Author Names
Villafaña. J, Cleland. J, Fernandez-de-las-peñas. C
Reviewer Name
Jaydee Dillon, 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 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
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Cannot Determine, Not Reported, Not Applicable
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Cannot Determine, Not Reported, Not Applicable
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
4-6 session of joint mobilizations over a 2-week period resulted in significantly greater improvements in pressure pain thresholds measured over the first CMC joint and scaphoid bone than nontherapeutic ultrasound.
Key Finding #2
Grade 3 posterior/anterior glide with distraction technique to the first CMC joint was used.
Key Finding #3
Results indicated that patients receiving a multimodal intervention of manual therapy and exercise exhibited significantly greater improvements in pain compared to those who received a placebo intervention.
Please provide your summary of the paper
The purpose of this study was to analyze the effectiveness of manual therapy and exercise on individuals with carpometacarpal (CMC) joint osteoarthritis. Manual therapy interventions consisted of grade 3 posterior/anterior glide with distraction technique to the first CMC joint. Exercise interventions consisted of active range of motion movements of the hand that were designed to improve joint flexibility, as well as grip and pinch strengthening. Patients received 12 sessions over a period of 4 weeks and data was compared to a placebo intervention where patients received the same number of treatment session but only experienced inactive doses of pulsed ultrasound with an intensity of 0W/cm^2 and gentle application of an inert gel for 10 minutes. Outcome measures used consisted of current pain, pressure pain thresholds, pinch strength, and grip strength. Results yielded patients receiving the multimodal intervention experienced a significantly greater reduction in pain, no difference between groups for pain pressure threshold after the intervention, except when measured over the hamate, and no changes in pinch or grip strength.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on the results presented in this paper, application of a multimodal intervention consisting of manual therapy and exercise should be considered for patients with CMC joint OA. This diagnosis can cause severe pain, as well as lead to limitations within a patient’s daily life. Joint mobilizations are an intervention that therapists can do in clinic, as well as teach their patients to do themselves at home. As the research has supported this intervention to reduce pain, it should be considered to teach patients proper techniques in the clinic that they would be able to utilize at home.
