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, PhDe, f

ABSTRACT

a Physical Thedenze Sanitarie AR.S.A “Don Men

b Doctoral SOccupational ThSchool of HeaMadrid, Spain.

c Principal Invtension, Mons. CCade Foundation

d Assistant Proof Nutrition, BioCuyo, San Juan,

110

Objective: This study evaluated the effects of Maitland's passive accessory mobilization on local hypoalgesia andstrength in thumb carpometacarpal osteoarthritis (TCOA).Methods: Twenty-eight patients between 70 and 90 years old with secondary TCOA were randomized into glidemobilization and sham groups. This study was designed as a double-blind, randomized controlled trial. Therapyconsisted of Maitland's passive accessory mobilization of the dominant hand during 4 sessions over 2 weeks. Wemeasured 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 theTMJ was 3.85 ± 0.35 kg/cm2, which increased after treatment to 3.99 ± 0.37 and was maintained at the same level duringthe first FU 3.94 ± 0.39 and second FU 4.74 ± 0.40. In contrast, we found no differences in PPT in the other studiedstructures 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 functionin patients with TCOA. (J Manipulative Physiol Ther 2012;35:110-120)

Key Indexing Terms: Thumb; Osteoarthritis; Hand Strength

Osteoarthritis (OA) is the one of the most commonjoint disorder in the United States and one of theleading causes of disability in the elderly.1

Osteoarthritis develops relatively frequent at the trapezio-metacarpal joint (TMJ),2 often as a result of athletic injuryor cumulative trauma associated with an arduous occupa-tion or hobby.3,4 Thumb carpometacarpal OA (TCOA)occurs with a disproportionally greater frequency in femalesand typically in their fifth and sixth decades of age.5,6

rapist, Department of Physical Therapy, Resi-ssistenziali “A. Maritano,” Sangano, Italy andzio,” Avigliana, Italy.tudent, Department of Physical Therapy,erapy, Rehabilitation and Physical Medicine,lth Sciences, Rey Juan Carlos University,

estigator, Department of Physiology and Hyper-arlos V. Cruvellier Foundation and J. Robert, San Juan, Argentina.fessor, Department of Research Methods, Schoolchemistry and Pharmacy, Catholic University ofArgentina.

Typically, patients report disability during a varietyof occupations, domestic tasks, hobbies, and sports.Specific aggravating activities include writing, gardening,turning taps, and opening jars, with pain frequentlylocalized at the volar surface of the joint.2,4,7,8

Experts suggest that surgery is only indicated ifconservative treatment is unsuccessful.9 However, themore usual options for conservative treatment are exercise,splint therapy, and active daily activities.10 These treatments

e Full Professor, Department of Physical Therapy, OccupationaTherapy, Rehabilitation and Physical Medicine, School of HealthSciences, Rey Juan Carlos University, Madrid, Spain.

f Principal Investigator, Research Group of Musculo-Skeletal Painand Motor Control, European University of Madrid, Spain.

Submit requests for reprints to: Jorge H. Villafañe PT, MScRegione Generala 11/16, Piossasco (TO), Italy(e-mail: mail@villafane.it).

Paper submitted September 3, 2011; in revised formNovember 14, 2011; accepted November 14, 2011.

0161-4754/$36.00Copyright © 2012 by National University of Health Sciencesdoi:10.1016/j.jmpt.2011.12.002

l

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Table 1. Baseline demographics for Maitland's passive accessorymobilization and sham groups

CharacteristicPassive jointmobilization group (14) Sham group (14) P

Age 81.43 ± 5.11 83.71 ± 5.80 .28Sex (M/F) 10/14

(71.43% female)10/14(71.43% female)

PPT (kg/cm2)

TMJ 3.85 ± 1.26 3.88 ± 1.29 .96Scaphoid bone 4.84 ± 1.61 5.03 ± 1.97 .78Hamate bone 6.32 ± 1.62 6.41 ± 2.04 .90

