Regional Interdependence In Treatment Of The Elbow

 Regional Interdependence of manipulation on elbow pain[edit | edit source]

Definition:  Treatment directed at one area of the body to ellicit changes in another[edit | edit source]

-in addition to treatment directed at the elbow, patients with elbow pain may benefit from treatment directed at the cervical or thoracic spine, elbow, and/or wrist.[edit | edit source]


I.Treatment techniques[edit | edit source]

Lateral epicondylitis

  •    Cervical (link to spot within this page)
  •    CT
  •    Thoracic 
  •    Wrist

Cubital tunnel

  •    Carpal Mobilization

Radial Nerve entrapment

  •    Median Nerve mobilization

III. Physiology of regional interdependence[edit | edit source]

A. Manipulation of cervical or thoracic spine produces an immediate, localized hypoalgesic effect and reduces pain in human subjects
B. Joint manipulation produces a non-opioid form of analgesia, mediated by spinal serotonergic and noradrenergic receptors utilizing descending inhibitory pathways from the RVM and dorsolateral pons.
C. central neural mechanisms mediate the reduction in hyperalgesia.
D. the antihyperalgesia produced by joint manipulation appears to involve descending inhibitory mechanisms that utilize serotonin and noradrenaline.
E. Further, cervical manipulation produces hypoalgesia in, people with lateral epicondylitis or cervical spine pain, that is accompanied by sympathoexcitation: evidenced by changes in skin conductance, blood flow and/or skin temperature
1. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord
2. D.A. Skybaa,c, R. Radhakrishnanb,c, J.J. Rohlwingb, A. Wrightd, K.A. Slukaa,b,c,*[edit | edit source]

IV: Treatment of Lateral Epicondylitis
A. Link to lateral epicondylitis
B. Clinical Presentation
1. Patients experiencing lateral epicondylitis are characterized as having two or more of the following signs and symptoms:
a. Pain on palpation over the lateral epicondyle and extensor unit
b. Pain on gripping a hand dynamometer
c. Pain with stretching or contraction of wrist extensor muscles[edit | edit source]

C. Treating Lateral Epicondylitis with Cervical Manipulation
1. Intervention Strategy
a.This cervical manipulation is directed at the C5-C6 vertebral level. The patient is in supine position with neck in a neutral position. The therapist applies contact over the posterolateral aspect of the zygapophyseal joint of C5 with their index finger. The therapist then moves the patient’s neck into ipsilateral flexion and contralateral rotation to the targeted segment. A high-velocity low-amplitude thrust manipulation is directed upward and medial in the direction of the subject’s contralateral eye. If an audible popping sound is not heard, the subject is repositioned and the procedure is repeated for a second time.

2. Outcomes of Cervical Manipulation
1. Manipulation at cervical spine created immediate increase in pressure pain thresholds in lateral epicondylitis.
2. Manipulation at cervical spine increased pain-free grip strength on affected side with lateral epicondylitis.
3. Cervical spine thrust manipulations have been shown to be superior to thoracic spine thrust manipulations in increasing pressure pain threshold and pain-free grip in those with lateral epicondylitis. 1[edit | edit source]

D. Thoracic Manipulation For Treatment of Lateral Epicondylitis
1. Intervention Strategy
A. Although cervical has been shown to be superior to thoracic manipulations, clinicians have attempted to treat the thoracic spine in order to make gains in lateral epicondylitis. This technique involves targeting the middle thoracic spine (T5-T8). To perform the manipulation, the stabilizing hand is placed at a level immediately distal to the restricted segment using a “pistol grip.” The subject is supine with their arms cross over their chest and hands grasping their opposite shoulder. The therapist’s other hand is used to stabilize the neck, head, and upper thoracic. Gentle flexion of the thoracic spine is introduced until tension is palpated under the therapist’s hand on the transverse process. The therapist then performs a high-velocity, low thrust manipulation in a downward, cephalad direction.
Outcomes of Intervention
1. Both thoracic and cervical spinal manipulation increases pain-free grip strength on affected side with lateral epicondylitis.
2. Cervical spinal manipulation produces an immediate bilateral increase in pressure pain threshold in patients with lateral epicondylitis, but thoracic spinal manipulation does not 2.[edit | edit source]

• Treatment of cervicothoracic spine for lateral epicondylitis[edit | edit source]

