The Effectiveness of a Manual Therapy and Exercise Protocol in Patients With Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial

Author Names

Villafañe, J. H, Cleland, J. A., & Fernández-de-las-Peñas, C

Reviewer Name

Jada Holmes, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

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 post-intervention. 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.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• No

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Yes

 

Key Finding #1

The application of a multi-modal manual therapy intervention of joint mobilization, neural mobilization, and exercise is beneficial to reduce pain in patients with CMC joint OA.

Key Finding #2

No changes in PPT and motor function were observed.

 

Please provide your summary of the paper

This study shows that when looking at short-term effects of joint mobilization, neural mobilization, and exercise when treating OA in the CMC joint, this produces better results for pain than ultrasound. This study used grade 3 PA glides with distraction of the 1st CMC joint, nerve sliders, and AROM stretching exercises as the treatment protocol for the intervention group versus ultrasound as the placebo group. The intervention group had significantly improved pain compared to the placebo group but had no difference in physical performance tests or grip strength between the groups. Some previous research has looked at the difference between the effects joint and neural mobilizations on PPTs, but this was not observed in this case. Future studies should investigate which treatment and exercise protocols are most appropriate for reducing pain and improving function in patients with OA in the CMC joint.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

Some, if not all, of these manual therapy techniques can be used on patients with CMC joint OA to help improve pain but will most likely not help function. It’s unclear if these treatments all work in conjunction together or if some will work on their own, so it’s important that you individualize your care to each patient and how they feel. If something isn’t helping their pain, make sure to modify or consult with another PT to see if there’s other treatments you haven’t thought of trying with what you’re already doing.