BILATERAL SENSORY EFFECTS OF UNILATERAL PASSIVE

ACCESSORY MOBILIZATION IN PATIENTS WITH THUMB

CARPOMETACARPAL OSTEOARTHRITIS

Jorge H. Villafañe, PT, MSc, PhD,a Joshua A. Cleland, PT, PhD,b, c andCesar Fernandez-de-las-Peñas, PT, MSc, PhDd,e

a Researcher/Pdation, Milan, Ita

b Professor, DUniversity, Conc

c Clinician, Phcord Hospital, Co

d Physical Thepational Therapyversidad Rey Jua

e Physical Th

232

ABSTRACT

Objective: The purpose of this study was to investigate changes in pressure sensitivity and pinch grip force in thenonsymptomatic side in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) after the application of aunilateral passive accessory mobilization to the symptomatic hand.Methods: Secondary analysis of data from a randomized trial with concealed allocation, blinded assessor, andintention-to-treat analysis was performed. Twenty-eight patients (72% females), with unilateral CMC OA and meanage ± SD of 82 ± 6 years, met all the inclusion criteria and agreed to participate. The experimental group receivedpassive accessory mobilization to the CMC OA, and the control group received a nontherapeutic dose of intermittentultrasound 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 thehamate bone and tip and tripod pinch and grip strength of the contralateral/unaffected hand were assessed at baselineas well as 1 and 2 weeks after treatment by an assessor blinded to the group allocation. A repeated measures analysisof 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, theexperimental group exhibited a significant increase in PPT at the CMC joint as compared with the control group0.6 kg/cm2 (95% confidence interval, 0.3-1.0; F3.0 = 4.89; P = .009). Although PPT changes in the experimentalgroup 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 mobilizationtargeted 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. Futurestudies including larger sample sizes are needed to examine the effects of joint mobilization on motor and sensoryeffects. (J Manipulative Physiol Ther 2013;36:232-237)

Key Indexing Terms: Osteoarthritis; Thumb; Carpometacarpal Joint; Pain; Pressure; MusculoskeletalManipulations

1

Thumb carpometacarpal (CMC) osteoarthritis (OA) isa degenerative condition of the thumb CMC joint,characterized by abrasion, progressive deterioration

of joint surfaces, and newly forming bone inducing pain at the

hysical Therapist, IRCCS Don Gnocchi Foun-ly.epartment of Physical Therapy, Franklin Pierceord, NH.ysical Therapist, Rehabilitation Services, Con-ncord, NH.rapist, Department of Physical Therapy, Occu-, Rehabilitation and Physical Medicine, Uni-n Carlos, Alcorcón, Madrid, Spain.erapist, Esthesiology Laboratory, Universidad

Rey Juan Carlos, Alcorcón, Spain.Submit requests for reprints to: Jorge Hugo Villafañe, PT,

MSc, PhD, Regione Generala 11/16, Piossasco (10045), Italy(e-mails: mail@villafane.it8 joshcleland@comcast.net8cesar.fernandez@urjc.es).

Paper submitted September 17, 2012; in revised formDecember 7, 2012; accepted December 27, 2012.

0161-4754/$36.00Copyright © 2013 by National University of Health Sciences.

base of the thumb joint and being a common manifestationin middle or older aged people.2 Thumb CMC OA causespain during thumb-index pinch and, therefore, results insubstantial limitations in hand function.1

http://dx.doi.org/10.1016/j.jmpt.2013.05.008

233Villafañe, Cleland, and Fernandez-de-las-PeñasJournal of Manipulative and Physiological TherapeuticsPassive Accessory Mobilization for Thumb OsteoarthritisVolume 36, Number 4

Osteoarthritis-related pain is being recognized to berelated to peripheral mechanisms and also to centralsensitization, at both spinal cord and supraspinal levels.3

Central sensitization is defined as a hyperresponsivenessof central pain-signaling neurons from low-threshold mech-anoreceptors.4 Central sensitization includes change insensory pain processing and regulation of descendinginhibitory mechanisms.5 Although these mechanisms haveyet to be investigated in patients with CMCOA, studies haveinvestigated the involvement of central pain modulation inkneeOA.6-8 Imamura et al6 found that patientswithmoderateto severe persistent knee pain and disability exhibited lowerpressure pain thresholds (PPTs) compared with controls.Bajaj et al7 described deep pain hyperalgesia and increasedreferred pain areas in the tibialis anteriormuscle in individualswith knee OA observing these effects bilaterally as a sign ofcentral sensitization. In addition, these mechanisms appearedto respond to local analgesics. Creamer et al8 reported that theinjection of local anesthetic into 1 knee relieved pain in thecontralateral noninjected knee. These studies suggest apossible role of the central nervous system in themaintenanceof chronic pain in patients with knee OA resulting insensitization to the contralateral side.

