short-term effects of neurodynamic mobilization in 15 patients with secondary thumb carpometacarpal...

SHORT-TERM EFFECTS OF NEURODYNAMIC MOBILIZATION

IN 15 PATIENTS WITH SECONDARY THUMB

CARPOMETACARPAL OSTEOARTHRITIS

Jorge H. Villafañe, PT, MSc,a,b Guillermo B. Silva, MSc, PhD,c,d and Josue Fernandez-Carnero, MSc, PhDe,f

ABSTRACT

a Physical TherSanitarie Assisten“Don Menzio,” A

b Doctoral Stutional Therapy, RHealth Sciences,

c Principal InHypertension, MJ. Robert Cade F

d Associate PSchool of NutrUniversity of Cu

Objective: The purpose of this study is to evaluate whether neurodynamic mobilization of the median nerveimproves pressure pain threshold (PPT) and pinch and grip strength in patients with secondary thumb carpometacarpalosteoarthritis (TCOA).Method: Fifteen patients with secondary TCOA (13 women and 2 men) between 70 and 90 years old werereceived by neurodynamic therapy. All patients received median nerve mobilization of the dominant hand by slidingtechnique during 4 sessions over 2 weeks. The outcome measures of this case series were monitored by using PPTmeasured by algometry as PPT at the trapeziometacarpal (TM) joint, tubercle of the scaphoid bone, and the unciformapophysis of the hamate bone. Tip and tripod pinch strength was also measured. Grip strength was measured by a gripdynamometer. These variables were measured at pretreatment, 5 minutes posttreatment, 1 week (first follow-up[FU]) and 2 weeks after treatment (second FU).Results: Pressure pain threshold in the TM joint was 3.54 ± 0.04 kg/cm2. After treatment, it increased to 4.38 ± 0.04kg/cm2 (P b .01) and maintained in the first FU (4.27 ± 0.04 kg/cm2, P b .02) and second FU (4.08 ± 0.04 kg/cm2,P b .02). In contrast, we found no differences in PPT in the other studied structures after treatment. Similarly, tipand tripod pinch strength remained without change after treatment. Grip strength was 10.77 ± 0.18 kg, and aftertreatment, it increased to 11.55 ± 0.16 kg (P b .05) and maintained in first FU (11.73 ± 0.18 kg, P b .02) and secondFU (11.2 ± 0.17 kg, P b .05).Conclusions: Median nerve mobilization decreased pain in the TM joint and increased grip strength in this group ofpatients with TCOA. (J Manipulative Physiol Ther 2011;34:449-456)
Key Indexing Terms: Thumb; Osteoarthritis; Hand Strength; Median Nerve
In Europe and the United States, 30% to 40% ofpostmenopausal women and 40- to 50-year-old menhave thumb carpometacarpal osteoarthritis (TCOA).1,2

This pathology causes most of the osteoarthritis-relatedsurgical procedures.2 Thumb carpometacarpal osteoarthritisis a degenerative alteration of the trapeziometacarpal (TM)joint, characterized by abrasion, progressive deteriorationof joint surfaces, and newly forming bone,3,4 presenting aspain at the base of the thumb.2,4

apist, Department of Physical Therapy, Residenzeziali “A. Maritano,” Sangano, Italy and R.S.Avigliana, Italy.dent, Department of Physical Therapy, Occupa-ehabilitation and Physical Medicine, School ofRey Juan Carlos University, Madrid, Spain.vestigator, Department of Physiology andons. Carlos V. Cruvellier Foundation andoundation, Argentina.rofessor, Department of Research Methods,ition, Biochemistry and Pharmacy, Catholicyo, San Juan, Argentina.

The TM joint is prone to be severely affected byosteoarthritis,3,5,6 the most common illness in surgicalreconstructions of the upper limb affecting the TM joint.The disposition of the TM joint allows the tweezermovement between the thumb and the long fingers andthe ability to make a powerful grip. It is functionallyimportant because any pathologic process that alters itcauses chronic sociolabor incapacity due to the severeinduced pain in this region of the hand.4,7

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

f Principal Investigator, ResearchGroup ofMusculo-skeletal Painand Motor Control, European University of Madrid, Madrid, Spain

Submit requests for reprints to: Jorge H. Villafañe,MSc, via RegGenerala 11/16, Piossasco (TO), Italy (e-mail: [email protected]).

