Effect of Thumb Joint Mobilization on Pressure Pain Threshold in Elderly Patients with Thumb Carpometacarpal Osteoarthritis

Comparison between Conditioned Pain Modulation Paradigms Using Cold Pressor Conditioning Stimulus versus Ischemic Pressure Stimulus in Women with Fibromyalgia and Its Impact on Clinical Status: A Cross-Sectional Study

Background/Objectives: Fibromyalgia (FM) is a syndrome characterized by widespread chronic pain as the primary symptom. Neurophysiological pain mechanisms, such as the function of the descending inhibitory system, are impaired in this condition. The main objective of this study was to compare the results of two paradigms to evaluate CPM in women with FM. The secondary objective was to correlate the results of each CPM paradigm with the clinical status of patients with FM. Methods: One hundred and three FM women were divided into two groups: fifty patients diagnosed with FM were assigned to the conditioned pain modulation (CPM) group using a cold pressor stimulus, and fifty-three patients were assigned to the CPM group using the ischemic pressure stimulus. The main outcome measures were pain intensity, disability, mechanical hyperalgesia, and CPM. Results: The primary analysis revealed significant differences between the results obtained from the different CPM protocols. Poorer outcomes in the cold pressor test correlated with higher pain intensity and a greater disability index. Conclusions: Pain modulation abnormalities in FM patients were evident when using either the cold pressor or ischemic pressure stimuli to establish the CPM paradigm. The cold pressor conditioning stimulus elicited a stronger response than the ischemic pressure stimulus in FM patients.

Effect of Shoulder Movement Routine on Postoperative Shoulder Pain in Total Laparoscopic Hysterectomy: A Randomized Clinical Trial

Background and Objectives: Postoperative shoulder pain is a common issue after total laparoscopic hysterectomy (TLH). This study evaluated the impact of a shoulder movement routine on postoperative shoulder pain in women undergoing uncomplicated TLH. Materials and Methods: An open-label randomized clinical trial included women without prior shoulder pain undergoing TLH between 20 January and 20 March 2024. Participants were randomized into two groups: Group 1 (n = 36) received a shoulder movement routine, while Group 2 (control, n = 39) performed a hand movement routine. Shoulder pain was assessed using the visual analog scale (VAS) at 6 h, 24 h, and 7 days postoperatively. Results: Seventy-five women participated. No significant differences were found between the groups regarding demographic variables, surgery duration, or hospital stay. Shoulder pain scores (VAS) at three time points (6 h, 24 h, and 7 days) showed no significant differences between groups (p = 0.57, p = 0.69, and p = 0.91, respectively). Similarly, there were no significant differences in incisional or abdominal pain. Conclusions: The shoulder movement routine did not significantly reduce postoperative shoulder pain in women undergoing uncomplicated TLH.

Assessing the Predictive Accuracy of the Eaton-Littler Classification in Thumb Carpometacarpal Osteoarthritis: A Comparative Analysis with the Outerbridge Classification in a Cohort of 51 Cases

(1) Background: The objective of this study is to evaluate the predictive value of the Eaton-Littler radiologic classification for thumb carpometacarpal osteoarthritis (CMC OA) relating to intra-articular cartilage damage assessed by the Outerbridge arthroscopic classification. (2) Methods: A total of 51 thumb CMC OA arthroscopies were performed on patients classified as Eaton stages 1, 2, or 3. Post-arthroscopic evaluations of cartilage damage were categorized using the Outerbridge classification. Comparative analyses were conducted between the radiological Eaton stages and the arthroscopic Outerbridge stages. (3) Results: Arthroscopic examination revealed Outerbridge stage 3 and 4 cartilage damage in 26 cases classified as Eaton stage 2 and in 18 cases classified as Eaton stage 3. The detection of severe cartilage damage in patients classified as Eaton stage 2 was unexpected. (4) Conclusions: Arthroscopy demonstrated that many patients with mild radiological degenerative signs exhibited significant cartilage destruction. Although the Eaton classification is widely used for staging thumb CMC OA, it may not accurately reflect the severity of intra-articular damage. The Eaton classification does not reliably predict intra-articular damage in Eaton stage 2 cases.

Nonoperative Management of Trapeziometacarpal Joint Arthritis: A Systematic Review of the Clinical Trials

This systematic review evaluates nonoperative treatments for trapeziometacarpal joint osteoarthritis (TMJO), a common degenerative condition in postmenopausal females causing pain, reduced mobility, and diminished grip strength. Following PRISMA guidelines, a search was conducted across PubMed, Cochrane, Embase, and MEDLINE for randomized controlled trials (RCTs) assessing pain outcomes with nonoperative interventions over at least a six-month follow-up, using the visual analog scale (VAS) for pain measurement. Eleven RCTs yielded moderate-quality evidence for the following: (1) corticosteroid (CSI) and hyaluronic acid (HA) injections exhibit comparable mean delta pain scores after six months, with CSI offering early relief at two to three weeks. After 12 months, CSI led to a continued decrease in pain, with a mean delta pain score of 1.0 (p<0.05), contrasting with hyaluronic acid (HA) injections, which presented a modest though nonsignificant improvement, demonstrating a mean delta pain score of 0.5 (p=0.16). (2) Relatively novel therapies for TMJO, such as platelet-rich plasma (PRP) and dextrose, appear to surpass CSI in long-term effectiveness, with dextrose showing a mean delta pain score of 3.8 (p<0.001) at six months and PRP achieving a mean delta pain score of 5.5 (p=0.005) at 12 months. (3) Various hand therapies, notably standard hand exercises and extracorporeal shockwave therapy (ESWT), demonstrated significant pain reduction, with the former achieving a mean delta pain score of 1.5 (p=0.019) and the latter a score of 4.2 (p<0.001). (4) The use of orthoses substantially decreases pain levels, demonstrating a mean delta pain score reduction of 2.6 at a 180-day follow-up (p=0.023) and 2.2 at a 12-month follow-up (p=0.002). In conclusion, nonoperative treatments for TMJO, including intra-articular injections, hand therapy, and orthoses, provide significant pain relief at a minimum of six months follow-up. The synergistic effect of combined nonoperative management, as well as the effect size of each, is unknown.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Rhizarthrosis Part II: A New Approach of Manual Therapy and Therapeutic Exercise