Clinical Presentation
1. Patients had a diagnosis of lateral epicondylitis as defined as a positive finding in 2 or more of
A. Pain with palpation of lateral epicondyle
B. Pain with resisted wrist extension
C. Pain with resisted middle finger extension
2. Patients also had to demonstrate articular impairments of the cervical, cervicothoracic, or upper thoracic spine.
3. Patients excluded if bilateral symptoms, multiple diagnoses, signs of radial tunnel syndrome, and if this was not the patient’s first episode of lateral epicondylitis
Patient Assessment
1. PROM, AROM, palpation of soft tissues, strength of the elbow and forearm, neurodynamic testing, joint assessment of the radiohumeral joint, ulnarhumeral joint, and proximal/distal radio-ulnar joints.
2. Cervical/thoracic assessment- AROM, overpressure, passive intervertebral mobility of OA for flexion, extension, and sidebending, AA flexion and rotation test, PPIVM of C2-C7 into flexion, extension, sidebending, rotation, and PA centrally of C2-T6
Intervention strategy
1. All groups received local treatment to the elbow which included stretching of wrist extensors, strengthening of the wrist and forearm musculature, mobilizations of the elbow/wrist, instructions to avoid activities that would aggravate their condition
2. Group received local treatment and manual therapy to the cervicothoracic spine. This group received grade III and IV PPIVM and PAIVM directed at the impaired segments.

Outcomes
1. Both local treatment and local treatment with manual therapy groups had success in global improvements and decreasing disability
2. Local treatment plus manual therapy group showed greater improvements in painfree grip strength, pain, and disability
3. Combined treatment group showed overall greater perception of change following treatments
4. Most dramatic difference in the combined treatment group was grip strength 3[edit | edit source]


• Wrist mobilization
Clinical Presentation
1. Patients with lateral epicondylitis defined as
A. Pain on lateral side of the elbow that is aggravated by both pressure applied to the lateral epicondyle and with resisted extension of the wrist
B. Symptoms for at least 6 weeks, but not longer than 6 months
C. Patients excluded from treatment if bilateral complaints, definite decrease in pain in the last 2 seeks, severe neck or shoulder problems
Intervention Strategy
1. The patient rests their forearm of their affected arm on the table with the palmar side of the hand facing down. The therapist sits at right angles to the patient’s affected side, gripping the patient’s scaphoid bone between their thumb and index finger. The therapist then places the thumb and index finger of his other hand on top of his hand gripping the scaphoid. The therapist performs the manipulation by extending the patient’s wrist dorsally while at the same time manipulating the scaphoid bone ventrally.

Outcomes of intervention
1. The wrist manipulation was more effective at increasing global improvement than combined treatment of ultrasound, friction massage, and muscle strengthening and stretching exercises. In addition, the manipulation was also superior at decreasing pain scores after 6 weeks of intervention.
2. Measures of pain free grip force, maximum grip force, and pressure pain threshold were not found to be significantly different between manipulation and combined treatment in this study. However, these findings may be due to a small number of subjects.
3. Additional studies done on the effectiveness of wrist manipulation in the treatment of lateral epicondylitis are needed 4[edit | edit source]

• 4. Treating Cubital Tunnel Syndrome 5
• Carpal manipulation
• Presentation
Insidious medial elbow pain, 2-6 out of 10 on VAS scale
Parathesia in ulnar distribution
Aggravating movements: pushing and pulling with R arm, lifting her children, holding phone to her ear, using a computer
Denied neck, shoulder, or radicular pain
• Examination
Cervical stability tests
Selective tissue tension test (STTT) for the upper extremity
AROM, PROM w/ OP and strength assessment at wrist and elbow
Cervical compression and distraction
Sensory testing: deep tendon reflexes C5-C8, sensory testing dermatones C5-T1, strength testing of muscle in C5-C8 myotomes
Elbow and wrist ligamentous testing
Elbow flexion test for Cubital Tunnel Syndrome
Upper Limb Tension Test (ULTT)
Joint passive mobility
• Intervention Strategy
With the patient seated comfortably, the therapist grasps the patient’s wrist with both hands. On the palmar side, the therapist stabilizes the patient’s hamate with both index fingers, one on top of the other. On the dorsal side, the therapist palpates the triquetral with both thumbs. To assess the patient’s tolerance to the mobilization a pre manipulation hold was implemented by pushing down palmarly through the triquetral while stabilizing the hamate. If tolerated, the therapist proceded to have the patient lean back to provide a little traction on the carpals and then while maintaining some wrist flexion, the therapist performed a downward HVLA thrust to the triquetral in a palmar direction. Immediately following manipulation the patient was asked to move the elbow, without pain, in the new unrestricted ROM: Elbow flexion, elbow supination, wrist extension, and ulnar deviation.