Paper submitted October 8, 2010; in revised form April 172011; accepted May 12, 2011.

0161-4754/$36.00Copyright © 2011 by National University of Health Sciencesdoi:10.1016/j.jmpt.2011.05.016

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http://dx.doi.org/10.1016/j.jmpt.2011.05.016

450 Journal of Manipulative and Physiological TherapeuticsVillafañe et alSeptember 2011Neurodynamic Mobilization

The actions of the median nerve include flexion of the 2phalanges of the thumb flexor pollicis longus8 andregulation of thumb opposition movements. Nerve mobi-lization is often used for the treatment of neurodynamicdysfunction.9 Although there is only limited evidence tosupport it, several studies have found advantages in itstherapeutic use.9

Nerve mobilization included sliding techniques, whichaim to glide the nerve by alternating movements of at least2 joints in which 1 movement loads the peripheral nervoussystem while the other movement simultaneously unloadsthe nervous system.10-12 There are several methods toinduce mechanical neural mobilization depending on thenerve structure that needs to be treated.10-12 The slidingtechnique of the median nerve has been described in thepast; however, to date, this is not a common practice for thetreatment of TCOA.10-12 It is thought that this techniqueslides the median nerve without tensioning the nerve.Through this method, gliding may occur within the nerveitself and between surrounding tissues.10-12

Neural mobilization is a part of manual therapy that hasbeen reported to be an effective intervention for certainconditions.13,14 Neural mobilization has been associatedwith decreased ratings of pain and disability when it isapplied for the treatment of several neurogenic andmusculoskeletal disorders.15-18

Taking into account the number of people affected byTCOA, the growing number of older adults, the lack ofhealing treatments, and the side effects of many pharma-cologic pain treatments, more research in this field isnecessary. In addition, the study of methods involvingnoninvasive interventions to achieve symptom relief isalso crucial.7,8,19

The purpose of this work was to determine whethermedian nerve mobilization by the sliding techniquedecreases mechanical hyperalgesia and increases strengthto the tip pinch and tripod pinch in patients with secondaryTCOA in the dominant hand.

METHODS

Study PopulationThe study population consisted of 15 patients, 2 men and

13 women, from 70 to 90 years old (mean ± SD age, 81.9 ±6.51 years), with secondary TCOA in the dominant handreferred by their primary care physician, and who wererecruited from the Department of Physical Therapy,“Residenze Sanitarie Assistenziali,” which depends onAzienda Sanitaria Locale 3, Collegno, Italy. The diagnosiswas obtained from the patient's medical history and x-raydetection of stage III and IV TCOA according to the Eaton-Littler-Burton Classification.20 Informed consent wasobtained from all participants, and all procedures wereconducted according to the Declaration of Helsinki. This

study was supervised by the Department of PhysicalTherapy, Occupational Therapy, Rehabilitation and Phys-ical Medicine, Universidad Rey Juan Carlos, Alcorcón,Spain. All patients gave consent to participate. The protocol(N°93571/c) was approved by the ethics committee inAzienda Sanitaria Locale 3, Collegno, Italy.

Inclusion and Exclusion CriteriaPatients were included if they had secondary TCOA in

the dominant hand, preserved age-related cognitive capac-ities, were ex-factory workers, and were housewives.Patients were excluded if they presented with carpal tunnelsyndrome, arthritis, surgical interventions on TM joint orfingers, and D'Quervain's tenosynovitis or degenerativeand nondegenerative neurologic conditions in which painperception is altered. All patients were given 2 supportingscales, the Beck Depression Inventory21 and the anxietyquestionnaire State Trait Anxiety Inventory,22 for subjectscreening. Patients with anxiety or depressive disorderswere excluded.

