July 2003 Volume 33, No. 7

Clinical Commentary /-- The Carpometacarpal Joint of the Thumb: Stability, Deformity, and Therapeutic Intervention

Teri Bielefeld
The carpometacarpal (CMC) of the thumb is a saddle joint that permits a wide range of motion and is largely responsible for the characteristic dexterity of human prehension. This joint, located at the very base of the thumb, is subject to large physical stresses throughout life. Osteoarthritis (posttraumatic or idiopathic), rheumatoid arthritis, and postmenopausal laxity of the capsular ligaments can predispose structural instability and impairment of this important joint. The instability is characterized by varying and often progressive dislocation of the joint surfaces, resulting in a displaced axis of rotation and abnormal actions of thumb muscles. The main consequence of the instability is most often pain and weakness, most notably during pinch and grasping actions. This paper is conceptually divided into 2 sections. The first section describes the anatomic structures that maintain stability in the normal CMC joint of the thumb and how disease or trauma can cause instability and ultimate deformity. The second section describes both nonsurgical and surgical interventions that are most often used to treat an unstable CMC joint. This paper is intended primarily as an overview for the physical therapist who does not specialize in the treatment of the hand, although desires basic information on this important topic.
J Orthop Sports Phys Ther. 2003;33(7):386--399.

Identical 3-MHz Ultrasound Treatments With Different Devices Produce Different Intramuscular Temperatures

Study Design: A counterbalanced, repeated-measures design with ultrasound device (Omnisound 3000C, Dynatron 950, Excel Ultra III) as the independent variable. The 2 dependent variables were intramuscular (IM) temperature at 6 minutes and at the end of a 10-minute treatment.
Objective: To compare IM temperatures produced by identical 3-MHz ultrasound treatments between 3 different ultrasound devices.
Background: Most recent studies prescribing intensity and duration parameters for thermal ultrasound treatments have been performed using an Omnisound device, but have not been verified in other common ultrasound devices.
Methods and Measures: Six uninjured volunteers (mean age � SD, 22 � 3.4 years; mean height � SD, 171.9 � 11.0 cm; mean mass � SD, 66.1 � 11.1 kg) gave informed consent and served as subjects. Separate ultrasound treatments using identical parameters (3 MHz, 1.5 W/cm2 , 10 minutes, treatment area equal to twice transducer surface area) were administered at 24 or 48 hours intervals using a different ultrasound device for each treatment. Left medial calf IM temperature was recorded every 20 seconds using implantable thermocouples at a depth of 1.6 cm below the treatment surface. Data were analyzed using MANOVA with Sidak adjusted multiple comparisons post hoc.
Results: Tissue heating using the Omnisound device was greater than with either the Dynatron or the Excel. The results of treatments using Dynatron or Excel devices did not differ. The Omnisound was the only device to consistently produce IM temperatures above the 40�C therapeutic threshold and did so in less than 6 minutes. The other devices did not reach this threshold within the 10-minute treatment session. Subjects routinely reported heating sensations approaching discomfort when the IM temperature reached the 40�C therapeutic threshold.
Conclusions: Because there are differences in thermal effects between ultrasound devices, our results suggest that recently published parameters for ultrasound intensity and duration parameters will not produce equally therapeutic effects for all ultrasound devices.
J Orthop Sports Phys Ther. 2003;33(7):379--385. Key Words: clinical efficacy, sonication, thermotherapy

Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold

Study design: Single-blind, placebo control, randomized, crossover, experimental study with repeated measures.
Objective: To determine the initial effects of a taping technique on grip strength and pain in individuals with lateral epicondylalgia.
Background: Taping techniques are advocated for chronic musculoskeletal conditions such as lateral epicondylalgia, a prevalent disorder with significant impact on the individual and community. Little evidence exists supporting the effects of taping techniques on musculoskeletal pain.
Methods and Measures: Sixteen participants (mean age � SD, 45.8 � 10.2 years) with chronic lateral epicondylalgia (mean duration � SD, 13.1 � 9.9 months) participated in a placebo control study of an elbow taping technique. Outcome measures were pain-free grip strength and pressure pain threshold taken before, immediately after, and 30 minutes after application of tape.
Results: The taping technique significantly improved pain-free grip strength by 24% from baseline (P = .028). The treatment effect was greater than that for placebo and control conditions. Changes in pressure pain threshold (19%), although positive, were not statistically significant.
Conclusion: This preliminary study demonstrated an initial ameliorative effect of a taping technique for lateral epicondylalgia and suggests that it should be considered as an adjunct in the management of this condition.
J Orthop Sports Phys Ther. 2003;33(7):400--407.
Key Words: epicondylitis, McConnell, tendinosis, tennis elbow, treatment

The Effect of Static Stretching of the Calf Muscle-Tendon Unit on Active Ankle Dorsiflexion Range of Motion