Rhizarthrosis (RA), also known as trapezium-metacarpal osteoarthritis, is a degenerative condition affecting the thumb's first joint, leading to functional impairment and pain. Conservative treatment options are preferred for mild to moderate cases (Eaton-Littler grades I and II) and typically encompass a range of therapeutic modalities, including manual therapy. However, for the existing manual therapy techniques, there is a lack of comparative studies for efficacy, and therapeutic exercises are often generic and non-specific to RA. This study proposes a novel treatment protocol that combines manual therapy with specific therapeutic exercises grounded in the biomechanical analysis of the trapeziometacarpal joint. The focus is on enhancing joint stability, reducing pain, and improving function. The manual therapy component includes three phases. A passive phase, during which joint distractions are applied to alleviate discomfort and improve joint mobility. An active phase that addresses joint mobility on the adduction-abduction plane, the first plane of movement to suffer limitation: the therapist facilitates the isometric adduction of the thumb, followed by an assisted abduction. A second active phase is where Mulligan's Mobilization With Movement concept is applied. This technique involves passive pain-free joint mobilization with simultaneous active finger movements, to provide additional therapeutic benefits. The therapeutic exercises component focuses on strengthening the first dorsal interosseous muscle as an abductor to reduce thumb adductor muscle activation and joint stress. Patients are encouraged to perform finger spreading exercises using a rubber band between the first and fifth fingers, emphasizing first dorsal interosseous activation and stability of the thumb. This type of muscle strengthening does not involve movement of the trapeziometacarpal joint. It is recommended to start performing 5-10 repetitions or 5 seconds of isometric contraction, repeat throughout the day, and progressively increase the load by adding a turn to the rubber band or changing it, increasing the number of repetitions bringing it to 15 and/or increase the isometric contraction time to 10/15 seconds. The proposed therapeutic rationale, informed by biomechanical insights, lays a promising foundation for further investigation. Nevertheless, empirical validation through rigorous clinical trials remains essential to substantiate its clinical utility and advance the management of RA.

Rhizarthrosis Part I: A Literature Review

Rhizarthrosis (RA), or trapeziometacarpal osteoarthritis, is an arthritic degenerative process that affects the first joint of the thumb. The objective of this work is to provide therapists with an overview of the fundamental issues related to the therapeutic management of trapeziometacarpal joint instability. Prevalent in females, especially post-menopause, and linked to age, RA involves ligament and muscle structures, with causes ranging from hormonal influences to mechanical factors. Understanding the biomechanics, stability, and factors contributing to RA is crucial for effective intervention. This study explores the role of ligaments, muscles, and anatomical variants in thumb joint degeneration, emphasizing the importance of stability and congruence. RA manifests as pain at the base of the thumb, limiting grip strength and hindering everyday tasks. Pain initially occurs during specific movements but can progress to constant discomfort, affecting sleep. Chronic RA leads to joint stiffness, deformities like the "Z thumb," and muscle atrophy, impacting daily functions. Clinical evaluation involves pain assessment, joint mobility examination, and palpation. Diagnostic tests like the grind test and lever test aid in confirming RA. Radiographic examination reveals joint space degeneration and osteophytes and helps classify RA stages using the Eaton-Littler classification. Conservative treatment aims to alleviate pain, reduce joint stress, and enhance function. Orthoses help stabilize the joint. Therapeutic exercises, emphasizing muscle strength and dynamic stability, prove beneficial. Manual therapies like neurodynamic, Kaltenborn, Mulligan, and Maitland techniques target pain reduction and improve joint mechanics. The studies on conservative approaches provide evidence that a multimodal intervention consisting of joint mobilization, neural mobilization, and exercise is beneficial in reducing pain in patients with RA. When conservative therapy fails, surgical intervention is indicated.

A Secondary Analysis: Comparison of Experimental Pain and Psychological Impact in Individuals with Carpometacarpal and Knee Osteoarthritis

Purpose

Evaluate sensory and psychological differences in individuals with thumb carpometacarpal (CMC) and/or knee osteoarthritis (OA) pain. This secondary analysis focuses on comparing the effects of OA at large and small joints in community-dwelling adults.

Patients and Methods

A total of 434 individuals were recruited from communities in Gainesville, FL and Birmingham, AL. Each participant completed health and clinical history questionnaires, quantitative sensory testing, and physical functional tests. Participants were divided into four groups based on their pain ("CMC pain" (n = 33), "knee pain" (n = 71), "CMC + knee pain" (n = 81), and "pain-free" controls (n = 60)). ANCOVAs were performed to identify significant differences in experimental pain and psychological variables across groups.

Results

The "CMC + knee pain" group had lower pressure pain thresholds (lateral knee site, p < 0.01) and higher temporal summation of mechanical pain (knee, p < 0.01) when compared to "CMC pain" and "pain-free" groups. The "knee pain" group had lower heat pain tolerance at the forearm site (p = 0.02) and higher mechanical pain (p < 0.01) at both tested sites in comparison to the "CMC pain" group. Lastly, the "CMC + knee pain" group had the highest self-reported pain (p < 0.01) and disability (p < 0.01) compared to all other groups.

Conclusion

Results suggest knee OA compounded with CMC OA increases disease impact and decreases emotional health compared to OA at either the CMC or knee joint alone. Results also support a relationship between the number of painful joints and enhanced widespread pain sensitivity. Measuring pain at sites other than the primary OA location is important and could contribute to more holistic treatment and prevention of OA progression.

Investigation of grip strength, pain threshold, pain tolerance and function in smartphone users

PURPOSE/AIM OF THE STUDY

Few studies have demonstrated the effects of smartphone use on grip strength and upper extremity function. The present study was purposed to compare smartphone users' grip/lateral pinch strength, pain threshold/tolerance and upper limb function.

MATERIALS AND METHODS

A prospective cross-sectional study was conducted with 241 individuals. Participants were divided into three groups with the cut-off values of the Smartphone Addiction Scale (SAS). The Edinburgh Handedness Inventory (EHI) was used to determine the dominant side. Thumb pain threshold and tolerance were evaluated with the algometer. A hand dynamometer measured the grip and lateral pinch strength. Upper extremity functions were evaluated with the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Quick-DASH).

RESULTS

Handgrip strength of the dominant/non-dominant extremities and Quick-DASH scores were higher in low-level smartphone users (p < 0.05). There was no significant difference between the groups on lateral pinch strength and pain threshold/tolerance (p > 0.05). Smartphone usage significantly affected dominant and non-dominant hand grip strength (Standardized β1 = -0.15, β2 = -0.15, p < 0.05). In addition, the smartphone use level negatively affected dominant lateral pinch strength (Standardized β = -0.12, p = 0.05). On the other hand, smartphone use positively affected upper extremity function (Standardized β = 0.17, p < 0.05).