InterventionThe median nerve mobilization technique by sliding

technique consists of a series of combined movements of atleast 2 joints in which 1 movement lengthens the nerve bed,thus increasing tension in the nerve, while the othermovement simultaneously decreases the length of thenerve bed, which unloads the nerve itself. These techniquesaim to mobilize a nerve with a minimal increase in tensionand are thought to result in a larger longitudinal excursionthan techniques that simply elongate the nerve bed, such astensioning techniques. In this study, the sliding techniqueconsisted of the alternation of elbow extension (loads themedian nerve) and wrist flexion (unloads the mediannerve), with elbow flexion (unloading) and wrist extension(loading). The range of motion was identical to theamplitudes in the tensioning technique (wrist, between0° and 60° extension; elbow, between 90° and 165°extension; Fig 1).11,23 In brief, all patients were studied insupine posture; the operator positioned his right elbow onthe scapular girdle of the patient and the forearm along theupright arm of the subject. To take precise control ofthe thumb and fingertips, the operator took the right hand ofthe patient. Then, a constant pressure point was appliedon the scapular girdle during movement. After that, theforearm was raised, the wrist and fingers were extended, theshoulder was turned laterally, and the elbow was extended.The mobilization and tension of the median proximal-distalnerve were performed by using the sliding technique thatconsists of simultaneous movements of the elbow (flexion),wrist and hand (extension), and then back to the initialposition.11,15,23

Fig 1. Representative technique of median nerve mobilization bythe sliding technique.

Table 1. Baseline demographics of the studied population

Characteristic Mean SD SEM

Age 81.93 ±6.51 1.74Sex 2/15 (86.66% female)BDI 1.93 ±1.22 0.33STAI 23.27 ±3.63 0.97

BDI, Beck Depression Inventory; STAI, State Trait Anxiety Inventory.

451Villafañe et alJournal of Manipulative and Physiological TherapeuticsNeurodynamic MobilizationVolume 34, Number 7

Measurement of PainWe measured the pressure pain threshold (PPT) by using

a mechanical pressure algometer (Wagner Instruments,Greenwich, CT) with a 1 cm2 rubber-tipped plungermounted on a force transducer.24,25 Pressure pain thresh-old is defined as the minimal amount of pressure that resultsin the sense of pressure changing to pain.24,25 The mean of3 measurements (intraexaminer reliability) was calculatedand used for the main analysis. The range of values of ourpressure algometer is 0 to 10 kg, with a minimal sensibilityof 0.1. For these specific cases, it has been described thatalgometry has the higher reliability (intraclass correlationcoefficient, 0.91; 95% confidence interval, 0.82-0.97) forPPT measurement in older patients.26 In addition, previousstudies have reported an intraexaminer reliability of thisprocedure ranging from 0.6 to 0.97, whereas the inter-examiner reliability ranged from 0.4 to 0.98.27-29 Thefollowing points were evaluated: TM joint at the bottom ofthe anatomical snuffbox, tubercle of the scaphoid bone, andunciform apophysis of the hamate bone.

Pinch StrengthThe pinch strength was measured by a mechanical pinch

gauge (Baseline, Irvington, NY) in the sitting position withthe shoulder adducted and neutrally rotated and the elbowflexed at 90°.4,7 Two different measurements were taken:first, the tip pinch between index and thumb fingers andthen the tripod pinch between index, medial, and thumbfingers. The reliability of this procedure to measure pinchstrength has been found to be in the order of 0.93.30

Grip Strength MeasurementsGrip strength measurements were taken with a grip

dynamometer (Baseline) in the same position, which has aprecision and reliability of ±3% for grip strength

measurements.29,30 Pinch and grip measurements wereexpressed in kilograms. The instrument was calibratedbefore and after treatment of each subject. The reliability ofthese measurements and instruments has been shown insome items of the subscale of the Australian/CanadianOsteoarthritis Hand Index.31,32

Study ProtocolTreatment took place in 4 sessions over 2 weeks and was

applied to the dominant hand 3 times during a 4-minuteperiod with 1-minute pauses between periods. The variableswere taken in the following order: first PPT, pinch strength,and grip strength. Three measurements were done with a 1-minute pause period between measurements. The mean ofthese 3 values was used for analysis. After pretreatmentmeasurements, the physiotherapist, blinded to pretreatmentdata, treated the patients as described in the median nervemobilization technique section. Posttreatment data wereassessed 5 minutes after finished treatment, first follow-up(FU) data were assessed 1 week after the treatment, andsecond FU data were assessed 2 weeks after the treatment,following the sequence mentioned before. The presentdocument was prepared according to the editorial form ofmedical publishing.33

StatisticsData were analyzed using SPSS package version 15.0

(SPSS Inc, Chicago, IL). Results are expressed as mean ±SE. Normal distribution of the sample was analyzed byusing the Kolmogorov-Smirnov test. A 1-way analysis ofvariance with repeated measurements and Bonferroni wasused as post hoc test to evaluate statistical significance. Forall the data of the study, P b .05 was considered significant.

