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Immediate Effects of Manual Traction on Radiographically Determined Joint Space Width in the Hip Joint
IMMEDIATE EFFECTS OF MANUAL TRACTION ON RADIOGRAPHICALLY DETERMINED JOINT SPACE WIDTH IN THE HIP JOINT Tomonori Sato, PhD, a Naomi Sato, PhD, b Kenji Masui, BS, c and Yukinobu Hirano, MS d
ABSTRACT Objective: The purpose of this study was to investigate the immediate effects of manual traction of the hip joint on joint space width (JSW) on asymptomatic subjects. Methods: Asymptomatic, healthy male volunteers (n = 15), aged 25 to 34 years were included in this study. Three radiographs were obtained with the subjects in the supine position, before and after loading with 10% of his body weight, and after manual traction on only the right hip joint. Joint space width was measured by a radiologist at the point described by Jacobson and Sonne-Holm. Results: There were significant changes in JSW on the right hip joint and left hip joint between the baseline (before loading) and immediately after loading. We also observed a significantly increased JSW on only the right hip joint between periods that followed loading and manual traction on the right hip joint. There was no significant change in JSW on the left hip joint between periods that followed loading and manual traction on the right hip joint. Conclusions: The results of this study suggest that a significant increase in JSW in young, healthy male patients can occur immediately after manual traction of the hip joint. (J Manipulative Physiol Ther 2014;xx:1-7) Key Indexing Terms: Hip; Traction; Radiography; Osteoarthritis
steoarthritis (OA) is a common disorder of the synovial joints and has increased prevalence in people who are 60 years or older. It is characterized by the narrowing of joint spaces (progressive damage to the articular cartilage) and new bone formation (osteophytes). The hip joint is the most commonly affected by OA after the knee, and OA has become one of the most common causes of disability in elderly individuals. 1 Risk factors for hip OA include genetics, age, obesity, joint malalignment, and sex. 2,3 Symptoms of hip OA include pain in the groin, buttocks, lateral or anterior thigh, and knee, particularly during or after weight-bearing activities. A clinical indicator of hip OA is painful restriction of hip
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Associate Professor, Department of Physical Therapy, Tokoha University, Shizuoka, Japan. b Professor, Department of Nursing, Hamamatsu University School of Medicine, Hamamatsu, Japan. c Chief Physical Therapist, Department of Physical Therapy, Osaka Kaisei Hospital, Osaka, Japan. d Professor, Department of Physical Therapy, Tokoha University, Shizuoka, Japan. Submit requests for reprints to: Tomonori Sato, PhD, Associate Professor, Tokoha University, 1-30 Mizuochi, Aoiku 420-0831, Japan. (e-mail: [email protected]). Paper submitted April 11, 2014; in revised form July 11, 2014; accepted August 4, 2014. 0161-4754/$36.00 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.08.002
movements. Radiologic indicators include decreased joint space, osteophyte formation, and subchondral sclerosis. 1,4 Severe hip OA leading to complete joint destruction eventually requires surgical intervention. Treatment of hip OA ranges from conservative management to surgery. Conservative management includes walking, aerobics or aquarobic exercise, and education. 5 -9 Joint mobilization and manipulation are also commonly used and recommended for patients with hip OA. 10 -14 In a treatment modality, traction force is applied manually along the long axis of the femur (manual traction) and is called long-axis mobilization or manipulation (also called long-axis distraction and traction). Previous studies reported that long-axis mobilization or manipulation of the hip joint results in favorable outcomes. 10-15 In long-axis mobilization or manipulation, the leg is pulled caudally to separate opposing joint surfaces; this may widen the joint space width (JSW) and may help unload the joint cartilage. MacDonald et al 11 reported the benefits of long-axis mobilization, which included a decrease in pain, and improvement in range of motion (ROM) and disability in 7 patients. Strunk et al 13 also reported that patients who received treatments including long-axis mobilization showed improvements in the impression of their change and gait. Furthermore, a randomized controlled trial found that patients treated with long-axis mobilization had better outcomes with regard to pain, function, and ROM compared with patients treated with only an exercise therapy program. 10
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Results from a recent study by Abbot et al 9 were consistent with those of Hoeksma et al. 10 Several studies have investigated the effects of traction force on JSW. 16 -19 One study examined JSW in the glenohumeral joint after manual traction but reported no change in JSW. 18 Studies involving the ankle and knee joints indicated an increase in JSW after treatment similar to manual traction. 16,17,19 However, in these studies, an external fixator was used to apply traction force. Thus, no studies have evaluated the mechanical effect of manual traction of the hip joint on JSW, although this technique is frequently used. Therefore, the purpose of this study was to investigate the immediate effects of manual traction of the hip joint on JSW in asymptomatic subjects.
