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.

Short term effect of spinal mobilization with movement (MWM) on pulmonary functions in nonsmokers with thoracic hyperkyphosis: a randomized single-blinded controlled trial

OBJECTIVES

To investigate the effect of mobilization with movement (MWM) on pulmonary functions in subjects with thoracic hyperkyphosis.

METHODS

This randomized single-blinded controlled trial included a sample of 50 subjects (age 18 - 25 years old) with thoracic hyperkyphosis. Subjects were randomly allocated into two groups; the Real MWM group (n = 25) which received thoracic MWM plus standard postural correction exercises, and the Sham MWM group (n = 25) which received sham MWM plus standard postural correction exercises. Digital X-ray and handheld spirometer were used to measure selected pulmonary function tests (FVC, FEV1/FVC ratio, MVV) respectively.

RESULTS

Within-group comparisons demonstrated a statistically significant improvement in all outcome measures in both groups. The between-group comparisons demonstrated significant improvement in the MWM compared to the Sham group regarding the value of FVC, FEV1/FVC ratio, and MVV (P < .05).

CONCLUSION

In young adults with thoracic hyperkyphosis, MWM plus postural exercise produces better improvements in FVC, FEV1, FEV1/FVC, and MVV compared to sham MWM plus postural exercise.

Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial

Objective: In a pragmatic and randomized clinical trial, patients with lateral ankle sprains were assessed, under blinded conditions, for their responsiveness and improvements during Mulligan mobilization-with-movement (MWM) therapy. Methods: Overall, 51 participants with subacute lateral ankle sprains (Grade I-II) were recruited. Following an MWM screening procedure, responders were randomized to either an intervention group (MWM) or a sham group. The MWM group received inferior tibiofibular, talocrural, or cubometatarsal MWM. The treatment or sham was administered upon three sessions, each 4 days apart. Changes from baseline were measured and compared between the sessions for dorsiflexion range of motion, pain, stiffness perception, and the Y-balance test. Results: In total, 43 participants were considered responders to MWM. Using a two-way repeated-measure ANOVA, a statistical and clinically meaningful improvement in dorsiflexion range of motion was revealed in the MWM group (p = 0.004, 1rst = +1.762 cm; 3rd = +2.714 cm), whereas no improvement following the first session occurred in the sham group (p = 0.454, 1rsttrial = +1.091 cm; 3rdtrial = +1.409 cm). Pain and stiffness significantly improved, yet below the clinically meaningful level. The MWM group demonstrated a significant improvement after three sessions for the Y-balance test (p = 0.001, +8.857 cm). Conclusion: More than 80% of participants with subacute lateral ankle sprains responded well to the MWM approach. Three sessions of pragmatically determined MWM provided a significant and clinically meaningful benefit in dorsiflexion range of motion and Y-balance test performance compared to a sham treatment.

Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: a pilot study

INTRODUCTION

Cervicogenic headache (CGH) may originate from the C1-C2 zygapophyseal joints. CGH is often associated with loss of range of motion (ROM), specific to this segment, and measurable by the cervical flexion-rotation test (CFRT). The main purposes of the study were: 1) to investigate the immediate effect of C1-C2 rotation SNAG mobilizations plus C1-C2 self-SNAG rotation exercise for patients with CGH and 2) to explore the link between the CFRT results and treatment response.

METHODS

A prospective quasi-experimental single-arm design was used where patients with CGH received eight physical therapy treatments using a C1-C2 rotational SNAG technique combined with a C1-C2 self-SNAG rotation exercise over a four-week period. Outcome measures were pain intensity/frequency and duration, active cervical ROM, CFRT, neck-related and headache-related self-perceived physical function, fear-avoidance beliefs, pain catastrophizing and kinesiophobia.

RESULTS

The intervention produced strong effects on pain intensity, CFRT, physical function and pain catastrophizing. Moderate improvement was noted on active cervical ROM and on fear-avoidance beliefs and kinesiophobia. No link was found between pre-intervention CFRT ROM and treatment response.

CONCLUSION

SNAG mobilization combined with a self-SNAG exercise resulted in favorable outcomes for the treatment of CGH on patient-important and biomechanical outcomes, as well as pain-related cognitive-affective factors.