RESULTS

The baseline characteristics of the 15 subjects are listedin Table 1. We found no differences in key demographicvariables, and all presented similar baseline levels of PPT,tip pinch and tripod pinch, and grip strength. The results aresummarized in Table 2.

Table 2. Pressure pain thresholds (kilograms per square centimeter) over the TM joint at the bottom of the anatomical snuffbox, tubercleof the scaphoid bone, and unciform apophysis of the hamate bone; tip and tripod pinch, and grip strength

Pretreatment Posttreatment First FU Second FU

PPT (kg/cm2)TM joint 3.54 ± 1.20 4.38 ± 1.67 4.28 ± 1.74 4.09 ± 1.60Scaphoid bone 5.13 ± 1.72 5.61 ± 1.55 5.22 ± 1.77 5.34 ± 1.61Hamate bone 6.13 ± 2.05 6.96 ± 1.81 6.93 ± 2.04 6.61 ± 2.24

Pinch and grip strength (kg)Tip pinch 2.32 ± 1.28 2.58 ± 1.32 2.52 ± 1.46 2.36 ± 1.53Tripod pinch 2.90 ± 1.53 3.28 ± 1.70 3.18 ± 1.83 3.03 ± 1.70Grip strength 11.30 ± 7.27 11.37 ± 6.47 11.73 ± 6.97 11.20 ± 6.86


Pressure Pain Threshold in TM JointWe found that, before treatment, patients presented a

PPT in the TM joint of 3.54 ± 0.04 kg/cm2 (F = 3.31). Incontrast, after 2 weeks of treatment, their PPT in the TMjoint had increased to 4.38 ± 0.04 kg/cm2 (P b .01 vspretreatment, n = 15; Fig 2A). In addition, during the firstFU session, patients presented a PPT in the TM joint of4.27 ± 0.04 kg/cm2 (P b .02 vs pretreatment, n = 15). Thistendency remained in the second FU session where thePPT in the TM joint was 4.08 ± 0.04 kg/cm2 (P b .02 vspretreatment, n = 15).

Pressure Pain Threshold in the Tubercle of the Scaphoid BoneWe found that, before treatment, patients presented a

PPT in the tubercle of the scaphoid bone of 5.14 ± 0.04 kg/cm2 (F = 0.24). After a 2-week therapy for median nervemobilization, patients presented comparable levels at 5.45 ±0.11 kg/cm2 without any statistically significant differences(P N .05; Fig 2B). The PPT remained at the same levels afterfinishing the treatment. During the first FU session, thePPT was 5.22 ± 0.05 kg/cm2 (P N .05), and in the follow-ing week, during the second FU session, it was 5.34 ± 0.06kg/cm2 (P N .05).

Pressure Pain Threshold in the Unciform Apophysis of the Hamate BoneWe found that, before treatment, patients presented a

PPT in the unciform apophysis of the hamate bone of 6.12 ±0.06 kg/cm2 (F = 2.30). After a 2-week therapy for mediannerve mobilization, patients presented comparable levels at6.92 ± 0.05 kg/cm2 without any statistically significantdifferences (P N .05; Fig 2C). The PPT remained at thesame levels after finishing the treatment. During the first FUsession, the PPT was 6.96 ± 0.10 kg/cm2 (P N .05), and inthe following week, during the second FU session, it was6.60 ± 0.10 kg/cm2 (P N .05).

Tip Pinch and Tripod PinchBefore treatment, we found that patients presented a tip

and tripod pinch strength of 2.31 ± 0.04 kg (F = 1.25) and2.90 ± 0.04 kg (F = 1.74), respectively. After a 2-weektherapy for median nerve mobilization, patients presented

comparable levels at 2.57 ± 0.04 kg and 3.28 ± 0.04 kg,respectively (P N .05; Fig 3A and B). Tip and tripodpinch strengths remained at similar levels after finishingthe treatment. During the first FU session, they were 2.48± 0.04 kg and 3.18 ± 0.04 kg, respectively (P N .05, n = 15),and in the following week, during the second FU session,they were 2.36 ± 0.06 kg and 3.03 ± 0.06 kg, respectively(P N .05). We found no statistically significant differencesin this variable at any time point.