CONCLUSIONS

As smartphone addiction increases, standard handgrip strength and functionality decrease. Pain threshold/tolerance is not affected by smartphone use. Future studies should focus on fine motor skills to present a more comprehensive upper limb function evaluation.

Is Hand Therapy Associated With a Delay in Surgical Treatment in Thumb Carpometacarpal Arthritis?

PURPOSE

Thumb carpometacarpal (CMC) osteoarthritis (OA) causes functional disability and an increased health care burden in the aging population. The role of therapy in thumb CMC OA has been minimally analyzed in the literature. We hypothesized that patients treated with therapy for thumb CMC OA would demonstrate reduced rates of surgery for this diagnosis.

METHODS

We queried a national insurance dataset for all patients with an International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases, Tenth Revision, code for thumb CMC OA, with a minimum of 2 years of follow-up. A 2:1 propensity-matched cohort of patients with CMC OA who did not receive therapy versus a therapy cohort was created, with a minimum of two sessions of hand therapy for inclusion. The primary outcome was the rate of thumb CMC OA surgery occurring within 2 years of diagnosis; time to surgery and use of thumb CMC injections were secondary outcomes. Multivariable logistic regression analysis was used to identify the risk factors for undergoing surgical treatment.

RESULTS

After matching, the therapy cohort comprised 14,548 patients, with a matched group of 28,930 patients who did not undergo therapy. In the overall sample, the rate of surgery within 2 years was 22.5%. Two-year surgical treatment rates were significantly higher for those who did not undergo therapy when compared with those who did (29.3% vs 13.1%). Patients treated with therapy had a significantly longer time to surgery, with no difference in the rate of surgery after one year. In multivariable regression of all included variables, lack of therapy intervention had the highest odds of surgery for thumb CMC OA (odds ratio 4.3).

CONCLUSIONS

We present the findings of a large insurance database evaluating the association of therapy with rates of surgical treatment for thumb CMC arthritis. On average, those treated with therapy had longer times to surgery, and the 2-year surgery rates for patients diagnosed with thumb CMC arthritis were significantly higher in those who did not undergo therapy treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

Arthroscopic Management of Thumb Carpometacarpal Joint Arthritis and Pathology

Basilar thumb arthritis is a debilitating condition characterized by pain, reduced joint stability, and reduced capacity for daily activities. Various arthroscopic approaches have been described based on patient factors, as well as radiographic and arthroscopic staging criteria. Here we provide an overview of arthroscopic management of basilar thumb arthritis, including patient evaluation, surgical techniques, outcomes, and new developments. We describe our preferred approach for Eaton stage I-III disease, consisting of arthroscopic hemitrapeziectomy with suture button suspensionplasty. This technique is safe, reliable, and allows for early range of motion and quicker recovery while minimizing scarring and reducing the risk of nerve injury.

Comparison of efficacy of fluidotherapy and paraffin bath in hand osteoarthritis: A randomized controlled trial

Objectives

This study aims to compare the efficacy of paraffin bath therapy and fluidotherapy on pain, hand muscle strength, functional status, and quality of life (QoL) in patients with hand osteoarthritis (OA).

Patients and methods

This prospective randomized controlled study included 77 patients (8 males, 69 females; mean age: 63.1±10.3 years; range 39 to 88 years) with primary hand OA who applied between July 2017 and March 2018. The patients were randomized into two groups with the sealed envelope method: Paraffin bath therapy (20 min, one session per day, for two weeks) was applied for 36 patients whereas 41 patients received fluidotherapy for the same period. The pain severity of the patients, both at rest and during activities of daily living (ADL) within the last 48 hours was questioned and scored using Visual Analog Scale. Duruöz Hand Index (DHI) was used to evaluate hand functions. Gross grip strength was measured using Jamar dynamometer whereas fine grip strength was measured using pinch meter in three different positions (lateral pinch, tip pinch, and palmar pinch). The 36-Item Short Form (SF-36) was used to analyze the QoL. All measurements were performed before, immediately after, and three months after treatment.

Results

Improvement was observed in pain score at rest and during ADL, DHI scores, gross and fine grip strengths, and SF-36 subscores in both groups after treatment. However, no significant difference was observed between the groups.

Conclusion

Both fluidotherapy and paraffin bath therapy have been found to have positive effects on pain, hand muscle strength, functional status, and QoL in the treatment of hand OA. However, no superiority was observed between the two treatment modalities.

Effectiveness of manual therapy in patients with thumb carpometacarpal osteoarthritis: a systematic review and meta-analysis

Background: The effectiveness of Manual Therapy (MT) in thumb carpometacarpal osteoarthritis (OA) is unclear.Objective: This study aimed to determine the effectiveness of MT for functional outcomes in patients with thumb carpometacarpal OA. Design: Systematic review and meta-analysis of randomized clinical trials. Methods: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared MT versus other interventions in functional outcomes, such as thumb and/or hand function questionnaires, pinch and/or grip strength, thumb and/or hand range of motion, and pain intensity or pressure pain threshold in patients with thumb carpometacarpal OA. Results: Five clinical trials met the eligibility criteria; for the quantitative synthesis, four studies were included. The mean difference (MD) for grip strength was 0.87kg (95% CI = 0.29-1.44, p = .003), for pinch strength was 0.10kg (95% CI = -0.01-0.20, p = .06), and for the pressure pain threshold was 0.64kg/cm² (95% CI = 0.07-1.20, p = .03). All differences were in favor of the MT group. Conclusions: In the short-term, there was moderate to high evidence, with statistically significant differences in the functional outcomes, in favor of MT versus sham interventions in patients with thumb carpometacarpal OA. However, these differences are not clinically important.

The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review

OBJECTIVE

The purpose of this review is to identify the role of joint mobilization for individuals with Carpal tunnel syndrome (CTS).

METHODS

A systematic search of 5 electronic databases (PubMed, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, and SPORTDiscus) was performed to identify eligible full-text randomized clinical trials related to the clinical question. Joint mobilization had to be included in one arm of the randomized clinical trials to be included. Two reviewers independently participated in each step of the screening process. A blinded third reviewer assisted in cases of discrepancy. The PEDro scale was used to assess quality.