The effect of Mulligan's mobilization with movement following total knee arthroplasty: Protocol of a single-blind randomized controlled trial

BACKGROUND

Mulligan's mobilization with movement (MWM) aims to enhance the kinematics of the joint. Kinematic impairment of the knee joint is significant following total knee arthroplasty (TKA), which could be managed with Mulligan's MWM. This article describes the study protocol for a single-blind randomized controlled trial investigating the effectiveness of Mulligan's MWM following TKA.

METHODS

A single-blind randomized controlled trial design will be employed to compare two groups: an intervention and control group. Each group will attend a standard post-operative rehabilitation program. The intervention group will additionally receive articular mobilization using a Mulligan's MWM approach. A blinded examiner will assess participants at four points: pre-operation, 3 weeks post-operation (when the intervention starts), 6 weeks post-operation (when the intervention ends), and at 6 months as a long-term follow-up. The two groups will be compared on the basis of knee range of motion (standard goniometry), knee joint pain (Visual Analogue Scales), walking speed using (15-metre walk test), functional mobility (timed up and go test) and participation (Western Ontario and McMaster Universities Osteoarthritis Index questionnaire). A blinded examiner will measure knee joint alignment using a computed tomography scanogram pre-operatively and at 3 months post operation. Mixed model ANOVA will be used to identify any group differences. Ethical approval has been secured from the ethical committee of Kuwait Ministry of Health, and the trial is registered in the ISRCTN registry (ref:13028992).

DISCUSSION

The study findings could inform the optimization of post-operative rehabilitation of patients following TKA.

The Effects of Posterior Talar Glide and Dorsiflexion of the Ankle Plus Mobilization with Movement on Balance and Gait Function in Patient with Chronic Stroke: A Randomized Controlled Trial

Background:

This study was to evaluate the effects of weight-bearing-based mobilization with movement (WBBMWM) on balance and gait in stroke patients.

Methods:

Thirty stroke patients participated in this study. All individuals were randomly assigned to either WBMWM group (n = 15) or weight-bearing with placebo mobilization with movement group (control, n = 15). Individuals in the WBMWM group were trained for 10 glides of 5 sets a day, 5 times a week during 4 weeks. Furthermore, individuals in the control group were trained for 10 lunges of 5 sets a day, 5 times a week during 4 weeks. All individuals were measured weight-bearing lunge test (WBLT), static balance ability, timed up and go test (TUG), and dynamic gait index (DGI) in before and after intervention.

Results:

The result showed that WBBMWM group and control group had significantly increased in WBLT, postural sway speed, total postural sway path length with eyes open and closed, TUG and DGI (P < 0.05). In particular, the WBMWM group showed significantly greater improvement than control group in WBLT, static balance measures, TUG, and DGI (P < 0.05).

Conclusion:

Therefore, WBMWM improved ankle range of motion, balance, and gait in stroke patients. These results suggest that WBBMWM is feasible and suitable for individuals with a stroke.

Four-week training involving ankle mobilization with movement versus static muscle stretching in patients with chronic stroke: a randomized controlled trial

BACKGROUND

Patients with stroke generally have diminished balance and gait. Mobilization with movement (MWM) can be used with manual force applied by a therapist to enhance talus gliding movement. Furthermore, the weight-bearing position during the lunge may enhance the stretch force.

OBJECTIVES

This study aimed to compare the effects of a 4-week program of MWM training with those of static muscle stretching (SMS). Ankle dorsiflexion passive range of motion (DF-PROM), static balance ability (SBA), the Berg balance scale (BBS), and gait parameters (gait speed and cadence) were measured in patients with chronic stroke.

METHODS

Twenty patients with chronic stroke participated in this study. Participants were randomized to either the MWM (n = 10) or the SMS (n = 10) group. Patients in both groups underwent standard rehabilitation therapy for 30 min per session. In addition, MWM and SMS techniques were performed three times per week for 4 weeks. Ankle DF-PROM, SBA, BBS score, and gait parameters were measured after 4 weeks of training.

RESULTS

After 4 weeks of training, the MWM group showed significant improvement in all outcome measures compared with baseline (p < 0.05). Furthermore, SBA, BBS, and cadence showed greater improvement in the MWM group compared to the SMS group (p < 0.05).

CONCLUSIONS

This study demonstrated that MWM training, combined with standard rehabilitation, improved ankle DF-PROM, SBA, BBS scores, and gait speed and cadence. Thus, MWM may be an effective treatment for patients with chronic stroke.