• Follow up
Patient returned 3 more times to the clinic at 2 days, 1 week, 2 week, and 4 weeks after the initial visit.
Negative ULTT with ulnar nerve bias 2 days later and normal carpal mobility both maintained until discharge.
Less provocative elbow flexion test at 2 days which resolved at 1 week, returned at 2 weeks, and had resolved by discharge.
At 2 weeks patient was manipulated with same procedure
At 4 weeks all positive tests were now negative and pain was 0/10
SOURCEMEDICAL DIAGNOSIS OF CUBITAL TUNNEL SYNDROME AMELIORATED WITH THRUST MANIPULATION OF THE ELBOW AND CARPALS- KEARNS, WANG[edit | edit source]


• 5. Treating Radial Tunnel Syndrome
Entrapment of the deep radial nerve/Radial Tunnel Syndrome: (ekstrom)
• Clinical Presentation:
o Right lateral elbow pain for four months
o Decreased joint prom during neural tension testing
o Burning pain over lateral epicondyle
o 4/5 Strength on right wrist, finger and thumb extensors
• Tests performed: neural tension testing of median and radial nerve
o Cervical ROM/Special tests
o Median nerve test:
 Shoulder girdle depression with elbow flexed to 90 degrees
 Shoulder abduction with the elbow flexed to 90 degrees
 Shoulder lateral rotation
 Wrist and finger extension with forearm supinated
 Elbow extension
o Radial nerve test:
 Shoulder girdle depression with elbow flexed to 90 degrees
 Forearm pronation
 Elbow extension
 Wrist and finger flexion
 Shoulder abduction
o Palpation for abnormal tenderness over the radial tunnel.
o Resisted supination
o Pronation
o Grip[edit | edit source]

• Interventions:
o Patient was placed into similar positions used for the tensioning tests then the mobilization was performed by flexing and extending the elbow.
o The mobilization were performed gently, extending the elbow for about 2 seconds just into the range where patient felt tension but no pain and then flexing the elbow to the point where the patient felt no tension.
o Six to seven mobilizations were done emphasizing the median nerve, followed by 6 to 7 mobilizations emphasizing the radial nerve. The patient’s response dictated the degree of elbow extension during mobilization.
o If pain or discomfort or any signs, such as tingling in the hand, were produced, the range of elbow extension was reduced.
Link to video: http://www.youtube.com/watch?v=ts1vBavU4kI&feature=youtu.be
• Outcome:
• Minimal tenderness or pain with palpation over the lateral epicodyle, the radial tunnel, and muscle bellies of the extensor carpi radialis longus and brevis muscle.
• Follow up:
o After first week of intervention, ROM in the right upper extremity increased
 Grip strength increased from 14 to 20 kg
 Slight decrease in tenderness and pain over lateral epicondyle and radial tunnel
o After ten weeks of intervention grip strength increased to 39 kg
o Minimal tenderness with palpation over the lateral epicondyle , the radial tunnel
o Pain free 70%-80% of the time and only had an aching pain when performing activities that would normally aggravate the elbow.[edit | edit source]


•
Pain can refer down the forearm and into the hand
B. Indications[edit | edit source]

C. Contraindications[edit | edit source]

a. Symptoms in cervical spine
b. Bilateral presentation
c. Cervical disc disruption
d. Previous whiplash
e. Cervical surgery[edit | edit source]


o
D. Reassessment[edit | edit source]

E. 11 Physical Therapy Management in addition to manipulation….[edit | edit source]

F. 14 Clinical Bottom Line (conclusion)[edit | edit source]

• Manipulation of the wrist in those with lateral epicondylitis might have additional treatment effects short term compared with ultrasound, friction massage, and muscle strengthening and stretching
• Incorporating manual therapy directed at the cervicothoracic spine may provide additional benefits over treatment directed only at the elbow.[edit | edit source]

G. 16 References[edit | edit source]


Search terms:
LE and Radial tunnel syndrome
MT and radial nerve
Manipulation and radial nerve
Posterior interoussens nerve syndrome
1. Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland J. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal Of Manipulative & Physiological Therapeutics. November 2008;31(9):675-681.[edit | edit source]

2. Fernández-Carnero J, Cleland J, Touche. Examination of Motor and Hypoalgesic Effects of Cervical vs Thoracic Spine Manipulation in Patients With Lateral Epicondylalgia: A Clinical Trial. Journal Of Manipulative & Physiological Therapeutics [serial online]. September 2011;34(7):432-440.[edit | edit source]

3. Cleland J, Flynn T, Palmer J. Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal Of Manual & Manipulative Therapy (Journal Of Manual & Manipulative Therapy). September 2005;13(3):143-151.[edit | edit source]

4. Struijs P, Damen P, Bakker E, Blankevoort L, Assendelft W, van Dijk C. Manipulation of the wrist for management of lateral epicondylitis: a randomized pilot study. Physical Therapy. July 2003;83(7):608-616.[edit | edit source]

5. Kearns G. Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals. Journal Of Manual & Manipulative Therapy (Maney Publishing). December 2010;18(4):228.
[edit | edit source]

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