A feature of central sensitization mechanisms in OA-related pain is the presence of pressure mechanical painhyperalgesia.4 Previous studies found that manual therapiesinduce mechanical hypoalgesia1,2,9-12 concurrent with sym-pathetic nervous system9 and motor11 excitation. Manualtherapies demonstrating these effects include median nerveslider neurodynamic gliding,13 passive accessory jointmobilization,14 posterior-anterior joint mobilization,11 andmobilization with movement of the elbow.10 Three recentrandomized trials analyzing the effects of Kaltenbornmobilization,12 passive accessory mobilization,2 and radialnerve slider neurodynamic gliding1 in patients with thumbCMC OA reported that unilateral interventions applied overthe symptomatic hand exerted local hypoalgesic effects byincreasing PPTs immediately and at follow-up. There isincreasing evidence suggesting thatmanual therapies targetedto the cervical spine induced bilateral hypoalgesic effectssuggestingacentralmechanismafter theapplicationofmanualphysical therapies.15-17 We do not currently known if similarmechanisms can be also present during manual therapiestargeted to the extremities. The identification of similarmechanisms after peripheral joint interventions will help tofurther elucidate the underlying effects of manual therapies.

It is not still known if the application of a unilateralpassive accessory mobilization on the symptomatic sideinduces sensory and motor effects over the contralateralhand in individuals with thumb CMC OA. The purpose ofthis study was to perform a secondary analysis of arandomized controlled trial by examining changes occur-ring in the contralateral hand and to investigate if theapplication of a unilateral passive accessory mobilizationover the symptomatic hand in patients with thumb CMC

OA would induce contralateral mechanical hypoalgesia andmotor effects.

METHODS

SubjectsWe performed a secondary analysis of data from a

randomized controlled clinical trial.2 The methods anddescription of the trial have been previously described.2 Themost relevant parts of the design are summarized below.

Subjects with dominant hand thumb CMC OA wererecruited. The diagnosis was based on the patient's medicalhistory and radiographic evidence of stage III and IV thumbCMC OA according to the Eaton-Littler-BurtonClassification.18,19 Inclusion criteria for this study wereage between 70 and 90 years with intact cognitive abilitiesand unilateral dominant thumb CMCOA. Exclusion criteriaincluded the following: (1) neuromuscular pathology in thehand, for example, de Quervain tenosynovitis; (2) surgicalinterventions on the CMC joint; (3) trigger finger: and (4)patients presenting with any neurologic condition in whichpain perception can be altered.20 The current study wasapproved by the Local Ethics Committee of AziendaSanitaria Locale, Collegno, Italy, and it was registered asISRCTN70578774.2 All patients provided informed con-sent prior their enrollment, and they were randomly assignedto either experimental or sham group by using a simplerandomization with random number generator. Blocked orstratified randomization was not used in this protocol.2

InterventionFollowing randomization, individuals were assigned to

either experimental group or control group. Both groupsreceived the treatment only on the affected/symptomatichand.2

As previously described in original clinical trial,2 theexperimental group received a passive accessory mobiliza-tion targeted to the symptomatic CMC joint for 4 sessionsover 2 weeks (2 sessions/week). The therapist took thethumb metacarpal bone of the subject with his thumb andindex fingers and made a specific passive accessorymobilization with posterior-anterior gliding of the CMCjoint. The intervention was applied 3 times for 3 minuteswith 1-minute rest periods.2 Participants in the placebogroup received a nontherapeutic dose of intermittentultrasound therapy to the thumb region for 10 minutes for4 sessions over 2 weeks.21-23

Outcome MeasuresIn the first study, we analyzed the results from the

symptomatic hand.2 The current secondary analysis wasfocused on the contralateral hand. Pressure pain thresholdwas measured over the contralateral thumb CMC joint at the

Control Group Detuned

ultrasound to the hypothenar area

10 min / session 4 sessions over 2

weeks

Screened for eligibility (n = 30)

Measured pressure-pain threshold and pinch strength Randomised (n = 28)

(n = 14) (n = 14) Week 0

Experimental Group passive accessory

mobilization 3 x 3 min, with 1-min

rest periods 4 sessions over 2

weeks

Week 2 Measured pressure-pain threshold and pinch strength (n = 14) (n = 14)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Excluded (n = 2) Not meeting inclusion criteria (n = 2)

Declined (n = 2)

Week 3 Measured pressure-pain threshold and pinch strength (n = 14) (n = 14)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Measured pressure-pain threshold and pinch strength (n = 14) (n = 14)

Week 4

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Fig 1. Flow diagram of patients throughout the course of the study.