RESULTS

Ten articles were included after screening 2068 titles. In each article where joint mobilization was used, positive effects in pain, function, or additional outcomes were noted. In most cases, the intervention group integrating joint mobilization performed better than the comparison group not receiving joint techniques.

CONCLUSION

In the articles reviewed, joint mobilization was associated with positive clinical effects for persons with CTS. No studies used joint mobilization in isolation; therefore, results must be interpreted cautiously. This review indicates that joint mobilization might be a useful adjunctive intervention in the management of CTS.

Metacarpal Abduction Orthosis for Patients With the Thumb Carpometacarpal Osteoarthritis

Purpose

A specific orthosis to increase radial abduction of the metacarpal of the thumb rather than immobilize it was designed for patients with carpometacarpal (CMC) joint osteoarthritis. This orthosis was designed especially for musicians, who need a large abduction angle of the thumb CMC joint to maintain their hand span to perform music.

Methods

The thumb abduction orthosis was custom-made of flexible polypropylene, leaving the thumb metacarpophalangeal and wrist joints unrestricted and compressing the ulnar side of the thenar muscle to increase the radial abduction angle of the thumb metacarpal. Hand span and grip strength were measured, and clinical symptoms were assessed with the visual analog scale and Quick–Disabilities of the Arm, Shoulder, and Hand score. The Tubiana and Chamagne score was used to assess musical performance.

Results

A total of 23 thumbs of 19 professional musicians with CMC joint osteoarthritis were placed in an orthosis. The radial abduction angle of the thumb CMC joint, grip strength, and hand span were significantly increased or enlarged after bracing. Clinical symptoms evaluated by visual analog score, Quick–Disabilities of the Arm, Shoulder, and Hand score, and Tubiana and Chamagne score also improved.

Conclusions

Placement of a metacarpal abduction orthosis improved the hand span and improved patient-reported outcomes.

Type of study/level of evidence

Therapeutic IV.

Thumb carpometacarpal osteoarthritis: A musculoskeletal physiotherapy perspective

PROPOSAL

To perform a literature review to provide the practitioner with a description of the information and techniques to enhance the provision of conservative interventions in clinical practice.

METHODS

Studies were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2017. Authors independently selected studies, conducted quality assessment, and extracted results.

RESULTS

There is evidence to support a multimodal approach to the therapeutic management of the patient with CMC OA. This distinct approach includes: patient education, manual therapy, therapeutic exercise programs, and orthotic provision.

CONCLUSION

There is evidence to support some of the commonly performed conservative interventions to improve hand function and decrease hand pain.

Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis

To update the evidence on efficacy and safety of non-pharmacological, pharmacological and surgical interventions for hand osteoarthritis (OA), a systematic literature review was performed up to June 2017, including (randomised) controlled trials or Cochrane systematic reviews. Main efficacy outcomes were pain, function and hand strength. Risk of bias was assessed. Meta-analysis was performed when advisable. Of 7036 records, 127 references were included, of which 50 studies concerned non-pharmacological, 64 pharmacological and 12 surgical interventions. Many studies had high risk of bias, mainly due to inadequate randomisation or blinding. Beneficial non-pharmacological treatments included hand exercise and prolonged thumb base splinting, while single trials showed positive results for joint protection and using assistive devices. Topical and oral non-steroidal anti-inflammatory drugs (NSAIDs) proved equally effective, while topical NSAIDs led to less adverse events. Single trials demonstrated positive results for chondroitin sulfate and intra-articular glucocorticoid injections in interphalangeal joints. Pharmacological treatments for which no clear beneficial effect was shown include paracetamol, intra-articular thumb base injections of glucocorticoids or hyaluronic acid, low-dose oral glucocorticoids, hydroxychloroquine and anti-tumour necrosis factor. No trials compared surgery to sham or non-operative treatment. No surgical intervention for thumb base OA appeared more effective than another, although in general more complex procedures led to more complications. No interventions slowed radiographic progression. In conclusion, an overview of the evidence on efficacy and safety of treatment options for hand OA was presented and informed the task force for the updated European League Against Rheumatism management recommendations for hand OA.

Necessity of Immobilizing the Metacarpophalangeal Joint in Carpometacarpal Osteoarthritis: Short-term Effect

BACKGROUND

Conservative treatment for carpometacarpal (CMC) joint osteoarthritis (OA) may include orthotic fabrication to decrease pain. Different types of orthoses have been used as conservative interventions to improve symptoms, but there are no guidelines specifying if inclusion of the thumb metacarpophalangeal (MCP) in an orthosis is required in the treatment of thumb CMC joint OA. The main objective of this study is to determine the effectiveness of 2 different thumb CMC joint orthotic designs on pain reduction and improved hand function: one design immobilizes both the MCP joint and the CMC joint and the other design immobilizes only the CMC joint.

METHODS

A total of 66 patients were included in the study. One group of 33 patients received a short thumb orthosis with the MCP joint excluded, and the other group of 33 patients received a short thumb orthosis with the MCP joint included. Outcomes measures included the visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; Spanish version) for function.

RESULTS

In both patient groups, the orthoses contributed to decreased pain levels and improved functional abilities ( F_1.0 = 315.467 and F_1.0 = 72.419; both, P < .001). There was no significant difference between the 2 groups regarding pain or improvement in daily activities ( F_1.0 = 0.553 and F_1.0 = 2.539; both, P > .05).

CONCLUSION

There are benefits of either thumb orthotic design on pain reduction and functional improvement even after 1 week of using the orthoses as the sole conservative treatment.

The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis

BACKGROUND

Trapeziometacarpal osteoarthritis (known as base of thumb OA) is a common condition causing pain and disability worldwide.

OBJECTIVE

The purpose of this review was to evaluate the effectiveness of multimodal and unimodal physical therapies for base of thumb osteoarthritis (OA) compared with usual care, placebo or sham interventions.

DESIGN

Systematic review and meta-analysis.

METHOD

We searched MEDLINE (PubMed), CINAHL, Embase, AMED, PEDro, Cochrane Database of Systematic Review, Cochrane Register of Controlled Trials (CENTRAL) from inception to May 2017. Randomized controlled trials involving adults comparing physical therapy treatment for base of thumb OA with an inactive control (placebo or sham treatment) and reported pain, strength or functional outcomes were included. Meta-analyses were performed where possible. Methodological risk of bias was assessed with the Cochrane Risk of Bias tool.