Pinch and grip strength (kg)

Tip pinch 2,35 ± 0.89 2.56 ± 1.78 .70Tripod pinch 3.01 ± 1.08 3.10 ± 1.92 .88Grip strength 10.93 ± 4.50 10.64 ± 8.33 .91

111Villafañe et alJournal of Manipulative and Physiological TherapeuticsThumb Carpometacarpal OsteoarthritisVolume 35, Number 2

are able to produce improvements at 12 months aftertreatment; however, no improvement in pain was found atshort periods after therapy.11

Orthopedic manual therapy avoids the risk of joint injuryduring application of the mobilization. To do that, it usuallyperformed the glide as a passive mobilization of the treatedjoint.12,13 It is suggested that passive accessory mobiliza-tion decreases articular pain and increases the pain-freerange of movement in other articular architectures.12,13

Despite the numerous manual therapy approaches to thetreatment of OA that have been proposed, passive accessorymobilization was never tested in patients with OA.14-16

In recent studies, we have applied different techniques ofmanual therapy for treating TCOA to increase strength tothe tip and tripod pinch and grip strengths and decreasemechanical hyperalgesia.17-19 However, we never pursueda passive joint mobilization with distraction in patients withhand OA.

On the other hand, it has been published that manualtherapy reduces pain and increases physical function inpatients with hip OA.20 In addition, data from animalmodels of articular pain suggest that joint mobilization maydecrease processing of pain,21 indicating the possibility thatjoint mobilization with a distraction could benefit patientswith OA of the dominant hand.

Several studies performed in humans have shown thatmobilization of other joints benefits patients in painperception and motor function,22-24 but studies focusingon the neurophysiologic effects in patients with TCOAare lacking.22-24

Therefore, the purpose of the present study was todetermine whether posterior-anterior passive accessorymobilization of the TMJ decreases mechanical hyper-algesia and increases strength to the tip and tripod pinchand grip strengths in patients with TCOA in thedominant hand.

METHODS

SubjectsTwenty-eight subjects, aged 70 to 90 years, with TCOA

in the dominant hand with a clinical pathologic history ofmore than 10 years were recruited by the Department ofPhysical Therapy, “Residenze Sanitarie Assistenziali”(RR.SS.AA), which depends on Azienda Sanitaria Locale3, Collegno (Italy). Patients were diagnosed by x-rays andrandomly separated into either treated or sham group. Thebaseline demographic characteristics of the population arelisted in Table 1.

The inclusion criteria involved those patients with OA ofthe dominant hand stage III and IV TCOA according to theEaton-Littler-Burton Classification6,25 and preserved cog-nitive capacities according to age, ex-factory workers, andhousewives whose use of the dominant hand was commonand systematic.

The exclusion criteria involved those patients withcarpal tunnel syndrome, arthritis, surgical interventions onthe TMJ, finger spring, or de Quervain tenosynovitis.Patients presenting degenerative or nondegenerative neu-rologic conditions in which pain perception was alteredwere also excluded.

This study was designed as a double-blind, random-ized controlled trial (RCT). Informed consent wasobtained from all participants, and all procedures wereconducted according to the Declaration of Helsinki. Thisstudy was supervised by the Department of PhysicalTherapy, Occupational Therapy, Rehabilitation andPhysical Medicine, Universidad Rey Juan Carlos,Alcorcón, Spain. The protocol (N°93571/c) was ap-proved by the Ethical Committee in Azienda SanitariaLocale 3, Collegno, Italy, and trial registration of theCurrent Controlled Trials ISRCTN70578774. The com-plete protocol can be accessed at http://www.controlled-trials.com/ISRCTN70578774. In the randomization pro-cedure, each subject was randomly assigned to either theexperimental group or the sham group using simplerandomization with a random number generator. Ran-dom sequences of 0 or 1 were run through the patientdatabase with a 50% chance of obtaining treatment orsham, respectively. The numbers were randomlyassigned to each participant, who was then allocatedaccordingly. The randomization procedure was facilitatedby the online software accessed at http://www.graphpad.com/quickcalcs/randomize1.cfm.