Table 1. Baseline characteristics of participants

Characteristic

Randomized (n = 28)

Exp (n = 14) Con (n = 14)

Age (y), mean (SD) 82 (5) 84 (6)Sex, n, females (%) 10 (71.4) 10 (71.4)

Exp, experimental group; Con, control group.

234 Journal of Manipulative and Physiological TherapeuticsVillafañe, Cleland, and Fernandez-de-las-PeñasMay 2013Passive Accessory Mobilization for Thumb Osteoarthritis

anatomical snuffbox, the tubercle of the scaphoid bone, andthe unciform apophysis of the hamate bone. The pressurewas approximately applied at a 0.1 kg/cm2 per second (untilthe onset of pain).1,2,12-14 The validity and reproducibilityof algometry have been described, and higher PPT suggestslower pain sensitivity.24 We also assessed motor perfor-mance by analyzing tip and tripod pinch and grip strength,which has been shown to be valid and reliable.25 Pressurepain threshold was expressed in kilograms per squarecentimeter, whereas pinch strength, in kilograms. For everyoutcome, 3 measurements were calculated and used for theanalysis. A 1-minute resting period was allowed betweeneach trial. They were assessed at baseline, immediately afterthe treatment, and 1 and 2 weeks after the treatment by anassessor blinded to the subject's allocated group.2

Data AnalysisData were analyzed using SPSS version 18.0 (SPSS, Inc,

Chicago, IL). The results are expressed as mean values,

SDs, and/or 95% confidence intervals. Normal distributionof the data was analyzed using the Kolmogorov-Smirnovtest (P N .05). The analysis revealed that all quantitativedata had a normal distribution. Intraclass correlationcoefficients and SEM were calculated to further determinethe intraexaminer repeatability of PPT data using the 3separate trials collected at baseline. Baseline differences inPPT and strength between both groups were assessed withthe unpaired Student t tests. A repeated measures analysisof variance (ANOVA) was used to determine thedifferences in PPT and pinch and grip strength levels withtime (preintervention, postintervention, and 1-week and 2-

ence

betweengrou

ps

etweengroups

sWeek3minus

week0

Week4minus

week0

Exp

minus

Con

Exp

minus

Con

1.8)

0.1(−

1.3to

1.2)

0.3(−

1.0to

1.6)

0.7)

0.2(−

0.2to

0.7)

0.6(0.3

to1.0)

0.9)

0.0(−

1.0to

1.0)

0.3(−

0.6to

1.2)

1.0)

0.1(−

1.2to

1.1)

0.1(−

1.1to

1.1)

0.3)

−0.1(−

0.5to

0.3)

0.0(−

0.4to

0.4)

0.7)

−0.1(−

0.6to

0.4)

0.0(−

0.5to

0.5)

1.7)

−1.0(−

2.5to

0.4)

0.4(−

1.2to

1.9)

235Villafañe, Cleland, and Fernandez-de-las-PeñasJournal of Manipulative and Physiological TherapeuticsPassive Accessory Mobilization for Thumb OsteoarthritisVolume 36, Number 4

week follow-ups) as the within-subjects factor and group(experimental or placebo) as the between-subjects factor.The hypothesis of interest was group × time interaction.Post hoc comparisons were done with Bonferroni correc-tions. Between-groups effect sizes were calculated usingCohen's d coefficient.26 An effect size greater than 0.8was considered large; around 0.5, moderate; and less than0.2, small.26 The statistical analysis was conducted ata 95% confidence level. A P b .05 was consideredstatistically significant.

ean(95%

confidence

interval)differ

Differenceb

sWeek4minus

week0

Week2minu

week0

onExp

Con

Exp

minus

Con

0.0(1.5)

0.0(1.8)−0.3(1.6)0.5(−

0.8to

0.1(0.5)

0.4(0.4)−0.2(0.6)0.2(−

0.3to

0.1(1.3)

0.3(0.9)

0.0(1.3)0.2(−

0.5to

0.0(0.9)−0.1(1.8)

0.0(0.9)0.0(−

1.1to

0.1(0.6)