METHODS Subjects This study included 15 asymptomatic, healthy male volunteers (25-34 years). Subjects were excluded if they had a history of hip disorders or surgery. All subjects were informed of the study design and objectives and provided written informed consent before participating in the study. This study was conducted with ethical approval from the Committee for Clinical Research of Osaka Kaisei Hospital.
Experimental Procedure. At the beginning of the study, subjects were asked to lie in a supine position for 10 minutes, with the aim of eliminating any abnormal loading on the hip joints that may have preceded the subject's arrival at the laboratory. After the resting period, the first anterior-posterior radiographs (baseline) (DR-1000; Hitachi, Tokyo, Japan) were obtained using a previously described method and well-established method for measuring JSW. 20-22 For all radiographs, subjects were asked to lie in the supine position with their feet straight and pointed upward, while their lower extremities were placed in a neutral abduction-adduction position along the limb's functional axis. The x-ray beam was centered 2 cm over the pubic symphysis along the vertical midline. The tube-to-film distance was 120 cm in all cases. After the first radiographs were obtained, subjects walked to an examination room that was approximately 3 m from the x-ray room. Then, subjects remained in a standing position and were loaded with 10% of their body weight placed directly over their waist for 10 minutes (Fig 1). This loading method, a modification of a method reported in previous studies, 23,24 was used to load the hip joints and subsequently reduce the joint space. Subjects were instructed to equally distribute their weight on both feet for bilateral loading on their hip joints. Subjects received feedback during this period via the MatScan system (Nitta Co, Osaka, Japan; Fig 1). After loading, subjects walked back to the x-ray room and returned to the
Fig 1. Weight bearing before first radiograph is shown. Subjects were standing 10 minutes with 10% of their weight over their weight. MatScan system was used for distributing their weight equally on the feet. (Color version of figure is available online.) supine position in which the first radiograph was taken, and we obtained a second set of radiographs. After the radiographs and while the subjects were in the same supine position, manual traction on the right hip joint was performed by an examiner who has more than 15 years of experience with this technique. To investigate the immediate effect of manual traction, we decided to apply traction force to subjects while they remained on the radiographic table. We also expected that the radiograph obtained without changing posture after application of manual traction could show the effects of the traction force and would mitigate confounding factors arising from positional change. Throughout the manual traction procedure, an assistant stabilized the subject's pelvis. The therapist performed traction by placing his hands just above the ankle and mobilizing the hip joint by flexing and abducting it to 30° and slight external rotation (maximum loose-packed position). The assistant used goniometer for having subjects taken maximum loose-packed position. The hip joint then was pulled caudally for traction force until the therapist felt maximum resistance (Fig 2). The traction force was applied 3 times for 10 seconds with a 5-second rest interval between each traction. The traction force applied was not controlled among subjects because the force required depended on the subject's clinical presentation. A third set of
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Fig 2. Manual traction. Subjects positioned supine with hip in 30° of flexion and 30° of abduction and slight lateral rotation. Therapists held proximal to the ankle and pulled toward the inferior direction. Arrow shows direction of the force. (Color version of figure is available online.) radiographs was obtained immediately after manual traction. Previous studies indicated that positional changes in the hip joint can alter JSW measured by radiograph. 25,26 Therefore, all 3 radiographs were obtained with subjects' hips in the same position to minimize variability.