RESULTS

Five papers with low risk of bias were included. Meta-analyses of mean differences (MD) with 95% confidence intervals (95% CI), were calculated for between-group differences in point estimates at 4 weeks post-intervention. Multimodal and unimodal physical therapies resulted in clinically worthwhile improvements in pain intensity (MD 2.9 [95% CI 2.8 to 3.0]; MD 3.1 [95% CI 2.5 to 3.8] on a 0-10 scale, respectively). Hand function improved following unimodal treatments (MD 6.8 points [95% CI 1.7 to 11.9)] on a 0-100 scale) and after a multimodal treatment (MD 20.5 (95%CI -0.7 to 41.7).

CONCLUSIONS

High quality evidence shows unimodal and multimodal physical therapy treatments can result in clinically worthwhile improvements in pain and function for patients with base of thumb OA.

The Treatment of Primary Arthritis of the Finger and Thumb Joint

BACKGROUND

Primary finger and thumb joint arthritis is common, with a markedly rising prevalence from age 50 onward. As the population as a whole ages, the need for effective, stage-appropriate treatment of this condition is increasing.

METHODS

This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

Pain on movement and morning stiffness are commonly reported symptoms. Thorough physical examination and plain x-rays are mandatory. In the early stages of primary finger and thumb joint arthritis, a conservative, multimodal treatment approach involving the use of splints, physiotherapy, and non-steroidal anti-inflammatory drugs can be helpful. The intraarticular injection of hyaluronic acid or cortisone seems to relieve pain in the short term, but its long-term efficacy in primary finger and thumb joint arthritis is questionable. Arthrodesis (joint fusion) is a reliable surgical treatment option for arthritis of the metacarpophalangeal and interphalangeal joints of the thumb. For mobility-preserving surgery of the metacarpophalangeal joints of the second through fifth fingers, silicone implant arthroplasty remains the gold standard. Symptomatic, advanced arthritis of the distal interphalangeal joint is most effectively treated with arthrodesis.

CONCLUSION

The efficacy of conservative treatment has been documented in high-quality clinical trials, while that of surgical treatment has not. The various surgical methods have yielded benefits in routine clinical use, but these remain to be assessed in randomized and controlled trials.

Class IV laser therapy for trapeziometacarpal joint osteoarthritis: Study protocol for a randomized placebo-controlled trial

OBJECTIVE

Osteoarthritis (OA) is a chronic and prevalent joint disorder with great impact on quality of life and high economic burden. Although a number of conservative therapies have proven to be effective for the management of hand OA, only modest treatment effects were reported for most individual interventions. The aim of the proposed study is to assess the effect of Class IV laser therapy (LT) on pain and pinch strength in patients with thumb carpometacarpal (TCMC) OA.

METHODS

A randomized, controlled, single-centre, double-blind, clinical trial, with 1:1 allocation ratio, will be carried out involving patients presenting TCMC-OA Grades 1-2 (aged >18 years). Both assessor and statistician will remain blinded. Patients with TCMC-OA will be randomly assigned to the experimental group (will receive LT) and control group (will receive a placebo treatment). Outcome measures will be pain scores at the base of the thumb measured with visual analogue scale (0-10: 0, no pain and 10, worst pain) and changes in pinch strength, both collected at baseline, 4, and 12 weeks. Statistical analyses will be based on an intention-to-treat analysis using the last value forward method. A two-tailed independent Student's t test for the continuous variable of age and baseline scores will be used for comparison of baseline characteristics and outcome variables. Paired Student's t tests will be used to determine the level of significance of the differences between the pretreatment and posttreatment measurements of the individual groups. Repeated measures analysis of variance will be used to determine the differences in time as the within-subjects factor and group as the between-subjects factor.

DISCUSSION

To our knowledge, the results of this study will provide the first double-blinded evidence for Class IV LT in patients with TCMC-OA.

Systematic review of non-surgical therapies for osteoarthritis of the hand: an update

OBJECTIVE

To update our earlier systematic reviews which evaluated all published randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological therapies in patients with hand osteoarthritis (OA). Surgical therapies were not evaluated.

DESIGN

RCTs published between March 2008 and December 2015 were added to the previous systematic reviews.

RESULTS

A total of 95 RCTs evaluating various pharmacological and non-pharmacological therapies in hand OA were analyzed in this update. Generally, the methodological quality of these RCTs has improved since the last update, with more studies describing their methods for randomization, blinding, and allocation concealment. However, RCTs continue to be weakened by a lack of consistent case definition and a lack of standardized outcome assessments specific to hand OA. The number and location of evaluated hand joints continues to be underreported, and only 25% of RCTs adequately described the method used to ensure allocation concealment. These remain major weaknesses of published RCTs. A meta-analysis could not be performed because of marked study heterogeneity, insufficient statistical data available in the published RCTs, and a small number of identical comparators.

CONCLUSION

Hand OA is a complex area in which to study the efficacy of therapies. There has been an improvement in the overall design and conduct of RCTs, however, additional large RCTs with a more robust methodological approach specific to hand OA are needed in order to make clinically relevant conclusions about the efficacy of the diverse treatment options available.

Neural manual vs. robotic assisted mobilization to improve motion and reduce pain hypersensitivity in hand osteoarthritis: study protocol for a randomized controlled trial

[Purpose] The aim of the present study is to detail the protocol for a randomised controlled trial (RCT) of neural manual vs. robotic assisted on pain in sensitivity as well as analyse the quantitative and qualitative movement of hand in subjects with hand osteoarthritis. [Subjects and Methods] Seventy-two patients, aged 50 to 90 years old of both genders, with a diagnosis of hand Osteoarthritis (OA), will be recruited. Two groups of 36 participants will receive an experimental intervention (neurodynamic mobilization intervention plus exercise) or a control intervention (robotic assisted passive mobilization plus exercise) for 12 sessions over 4 weeks. Assessment points will be at baseline, end of therapy, and 1 and 3 months after end of therapy. The outcomes of this intervention will be pain and determine the central pain processing mechanisms. [Result] Not applicable. [Conclusion] If there is a reduction in pain hypersensitivity in hand OA patients it can suggest that supraspinal pain-inhibitory areas, including the periaqueductal gray matter, can be stimulated by joint mobilization.

