Evidence-Based Upper Extremity Thrust Manipulation
Original Editors - Samantha Jewell, Kelly Mills, Kassandra Schuppe, Erin Verschoor, and Whitney Wilson part of the Des Moines University Student Project
Introduction [edit | edit source]
Manipulation is a manual technique often used in physical therapy as an adjunctive treatment for a variety of musculoskeletal pathologies. However, quality research and evidence-based practice recommendations are extremely lacking with regard to thrust manipulation of the upper extremity. The purpose of this literature review was to help clinicians identify upper extremity pathologies for which thrust manipulation is supported by research.
Evidence Summary Table[edit | edit source]
| Author (Year) | Level of Evidence | Pathology | Upper Extremity Manipulation(s) Performed |
| Struijs et al. (2003)[1] | 1b | Lateral Epicondylitis |
|
| Nagrale et al. (2009)[2] | 1b | Lateral Epicondylitis |
|
| Goyal et al. (2013)[3] | 1b | Lateral Epicondylitis |
|
| Kearns et al. (2012)[4] | 4 | Cubital Tunnel Syndrome |
|
| Siu et al. (2012)[5] | 5 |
Carpal Tunnel Syndrome |
|
Lateral Epicondylitis [edit | edit source]
Struijs et al. (2003)
[edit | edit source]
- Intervention
+ Wrist manipulation (scaphoid)
- Technique
~ Patient forearm on table with palmar side facing down
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist sits at right angle to the patient's affected side
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist grips scaphoid between thumb and index finger
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist extends subjects wrist dorsally, while scaphoid bone is manipulated ventrally
- Results
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Following 3 weeks of treatment:
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- 62% of patients receiving thrust manipulation reported being "much improved or "completely improved"
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Only 20% of the control group achieved these outcomes
- Manipulation of the wrist might have additional treatment effects compared with ultrasound, friction massage, and muscle stretching and strengthening exercises for management of lateral epicondylitis over the short term.
Nagral et al. (2009)[edit | edit source]
- Intervention
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Cyriax physiotherapy (deep tendon massage + Mill's manipulation) vs. Phonophoresis
- Results
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Following 4 weeks of treatment:
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- 26% increase in function on the Tennis Elbow Function Scale
- Pain-free grip improved 25% more with elbow manipulation compared to phonophoresis and exercise group
- Cyriax physiotherapy was found to provide a superior benefit in terms of pain, pain-free grip, and functional status when compared to a treatment regimen consisting of phonophoresis with supervised exercise and static stretching. The long-term effects of treatment remain unknown past 8 weeks.
Goyal et al. (2013) [edit | edit source]
- Intervention
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Cyriax Physiotherapy vs. Wrist Manipulation (scaphoid)
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Wrist Manipulation Technique
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Patient forearm on table with palmar side facing down
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist sits at right angle to the patient's affected side
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist grips scaphoid between thumb and index finger
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist extends subjects wrist dorsally, while scaphoid bone is manipulated ventrally
- Results
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Following 3 weeks of treatment:
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Both the Cyriax group and the wrist manipulation group improved
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Pain reduction favored the wrist manipulation group (47% reduction vs. 26% reduction with Cyriax)
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Grip strength improvements favored the wrist manipulation group (24% increase vs. 12% increase with Cyriax)
Cubital Tunnel Syndrome[edit | edit source]
Kearns et al. (2012) [edit | edit source]
- Intervention
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Lateral Thrust Manipulation of Humeroulnar Joint
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Patient lying in supine position
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Grasp distal medial humerus proximal to humeroulnar joint with one hand
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Support proximal radius, immediatley distal to the humeroulnar joint with the other hand
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Thrust delivered on the distal humerus at the humeroulnar barrier in a medial to lateral direction
<span style="white-space: pre" class="Apple-tab-span" />+ Palmar Thrust Manipulation of Triquetrum on Hamate
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Patient in seated position
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist grasp patient's wrist with their palm down
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Stabilize the hamate palmarly with both index fingers
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Place thumbs over the patient's triquetral on the dorsum
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Patient gently leans back to produce a small amount of traction through the carpals
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Maintain slight wrist flexion while thumbs exert downward pressure in a palmar direction to the triquetral
- Results
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ After the first visit:
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Immediate relief of elbow pain following lateral thrust manipulation of humeroulnar joint
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Pain-free wrist extension and ulnar deviation following the palmar thrust manipulation of triquetrum on hamate
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Full and pain-free elbow flexion and supination was attained
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Lateral glide of humeroulnar joint was restored
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Normalized mobility of the carpals was attained
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ After the 5th (final) visit:
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Negative elbow flexion test and negative upper limb tension test
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Carpal and humeroulnar joint mobility WNL
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- 0.10 on numeric pain rating scale
Carpal Tunnel Syndrome
[edit | edit source]
Siu et al. (2012)
[edit | edit source]
- Although not evidence-based, this review of carpal tunnel syndrome outlines several thrust manipulations that may be clinically useful for a physical therapist. It is evident that further research is warranted for thrust manipulation in the management of carpal tunnel syndrome, along with many other upper extremity pathologies.