Radiographic Analysis. Joint space width was measured in the upper, weight-bearing part of the joint using the method described by Jacobsen et al, 20 -22 in which an apical transaction was determined by a vertical line through the center of femoral head (Fig 3). The center of the femoral head was determined by the intersection between 2 linear perpendicular bisectors that connect the centers of 2 adjacent points on the outer layer of the humeral head. A single radiologist performed measurements in all 15 subjects using a 0.01-mm graded scale. This included right and left side radiographs for all 15 subjects at baseline and after the 10% weight-bearing period, after manual traction. Each radiograph was randomly presented to the radiologist. Reliability. Before the main study, we performed a pilot study to examine intrarater reliability for radiologic JSW measurements. The pilot study included 5 subjects who fulfilled the study inclusion criteria; the second measurement was performed 24 hours later. Statistical Analysis. Data were analyzed using the SPSS (version 17.0; SPSS, Tokyo, Japan). Intrarater reliability for radiologic measurements was assessed using the intraclass correlation coefficient (ICC). Differences in mean JSW at baseline and after loading as well as those after loading and manual traction were
Sato et al Manual Traction and Hip Joint Space
Fig 3. Measurement of hip JSW. “A” showing the JSW: apical transaction by a vertical line through the center of femoral head. analyzed using 1-way analysis of variance. The values of P b .05 were defined to be statistically significant.
RESULTS The ICC(1,2) for radiologic measurement indicated a high levels of intrarater reliability (Table 1). We observed significant changes in JSW between baseline and after loading for both the right and the left hip joints (P b .001; Table 2). In addition, we observed a significant difference in JSW between the periods that followed loading and manual traction. For the right side, JSW significantly increased after manual traction compared with JSW after loading (P b .001). No significant change was observed in JSW on the left side (control) between periods after loading and manual traction on the right hip joint.
DISCUSSION Manual traction (long-axis mobilization) of the hip has been considered to increase JSW. However, no studies have qualitatively examined whether manual traction of the hip joint causes increase in JSW. In the present study, we found that manual traction of the hip joint significantly increased JSW. Furthermore, we did not observe a significant change in JSW on the left (control) side. Hence, it is unlikely that the increase in JSW was due to homeostatic recovery from loading, but rather, it can be attributed to manual traction. Gokeler et al 18 examined the effects of manual traction on JSW in the shoulder joint for asymptomatic subjects, but they found that manual traction showed no significant effects on JSW. Perhaps structure differences between the shoulder and hip joints may explain why their results were different from ours. Nevertheless, we are confident that joint loading before manual traction amplified the latter's
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Table 1. Intrarater Reliability of the Radiologist
Table 2. Comparison of the Joint Space Width Before and After Loading With 10% Weight and After Manual Traction.
First Measurement (mean ± SD)
Second Measurement (mean ± SD)
After 24 h
ICC, Upper Band
95% CI, Lower Band
3.56 ± 0.82
3.55 ± 0.80
0.95
0.99
0.96
CI, confidence interval.
Before Loading After 10% Loading After Manual Traction (mean ± SD) (mean ± SD) (mean ± SD) Right side 3.86 ± 0.7 Left side 3.59 ± 0.59 a
effect in the present study conducted in asymptomatic subjects. In the present study, subjects were loaded with 10% of their body weight using a modification from a previously described method. 23,24 Previous studies 23,24 applied compressive force to the shoulder to investigate the loading effect on intervertebral disks, which is different from our study that applied compressive force to the waist to examine the loading effect on hip joint cartilage. As noted above, we found that 10% body weight resulted in a significant decrease in JSW. We expected these results because the percentage of water content in the wet weight of joint cartilage is almost the same as that in intervertebral disks. 27,28 We suspect that fluid loss from the cartilage and viscoelastic deformation produced the narrowing of the joint space. 23,24,29-31 Treatments including manual traction of the hip joint are effective in reducing pain and improving function. 10-14 Furthermore, self-reported pain is significantly associated with narrowing of JSW. 20-22,32 Therefore, we hypothesize that the mechanical effects of manual traction of the hip joint can decrease pain observed in clinical practice. Several studies have proposed a neurophysiological mechanism for the pain-relieving effects of joint mobilization. 33-38 However, the duration of treatments in our study differed from those reported in previous studies and can be considered very short. We included only 3 repetitions of 10-second duration, whereas previous studies that examined the neurophysiological effects of joint mobilization included durations ranging from 30 seconds to several minutes. In addition, the gliding technique was used in some of these neurophysiological studies, which is in contrast to the manual traction used in this study. Therefore, the neurophysiological effects alone may not explain the pain-relieving effects of manual traction of the hip joint. Therefore, based on our current results, we propose additional mechanisms that may explain how our technique can reduce pain. The first mechanism is a change in intra-articular pressure. In the normal hip joint, there is no increase in intra-articular pressures, nor is there any tension in the capsule within the normal ROM. 39 -41 However, Goddard and Gosling 42 reported that intra-articular pressure in OA hips could increase or decrease depending on the extent of degeneration. Furthermore, they reported that pain was more often experienced by patients who presented with a higher intra-articular pressure. Unsworth et al 43 reported that a decrease in intra-articular pressure results from a distraction force on the metacarpophalangeal joint. Although the present study was performed on a lower extremity, manual traction may improve elasticity of the joint capsule and may decrease joint pressure, thereby reducing pain.