Effectiveness of physical and occupational therapy on pain, function and quality of life in patients with trapeziometacarpal osteoarthritis - A systematic review and meta-analysis

Introduction

Trapeziometacarpal osteoarthritis is associated with more pain and restrictions than other hand osteoarthritis due to the functional importance of the thumb. While the effectiveness of surgical and pharmacological interventions has been widely examined, there is a lack of specific evidence about conservative non-pharmacological trapeziometacarpal osteoarthritis therapies. The objective of this systematic review was to provide evidence-based knowledge on the effectiveness of physiotherapy and occupational therapy on pain, function and quality of life.

Methods

A literature search of Medline, CINAHL, PEDro, OTseeker, EMB Dare Cochrane Database of Systematic Reviews and Cochrane CENTRAL was performed. Randomized and quasi-randomized controlled trials and corresponding systematic reviews, observational studies, pragmatic studies and case–control studies were included. The risk of bias was assessed.

Results

Out of 218 studies, 27 were retained. A narrative summary and a series of meta-analyses were performed. Concerning pain reduction, the meta-analysis showed parity of pre-fabricated neoprene and custom-made thermoplastic splints: standardized mean difference (SMD) –0.01 (95%CI −0.43, 0.40) (p=0.95). Multimodal interventions are more effective on pain compared to single interventions: standardized mean difference −3.16 (95%CI −5.56, −0.75) (p = 0.01).

Discussion

Physical and occupational therapy-related interventions, especially multimodal interventions, seem to be effective to treat pain in patients with trapeziometacarpal osteoarthritis. Pre-fabricated neoprene splints and custom-made thermoplastic splints may reduce pain equally. Single interventions seem not to be effective. Significant evidence for effectiveness on function and quality of life could not be found.

Early osteoarthritis of the trapeziometacarpal joint is not associated with joint instability during typical isometric loading

The saddle-shaped trapeziometacarpal (TMC) joint contributes importantly to the function of the human thumb. A balance between mobility and stability is essential in this joint, which experiences high loads and is prone to osteoarthritis (OA). Since instability is considered a risk factor for TMC OA, we assessed TMC joint instability during the execution of three isometric functional tasks (key pinch, jar grasp, and jar twist) in 76 patients with early TMC OA and 44 asymptomatic controls. Computed tomography images were acquired while subjects held their hands relaxed and while they applied 80% of their maximum effort for each task. Six degree-of-freedom rigid body kinematics of the metacarpal with respect to the trapezium from the unloaded to the loaded task positions were computed in terms of a TMC joint coordinate system. Joint instability was expressed as a function of the metacarpal translation and the applied force. We found that the TMC joint was more unstable during a key pinch task than during a jar grasp or a jar twist task. Sex, age, and early OA did not have an effect on TMC joint instability, suggesting that instability during these three tasks is not a predisposing factor in TMC OA.

Comparison of Hypoalgesic Effects of Neural Stretching vs Neural Gliding: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to evaluate the immediate mechanical hypoalgesic effect of neural mobilization in asymptomatic subjects. We also compared neural gliding vs neural stretching to see which produced greater hypoalgesic effects in asymptomatic subjects.

METHODS

Forty-five asymptomatic subjects (20 men and 25 women; mean ± SD age, 20.8 ± 2.83 years) were randomly allocated into 3 groups: the neural glide group, the neural stretch group, and the placebo group. Each subject received 1 treatment session. Outcome measures included bilateral pressure pain threshold measured at the trigeminal, cervical, and tibialis anterior points, assessed pre-treatment and immediately post-treatment by a blinded assessor. Three-way repeated-measures analysis of variance was used to evaluate changes in pressure pain threshold, with group (experimental or control) as the between-subjects variable and time (pre-, post-treatment) or side (dominant, nondominant) as the within-subjects variable.

RESULTS

Group differences were identified between neural mobilization groups and the placebo group. Changes occurred in all of the pressure pain threshold measures for neural gliding, and in all but the trigeminal point for neural stretch. No changes in the pressure pain threshold measures occurred in the placebo group.

CONCLUSIONS

This research provides new experimental evidence that neural mobilization produces an immediate widespread hypoalgesic effect vs placebo but neural gliding produces hypoalgesic effects in more body sites than neural stretching.

Reliability of handgrip strength test in elderly subjects with unilateral thumb carpometacarpal osteoarthritis

BACKGROUND

The grip strength test is widely used; however, little has been investigated about its reliability when used in elderly with subjects thumb carpometacarpal (CMC) osteoarthritis (OA). The purpose of this study was to examine the test-retest reliability of the grip strength test in elderly subjects with thumb CMC OA.

METHODS

A total of 78 patients with unilateral thumb CMC OA, 84.6 % female (mean ± SD age 83 ± 5 years), were recruited. Each patient performed three pain free maximal isometric contractions on each hand in two occasions, 1 week apart. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and 95 % limits of agreement (LOA) were calculated.

RESULTS

Test-retest reliability was excellent for side affected (ICC = 0.947; p = 0.001) and contralateral (ICC = 0.96; p = 0.001) thumb CMC OA.

CONCLUSIONS

The present results indicate that maximum handgrip strength can be measured reliably, using the Jamar hand dynamometer, in patients with thumb CMC OA, which enables its use in research and in the clinic to determine the effect of interventions on improving grip.

Ulnar digits contribution to grip strength in patients with thumb carpometacarpal osteoarthritis is less than in normal controls

BACKGROUND

Grip testing is commonly used as an objective measure of strength in the hand and upper extremity and is frequently used clinically as a proxy measure of function. Increasing knowledge of hand biomechanics, muscle strength, and prehension patterns can provide us with a better understanding of the functional capabilities of the hand. The objectives of this study were to determine the contribution of ulnar digits to overall grip strength in individuals with thumb carpometacarpal (CMC) osteoarthritis (OA).

METHODS

Thirty-seven subjects participated in the study. This group consisted of 19 patients with CMC OA (aged 60-88 years) and 18 healthy subjects (60-88 years). Three hand configurations were used by the subjects during grip testing: use of the entire hand (index, middle, ring, and little fingers) (IMRL); use of the index, middle, and ring fingers (IMR); and use of only the index and middle fingers (IM).

RESULTS

Grip strength findings for the two groups found that compared to their healthy counterparts, CMC OA patients had, on average, a strength deficiency of 45.6, 35.5, and 28.8 % in IMRL, IMR, and IM, respectively. The small finger contribution to grip is 14.3 % and the ring and small finger contribute 34 % in subjects with CMC OA.