Pain MeasurementPatients with TCOA frequently refer pain in the base of

the hand. Because the TMJ is the most affected duringTCOA, we measured pressure pain threshold (PPT) in thebones linked to the TMJ; those are the unciform apophysisof the hamate bone and the scaphoid bone.

Fig 1. Maitland's passive accessory mobilization techniquemobilization of posterior-anterior gliding of the TMJ.

112 Journal of Manipulative and Physiological TherapeuticsVillafañe et alFebruary 2012Thumb Carpometacarpal Osteoarthritis

We measured the PPT with a mechanical pressurealgometer (Wagner Instruments, Greenwich, CT) with a1-cm2 rubber-tipped plunger mounted on a forcetransducer.26,27 This method has been used in the past byus17-19 and others28,29 with positive results. The PPT isdefined as the minimum amount of pressure that results inthe sense of pressure changing to pain.30,31 The mean of 3measurements (intraexaminer reliability) was calculatedand used for the main analysis. The range of values of thepressure algometer was 0 to 10 kg, with a minimalsensibility of 0.1 kg. For these specific cases, the algometryhas higher reliability (intraclass correlation coefficient[ICC], 0.91; 95% confidence interval, 0.82-0.97) for PPTmeasurements in older patients.30 In addition, previousstudies have reported an intraexaminer reliability for thisprocedure ranging from 0.6 to 0.97, and the interexaminerreliability ranged from 0.4 to 0.98.32 Pressure painthreshold measurements were collected at both the TMJ atthe bottom of the anatomical snuffbox, tubercle of thescaphoid bone, and unciform apophysis of the hamate bone.

Strength MeasurementsPinch Strength. The pinch strength was measured by a

mechanical pinch gauge (Baseline, Irvington, NY), whilethe patient was in the sitting position with the shoulderadducted and neutrally rotated and the elbow flexed at90°.33-35 Two different measurements were taken: first, thetip pinch between the index finger and thumb and second,the tripod pinch between the index and medial fingers andthe thumb. The reliability of this procedure to measure thepinch strength has been found to be on the order of 0.93.36

Likewise, this method has been used in the past by us17-19

and others34,37 with positive results.

Grip Strength Measurements. Grip strength measurements weretaken with a grip dynamometer (Baseline, Irvington, NY),while the patient was also in the sitting position, which has aprecision and reliability of ±3% for grip strengthmeasurements.38-40 We have used in this method in thepast17,18 as others34,37 finding it as a popper method tomeasure this variable. The reliability of the measurementswas expressed by ICC between 0.82 and 0.97 for gripstrength measurements.36

Pinch and grip strength measurements were expressed inkilograms. The instrument was calibrated before and aftertreatment of each subject. The reliability of these measure-ments and instruments has been shown by the Australian/-Canadian Osteoarthritis Hand Index.41,42 We17-19 andothers28,29,34,37 have used this method in the past tomeasure the pinch and grip strength in patients with TCOAfinding positive results.

InterventionThe treatment was delivered in 4 sessions that were

distributed over 2 weeks. These patients received 4 sessions

:

of Maitland's passive accessory mobilization or sham, withthe treatment being applied to the dominant hand.

Passive Accessory Mobilization: Application of Convex/Concave Rule.We performed a passive accessory mobilization alsoknown as mobilization of posterior-anterior gliding of theTMJ (Fig 1).

