoid this parameter completely, we chose a technique that would minimize the intervention of the physical therapist. In addition, it could have been of great interest to compare results linked to sex information; however, the patient availability and sample size calculations made that comparison impossible. Therefore, our result can only refer to the heterogenic group. Finally, based on the limitations, the results of this study should be interpreted with caution.
CONCLUSIONS In conclusion, we found that a specific mobilization of posterior-anterior passive accessory mobilization of the TMJ produces significant decrease of pain to pressure in patients with dominant hand TCOA.
Practical Applications • Maitland's passive accessory mobilization decreases pain sensitivity in the TMJ and increases hand strength. • This study suggests that this conservative intervention has neurophysiologic mechanisms of action and could be used as a supplementary rehabilitation method.
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FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST This work was supported in part by personal funds of JHV and grants from J. Robert Cade Foundation and Mons Carlos V. Cruvellier Foundation to JHV and GBS. The authors report no other conflicts of interest.
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