0.1(0.5)

0.1(0.5)0.0(−

1.9to

0.2(0.7)−0.1(0.7)

−01

(06)

0.2(−

0.2to

0.7(1.8)

0.4(2.0)

0.0(1.9)0.3(−

1.3to

RESULTS

Flow of Participants Through the StudyTwenty-eight patients (72% females), with unilateral

CMC OA and mean age ± SD of 82 ± 6 years, met all theinclusion criteria and agreed to participate (Fig 1). Nosignificant differences in any outcome were found atbaseline between groups. Baseline data of the participantsare summarized in Table 1.

udyvisitsforeach

grou

p,mean(SD)differencewith

ingrou

ps,an

dm

Differencewith

ingroups

Week3

Week4

Week2minus

week0

Week3minu

week0

onExp

Con

Exp

Con

Exp

Con

Exp

C=14)

(n=14)(n

=14)

(n=14)

(n=14)

.2(2.0)5.5(1.6)

5.5(2.1)

5.5(2.0)

5.1(1.6)

3.3(1.9)−0.2(1.5)

0.0(1.7)

.6(1.3)4.1(1.5)

3.8(1.3)

4.2(1.1)

3.5(1.4)

0.1(0.7)−0.1(0.6)

0.3(0.7)

.7(1.7)4.7(1.5)

4.7(1.5)

4.9(1.8)

4.6(1.9)

0.4(0.3)

0.1(1.3)

0.1(1.3)

.8(1.8)5.8(2.1)

5.8(2.0)

5.8(2.0)

5.8(2.0)

0.0(1.9)

0.0(0.5)−0.1(2.0)

.9(0.8)1.9(0.9)

2.0(0.8)

2.0(1.0)

2.0(0.9)

0.0(0.3)

0.0(0.3)

0.0(0.4)

.5(1.2)2.5(1.2)

2.7(1.2)

2.4(1.2)

2.5(1.2)

0.1(0.4)−0.1(0.7)

0.0(0.5)−

.4(9.2)9.6(5.6)11.1

(10.0)

10.3

(6.0)10.4

(8.7)

0.3(1.8)

0.0(2.1)−0.3(1.9)

PT,pressure-painthreshold.

Changes in Mechanical Pain SensitivityThe intraexaminer repeatability of PPTs over the

contralateral lateral epicondyle, thumb CMC joint, scaph-oid, and hamate bones was 0.93, 0.95, 0.78, and 0.89,respectively. The SEM was 0.44, 0.29, 0.82, and 0.58kg/cm2, respectively.

The ANOVA revealed significant group × time in-teractions for PPT over the thumb CMC joint (F3.00 = 4.89;P = .009) but not for the lateral epicondyle (F3.00 = 0.46;P = .74), scaphoid (F3.00 = 1.38; P = .27), and hamate(F3.00 = 2.28; P = .1) bones. The post hoc testing revealedsignificant increases in PPT on the thumb CMC joint in theexperimental group at the second follow-up periodcompared with baseline data (P = .012). No differencesbetween postintervention and first follow-up periods wereobserved (P N .10). Between-group effect size wasmoderate (d = 0.27) after the intervention and small tomoderate (d = 0.56) at both follow-up periods. The data aresummarized in Table 2.

Tab

le2.Mean(SD)forou

tcom

esat

allst

Outcome

Groups

Week0

Week2

Exp

Con

Exp

C

(n=14)(n

=14)

(n=14)

(n

Epicondyle

PPT,(kg/cm2 )

5.5(2.1)

5.4(1.2)

5.8(1.8)

5

CMCjoint

PPT,(kg/cm2 )

3.8(0.9)

3.7(1.1)

3.9(1.1)

3

Scaphoid

PPT,(kg/cm2 )

4.6(1.2)

4.6(1.7)

5.0(1.2)

4

Ham

ate

PPT,(kg/cm2 )

5.9(2.0)

5.8(1.8)

5.9(1.9)

5

Tippinch

strength(kg)

1.9(0.9)

1.9(0.7)

1.9(0.9)

1

Trip

odpinch

strength(kg)

2.5(1.2)

2.6(1.0)

2.6(1.2)

2

Grip st

rength(kg)

9.9(5.3)10.4

(9.4)10.2

(6.4)10

Con,controlgrou

p;Exp,experimentalgroup;

P

Changes in Motor PerformanceThe intraexaminer repeatability in motor performance

over the tip and tripod pinch and grip strength was0.72, 0.89, and 0.90, with a SEM of 0.74, 0.51, and2.07 kg, respectively.

