Evidence-Based Upper Extremity Thrust Manipulation

Original Editors - Samantha Jewell, Kelly Mills, Kassandra Schuppe, Erin Verschoor, Whitney Wilson and Shannon Petersen part of the Des Moines University Student Project    

Introduction  

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

Author (Year)	Level of Evidence	Pathology	Upper Extremity Manipulation(s) Performed
Struijs et al. (2003)	1b	Lateral Epicondylitis	Wrist manipulation (Scaphoid)
Nagrale et al. (2009)	1b	Lateral Epicondylitis	Cyriax Physiotherapy
Goyal et al. (2013)	1b	Lateral Epicondylitis	Cyriax Physiotherapy  Wrist manipulation (Scaphoid)
Kearns et al. (2012)	4	Cubital Tunnel Syndrome	Lateral thrust manipulation of humeroulnar joint Palmar thrust manipulation of triquetrum on hamate
Siu et al. (2012)	5	Carpal Tunnel Syndrome	Carpal bone thrust manipulation Metacarophalangeal thrust manipulation Carpometacarpal joint thrust manipulation Radial head thrust manipulation

Lateral Epicondylitis   

Struijs et al. (2003)

• Intervention

+ Wrist manipulation (scaphoid)

- Technique

~ Patient forearm on table with palmar side facing down

~ Therapist sits  at right angle to the patient's affected side

~ Therapist grips scaphoid between thumb and index finger

~ Therapist extends subjects wrist dorsally, while scaphoid bone is manipulated ventrally

• Results

+ Following 3 weeks of treatment:

- 62% of patients receiving thrust manipulation reported being "much improved or "completely improved"

- 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)

• Intervention

+ Cyriax physiotherapy (deep tendon massage + Mill's manipulation) vs. Phonophoresis

• Results

+ Following 4 weeks of treatment:

- 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)   

• Intervention

+  Cyriax Physiotherapy vs. Wrist Manipulation (scaphoid)

Mill's Manipulation: component of Cyriax Physiotherapy

- Wrist Manipulation Technique

~ Patient forearm on table with palmar side facing down

~ Therapist sits at right angle to the patient's affected side

~ Therapist grips scaphoid between thumb and index finger

~ Therapist extends subjects wrist dorsally, while scaphoid bone is manipulated ventrally

• Results

+ Following 3 weeks of treatment:

- Both the Cyriax group and the wrist manipulation group improved

- Pain reduction favored the wrist manipulation group (47% reduction vs. 26% reduction with Cyriax)

- Grip strength improvements favored the wrist manipulation group (24% increase vs. 12% increase with Cyriax)

Cubital Tunnel Syndrome

 Kearns et al. (2012) 

• Intervention

+  Lateral Thrust Manipulation of Humeroulnar Joint

- Technique

~ Patient lying in supine position

~ Grasp distal medial humerus proximal to humeroulnar joint with one hand

~ Support proximal radius, immediatley distal to the humeroulnar joint with the other hand

~ Thrust delivered on the distal humerus at the humeroulnar barrier in a medial to lateral direction

+  Palmar Thrust Manipulation of Triquetrum on Hamate

- Technique

~ Patient in seated position

~ Therapist grasp patient's wrist with their palm down

~ Stabilize the hamate palmarly with both index fingers

~ Place thumbs over the patient's triquetral on the dorsum

~ Patient gently leans back to produce a small amount of traction through the carpals

~ Maintain slight wrist flexion while thumbs exert downward pressure in a palmar direction to the triquetral

• Results

+ After the first visit:

- Immediate relief of elbow pain following lateral thrust manipulation of humeroulnar joint

- Pain-free wrist extension and ulnar deviation following the palmar thrust manipulation of triquetrum on hamate

- Full and pain-free elbow flexion and supination was attained

- Lateral glide of humeroulnar joint was restored

- Normalized mobility of the carpals was attained

+ After the 5th (final) visit:

- Negative elbow flexion test and negative upper limb tension test

- Carpal and humeroulnar joint mobility WNL

- 0.10 on numeric pain rating scale

Carpal Tunnel Syndrome

Siu et al. (2012)

• 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

+  Carpal Bone Thrust Manipulation

- Technique

~ Therapist grasp patient wrist with index fingers on the anterior aspect of the carpal bones

~ An extension barrier is engaged

~ Thrust is applied by moving the patient's wrist toward the floor in a whipping motion

~ A flexion barrier is then engaged

~ Another thrust is applied by moving the patient's wrist in the opposite direction

+  Metacarpophalangeal and Carpometacarpal Thrust Manipulation

- Technique A

~ Therapist grasps an individual phalanx with his/her index fingers and palm

~ Traction is then applied to the metacarpophalangeal joint

~ Thrust is applied distally in an axial manner

- Technique B

~ Therapist's thumb contacts the dorsal aspect of an individual metacarpal

~ Therapist's index fingers grasp the dorsal aspect of the metacarpal

~ Thrust is applied in a downward force with the thumb until a barrier is engaged

~ A subsequent force is applied upward with the index fingers

MCP and CM joint manipulation

+  Radial Head Thrust Manipulation

- Technique

~ Therapist places his/her thenar eminence on the patient's posterior radial head

~ Therapist uses his/her index fingers to grasp the patient's medial elbow

~ Patient's forearm is supinated until the restrictive barrier is reached

~ The forearm is extended and the thrust is applied with the thenar eminence

References

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.