b c
3.55 ± 0.65 a 3.31 ± 0.57 a
3.95 ± 0.74 b 3.37 ± 0.56 c
P b .01 (compared with before loading). P b .01 (compared with after 10% loading). P N .05 (compared with after 10% loading).
In the second mechanism, manual traction may relieve pressure on sensitive tissues. Muscles surrounding the hip joint compress the joint capsule and subsequently cause pain because the capsule and synovium are richly innervated. 44 -46 Joint separation after manual traction may release compression of the capsule and synovium. The JSW was measured at the point described by Jacobsen et al. 20 -22 Buchanan and Kean 47 hypothesize that there are 3 types of joint degeneration that exist depending on where osteophytes form around the hip joint. The most common type includes osteophytes along superior and lateral aspects of the joint, which is observed in 80% patients. Therefore, JSW at the point used in the current study suggests that the mechanical effect demonstrated in our study may apply to all patients with OA. Subjects in the present study were asymptomatic volunteers whom we studied because they do not necessarily have an unrestricted ROM in other joints. 48,49 This supports our conclusion that including asymptomatic volunteers provides validity to the findings in terms of clinical efficacy. Another reason for including asymptomatic subjects is that symptomatic subjects are expected to have more severe degenerative changes in the periarticular tissue and greater restriction in ROM. 45,50,51 Lloyd-Roberts 45 reported that as OA develops, the capsular elasticity decreases with a subsequent increase in capsular contracture. Thus, changes in JSW after manual traction would not have been observed following the limited repetitions performed in the present study if joint capsules were fibrotic and resistant to the force generated by joint mobilization. We consider that manual traction gives rise to a positive mechanical effect if OA has not reached severe degeneration. 52 Therefore, we chose asymptomatic subjects who may have a possible restriction but are still likely to respond to manual traction. Furthermore, to provide more validity to the findings in terms of clinical efficacy, the subjects' hip joints were loaded with 10% of their body weight, resulting in a narrowed joint space. This loading made the effects of manual traction on the JSW more evident in asymptomatic subjects.
Limitations The current study has several limitations. This study involved a small number of subjects (N = 15), and only
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male subjects were included because of concerns regarding radiation effects. We chose asymptomatic subjects, but because symptomatic patients tend to have more restricted ROM and capsular contracture compared with asymptomatic subjects, one may speculate that manual traction may be of greater benefit to this population. This study concentrated only on the immediate effects of mobilization; therefore, long-term effects cannot be concluded.
Future Studies Future studies should assess not only the immediate effects but also the long-term effects on patients with hip arthritis and will include a larger sample size and a control group. Future evaluation should be performed that will measure manual traction force to preserve JSW and possibly measure the slowing of joint degeneration.
CONCLUSION This study investigated the immediate effects of manual traction force on JSW of the hip joint in asymptomatic subjects. The results of this study suggest that a significant increase in JSW in young, healthy male patients can occur immediately after manual traction of the hip joint.
Practical Applications • This study showed significantly increased JSW after manual traction in young asymptomatic subjects. • Theoretically, manual traction may potentially be used for patients with hip OA for unloading hip joint or for slowing joint degeneration; however, future studies are needed to confirm this on appropriate patient populations.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): T.S. Design (planned the methods to generate the results): T.S., Y.H. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): T.S.
Sato et al Manual Traction and Hip Joint Space
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): T.S., K.M. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): N.S., T.S. Literature search (performed the literature search): T.S., N.S. Writing (responsible for writing a substantive part of the manuscript): T.S.