The initial posture involved the subject in sitting posewith his arm in the anatomical position, the elbow flexed at90°, the forearm and hand with the cubital facingdownwards, and the dorsal face against the body of thephysiotherapist. The physiotherapist took the right thumbmetacarpal bone of the subject with his right thumb andindex finger and made a specific passive accessorymobilization with posterior-anterior gliding of the TMJ for3 minutes with a 1-minute pause. This action was repeated 3times. Then, the physiotherapist glides the first metacarpalbone and with a gentle oscillatory technique as described byMaitland.43 The latter was applied in a posterior-anteriordirection. To avoid pain or spasm, which may interfere withthe study, the force used for the mobilization correspondedto a small-amplitude oscillation. It is important to emphasizeat this point that in the posterior-anterior passive accessorymobilization of the first metacarpal bone, the head and bodymust slide in the same direction. Subjects were frequentlyquestioned in an attempt to ensure that no pain wasproduced, and the magnitude of the force applied wasbased on this feedback. The technique was performed as faras possible into range of the accessory-passive mobilizationmovement without producing pain. Throughout the study,the mobilization technique was performed for 3 minutes andrepeated 3 more times with 1-minute rest betweenrepetitions. During the mobilization period, approximately60 oscillations per minute were performed. This is becausethe articular surface of the trapezium is convex, and thesurface of the first metacarpal bone is concave.14,44

Sham Technique. Because sham manipulations involveextensive therapist handlings,22 we chose a technique thatwould minimize the intervention of the physical therapist.Therefore, participants in the sham group attended the samenumber of sessions as did those in the passive jointmobilization group, but they received intermittent ultra-sound at nontherapeutic doses (0 watts/cm2) for 10 minutes

Enrollment Assessed for eligibility (n = 30)

Excluded (n = 2) ♦ Not meeting inclusion criteria

(n = 2)

Randomized (n = 28)

Lost to follow-up (n = 0) Discontinued intervention (n = 0)

Allocated to intervention (n = 14) ♦ Received allocated intervention

(n = 14)♦ Did not receive allocated

Analysis

Follow-Up

AllocationAllocated to intervention (n = 14) ♦ Received allocated intervention

(n = 14)♦ Did not receive allocated (n = 0)

Lost to follow-up (n = 0) Discontinued intervention (n = 0)

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.

113Villafañe et alJournal of Manipulative and Physiological TherapeuticsThumb Carpometacarpal OsteoarthritisVolume 35, Number 2

in the hypothenar area of the dominant hand. Gel was usedas required.45-47

Study ProtocolEach subject attended 4 passive accessory mobilization

or sham technique sessions, scheduled on separate days, atleast 48 hours apart and at the same time of day. Participantswere not allowed to take any analgesic or anti-inflammatorydrug for approximately 24 hours before each session.

After that, pretreatmentmeasurements were assessed by ablinded assessor, withmore than 5 years of experience. Threemeasurements were done with a 1-minute pause periodbetween measurements to avoid temporal summation. Themean of these 3 measurements was used for analysis. Thesubjects were divided randomly, using the followingcomputer program: http://www.graphpad.com/quickcalcs/randomize1.cfm, into 2 groups: passive accessory mobili-zation technique or sham technique. Subjects received 4sessions, distributed in 2 weeks by a manipulative physio-

therapist blinded to the subjects' condition and with 9 yearsof experience. Posttreatment data were recorded 5 minutesafter finished treatment, the first follow-up data wereassessed 1 week after the treatment, and the second follow-up data were assessed 2 weeks after the treatment accordingto the sequence mentioned previously. The present docu-ment was prepared according to the editorial form ofmedicalpublishing and CONSORT publishing rules.48

Sample Size DeterminationThe sample size and power calculations were performed

using Sample Power statistical software version 15 (SPSS,Inc, Chicago, IL). Within-group effect size was calculatedusing Cohen d coefficient. The calculations were based ondetecting differences of 20% in PPT after posttreatment, a2-tailed test, and an α level equal to .05, and a power of80%. These variables generated a sample size of 14 subjectsper group.

Statistics. The data were analyzed using SPSS version 15.0(SPSS, Inc, Chicago, IL). The results were expressed as the

Fig 3. Effect of passive accessory mobilization on PPT in A, TMJ; B, scaphoid bone; and C, apophysis of the hamate bone.

