Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis

Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial

Objective: Previous studies on learning joint mobilization techniques have used expert practitioners as the reference standard as there is no current evidence on what ideal forces would be for effective mobilizations. However, none of these trials have documented the reliability or accuracy of the reference standard. Therefore, the purpose of this study was to report both the reliability and accuracy of an expert physical therapist (PT) acting as a reference standard for a manual therapy joint mobilization trial.Methods: A secondary analysis was performed using data from a published randomized, controlled, crossover study. The mobilization technique studied was the central posterior to anterior (PA) joint mobilization of the L3 vertebra. Reliability and accuracy data for the reference standard were collected over four time periods spanning 16 weeks.Results: Intrarater reliability of the expert PT for R1 and R2 joint forces was excellent (R1 Force ICC_3,3 0.95, 95%CI 0.76-0.99 and R2 Force ICC_3,3 0.90, 95%CI 0.49-0.99). Additionally, the expert PT was 92.3% accurate (mean % error±SD, 7.7 ± 5.5) when finding Grade III mean peak mobilization force and 85.1% accurate (mean % error±SD, 14.9 ± 8.3) when finding Grade IV mean peak mobilization force. Finally, correlations between actual applied forces and computed ideal forces were excellent (Pearson r 0.79-0.92, n = 24, P < 0.01 for all correlations).Discussion: The expert PT in this manual therapy joint mobilization trial showed excellent reliability and accuracy as the reference standard. The study supports the use of implementing quantitative feedback devices into the teaching of joint mobilization when a reliable and accurate reference standard has been identified.Level of Evidence: 2b.

The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial

OBJECTIVE

To examine the effects of real-time, objective feedback on learning lumbar spine joint mobilization techniques by entry-level Doctor of Physical Therapy (DPT) students.

METHODS

A randomized, controlled, crossover design was used. Twenty-four 1st Year DPT students were randomized into two groups. Group 1 (n = 12) practiced with the real-time feedback device first and then without it, while Group 2 (n = 12) practiced without the device first and then with it. Both practice periods with and without the device were 4 weeks long. Data were collected at Baseline, 5 weeks, 11 weeks, and 16 weeks. The crossover period was 5 weeks long, during which neither group practiced with or without the device. Eight force parameters were measured: R1 force; R2 force; Grade III and Grade IV mean peak force, frequency, and amplitude.

RESULTS

When students practiced with the real-time feedback device, they more closely matched the reference standard for two outcomes: 1) the mean difference in R2 force between student and reference standard was better with device (38.0 ± 26.7 N) than without it (51.0 ± 38.5 N); P = .013; and 2) the mean difference in Grade III peak to peak amplitude force was also better with device (8.9 ± 9.3 N) than without it (11.8 ± 11.0); P = .026. All other force parameters improved when students practiced with the real-time feedback device, however, the differences between when they practiced without the device were not statistically significant.

DISCUSSION

Real-time, objective feedback using a direct force measurement device improved learning for some aspects of lumbar spine joint mobilization by entry-level physical therapy students.

LEVEL OF EVIDENCE

2b.

Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).

DATA SOURCES

Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.

STUDY SELECTION

Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.

DATA EXTRACTION

Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.

RESULTS

Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).

CONCLUSIONS

This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

REVIEW REGISTRATION

PROSPERO 2016:CRD42016032799.

Quantifying performance metrics of cervical spine mobilization for improved education and clinical outcomes: Early experience with a novel wearable device

Introduction

Evaluation of manual skills training for spinal rehabilitation has been stagnant for 40 years. Observation and mimicry are coupled with feedback from “expert” observers to train and evaluate learners, relying on rater experience to discern speed and force. Spinal manipulation is a controlled act under the Regulated Health Professions Act (1991) as it is not without risk. The discordance between current methods for evaluating proficiency and the potential risks of inadequate application is a critical gap.

Methods

This work reports a novel wearable device that measures finger forces via microstrain bending of the physiotherapist’s nail. The device leaves the tactile finger pad unobstructed and does not interfere with treatment application. Five expert-level physiotherapists performed a standard postero-anteriorly directed spinal segmental mobilization treatment for 1 min at 1–1.5 Hz rhythm.

Results

The device successfully measured all treatment forces (0.2–27.3 N). Physiotherapists applied a maximum force rate of 0.03 ± 0.01 N/s with a rhythm of 1.76 ± 0.38 Hz. In 15 trials, there were no device failures. The device was easily applied and removed, and physiotherapists were able to walk about and interact normally with patients.

Conclusions

These results indicate that this technology can be integrated into a skills training program to provide quantitative feedback for objective assessments.

Effect of joint mobilization techniques for primary total knee arthroplasty: Study protocol for a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has become the most preferred procedure by patients for the relief of pain caused by knee osteoarthritis. TKA patients aim a speedy recovery after the surgery. Joint mobilization techniques for rehabilitation have been widely used to relieve pain and improve joint mobility. However, relevant randomized controlled trials showing the curative effect of these techniques remain lacking to date. Accordingly, this study aims to investigate whether joint mobilization techniques are valid for primary TKA.

METHODS/DESIGN

We will manage a single-blind, prospective, randomized, controlled trial of 120 patients with unilateral TKA. Patients will be randomized into an intervention group, a physical modality therapy group, and a usual care group. The intervention group will undergo joint mobilization manipulation treatment once a day and regular training twice a day for a month. The physical modality therapy group will undergo physical therapy once a day and regular training twice a day for a month. The usual care group will perform regular training twice a day for a month. Primary outcome measures will be based on the visual analog scale, the knee joint Hospital for Special Surgery score, range of motion, surrounded degree, and adverse effect. Secondary indicators will include manual muscle testing, 36-Item Short Form Health Survey, Berg Balance Scale function evaluation, Pittsburgh Sleep Quality Index, proprioception, and muscle morphology. We will direct intention-to-treat analysis if a subject withdraws from the trial.