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ABSTRACT Objective: The purpose of this study was to investigate the immediate effects of manual traction of the hip joint on joint space width (JSW) on asymptomatic subjects. Methods: Asymptomatic, healthy male volunteers (n = 15), aged 25 to 34 years were included in this study. Three radiographs were obtained with the subjects in the supine position, before and after loading with 10% of his body weight, and after manual traction on only the right hip joint. Joint space width was measured by a radiologist at the point described by Jacobson and Sonne-Holm. Results: There were significant changes in JSW on the right hip joint and left hip joint between the baseline (before loading) and immediately after loading. We also observed a significantly increased JSW on only the right hip joint between periods that followed loading and manual traction on the right hip joint. There was no significant change in JSW on the left hip joint between periods that followed loading and manual traction on the right hip joint. Conclusions: The results of this study suggest that a significant increase in JSW in young, healthy male patients can occur immediately after manual traction of the hip joint. (J Manipulative Physiol Ther 2014;xx:1-7) Key Indexing Terms: Hip; Traction; Radiography; Osteoarthritis
steoarthritis (OA) is a common disorder of the synovial joints and has increased prevalence in people who are 60 years or older. It is characterized by the narrowing of joint spaces (progressive damage to the articular cartilage) and new bone formation (osteophytes). The hip joint is the most commonly affected by OA after the knee, and OA has become one of the most common causes of disability in elderly individuals. 1 Risk factors for hip OA include genetics, age, obesity, joint malalignment, and sex. 2,3 Symptoms of hip OA include pain in the groin, buttocks, lateral or anterior thigh, and knee, particularly during or after weight-bearing activities. A clinical indicator of hip OA is painful restriction of hip
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a
Associate Professor, Department of Physical Therapy, Tokoha University, Shizuoka, Japan. b Professor, Department of Nursing, Hamamatsu University School of Medicine, Hamamatsu, Japan. c Chief Physical Therapist, Department of Physical Therapy, Osaka Kaisei Hospital, Osaka, Japan. d Professor, Department of Physical Therapy, Tokoha University, Shizuoka, Japan. Submit requests for reprints to: Tomonori Sato, PhD, Associate Professor, Tokoha University, 1-30 Mizuochi, Aoiku 420-0831, Japan. (e-mail: [email protected]). Paper submitted April 11, 2014; in revised form July 11, 2014; accepted August 4, 2014. 0161-4754/$36.00 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2014.08.002
movements. Radiologic indicators include decreased joint space, osteophyte formation, and subchondral sclerosis. 1,4 Severe hip OA leading to complete joint destruction eventually requires surgical intervention. Treatment of hip OA ranges from conservative management to surgery. Conservative management includes walking, aerobics or aquarobic exercise, and education. 5 -9 Joint mobilization and manipulation are also commonly used and recommended for patients with hip OA. 10 -14 In a treatment modality, traction force is applied manually along the long axis of the femur (manual traction) and is called long-axis mobilization or manipulation (also called long-axis distraction and traction). Previous studies reported that long-axis mobilization or manipulation of the hip joint results in favorable outcomes. 10-15 In long-axis mobilization or manipulation, the leg is pulled caudally to separate opposing joint surfaces; this may widen the joint space width (JSW) and may help unload the joint cartilage. MacDonald et al 11 reported the benefits of long-axis mobilization, which included a decrease in pain, and improvement in range of motion (ROM) and disability in 7 patients. Strunk et al 13 also reported that patients who received treatments including long-axis mobilization showed improvements in the impression of their change and gait. Furthermore, a randomized controlled trial found that patients treated with long-axis mobilization had better outcomes with regard to pain, function, and ROM compared with patients treated with only an exercise therapy program. 10
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Journal of Manipulative and Physiological Therapeutics Month 2014
Results from a recent study by Abbot et al 9 were consistent with those of Hoeksma et al. 10 Several studies have investigated the effects of traction force on JSW. 16 -19 One study examined JSW in the glenohumeral joint after manual traction but reported no change in JSW. 18 Studies involving the ankle and knee joints indicated an increase in JSW after treatment similar to manual traction. 16,17,19 However, in these studies, an external fixator was used to apply traction force. Thus, no studies have evaluated the mechanical effect of manual traction of the hip joint on JSW, although this technique is frequently used. Therefore, the purpose of this study was to investigate the immediate effects of manual traction of the hip joint on JSW in asymptomatic subjects.