Study Design: Masked randomized trial.
Objective: To examine the effects of a 6-week program of static stretching of the calf muscle-tendon unit (MTU) on active ankle dorsiflexion range of motion (ADFROM) in healthy subjects.
Background: Static stretching of the calf MTU is often prescribed to increase flexibility in patients with shortened connective tissues or to maintain ADFROM in healthy individuals. Presently, physical therapists lack specific information on the optimal dosage of calf MTU stretching necessary to produce improvement in ADFROM.
Methods and Measures: One hundred one adults (63 women, 38 men; mean age � SD, 40.0 � 10.9 years; range, 21-59) with no visual evidence of gait impairment due to lower-extremity dysfunction participated in the study. Active ADFROM was measured with a universal goniometer. Participants were randomly assigned to group 1, no stretch controls (n = 24), or to 1 of 3 experimental groups carrying out a 6-week program of standing wall stretches once per day: individuals in group 2 stretched for 30 seconds (n = 26); individuals in group 3 stretched for 1 minute (n = 24); individuals in group 4 stretched for 2 minutes (n = 27).
Results: After 6 weeks, the results of an analysis of variance found no effect of treatment on active ADFROM.
Conclusion: The results of this study show that a 6-week program of once-per-day static stretching for up to 2 minutes is not sufficient to increase active ADFROM in healthy subjects.
J Orthop Sports Phys Ther. 2003;33(7):408--417.
Key Words: flexibility, lower extremity, rehabilitation, triceps surae

The Immediate Effects of a Cervical Lateral Glide Treatment Technique in Patients With Neurogenic Cervicobrachial Pain

Michael W. Coppieters, Karel H. Stappaerts
Study Design: Randomized clinical trial.
Objectives: To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain.
Background: Different treatment modalities have been described for patients with neurogenic cervicobrachial pain. Although it has been suggested that a more specific approach, like cervical mobilization, would be more effective, effect studies are scarce.
Methods and Measures: Twenty patients with subacute peripheral neurogenic cervicobrachial pain were assessed. Besides other criteria, patients were included if a cervical segmental motion restriction was present which could be regarded as a possible cause of the neurogenic disorder. Patients were randomly assigned to a mobilization or ultrasound group. Mobilization consisted of a contralateral lateral glide technique. The range of elbow extension, symptom distribution, and pain intensity during the neural tissue provocation test for the median nerve were used as outcome measures. Results were analyzed using a 2-way mixed-design ANOVA.
Results: Significant differences in treatment effects between the 2 groups could be observed for all outcome measures (P=.0306). For the mobilization group, the increase in elbow extension from 137.3� to 156.7�, the 43.4% decrease in area of symptom distribution, and the decreased pain intensity from 7.3 to 5.8 were significant (P=.0003). For the ultrasound group, there were no significant improvements (P=.0521).
Conclusions: When a cervical dysfunction can be regarded as a cause of the neurogenic disorder or as a contributing factor that impedes natural recovery, a cervical lateral glide mobilization has positive immediate effects in patients with subacute peripheral neurogenic cervicobrachial pain. This movement-based approach seems preferable to ultrasound.
J Orthop Sports Phys Ther. 2003;33(7):369--378.

Key Words:Brachial plexus, cervical spine, manipulative therapy, manual therapy, neurodynamic test

Editor’s Note: www.jospt.org

Dear Journal readers,
Last month, we inaugurated an improved, robust website for the Journal of Orthopaedic & Sports Physical Therapy. This online resource offers you far more functionality than it provided in the past and is intended as a new tool to facilitate access to the content and other activities of the Journal.
Now when you visit www.jospt.org, you will be able to search abstracts from 2002 to the present. Over the remainder of this year, we will continue to add to this information until we have included abstracts of articles that date back to the JOSPT's beginnings in 1979.
Further, as a member of the American Physical Therapy Association’s Orthopaedic and/or Sports Physical Therapy Sections or as an independent Journal subscriber, you have full-text online access to articles published since January 2002. The contents of the current issue are posted each month at the same time the publication is mailed to you. To access this protected area of the JOSPT site, simply enter your APTA member or JOSPT subscriber number, which is located at the top left-hand corner of the mailing label of your copy of the Journal, and then enter the city where you receive the publication. If you have any difficulty gaining access to the articles, please call the JOSPT office at 1-877-766-3450 and a member of our staff will assist you.
The new JOSPT website also makes it easy for you to apply to become a manuscript or book reviewer for the Journal. In addition, for the first time, JOSPT subscribers and APTA members can submit changes of address, claim missing or damaged print issues, and order single issues or articles online. Those of you who subscribe can also renew your subscriptions online.
We hope you find www.jospt.org a valuable resource for your clinical, educational, and research activities. Please let us know what you think of the site. We look forward to hearing from you.

Sincerely,
Guy G. Simoneau PT, PhD, ATC
Editor-in-Chief

How to Report Nonsignificant Results: Frequently Asked Questions

Janice Derr