The ANOVA did not reveal a significant group × timeinteraction for either tip pinch (F = 0.09; P = .97), tripodpinch (F = 0.6; P = .61), or grip strength (F = 0.46; P = .71).Between-group effect sizes were small (d b 0.2) after theintervention and at both follow-up periods for all outcomes.Data are summarized in Table 2.

236 Journal of Manipulative and Physiological TherapeuticsVillafañe, Cleland, and Fernandez-de-las-PeñasMay 2013Passive Accessory Mobilization for Thumb Osteoarthritis

DISCUSSION

This secondary analysis found that the application of aunilateral passive accessory mobilization interventiontargeted to the symptomatic thumb CMC joint in in-dividuals with thumb CMC OA resulted in limitedhypoalgesic effects over the contralateral CMC only atthe 4-week follow-up period. No differences were noted forPPT level over the contralateral lateral epicondyle, thetubercle of the scaphoid bone, and the unciform apophysisof the hamate. Therefore, it is likely that joint mobilizationtargeted to the symptomatic CMC has a limited hypoalgesiceffects on the contralateral hand.

Previous studies have reported that mobilization targetedto the symptomatic CMC joint increased PPT on theipsilateral hand/elbow. Villafañe et al2 recently demon-strated that mobilization to the symptomatic side resulted insignificant improvements in PPT over the ipsilateral CMCand scaphoid bone in individuals with CMC OA.2 In thecurrent study, a small hypoalgesic effect was also observedover the CMC joint, which surpassed the SEM (0.29 kg/cm2). However, this change was only found 2 weeksafter the intervention. Furthermore, changes observed inPPTs on the remaining points did not surpass the SEM. Itseems plausible that joint mobilization of the symptomaticCMC joint would result primarily in hypoalgesia on thesymptomatic side. Another possible explanation is thatbilateral hypoalgesic effects can be only observed with jointmobilization techniques targeted to the spine as previouslysuggested.15-17 Some studies examining the effects ofmanual therapies directed at the cervical and thoracic spinein individuals with lateral epicondylalgia found bilateralchanges in PPTs.27,28 However, the aforementioned studiesused manipulation and not joint mobilization so we cannotgeneralize the results to mobilization techniques. This is animportant topic because spinal manipulation has differenteffects than spinal mobilization.29

The current study did not observe any change incontralateral motor control. This finding is not surprisinggiven that mobilization techniques targeted to the symp-tomatic joint did not result in ipsilateral changes in pinchor grip strength over a control group.2 It is interestingthat mobilization of the symptomatic CMC joint did notelicit either contralateral or ipsilateral strength change.2

Our results disagree with a previous published study wheremobilization techniques directed at the painful elbow inpatients with lateral epicondylalgia showed statisticallysignificant and clinically meaningful improvements in gripstrength.10 It is possible that active interventions, that is,mobilization with movement, induce greater motor effectsthan passive joint mobilizations such as the applied in thecurrent study.

This study has some implications for clinical practice,which include the following. Current and previous findingssuggest that joint mobilization of the peripheral joints

induces localized hypoalgesic effect. Therefore, combina-tion of spine and peripheral interventions should berecommended for the management of individuals withthumb CMC OA. Future studies should investigate theeffects of multimodal approaches including both spinal andperipheral interventions in this patient population.

LimitationsThere are a number of limitations to this study that

should be considered. First, 1 therapist performed allmobilization techniques, which limits the generalizability.The study included a small sample size and a short-termfollow-up. Because we included a small sample size andconducted several statistical analyses, it is possible that thestudy may have been underpowered. Second, we applied alocalized manual intervention over the symptomatic joint,which does not represent the clinical practice managementfor this population. Finally, the analyses reported in thecurrent study were exploratory and hypothesis generatingrather than confirmatory because secondary outcomes wereincluded. Future studies should include larger sample sizes,use more treating therapists, and collect data at long-termfollow-up periods.

CONCLUSIONS

The findings of this secondary analysis showed that theapplication of a unilateral passive accessory mobilizationintervention targeting the symptomatic thumb CMC jointin patients with thumb CMC OA resulted in limitedhypoalgesic effects over the contralateral CMC joint at 2weeks after the intervention. No changes were observed forPPT levels over the lateral epicondyle, the tubercle of thescaphoid bone, and the unciform apophysis of the hamate.No motor effects were associated with the mobilization forthe symptomatic hand.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST

No funding sources or conflicts of interest were reportedfor this study.

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