DISCUSSION

Grip strength decreases as the number of digits contributing decreased in both groups. The ulnar digits contribution to grip strength is greater than one third of total grip strength in subjects with CMC OA. Individuals with CMC OA demonstrate significantly decreased grip strength when compared to their healthy counterparts.

Conservative treatment of thumb base osteoarthritis: a systematic review

PURPOSE

To provide a systematic review of randomized controlled trials regarding the conservative treatment of thumb base osteoarthritis (OA).

METHODS

A systematic literature search was conducted in the electronic bibliographic databases Medline (Pubmed) and Embase (both starting year to May 2014) using predetermined criteria for studies on nonoperative treatment of thumb base OA.

RESULTS

Twenty-three articles fulfilled our inclusion criteria. Systematic evaluation demonstrated the following: (1) Hand therapy can possibly reduce pain. However, owing to the lack of good-quality (randomized controlled) trials with sufficient follow-up time, no proper conclusions can be drawn. (2) Although both steroid and hyaluronate intra-articular injections can provide pain relief, most authors conclude that injection of hyaluronate is more effective. Follow-up is rather short with a maximum of 12 months in 1 study. Furthermore, study comparison is hampered by heterogeneity of study design and outcome parameters. (3) The use of orthoses reduces pain without effect on function, strength, or dexterity. Included studies used various types of orthoses. Follow-up times varied (2 wk-7 y). (4) There is no justification for the use of transdermal steroid delivery. (5) There is insufficient evidence justifying the use of leech therapy. (6) There are no high-level evidence studies specifically evaluating the effect of analgesics and patient education in joint protection in patients with thumb base OA.

CONCLUSIONS

There are only a few high-quality studies addressing the conservative treatment of trapeziometacarpal OA. Available evidence suggests only some effect of orthoses and intra-articular hyaluronate or steroid injections.

Reliability of pinch strength testing in elderly subjects with unilateral thumb carpometacarpal osteoarthritis

[Purpose] The aim of this study was to examine the test-retest reliability of pinch strength testing in elderly subjects with thumb CMC OA. [Subjects and Methods] A total of 27 patients with unilateral right-thumb CMC OA (mean ± SD age: 81.3 ± 4.7 years) were recruited. Each patient performed three pain-free maximal isometric contractions on each hand on two occasions, one week apart. Three different measurements were taken: tip, tripod, and key pinch strength. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and 95% limits of agreement (LOA) calculations were performed. [Results] Test-retest reliability of measurements of tip, tripod, and key pinch strength was excellent for the affected side (ICC=0.93, 0.96, and 0.99) and the contralateral thumb (ICC=0.91, 0.92, and 0.94). [Conclusions] The present results indicate that maximum pinch strength can be measured reliably using the Pinch Gauge Dynamometer, in patients with thumb CMC OA, which enables its use in research and in the clinic to determine the effect of interventions on improving pinch strength.

Reliability of pinch strength testing in elderly subjects with unilateral thumb carpometacarpal osteoarthritis

[Purpose] The aim of this study was to examine the test-retest reliability of pinch strength testing in elderly subjects with thumb CMC OA. [Subjects and Methods] A total of 27 patients with unilateral right-thumb CMC OA (mean ± SD age: 81.3 ± 4.7 years) were recruited. Each patient performed three pain-free maximal isometric contractions on each hand on two occasions, one week apart. Three different measurements were taken: tip, tripod, and key pinch strength. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and 95% limits of agreement (LOA) calculations were performed. [Results] Test-retest reliability of measurements of tip, tripod, and key pinch strength was excellent for the affected side (ICC=0.93, 0.96, and 0.99) and the contralateral thumb (ICC=0.91, 0.92, and 0.94). [Conclusions] The present results indicate that maximum pinch strength can be measured reliably using the Pinch Gauge Dynamometer, in patients with thumb CMC OA, which enables its use in research and in the clinic to determine the effect of interventions on improving pinch strength.

Contralateral sensory and motor effects of unilateral kaltenborn mobilization in patients with thumb carpometacarpal osteoarthritis: a secondary analysis

[Purpose] The aim of this study was to determine changes in pressure sensitivity and pinch strength in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) in the contralateral hand after unilateral Kaltenborn mobilization on the symptomatic hand. [Subjects and Methods] Twenty-nine females with dominant hand thumb CMC osteoarthritis participated (age 70–90), and were randomized into 2 groups. The experimental group received a Kaltenborn mobilization, and the placebo group received a nontherapeutic dose of intermittent ultrasound. Pressure pain thresholds (PPT) at the thumb CMC joint, scaphoid bone and hamate bone and tip and tripod pinch strength were assessed before and after the intervention and 1 week (1st follow-up) and 2 weeks (2nd follow-up) after the intervention. [Results] Significant increases in PPT in the experimental group at all follow-up periods as compared with baseline data were found. The post-intervention between-group mean differences for PPT were 1.1 (95%CI 0.4–1.8) for the CMC joint, 1.1 (95%CI 0.2–2.1) for the scaphoid, and 1.5 (95%CI 0.5–2.8) for the hamate. The post-intervention between-group mean differences were 0.5 (95%CI 0.2–0.9) for the tip pinch and 0.3 (95%CI 0.1–0.6) for the tripod pinch. [Conclusion] The current secondary analysis found that Kaltenborn mobilization for the symptomatic hand reduces pressure pain sensitivity (PPT increases) and also produces motor changes in the contralateral non-treated hand compared with a placebo group.

Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report

OBJECTIVE

The purpose of this report is to describe the management of a patient with advanced trapeziometacarpal (TMC) osteoarthritis (OA) using mobilization with movement technique in combination with kinesiology tape to decrease pain and improve range of motion.

CLINICAL FEATURES

A 52-year-old female seamstress (a career of 35 years' duration) presented to a physiotherapy clinic with pain in the dorsal aspect of the thumb carpometacarpal region of the right (dominant) hand. Examination revealed reduced ability to abduct the right thumb, significant loss of web space, weakness of pinch grip, and deterioration of hand function. Radiographs demonstrated OA of the TMC stage IV according to the Eaton-Littler-Burton classification, with instability and subluxation of the joint.