DISCUSSION

The important features of this trial for joint mobilization techniques in primary TKA are randomization procedures, single-blind, large sample size, and standardized protocol. This study aims to investigate whether joint mobilization techniques are effective for early TKA patients. The result of this study may serve as a guide for TKA patients, medical personnel, and healthcare decision makers.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/showproj.aspx?proj=15262 (Identifier:ChiCTR-IOR-16009192), Registered 11 September 2016. We also could provide the correct URL of the online registry in the WHO Trial Registration. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-IOR-16009192.

The intra-rater reliability of a revised 3-point grading system for accessory joint mobilizations

OBJECTIVES

Joint mobilizations are often quantified using a 4-point grading system based on the physiotherapist's detection of resistance. It is suggested that the initial resistance to joint mobilizations is imperceptible to physiotherapists, but that at some point through range becomes perceptible, a point termed R1. Grades of mobilization traditionally hinge around this concept and are performed either before or after R1. Physiotherapists, however, show poor reliability in applying grades of mobilization. The definition of R1 is ambiguous and dependent on the skills of the individual physiotherapist. The aim of this study is to test a revised grading system where R1 is considered at the beginning of range, and the entire range, as perceived by the physiotherapists maximum force application, is divided into three, creating 3 grades of mobilization.

METHOD

Thirty-two post-registration physiotherapists and nineteen pre-registration students assessed end of range (point R2) and then applied 3 grades of AP mobilizations, over the talus, in an asymptomatic models ankle. Vertical forces were recorded through a force platform. Intra-class Correlation Coefficients, Standard Error of Measurement, and Minimal Detectable Change were calculated to explore intra-rater reliability on intra-day and inter-day testing. T-tests determined group differences.

RESULTS

Intra-rater reliability was excellent for intra-day testing (ICC 0.96-0.97), and inter-day testing (ICC 0.85-0.93). No statistical difference was found between pre- and post-registration groups.

DISCUSSION

Standardizing the definition of grades of mobilization, by moving R1 to the beginning of range and separating grades into thirds, results in excellent intra-rater reliability on intra-day and inter-day tests.

LEVEL OF EVIDENCE

3b.

Establishing the Basis for Mechanobiology-Based Physical Therapy Protocols to Potentiate Cellular Healing and Tissue Regeneration

Life is mechanobiological: mechanical stimuli play a pivotal role in the formation of structurally and functionally appropriate body templates through mechanobiologically-driven cellular and tissue re/modeling. The body responds to mechanical stimuli engendered through physical movement in an integrated fashion, internalizing and transferring forces from organ, through tissue and cellular length scales. In the context of rehabilitation and therapeutic outcomes, such mechanical stimuli are referred to as mechanotherapy. Physical therapists use mechanotherapy and mechanical interventions, e.g., exercise therapy and manual mobilizations, to restore function and treat disease and/or injury. While the effect of directed movement, such as in physical therapy, is well documented at the length scale of the body and its organs, a number of recent studies implicate its integral effect in modulating cellular behavior and subsequent tissue adaptation. Yet the link between movement biomechanics, physical therapy, and subsequent cellular and tissue mechanoadaptation is not well established in the literature. Here we review mechanoadaptation in the context of physical therapy, from organ to cell scale mechanotransduction and cell to organ scale extracellular matrix genesis and re/modeling. We suggest that physical therapy can be developed to harness the mechanosensitivity of cells and tissues, enabling prescriptive definition of physical and mechanical interventions to enhance tissue genesis, healing, and rehabilitation.

Unilateral anterior crossbite induces aberrant mineral deposition in degenerative temporomandibular cartilage in rats

OBJECTIVE

To investigate whether mechanical stress induces mineral deposits that contribute to matrix degradation at the onset of osteoarthritis (OA) in temporomandibular joint (TMJ) cartilage.

DESIGN

Female Spraguee-Dawley rats were subjected to an unilateral anterior crossbite (UAC) procedure. Histology, electron microscopy, and energy dispersive spectrometer (EDS) were used to examine cartilage matrix structures and composition of mineral deposit in the affected TMJ cartilage. Protein and/or RNA expression of phenotypic markers and mineralization modulators and matrix degradation was analyzed by immunohistochemistry and/or real-time PCR. Synthetic basic calcium phosphate (BCP) and calcium pyrophosphate dehydrate (CPPD) crystals were used to stimulate ATDC5 cells for their impact on cell differentiation and gene expression.

RESULTS

Fragmented and disorganized collagen fibers, expanded fibrous spaces, and enhancement of matrix vesicle production and mineral deposition were observed in matrices surrounding hypertrophic chondrocytes in cartilage as early as 2-weeks post-UAC and exacerbated with time. The mineral deposits in TMJ cartilage at 12- and 20-weeks post-UAC had Ca/P ratios of 1.42 and 1.44, which are similar to the ratios for BCP. The expression of mineralization inhibitors, NPP1, ANK, CD73, and Matrix gla protein (MGP) was decreased from 2 to 8 weeks post-UAC, so were the chondrogenic markers, Col-2, Col-X and aggrecan. In contrast, the expression of tissue-nonspecific alkaline phosphatase (TNAP) and MMP13 was increased 4-weeks post-UAC. Treating ADTC5 cells with BCP crystals increased MMPs and ADAMTS5 expression, but reduced matrix production in a time-dependent manner.

CONCLUSION

UAC induces deposition of BCP-like minerals in osteoarthritic cartilage, which can stimulate matrix degradation by promoting the expression of cartilage-degrading enzymes to facilitate OA progression.