METHODS Subjects This study included 15 asymptomatic, healthy male volunteers (25-34 years). Subjects were excluded if they had a history of hip disorders or surgery. All subjects were informed of the study design and objectives and provided written informed consent before participating in the study. This study was conducted with ethical approval from the Committee for Clinical Research of Osaka Kaisei Hospital.
Experimental Procedure. At the beginning of the study, subjects were asked to lie in a supine position for 10 minutes, with the aim of eliminating any abnormal loading on the hip joints that may have preceded the subject's arrival at the laboratory. After the resting period, the first anterior-posterior radiographs (baseline) (DR-1000; Hitachi, Tokyo, Japan) were obtained using a previously described method and well-established method for measuring JSW. 20-22 For all radiographs, subjects were asked to lie in the supine position with their feet straight and pointed upward, while their lower extremities were placed in a neutral abduction-adduction position along the limb's functional axis. The x-ray beam was centered 2 cm over the pubic symphysis along the vertical midline. The tube-to-film distance was 120 cm in all cases. After the first radiographs were obtained, subjects walked to an examination room that was approximately 3 m from the x-ray room. Then, subjects remained in a standing position and were loaded with 10% of their body weight placed directly over their waist for 10 minutes (Fig 1). This loading method, a modification of a method reported in previous studies, 23,24 was used to load the hip joints and subsequently reduce the joint space. Subjects were instructed to equally distribute their weight on both feet for bilateral loading on their hip joints. Subjects received feedback during this period via the MatScan system (Nitta Co, Osaka, Japan; Fig 1). After loading, subjects walked back to the x-ray room and returned to the
Fig 1. Weight bearing before first radiograph is shown. Subjects were standing 10 minutes with 10% of their weight over their weight. MatScan system was used for distributing their weight equally on the feet. (Color version of figure is available online.) supine position in which the first radiograph was taken, and we obtained a second set of radiographs. After the radiographs and while the subjects were in the same supine position, manual traction on the right hip joint was performed by an examiner who has more than 15 years of experience with this technique. To investigate the immediate effect of manual traction, we decided to apply traction force to subjects while they remained on the radiographic table. We also expected that the radiograph obtained without changing posture after application of manual traction could show the effects of the traction force and would mitigate confounding factors arising from positional change. Throughout the manual traction procedure, an assistant stabilized the subject's pelvis. The therapist performed traction by placing his hands just above the ankle and mobilizing the hip joint by flexing and abducting it to 30° and slight external rotation (maximum loose-packed position). The assistant used goniometer for having subjects taken maximum loose-packed position. The hip joint then was pulled caudally for traction force until the therapist felt maximum resistance (Fig 2). The traction force was applied 3 times for 10 seconds with a 5-second rest interval between each traction. The traction force applied was not controlled among subjects because the force required depended on the subject's clinical presentation. A third set of
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Fig 2. Manual traction. Subjects positioned supine with hip in 30° of flexion and 30° of abduction and slight lateral rotation. Therapists held proximal to the ankle and pulled toward the inferior direction. Arrow shows direction of the force. (Color version of figure is available online.) radiographs was obtained immediately after manual traction. Previous studies indicated that positional changes in the hip joint can alter JSW measured by radiograph. 25,26 Therefore, all 3 radiographs were obtained with subjects' hips in the same position to minimize variability.