114 Journal of Manipulative and Physiological TherapeuticsVillafañe et alFebruary 2012Thumb Carpometacarpal Osteoarthritis

mean ± SE. Intraclass correlation coefficient and standarderror of measurement (SEM) were calculated to assessintraexaminer reliability of PPT data. Normal distribution ofthe sample was analyzed using the Kolmogorov-Smirnovtest (P N .05). The Student t test was used to analyze the PPTvariables and strength measurements, comparing theexperimental 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 ofspecific comparisons between variables. When the differ-ences were not significant with ANOVA, the post hoc wasnot performed, and the statistical analysis, finished. For alldata in the study, P b .05 was considered significant. CohenD 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), wereincluded in this study and assigned to 1 of 2 groups who

received either the passive accessory mobilization tech-nique (n = 14) or a sham (n = 14). Figure 2 shows the flowdiagram of subject progress through the study and thefollowing criteria. All subjects were right-hand dominant.No significant differences between the groups (P N .05)were found on key demographic variables and baselinelevels of PPT, tip pinch, tripod pinch, or grip strength. Thedemographic and clinical data of each group are detailed inTable 1. A normal distribution was confirmed with theKolmogorov-Smirnov test (P N .05). No subjects droppedout during the different phases of the study, and no adverseeffects were detected after the application of the threetreatments. None of the subjects began drug therapy duringthe course of the study.

Pressure Pain Threshold in the TMJThe intraexaminer reliability of PPT measurements of

the TMJ was determined as ICC of 0.96, and the SEM was1.26 kg/cm2.

The PPT outcomes for the TMJ demonstrated signifi-cant differences for the time factor (F = 5.67; P = .001;

Table 2. Pressure pain thresholds (kg/cm2) over the TMJ, the scaphoid bone, and hamate bone

PPT (kg/cm2) Passive joint mobilization group (14) Sham group (14) Effect size calculations

TMJ Mean ± SD—% changes Mean ± SD—% changes Cohen's D

Pretreatment 3.85 ± 1.26 3.88 ± 1.29 0.81Posttreatment 3.99 ± 1.35 3.34 ± 1.53 1.67First follow-up 3.94 ± 1.36 4.01 ± 1.48 0.15Second follow-up 4.75 ± 1.45 3.94 ± 1.61 2.16Predifference/postdifference −0.14 ± 0.28 —3.61 0.54 ± 0.28 —13.81Predifference/first follow-up difference −0.09 ± 0.25 —2.22 −0.13 ± 0.25 —3.31Predifference/second follow-up difference −0.89 ⁎ ± 0.24 —22.98 −0.06 ± 0.24 —1.66

Scaphoid bone

Pretreatment 4.84 ± 1.61 5.03 ± 1.97 2.03Posttreatment 4.71 ± 1.94 5.18 ± 2.39 2.31First follow-up 4.59 ± 1.97 5.54 ± 2.52 2.13Second follow-up 5.27 ± 1.76 4.96 ± 2.39 2.88Predifference/postdifference 0.13 ± 0.48 —2.73 −0.15 ± 0.48 —3.05Predifference/first follow-up difference 0.25 ± 0.42 —5.17 −0.51 ± 0.42 —10.09Predifference/second follow-up difference −0.43 ± 0.32 —8.86 0.07 ± 0.32 —1.35

Hamate bone

Pretreatment 6.32 ± 1.62 6.41 ± 2.04 2.82Posttreatment 5.93 ± 2.00 6.67 ± 2.26 2.8First follow-up 5.81 ± 2.06 7.17 ± 2.69 2.79Second follow-up 6.58 ± 1.51 6.16 ± 2.83 3.74Predifference/postdifference 0.39 ± 0.47 —6.16 −0.26 ± 0.47 —4.12Predifference/first follow-up difference 0.51 ± 0.44 —8.14 −0.76 ± 0.44 —11.93Predifference/second follow-up difference −0.25 ± 0.34 —4.01 0.24 ± 0.34 —3.79

⁎ The mean difference is significant at P b .05 level.