Immediate and short-term effects of mulligan concept positional sustained natural apophyseal glides on an athletic young-adult population classified with mechanical neck pain: an exploratory investigation

Objectives: Mechanical neck pain (MNP) is common in the athletic population. While symptoms may present at the cervical spine for patients complaining of MNP, thoracic spinal alignment or dysfunction may influence cervical positioning and overall cervical function. Clinicians often employ cervical high-velocity low-amplitude (HVLA) thrust manipulations to treat MNP, albeit with a small level of inherent risk. Mulligan Concept positional sustained natural apophyseal glides (SNAGs) directed at the cervicothoracic region are emerging to treat patients with cervical pain and dysfunction, as evidence supporting an interdependent relationship between the thoracic and cervical spine grows. The purpose of this a priori study was to evaluate outcome measures of patients classified with MNP treated with the Mulligan Concept Positional SNAGs. Methods: Ten consecutive young-adult patients, ages ranging from 15 to 18 years (mean = 16.5 ± 1.78), classified with MNP were treated utilizing Mulligan Concept Positional SNAGs. The Numeric Rating Scale (NRS), Patient-Specific Functional Scale (PSFS), Neck Disability Index (NDI), Disablement in the Physically Active (DPAS), and Fear-Avoidance Based Questionnaire-Physical Activity (FABQPA) were collected for inclusion criteria and to identify patient-reported pain and dysfunction. Results: Patients reported decreases in pain on the NRS [5.4 to .16, p = .001], increases in function on the PSFS [5.2 to 10, p = .001], and increases in cervical range of motion (CROM) [ext p = .003, flex p = .009, left rot p = .001, right rot p = .002] immediately post-treatment and between treatments. Discussion: Positional SNAGs directed at the cervicothoracic region may address a variety of patient reported symptoms for MNP, and the number of treatment sessions needed for symptom resolution may be closer to a single session rather than multiple treatments. Level of Evidence: 4.

A pragmatic regional interdependence approach to primary frozen shoulder: a retrospective case series

Objectives

Although the shoulder is known to move together with the scapula and other upper quarter joints, the current frozen shoulder clinical practice guidelines describe only physical therapy study treatments directed to the shoulder. None received a strong recommendation, highlighting the need for alternate interventions. This retrospective case series describes a pragmatic regional interdependence approach to frozen shoulder with impairment and functional outcomes, noting whether final ROM approached normal.

Methods

Five consecutive patients referred with frozen shoulder diagnoses attended 11-21 sessions over 5-10 weeks with one physical therapist. Treatment addressed inter-related regions (shoulder, shoulder girdle, scapulothoracic/humerothoracic, and spine) following a pragmatic approach using impairment-based interventions (joint/soft tissue mobilization, muscle stretching/strengthening) as well as patient education, modalities and warm up that addressed individual presentations.

Results

All patients improved on all outcomes. Mean shoulder ROM at discharge, the impairment outcome, demonstrated large effect size increases: flexion (117 ± 10-179 ± 12, d = 5.9), abduction (74 ± 8-175 ± 9, d = 9.3), external rotation (23 ± 7-89 ± 2, d = 12.0). The Disability of Arm Shoulder Hand functional outcome score upon follow up demonstrated a large effect size improvement (d = 1.5) from 40.0 ± 19.4-6.2 ± 3.7. Final ROM approached normal.

Discussion

This case series utilized a regional interdependence approach to frozen shoulder that included manual therapy interventions directed to consistent upper quarter body segments. Shoulder ROM was returned to near normal with functional improvements evident months after discharge. A pragmatic regional interdependence approach addressing multiple joints related to shoulder function may benefit other people with frozen shoulder.

Level of Evidence

4.

Effect of mobilization with movement on lateral knee pain due to proximal tibiofibular joint hypomobility

This case report describes a 45-year-old female who presented with lateral knee pain over the right proximal tibiofibular joint (PTFJ) managed unsuccessfully with rest, medications, bracing, injection, and physiotherapy. Clinical diagnosis of PTFJ hypomobility was based on concordant symptom reproduction with palpatory tenderness, accessory motion testing, and restricted anterior glide of the fibula. Intervention consisted of Mulligan's mobilization with movement and taping over the right PTFJ with immediate improvements noticed in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 6 months revealed that the patient was pain free and fully functional.