Radiographic Analysis. Joint space width was measured in the upper, weight-bearing part of the joint using the method described by Jacobsen et al, 20 -22 in which an apical transaction was determined by a vertical line through the center of femoral head (Fig 3). The center of the femoral head was determined by the intersection between 2 linear perpendicular bisectors that connect the centers of 2 adjacent points on the outer layer of the humeral head. A single radiologist performed measurements in all 15 subjects using a 0.01-mm graded scale. This included right and left side radiographs for all 15 subjects at baseline and after the 10% weight-bearing period, after manual traction. Each radiograph was randomly presented to the radiologist. Reliability. Before the main study, we performed a pilot study to examine intrarater reliability for radiologic JSW measurements. The pilot study included 5 subjects who fulfilled the study inclusion criteria; the second measurement was performed 24 hours later. Statistical Analysis. Data were analyzed using the SPSS (version 17.0; SPSS, Tokyo, Japan). Intrarater reliability for radiologic measurements was assessed using the intraclass correlation coefficient (ICC). Differences in mean JSW at baseline and after loading as well as those after loading and manual traction were
Sato et al Manual Traction and Hip Joint Space
Fig 3. Measurement of hip JSW. “A” showing the JSW: apical transaction by a vertical line through the center of femoral head. analyzed using 1-way analysis of variance. The values of P b .05 were defined to be statistically significant.
RESULTS The ICC(1,2) for radiologic measurement indicated a high levels of intrarater reliability (Table 1). We observed significant changes in JSW between baseline and after loading for both the right and the left hip joints (P b .001; Table 2). In addition, we observed a significant difference in JSW between the periods that followed loading and manual traction. For the right side, JSW significantly increased after manual traction compared with JSW after loading (P b .001). No significant change was observed in JSW on the left side (control) between periods after loading and manual traction on the right hip joint.
DISCUSSION Manual traction (long-axis mobilization) of the hip has been considered to increase JSW. However, no studies have qualitatively examined whether manual traction of the hip joint causes increase in JSW. In the present study, we found that manual traction of the hip joint significantly increased JSW. Furthermore, we did not observe a significant change in JSW on the left (control) side. Hence, it is unlikely that the increase in JSW was due to homeostatic recovery from loading, but rather, it can be attributed to manual traction. Gokeler et al 18 examined the effects of manual traction on JSW in the shoulder joint for asymptomatic subjects, but they found that manual traction showed no significant effects on JSW. Perhaps structure differences between the shoulder and hip joints may explain why their results were different from ours. Nevertheless, we are confident that joint loading before manual traction amplified the latter's
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Journal of Manipulative and Physiological Therapeutics Month 2014
Table 1. Intrarater Reliability of the Radiologist
Table 2. Comparison of the Joint Space Width Before and After Loading With 10% Weight and After Manual Traction.
First Measurement (mean ± SD)
Second Measurement (mean ± SD)
After 24 h
ICC, Upper Band
95% CI, Lower Band
3.56 ± 0.82
3.55 ± 0.80
0.95
0.99
0.96
CI, confidence interval.
Before Loading After 10% Loading After Manual Traction (mean ± SD) (mean ± SD) (mean ± SD) Right side 3.86 ± 0.7 Left side 3.59 ± 0.59 a
effect in the present study conducted in asymptomatic subjects. In the present study, subjects were loaded with 10% of their body weight using a modification from a previously described method. 23,24 Previous studies 23,24 applied compressive force to the shoulder to investigate the loading effect on intervertebral disks, which is different from our study that applied compressive force to the waist to examine the loading effect on hip joint cartilage. As noted above, we found that 10% body weight resulted in a significant decrease in JSW. We expected these results because the percentage of water content in the wet weight of joint cartilage is almost the same as that in intervertebral disks. 27,28 We suspect that fluid loss from the cartilage and viscoelastic deformation produced the narrowing of the joint space. 23,24,29-31 Treatments including manual traction of the hip joint are effective in reducing pain and improving function. 10-14 Furthermore, self-reported pain is significantly associated with narrowing of JSW. 20-22,32 Therefore, we hypothesize that the mechanical effects of manual traction of the hip joint can decrease pain observed in clinical practice. Several studies have proposed a neurophysiological mechanism for the pain-relieving effects of joint mobilization. 33-38 However, the duration of treatments in our study differed from those reported in previous studies and can be considered very short. We included only 3 repetitions of 10-second duration, whereas previous studies that examined the neurophysiological effects of joint mobilization included durations ranging from 30 seconds to several minutes. In addition, the gliding technique was used in some of these neurophysiological studies, which is in contrast to the manual traction used in this study. Therefore, the neurophysiological effects alone may not explain the pain-relieving effects of manual traction of the hip joint. Therefore, based on our current results, we propose additional mechanisms that may explain how our technique can reduce pain. The first mechanism is a change in intra-articular pressure. In the normal hip joint, there is no increase in intra-articular pressures, nor is there any tension in the capsule within the normal ROM. 39 -41 However, Goddard and Gosling 42 reported that intra-articular pressure in OA hips could increase or decrease depending on the extent of degeneration. Furthermore, they reported that pain was more often experienced by patients who presented with a higher intra-articular pressure. Unsworth et al 43 reported that a decrease in intra-articular pressure results from a distraction force on the metacarpophalangeal joint. Although the present study was performed on a lower extremity, manual traction may improve elasticity of the joint capsule and may decrease joint pressure, thereby reducing pain.