115Villafañe et alJournal of Manipulative and Physiological TherapeuticsThumb Carpometacarpal OsteoarthritisVolume 35, Number 2

partial eta = 0.18) and for the group × time interaction (F =3.57; P = .018; partial eta = 0.12). We found significantdifferences between the pretreatment (3.85 ± 1.26 kg/cm2)and second follow-up periods in the passive accessorymobilization group (4.75 ± 1.45 kg/cm2; P b .007) but didnot find statistical differences in the first follow-up periodpostintervention for mechanical hypoalgesia on the TMJ(3.99 ± 1.35 kg/cm2; P N .05). However, no significantdifference was identified between the pretreatment andsecond follow-up periods (3.94 ± 1.36 kg/cm2; P N .05). Nosignificant 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 BoneThe intraexaminer reliability of PPT measurements of

the scaphoid bone was determined as ICC of 0.77, and theSEM was 4.40 kg/cm2.

The ANOVA detected no interaction effects; however, asignificant 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 dataare summarized in Table 2.

Pressure Pain Threshold in the Hamate BoneThe intraexaminer reliability of PPT measurements of

the hamate bone was determined as ICC of 0.72, and theSEM was 3.81 kg/cm2.

The ANOVA revealed significant differences for thegroup × 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 hamatebone.We found that the passive accessorymobilization groupcaused no significant differences between pretreatment(6.32 ± 1.62 kg/cm2) and posttreatment and follow-upperiods (PN .05; Fig 3C). The data are summarized inTable 2.

Tip and Tripod Pinch and Grip StrengthThe intraexaminer reliability of strength measurements

with tip pinch, tripod pinch, and grip strength wasdetermined as ICC of 0.72, 0.89, and 0.90, respectively.The SEM was 3.81 kg for tip pinch, 2.68 kg for tripodpinch, and 10.79 kg for grip strength.

The ANOVA revealed significant differences betweentimes but not between groups × times for force levels overthe tip pinch (time: F = 3.37; P = .02; partial eta = 0.11 andgroup × time: F = 0.16; P = .92; partial eta = 0.006), tripodpinch (time: F = 2.20; P = .095; partial eta = 0.078 andgroup × time: F = 0.39; P = .76; partial eta = 0.015), and grippinch (time: F = 0.74; P = .53; partial eta = 0.028 andgroup × time: F = 2.73; P = .05; partial eta = 0.095). Wefound that passive accessory mobilization does notproduced significant differences among pretreatment, post-treatment, and follow-up periods (P N .05). Finally, nosignificant differences among pretreatment, posttreatment,

Fig 4. Effect of passive accessory mobilization on A, tip pinch; B, tripod pinch; and C, grip strength.

116 Journal of Manipulative and Physiological TherapeuticsVillafañe et alFebruary 2012Thumb Carpometacarpal Osteoarthritis

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 mobilizationwith posterior-anterior gliding of the TMJ increases PPTbut does not increases pinch or grip strength in patients withTCOA. We found no significant changes in PPT in thescaphoid bone or the hamate bone of the dominant handbefore or after the treatment. Our findings suggest thatintermittent ultrasound at nontherapeutic of the TMJ doesnot provide benefit to the patients.

To our knowledge, this is the first report in which theTCOA is treated using this technique, which is in contrast toother studies in patients with TCOA.

Hypoalgesic EffectsThis study established that 4 sessions of 9 minutes

each with posterior-anterior passive accessory mobiliza-tion of the TMJ of the thumb increased the PPT of theTMJ more significantly than did the sham procedure, inpatients with TCOA.