Grip StrengthBefore treatment, patients presented a grip strength of

10.77 ± 0.18 kg (F = 0.50). After 2 weeks of treatment, inthe posttreatment session, grip strength had significantlyincreased to 11.55 ± 0.16 kg (P b .05; Fig 4). Two weekslater, in the first FU session, grip strength had increased to11.73 ± 0.18 kg (P b .02). In the second FU session, gripstrength was still 11.2 ± 0.17 kg (P b .05).

DISCUSSION

The present work shows that median nerve mobilizationtherapy decreases pain in the TM joint and increases gripstrength in patients with dominant-hand secondary TCOA.In the future, this could reinforce therapies aimed todecrease part of the symptoms of this pathology.

To our knowledge, this is the first study in which TCOAis treated with this technique. In other studies in patientswith TCOA,7 only exercises were used along with trainingat home, which raises the problem of the correctperformance of the treatment, considering the average ageof the subjects having TCOA and the need for surveillanceand professional direction. In the present study, all patientswere attended by the same medical team, including thephysiotherapist, thus eliminating an important source oferror, ensuring that proper routine was followed whenperforming the treatment.

Other types of therapy have shown little or noimprovement in the symptoms of patients with dominant-hand TCOA, particularly in the aim to decrease pain in theTM joint.7,34 We found significant changes in PPT in the

Fig 3. A, Tip pinch strength after median nerve mobilization inposttreatment (Post), first FU, and second FU compared withinitial values (Pre). B, Tripod pinch strength after median nervemobilization in posttreatment (Post), first FU, and second FUcompared with initial values (Pre) (n = 15).

Fig 2. Pressure pain threshold before and after median nervemobilization over TM joint after median nerve mobilization inposttreatment (Post), first FU, and second FU compared withinitial values (Pre) (A); the scaphoid bone after median nervemobilization in posttreatment (Post), first FU and second FUcompared with initial values (Pre) (B); and Hamate bone aftermedian nerve mobilization in posttreatment (Post), first FU, andsecond FU compared with initial values (Pre) (n = 15) (C).


TM joint, although we recognize the limitations of thesemeasurements. Like any other subjective experience, pain isa complex variable to be monitored. However, to obtainreliable data, we used several methods including disabilityquestionnaires.35 Similarly, we used pressure algometry toquantify the PPT to minimize the error associated with themeasurement itself.

The participants of the current study had a significantimprovement in PPT over TM joint. These findings areconsistent with prior studies of neurodynamic techniques inthe treatment of neurogenic pain, such us carpal tunnelsyndrome,36 where hypoalgesic effects were found.

To date, the effect of neurodynamic mobilization is notfully understood, and very few authors have reportedresults. However, our findings are in agreement withprevious studies. In fact, in patients with neurogeniccervicobrachial disorder, cervical lateral glide treatmenthas improved the neurodynamic test for the median nerve.Although PPT was not assessed, neural tissue provocationtest of median nerve may be considered as a mechanicalstimulus to assess mechanical hyperalgesia.17

We found no significant changes in pain in the tubercleof the scaphoid bone or the unciform apophysis of thehamate bone of the dominant hand before and aftertreatment. In similar studies where general physiotherapy

image of Fig 3

image of Fig 2

Fig 4. Grip strength in the dominant hand increased after mediannerve mobilization in posttreatment (Post), first FU, and secondFU compared with initial values (Pre) (n = 15).


exercises were used, pain was not decreased.7 Pain is a verydifficult variable to measure; because of the advanceddegree of osteoarthritis, there is no pain while the hand isresting, but in provoking tests, there is a considerableamount of pain, which results in a variable with highinternal variability. In addition, most of the patients wereretired and did not require any extreme use of the joint.Therefore, lack of general movement of the hand worsenedthe condition and sensitized to higher levels of pain in thestructures we studied.

We found that pinch strength (tip pinch and tripodpinch) does not increase after treatment. This agrees withother authors who have likewise found no improvement inthese variables after physiotherapy. Clinical trials inpatients with TCOA treated with two 6-week splints andexercise did not show improvements in tip pinchstrength.34 Although it is well documented that thesemovements are affected by osteoarthritis of the hand, it isimportant to emphasize that the median nerve mainlycontrols general motor skills of the hand but not directly thethumb or finger movements.