- Intervention
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Carpal Bone Thrust Manipulation
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist grasp patient wrist with index fingers on the anterior aspect of the carpal bones
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ An extension barrier is engaged
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Thrust is applied by moving the patient's wrist toward the floor in a whipping motion
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ A flexion barrier is then engaged
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Another thrust is applied by moving the patient's wrist in the opposite direction
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Metacarpophalangeal and Carpometacarpal Thrust Manipulation
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique A
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist grasps an individual phalanx with his/her index fingers and palm
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Traction is then applied to the metacarpophalangeal joint
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Thrust is applied distally in an axial manner
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique B
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist's thumb contacts the dorsal aspect of an individual metacarpal
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist's index fingers grasp the dorsal aspect of the metacarpal
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Thrust is applied in a downward force with the thumb until a barrier is engaged
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ A subsequent force is applied upward with the index fingers
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />+ Radial Head Thrust Manipulation
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />- Technique
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist places his/her thenar eminence on the patient's posterior radial head
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Therapist uses his/her index fingers to grasp the patient's medial elbow
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ Patient's forearm is supinated until the restrictive barrier is reached
<span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" /><span style="white-space: pre" class="Apple-tab-span" />~ The forearm is extended and the thrust is applied with the thenar eminence
References
[edit | edit source]
1. Struijs P, Damen PJ, Bakker E, Blankevoort L, Assendelft W, Dijk CN. Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study. Phys Ther 2003; 83(7):608-616.
2. Nagrale AV, Herd CR, Ganvir S, Remteke G. Cyriax physiotherapy versus phonophoresis with supervised exercises in subjects with lateral epicondylagia: a randomized clinical trial. J Man Manip Ther. 2009; 17(3): 171-8.
3. Goyal M, Kumar A, Monga M, Moitra M. Effect of Wrist Manipulation & Cyriax Physiotherapy Training on Pain & Grip Strength in Lateral Epicondylitis Patients. J Ex Sci Physiother. 2003; 9(1): 17-22.
4. Kearns G, Sharon W. Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals. J Man Manip Ther. 2012; 20(2): 90-95.
5. Siu G, Jaffe JD, Rafique M, Weinik MM. Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome. J Am Osteopath Assoc. 2012; 112(3): 127-139.
- ↑ Struijs P, Damen PJ, Bakker E, Blankevoort L, Assendelft W, Dijk CN. Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study. Phys Ther 2003; 83:608-616.
- ↑ Nagrale AV, Herd CR, Ganvir S, Remteke G. Cyriax physiotherapy versus phonophoresis with supervised exercises in subjects with lateral epicondylagia: a randomized clinical trial. J Man Manip Ther. 2009; 17(3): 171-8.
- ↑ Goyal M, Kumar A, Monga M, Moitra M. Effect of Wrist Manipulation &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Cyriax Physiotherapy Training on Pain &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Grip Strength in Lateral Epicondylitis Patients. J Ex Sci Physiother. 2003; 9(1): 17-22.
- ↑ Kearns G, Sharon W. Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals. J Man Manip Ther. 2012; 20(2): 90-95.
- ↑ Siu G, Jaffe JD, Rafique M, Weinik MM. Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome. J Am Osteopath Assoc. 2012; 112(3): 127-139.