We found that passive accessory mobilization increasedthe 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 decreasein pain to pressure. These data are consistent with evidencefrom spinal mobilization studies22,49 that demonstratedimprovement in the PPT by approximately 25% and 30%after treatment. Mobilization in the peripheral joint showeda 15.4% increase of the PPT in conjunction with movementof the elbow.50 These reports are clinically significantbecause Bird and Dickson51 reported that the minimumclinically significant change in PPT could be consideredmore than 15%. Therefore, both peripheral and spinalmobilizations immediately reduce mechanical hyperalgesia,compared with the sham procedures.52 Consistent withreports of other measurements, an improvement of morethan 15% may be considered to reflect a clinicallysignificant effect.51,53 That is, the case of passive accessorymobilization in patients with adhesive capsulitis (frozenshoulder). Half of the patients were mobilized anteriorlyand the other half posteriorly. They found pain relief in bothgroups; however, the posterior passive accessory mobili-zation group had better results in range of motion.12 In a

Table 3. Evaluation of pinch tip, tripod pinch, and grip strength

Pinch and grip strength (kg) Passive joint mobilization group (14) Sham group (14) Effect size calculations

Tip pinch Mean ± SD—% changes Mean ± SD—% changes Cohen's D

Pretreatment 2.35 ± 0.89 2.56 ± 1.78 0.44Posttreatment 2.15 ± 0.8 2.50 ± 1.67 0.14First follow-up 2.03 ± 0.88 2.27 ± 1.54 0.15Second follow-up 2.08 ± 0.99 2.31 ± 1.42 0.16Predifference/postdifference 0.20 ± 0.16 —8.5 0.06 ± 0.16 —2.37Predifference/first follow-up difference 0.33 ± 0.14 —13.96 0.29 ± 0.14 —11.31Predifference/second follow-up difference 0.28 ± 0.19 —11.84 0.25 ± 0.19 —9.64

Tripod pinch

Pretreatment 3.01 ± 1.08 3.10 ± 1.92 0.95Posttreatment 2.89 ± 1.06 3.05 ± 2.06 0.94First follow-up 2.74 ± 1.17 3.01 ± 1.83 0.73Second follow-up 2.65 ± 1.08 2.94 ± 1.64 0.49Predifference/postdifference 0.12 ± 0.14 —4.15 0.05 ± 0.14 —1.84Predifference/first follow-up difference 0.27 ± 0.18 —9.0 0.09 ± 0.18 —2.88Predifference/second follow-up difference 0.37 ± 0.14 —12.2 0.16 ± 0.14 —5.29

Grip strength

Pretreatment 10.93 ± 4.50 10.64 ± 8.33 9.27Posttreatment 11.21 ± 4.64 11.00 ± 8.17 9.5First follow-up 10.21 ± 3.70 11.71 ± 8.90 8.35Second follow-up 10.96 ± 4.85 11.64 ± 8.92 9.27Predifference/postdifference −0.29 ± 0.47 —2.61 −0.36 ± 0.47 —3.36Predifference/first follow-up difference 0.71 ± 0.60 —6.54 −1.07 ± 0.60 —10.07Predifference/second follow-up difference −0.04 ± 0.43 —0.33 −1.00 ± 0.43 —9.4

117Villafañe et alJournal of Manipulative and Physiological TherapeuticsThumb Carpometacarpal OsteoarthritisVolume 35, Number 2

recent study, the same mobilization technique was appliedto patients with ankle sprain and showed a 17.6% increaseof the PPT.54 Similarly, another study52 using passiveaccessory mobilization in patients with OA of the kneeshowed the same results.