In the present study, we found that mobilization of themedian nerve decreases symptoms and increases handfunction. In other hand movement–related pathologies,such as carpal tunnel syndrome, general exercises involv-ing neurodynamic mobilization have also been used.10

Although neurodynamic mobilization has proved to beuseful to decrease the symptoms, there is no guarantee thatonly 1 nerve is being mobilized.37 However, becauseneurodynamic mobilization involves tension and slidingof the nerves,10,37 this kind of manipulation by physio-therapists may be a major component in the success ofthe treatment.

In contrast to other studies in which different tech-niques and treatments were used,7,34 we found that gripstrength was increased after median nerve mobilization.However, we observed that the effect of the therapy someweeks posttreatment tended to decrease, probably gettingclose to the initial value after longer periods. This suggests

that the experimental treatment does not have a long-lastingeffect on the increase of strength. Patients with dominant-hand TCOA present a harshly damaged motor function.Therefore, it is quite plausible that those other nervesdirectly affecting the thumb have a more significant effecton motor function.

Another possible explanation for our results mightinvolve the activation central structures, which may becomereflected in the concurrent hypoalgesic and motor effects. Inaddition, neural tissue provocations test for the mediannerve38 increased muscle activity in the normal population.This, in fact, could be the result of spinal reflex responseto a nociceptive input.

Another probable mechanism that improves part of thefunction in these patients could involve improved vascularreactivity. Mobilization of a nerve may reduce thepressure existing within the nerve and could thereforeresult in an improvement of blood flow to the nerve;therefore, this mechanism could improve axonal transportand nerve conduction.39 Similarly, elongation of the nervebed induces nerve gliding, which increases nerve tensionand intraneural pressure. On the other hand, sustainedelevated intraneural fluid pressure reduces intraneuralblood flow in edematous neuropathies; a dynamicvariation in intraneural pressure when correctly appliedmay facilitate evacuation of intraneural edema and reducesymptoms.24 Therefore, the concept of nerve tension(stress and strain) and glide (excursion) may play a majorrole in treatment formulation.

In addition, it is also possible that reducing mechanicalforces on nerves and stretching fibrotic tissue24 maydecrease inflammatory infiltrate and diminish proinflam-matory factors release around nerves and neurons. In turn,this could stimulate tissue neovascularization and thereforeimprove the oxygen and nutrient supply to the nerve.

LimitationsOur study has several limitations. We recognize that the

sample size was small and that there was the lack of acontrol group. However, because this pathology is oftenaccompanied with depression and neurodegenerative dis-orders, we had an important number of patients with TCOAwho were excluded from the study. Although median nervemobilization has been described by Butler et al12 beforeindicating only the nerve tension and not reportingcontraction of the surrounding muscles of the arm, wecannot rule out that other nerves are being mobilized;therefore, future studies involving other arm and handnerves are needed.

We are aware that we only examined the mid short-termeffects of median nerve mobilization directed at the TCOA.Therefore, we cannot affirm that the positive results willremain in time. Long-term effects of median nerve mobi-lization in TCOA are also required to reinforce our findings.

image of Fig 4


Finally, we recognize that a single treatment proceduredoes not represent the common clinical practice becausepatients are usually treated with several mobilizationsduring their treatment. It would be interesting to analyzewhether inclusion of medial nerve mobilization proceduresin clinical practice induces faster and better outcomes.

CONCLUSIONS

In conclusion, we found that median nerve mobilizationproduced significant hypoalgesia and increased strength inthis group of patients with dominant-hand TCOA. Becausethe mobility of other similar and adjacent nerves was notexplored in this work, future studies with radial nervemobilization techniques will be necessary to compare theeffects in the treatment of pain and increase of strength andespecially in posttreatment efficacy.

Practical Applications

• This study showed that median nerve mobilizationdecreased pain and increased grip strength inpatients with secondary carpometacarpal osteoar-thritis of the dominant hand.

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST

This work was supported in part by a grant to Jorge H.Villafañe.

No conflicts of interest were reported for this study.

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short-term effects of neurodynamic mobilization in 15 patients with secondary thumb carpometacarpal...

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