Abstracted by: Ryan Lasley PT, MPT, AT/L, COMT, NASM-CES/PES, Phoenix, AZ – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.
Context: Patients experiencing hip osteoarthrosis (OA) display many forms of pain and dysfunction. For patients experiencing mild to moderate OA the utilization of long-axis distraction mobilization (LADM) has been found to be beneficial. Numerous studies highlight the use of high-force high velocity low amplitude (HVLA) manipulation on hip pain; however, there is limited research determining the different amounts of force needed to achieve similar outcomes on pain and function following LADM.
Objective: The current study’s main purpose was to identify the force a therapist should deliver while performing a LADM in order to improve ROM, decrease pain, and increase function.
Design: Double blinded randomized controlled test-retest trial.
Setting: Private practice physiotherapy clinic.
Patients or Other Participants: There were initially 73 chosen for the research study however, thirteen subjects were excluded due to a failure to meet inclusion criteria. The remaining 60 participants (mean age 63 ± 9.7 years; 58.3% male) were randomly assigned to either the low, medium, or high-force LADM groups. Each group included 20 subjects.
Intervention(s): The three treatment groups included the low-force (26.4 ± 6.8 N) group, the medium-force (50.7 ± 7.8 N) group, and the high-force (68.6 ± 2.9 N) group. Each group received a total of three trials of LADM on consecutive days. A force dynamometer was utilized by a qualified physical therapist to gauge the exact force performed with each LADM. The force delivered to the low-force group was performed and sustained over a 10-minute period of time. The medium- and high-force group received the LADM in an interspersed fashion over a 10-minute period of time. During each of these interspersed periods the force was applied for 45 seconds for the medium-force LADM group and 30 seconds for the high-force LADM group. There was a rest period of 15 seconds between each set for the medium and high-force treatment groups.
Main Outcome Measure(s): The outcome measures were assessed via a qualified and blinded research participant. This was a test-retest study; therefore hip ROM (sagittal, frontal, transverse plane) was tested prior to LADM delivery and then 5 minutes after LADM procedure delivery. Hip pain was assessed via the Western Ontario and McMaster University (WOMAC) pain subscale and the 100-mm visual analog scale (VAS).
Results: Significant inter-group differences were found with motion into all three planes when comparing the high-force LADM group to the low-force LADM group. In the case of the high-force LADM flexion group, flexion increased on average by 5.25° with the improvement in flexion ranging from 77° to 88°. The low-force LADM flexion group’s flexion range improved 0.41° on average with a range of 76.4° to 77.09°. In the case of the high-force LADM extension group, extension improved on average 3.14° with the improvement ranging from -3.5° to +4.5°. The low-force LADM extension group’s extension range improved on average 0.2° with the improvement ranging from -3.4° to -3.2°. This trend was seen for all other motions when comparing the high and low-force LADM groups. No such difference was found when comparing the high-force group to the medium-force group. There was a significant increase found in hip ROM after each treatment session of high-force LADM for all motions except hip external rotation. Hip external rotation ROM was found to be significant after the third and final trial however. The low-force and high-force groups displayed significant improvements in the WOMAC pain subscales as well. The three groups demonstrated no significant improvement in pain ratings via the 100-mm visual analog scale by the end of the study.
Conclusions: This article indicates that high-force LADM causes a significant improvement in hip ROM into all three planes of motion when performed over repeated trials. Additionally, WOMAC pain subscales improved with both the low-force and high-force LADM groups.
Clinical Impression: During my time as a practicing physical therapist I have based the force at which I deliver manual therapy more on the patient’s pain level and the feel of the patient’s connective tissue and less on the amount of force delivered. To gauge pain, I regularly interact with the patient and modify the force of my manual therapy techniques in response to the patient. When it comes to the performance of joint mobilizations, I mostly have performed mobilizations based on the Maitland model of treatment. In this model Maitland addresses connective tissue through a five-grade system (I-V) that integrates both soft tissue feel and oscillatory actions to achieve both pain reduction and tissue mobility improvement. The currently reviewed article however focuses on the Kaltenborn approach of addressing joint mobility and uses a 3-grade system to address connective tissue and achieve improved hip joint ROM.1 The Kaltenborn approach mainly focuses on the forces delivered to the connective tissue which apparently results in a positive improvement in connective tissue mobility and improves hip joint ROM. Maitland only describes high-force delivery when performing grade V mobilization/manipulation and with this force the mobilizations are not sustained for fear of harming the connective tissue. The Kaltenborn’s approach might be more beneficial to the treatment of minimal to moderate severity OA due to applying a more aggressive force for prolonged periods of time when compared to the Maitland approach.
Consistency of the Content: This article serves as a good reminder of the different principles utilized in physical therapy and brings to light another way in which to treat patients with hip pain and movement dysfunction. This article provides an argument that the sustained Kaltenborn joint mobilization techniques could be favored over Maitland mobilization techniques when treating a patient with minimal to moderate hip OA.
- Kaltenborn FM, Evjenth O, Kaltenborn T.B., Morgan D.V.E., 2014. In: Vollowitz, E. (Ed.), Manual Mobilization of the Joints: Joint Examination and Basic Treatment: Volume I: the Extremities, eighth ed. Norli, Oslo (Norway).
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