INTERVENTION AND OUTCOME

A combined treatment protocol of mobilization with movement and kinesiology tape at the TMC joint for 12 weekly sessions was performed. Outcome measures were assessed at baseline, immediately upon completion of treatment, and at 2-month follow-up and included numeric pain rating scale, range of motion, pressure pain threshold, and tip pinch strength at the TMC joint. Treatment interventions were applied for 12 sessions over a period of 2 months. Outcome measures indicated significant reduction of the patient's subjective pain reports and considerable improvement in functional and occupational tasks. A follow-up visit at 4 months (2 months after last treatment) showed that the improvement was maintained.

CONCLUSION

A combined program of mobilization with movement and kinesiology tape reduced pain, increased range of motion, and increased tip pinch strength in a patient with severe functional impairment related to dominant TMC OA.

The effects of collateral meridian therapy for knee osteoarthritis pain management: a pilot study

OBJECTIVE

The purpose of this preliminary study was to examine whether collateral meridian (CM) therapy was feasible in treating knee osteoarthritis (OA) pain.

METHODS

Twenty-eight patients with knee OA and knee pain were randomly allocated to 2 groups. The CM group patients received CM therapy, whereas the control patients received placebo treatment for knee pain relief. Patients in the CM group received 2 CM treatments weekly for 3 weeks. The outcome measures were pain intensity on a visual analog scale, and knee function was determined using the Western Ontario and McMaster Universities Osteoarthritis Index.

RESULTS

In the CM group, the posttreatment visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index scores were lower than those of the control group; a significant reduction in pain intensity (P = .02, P = .01, respectively) and improvement in knee function (P = .04, P = .03, respectively) were shown in the CM group at the second and third week.

CONCLUSION

Collateral meridian therapy may be feasible and effective for knee OA pain relief and knee function recovery. Therefore, additional randomized control trials are warranted.

Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis

OBJECTIVE

The purpose of this study was to investigate changes in pressure sensitivity and pinch grip force in the nonsymptomatic side in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) after the application of a unilateral passive accessory mobilization to the symptomatic hand.

METHODS

Secondary analysis of data from a randomized trial with concealed allocation, blinded assessor, and intention-to-treat analysis was performed. Twenty-eight patients (72% females), with unilateral CMC OA and mean age ± SD of 82 ± 6 years, met all the inclusion criteria and agreed to participate. The experimental group received passive accessory mobilization to the CMC OA, and the control group received a nontherapeutic dose of intermittent ultrasound on the affected side for 4 sessions over 2 weeks. Outcome measures including pressure pain thresholds (PPTs) at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone and tip and tripod pinch and grip strength of the contralateral/unaffected hand were assessed at baseline as well as 1 and 2 weeks after treatment by an assessor blinded to the group allocation. A repeated measures analysis of variance was used to determine changes in PPT and pinch and grip strength.

RESULTS

No important baseline differences were observed between groups. At the end of the follow-up period, the experimental group exhibited a significant increase in PPT at the CMC joint as compared with the control group 0.6 kg/cm(2) (95% confidence interval, 0.3-1.0; F3.0 = 4.89; P = .009). Although PPT changes in the experimental group were higher than the control group at the remaining sites, differences did not reach statistically significance. Similarly, tip, tripod pinch, and grip strength remained unchanged after the intervention.

CONCLUSION

This secondary analysis found that the application of a unilateral passive accessory mobilization targeted to the symptomatic CMC joint induced an increase of PPT levels 2 weeks after treatment; however, differences were small and likely of limited clinical value. No contralateral motor effects were observed. Future studies including larger sample sizes are needed to examine the effects of joint mobilization on motor and sensory effects.

The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial

STUDY DESIGN

Double-blind, randomized controlled trial.

OBJECTIVE

To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA).

BACKGROUND

Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population.

METHODS

Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable.

RESULTS

The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention.

CONCLUSION

This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN37143779.

LEVEL OF EVIDENCE

Therapy, level 1b.

Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial

QUESTION

In people with thumb carpometacarpal osteoarthritis, does radial nerve mobilisation to the affected hand reduce pressure pain sensitivity in the contralateral hand?

DESIGN

Secondary analysis of data from a randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Sixty people with thumb CMC osteoarthritis in the dominant hand aged 70-90 years.

INTERVENTIONS

The experimental group received sliding mobilisation of the radial nerve and the control group received a non-therapeutic dose of intermittent ultrasound, on the affected side for six sessions over four weeks.

OUTCOME MEASURES

On the contralateral side, pressure pain thresholds at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and hamate bone were assessed before and after the intervention with follow-up at 1 and 2 months.

RESULTS

No important baseline differences were noted between groups. At the end of the intervention period, the experimental group had significantly a higher (ie, better) pressure pain threshold than the control group at the lateral epicondyle by 1.5kg/cm(2) (95% CI 0.2 to 2.2), CMC joint by 1.2kg/cm(2) (95% CI 0.5 to 2.0), scaphoid bone by 1.0kg/cm(2) (95% CI 0.2 to 1.8) and hamate bone by 1.9kg/cm(2) (95% CI 1.0 to 2.7). Although mean values in the experimental group remained better than the control group at all sites at both follow-up assessments, these differences were not statistically significant.

CONCLUSION

Radial nerve gliding applied to the symptomatic hand induced hypoalgesic effects on the contralateral hand in people with CMC osteoarthritis, suggesting bilateral hypoalgesic effects of the intervention.

Botulinum toxin type A combined with neurodynamic mobilization for upper limb spasticity after stroke: a case report

OBJECTIVE

The purpose of this study is to report a case in which combinatory therapy of botulinum toxin type A (BoNT-A) and neurodynamic mobilization (NM) was used as treatment for a patient with severe upper limb spasticity and pain after stroke.

CLINICAL FEATURES

A 76-year-old male patient had spastic muscles in the upper limb 10 months after an ischemic stroke.

INTERVENTION AND OUTCOME

The patient underwent combined treatment with BoNT-A and NM of the upper limb in 6 monthly applications. Evaluation was performed pretreatment, 3 months after the first injection, 3 months after the second injection, and at a follow-up session 9 months after starting the treatment. The following outcomes were measured: pain by using a numeric rating scale, spasticity by the Modified Ashworth Scale for Grading Spasticity, acceptance and emotional reaction to the treatment by the Hospital Anxiety and Depression Scale, and functionality by ranges of motion. The patient improved in all outcomes after treatment, and results were maintained during the follow-up sessions.

CONCLUSION

The combined NM and BoNT-A treatment appeared to decrease pain and improve joint ranges of motion during treatment for this patient. The patient showed decreased anxiety and depression during and after the treatment.