Effect of a novel mobilization with movement procedure on anterolateral ankle impingement - A case report

This case report describes a 50-year-old male who presented with right anterolateral ankle pain managed unsuccessfully with rest, medications, bracing, injection, physical therapy, and massage therapy. Clinical diagnosis of anterolateral ankle impingement was based on concordant symptom reproduction with palpatory tenderness and a positive lateral synovial impingement test. This case report is a potential first time description of the successful management of anterolateral ankle impingement utilizing a novel Mulligan's mobilization with movement procedure (consisting of internal rotation of the distal tibia) and taping with immediate improvements noted in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 4 months revealed that the patient was pain free and fully functional.

AN ALTERNATIVE APPROACH TO THE TREATMENT OF MENISCAL PATHOLOGIES: A CASE SERIES ANALYSIS OF THE MULLIGAN CONCEPT "SQUEEZE" TECHNIQUE

BACKGROUND

Partial meniscectomy does not consistently produce the desired positive outcomes intended for meniscal tears lesions; therefore, a need exists for research into alternatives for treating symptoms of meniscal tears. The purpose of this case series was to examine the effect of the Mulligan Concept (MC) "Squeeze" technique in physically active participants who presented with clinical symptoms of meniscal tears.

DESCRIPTION OF CASES

The MC "Squeeze" technique was applied in five cases of clinically diagnosed meniscal tears in a physically active population. The Numeric Pain Rating Scale (NRS), the Patient Specific Functional Scale (PSFS), the Disability in the Physically Active (DPA) Scale, and the Knee injury and Osteoarthritis Outcomes Score (KOOS) were administered to assess participant pain level and function.

OUTCOMES

Statistically significant improvements were found on cumulative NRS (p ≤ 0.001), current NRS (p ≤ 0.002), PSFS (p ≤ 0.003), DPA (p ≤ 0.019), and KOOS (p ≤ 0.002) scores across all five participants. All participants exceeded the minimal clinically important difference (MCID) on the first treatment and reported an NRS score and current pain score of one point or less at discharge. The MC "Squeeze" technique produced statistically and clinically significant changes across all outcome measures in all five participants.

DISCUSSION

The use of the MC "Squeeze" technique in this case series indicated positive outcomes in five participants who presented with meniscal tear symptoms. Of importance to the athletic population, each of the participants continued to engage in sport activity as tolerated unless otherwise required during the treatment period. The outcomes reported in this case series exceed those reported when using traditional conservative therapy and the return to play timelines for meniscal tears treated with partial meniscectomies.

LEVELS OF EVIDENCE

Level 4.

A modified mobilization-with-movement to treat a lateral ankle sprain

INTRODUCTION AND BACKGROUND

Lateral ankle sprains (LAS) are common in sports medicine and can result in a high rate of re-injury and chronic ankle instability (CAI). Recent evidence supports the use on mobilizations directed at the ankle in patients who have suffered a LAS. The Mulligan Concept of Mobilization-with-Movement (MWM) provides an intervention strategy for LASs, but requires pain-free mobilization application and little literature exists on modifications of these techniques.

PURPOSE

To present the use of a modified MWM to treat LASs when the traditional MWM technique could not be performed due to patient reported pain and to assess outcomes of the treatment.

CASE DESCRIPTION

The subject of this case report is a 23 year-old female collegiate basketball player who had failed to respond to initial conservative treatments after being diagnosed with a lateral ankle sprain. The initial management and subsequent interventions are presented. After re-examination, the addition of a modification of a MWM technique produced immediate and clinically significant changes in patient symptoms. The use of the modified-MWM resulted in full resolution of symptoms and a rapid return to full athletic participation.

OUTCOMES

After the initial application of the modified-MWM, the patient reported immediate pain-free ankle motion and ambulation. Following a total of 5 treatments, using only the modified MWM and taping technique, the patient was discharged with equal range of motion (ROM) bilaterally, a decreased Disablement in the Physically Active (DPA) Scale score, and an asymptomatic physical exam. Follow-up exam 6 weeks later indicated a full maintenance of these results.

DISCUSSION

Recent evidence has been presented to support the use of mobilization techniques to treat patient limitations following ankle injury; however, the majority of evidence is associated with addressing the talar and dorsiflexion limitations. Currently, little evidence is available regarding the use of the MWM technique designed for LASs and the expected outcomes. This case adds to the emerging evidence supporting the use for MWMs to treat ankle pathology and introduces a modification that may be applied in cases where patient reported pain prevents traditional application.

LEVEL OF EVIDENCE

Level 5; Single case report.