1. Presented by Brooke Dentlinger, Kelsey Nenneman, & Jennie Ollason

2.  Title: The use of joint mobilization to improve clinical outcomes in hand therapy: A systematic review of the literature  Authors: Rick Heiser, OTD, OTR/L, CHT, CLT, Virginia H. O’Brien OTD, OTR/L, CHT, & Deborah A. Schwartz OTD, OTR/L, CHT  Journal of Hand Therapy, September 2013

3.  Joint mobilization – a manual therapy technique used to increase range of motion and decrease pain. There are 3 types: ◦ Oscillations – repetitive passive movement of varying amplitudes and low velocity (within control of the patient) ◦ Sustained mobilizations – traction type movement which may simply decrease compressive forces on the joint or may distract the articular surfaces and take up the slack of the soft tissue surrounding the joint ◦ Manipulations – sudden high velocity thrust type movement of small amplitude at the limit of available movement (the patient is unable to halt)

4.  Two types of joint movement exist: ◦ Osteokinematic – motions of the bones that produce voluntary movements ◦ Arthrokinematic – movement that occurs between joint surfaces and is necessary for normal joint range of motion but cannot be performed voluntarily  Five arthrokinematic motions:  Roll  Spin  Slide  Compression  Distraction

5.  Mobilization with movement (MWM) – an additional manual therapy technique that applies a sustained accessory glide at a peripheral joint while a movement that would normally be pain provoking is performed actively or passively

6.  Purpose: to examine the current evidence describing joint mobilization for treatment of conditions of the elbow, wrist, and hand and offer informative practical clinical guidance ◦ Much of the current literature focuses on shoulder mobilizations, with fewer on studies on elbow, and even fewer on wrist and hand  Methods: Systematic review, including twenty- two studies between 1980 and 2011, included only English studies done with adults

7.  Key Findings: ◦ Elbow joint mobilization (16 studies) – all were about treating lateral epicondylitis (tennis elbow)  1. Moderate evidence that MWM will have a positive effect on pain and strength in the short term.  2. Moderate evidence that elbow joint mobilizations will have a positive effect on ROM in the short term.  3. Moderate evidence to high evidence that mobilization is as good as or better than injection in the long term.  4. Moderate evidence joint mobilization has a positive effect on function in the short and long term.

8.  Key Findings: ◦ Wrist mobilization (4 studies)  1. For patients with distal radius fractures, there is moderate evidence that mobilization has a positive effect on ROM, pain, and function in the short term. In addition, there is moderate evidence that in this diagnosis group MWM may be more effective for pain relief and a Maitland style mobilization may be more effective for ROM change.  2. For patients with CTS, there is limited evidence mobilization has a positive effect on pain and ROM, with a positive trend toward functional improvement. ◦ Hand mobilization (2 studies)  1. For patients with limited ROM in the MCP joints, there is evidence, albeit limited, that mobilization will affect change in ROM in the short term.  2. For patients with first CMC OA there is evidence, albeit limited, that mobilizations reduce pain in the short term.

9.  Current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for lateral epicondylitis. There is moderate support for mobilization with movement.  Joint mobilization can be used in practice as a preparatory method to help reduce pain and stiffness before participation in functional interventions.  More research is needed in this area

10. StrengthsWeaknesses  Through review of current literature available  Provides practical treatment information for clinicians to make informed decisions  Had a high standard for research, level 3 or higher Only includes English studies High standards may have excluded some studies that could add to knowledge on the topic

11.  Has anyone seen joint mobilizations used during hand therapy sessions while out on clinical rotations?  After reviewing this article, would you decide to incorporate joint mobilizations into therapy sessions? Why or why not?

12. Heiser, R., O’Brien, V.H., & Schwartz, D.A. (2013). The use of joint mobilization to improve clinical outcomes in hand therapy: A systematic review of the literature. Journal of Hand Therapy, 26, 297-311.

13. Any Questions??