b c
3.55 ± 0.65 a 3.31 ± 0.57 a
3.95 ± 0.74 b 3.37 ± 0.56 c
P b .01 (compared with before loading). P b .01 (compared with after 10% loading). P N .05 (compared with after 10% loading).
In the second mechanism, manual traction may relieve pressure on sensitive tissues. Muscles surrounding the hip joint compress the joint capsule and subsequently cause pain because the capsule and synovium are richly innervated. 44 -46 Joint separation after manual traction may release compression of the capsule and synovium. The JSW was measured at the point described by Jacobsen et al. 20 -22 Buchanan and Kean 47 hypothesize that there are 3 types of joint degeneration that exist depending on where osteophytes form around the hip joint. The most common type includes osteophytes along superior and lateral aspects of the joint, which is observed in 80% patients. Therefore, JSW at the point used in the current study suggests that the mechanical effect demonstrated in our study may apply to all patients with OA. Subjects in the present study were asymptomatic volunteers whom we studied because they do not necessarily have an unrestricted ROM in other joints. 48,49 This supports our conclusion that including asymptomatic volunteers provides validity to the findings in terms of clinical efficacy. Another reason for including asymptomatic subjects is that symptomatic subjects are expected to have more severe degenerative changes in the periarticular tissue and greater restriction in ROM. 45,50,51 Lloyd-Roberts 45 reported that as OA develops, the capsular elasticity decreases with a subsequent increase in capsular contracture. Thus, changes in JSW after manual traction would not have been observed following the limited repetitions performed in the present study if joint capsules were fibrotic and resistant to the force generated by joint mobilization. We consider that manual traction gives rise to a positive mechanical effect if OA has not reached severe degeneration. 52 Therefore, we chose asymptomatic subjects who may have a possible restriction but are still likely to respond to manual traction. Furthermore, to provide more validity to the findings in terms of clinical efficacy, the subjects' hip joints were loaded with 10% of their body weight, resulting in a narrowed joint space. This loading made the effects of manual traction on the JSW more evident in asymptomatic subjects.
Limitations The current study has several limitations. This study involved a small number of subjects (N = 15), and only
Journal of Manipulative and Physiological Therapeutics Volume xx, Number
male subjects were included because of concerns regarding radiation effects. We chose asymptomatic subjects, but because symptomatic patients tend to have more restricted ROM and capsular contracture compared with asymptomatic subjects, one may speculate that manual traction may be of greater benefit to this population. This study concentrated only on the immediate effects of mobilization; therefore, long-term effects cannot be concluded.
Future Studies Future studies should assess not only the immediate effects but also the long-term effects on patients with hip arthritis and will include a larger sample size and a control group. Future evaluation should be performed that will measure manual traction force to preserve JSW and possibly measure the slowing of joint degeneration.
CONCLUSION This study investigated the immediate effects of manual traction force on JSW of the hip joint in asymptomatic subjects. The results of this study suggest that a significant increase in JSW in young, healthy male patients can occur immediately after manual traction of the hip joint.
Practical Applications • This study showed significantly increased JSW after manual traction in young asymptomatic subjects. • Theoretically, manual traction may potentially be used for patients with hip OA for unloading hip joint or for slowing joint degeneration; however, future studies are needed to confirm this on appropriate patient populations.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): T.S. Design (planned the methods to generate the results): T.S., Y.H. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): T.S.
Sato et al Manual Traction and Hip Joint Space
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): T.S., K.M. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): N.S., T.S. Literature search (performed the literature search): T.S., N.S. Writing (responsible for writing a substantive part of the manuscript): T.S.
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