In other structures such the spine, Sterling et al22

demonstrated that a posterior-anterior mobilization tech-nique applied to the posterior joint of the C5-6 spinallevel resulted in an immediate increase of 25% in PPTon the symptomatic cervical level in patients withidiopathic neck pain. Likewise, others have reported anincrease in PPT ranging from 10% to 20% in patientswith lateral epicondylalgia.50

The effect of hand OA on hand function has beeninvestigated by several authors. It has been generallyaccepted that hand OA has a negative effect on handfunction, which is mostly seen in grade III and IV hand OAbut does not result in significant disability.8 If the patienthad a grade IV OA or higher, the effect was mild and not acause of significant disability. Severe grade IV OA,however, leads to major impairment.8

Although we found significant effects in our study, at themoment, we lack of the information necessary to explainthe mechanism involved. In other structures, these types oftechniques have caused hypoalgesia by inhibiting thermaltemporal summation of pain.55,56 This is a mechanism

mediated by the C fibers and, therefore, associated with thedevelopment of acute into chronic pain and maintenance ofthe chronic pain.57

Our results regarding the changes in the PPT of thisstudy may raise a controversy. Because PPT wasstatistically significant at the TMJ but not at the scaphoidbone and the hamate bone, it is essential that future studiesinvestigate whether the passive accessory mobilizationtechnique has more influence when used to treat a particularanatomical area.

Motor EffectsWe found no changes in motor activity. Our results differ

from those obtained in patients with cubital tunnelsyndrome treated with mobilization techniques, in whichthere was an improvement of grip and pinch strengths.58

Similarly, hand function was maintained over a period of 12months after the end of treatment.58 Other studies usingdaily home-based exercises for 16 weeks modestly im-proved grip and pinch strengths, although this benefit wasnot sufficient to see an improvement in self-reported handphysical function.2 In the past, passive translatory move-ments have been used,12,13 and different results have beenobtained with the use of translatory actions plus dynamicmovements, whereas passive mobilization is maintained.59

It is important to emphasize that any of these techniques

118 Journal of Manipulative and Physiological TherapeuticsVillafañe et alFebruary 2012Thumb Carpometacarpal Osteoarthritis

include neurodynamic intervention. Therefore, as shownbefore, it is quite plausible that, to get increases in strength,neurologic tension might be needed.17,19

LimitationsAlthough we had positive results, we recognize the

limitations of the study. Basically, population-basedepidemiological studies with greater sample sizes areneeded to permit a more generalized interpretation of theseresults. We recognize that a restriction in the glidecomponent of a joint motion biomechanically leads toboth compression and gapping during end-range move-ments due to incongruence of the joint surfaces and this maylead to pain. In addition, we did not use the distractionmobilization technique. This, in turn, may cause pain by thecontact generated between the articular surfaces duringmobilization. Furthermore, it could raise controversy thatimprovements were not quantified in a disability scale of thehand or upper extremity. Although the improvements werenot quantified with a disability scale of hand or upperextremity nor visual analog scales pain intensity, these datamight have been relevant to determining the significanceclinical results; manual algometry has been shown to beassociated with levels of pain similar to the range of valuesthat we obtained in our subjects.60,61 We used ultrasound asa sham. This was because sham manipulations involveextensive therapist handlings.22 As we wanted to avoid thisparameter completely, we chose a technique that wouldminimize the intervention of the physical therapist. Inaddition, it could have been of great interest to compareresults linked to sex information; however, the patientavailability and sample size calculations made that compar-ison impossible. Therefore, our result can only refer to theheterogenic group. Finally, based on the limitations, theresults of this study should be interpreted with caution.

CONCLUSIONS

In conclusion, we found that a specific mobilization ofposterior-anterior passive accessory mobilization of theTMJ produces significant decrease of pain to pressure inpatients with dominant hand TCOA.

Practical Applications• Maitland's passive accessory mobilizationdecreases pain sensitivity in the TMJ and increaseshand strength.

• This study suggests that this conservative inter-vention has neurophysiologic mechanisms ofaction and could be used as a supplementaryrehabilitation method.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTERESTThis work was supported in part by personal funds of

JHV and grants from J. Robert Cade Foundation and MonsCarlos V. Cruvellier Foundation to JHV and GBS. Theauthors report no other conflicts of interest.

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