Evidence-Based Upper Extremity Thrust Manipulation

 Evidence Summary Table

Author (Year)	Level of Evidence	Pathology	Upper Extremity Manipulation(s) Performed
Struijs et al. (2003)	1b	Lateral Epicondylitis	Wrist manipulated from neutral position to maximal extension
Nagrale et al. (2009)	1b	Lateral Epicondylitis	Mill's manipulation
Goyal et al. (2013)	1b	Lateral Epicondylitis	Cyriax (Mill's manipulation + deep transverse friction massage) Wrist manipulation (Scaphoid)
Kearns et al. (2012)	4	Cubital Tunnel Syndrome	Lateral thrust manipulation of humeroulnar joint Palmar thrust manipulation of triquetrum on hamate
Sucher BM (1994)	1b	Carpal Tunnel Syndrome	Opponens roll
Siu et al. (2012)	5	Carpal Tunnel Syndrome	Opponens roll Carpal bone HVLA Metacarophalangeal joint HVLA Carpometacarpal joint HVLA Posterior radial head HVLA

Lateral Epicondylitis

Struijs et al. (2003)

• Manipulation Performed

+ Wrist manipulated from neutral position to maximal extension

• Results
  

+ Following 3 weeks of treatment

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

- Only 20% of the control group achieved these outcomes

Nagral et al. (2009)

• Treatment

+ 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

Goyal et al. (2013)
 

•  Manipulations Performed

                + Cyriax Physiotherapy (Mills manipulation and deep transverse friction massage) vs. Wrist Manipulation (scaphoid)

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) 

•  Manipulations Performed

                + Lateral Thrust Manipulation of Humeroulnar Joint
                + Palmar Thrust Manipulation of Triquetrum on Hamate

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, negative ULTT, carpal and humeroulnar joint mobility WNL, 0.10 on numeric pain rating scale.

Carpal Tunnel Syndrome

Siu et al. (2012)

• Opponens roll maneuver:
  
• This maneuver involves lateral and axial rotation of the thumb, which creates substantial traction on the attachment of the opponens pollicis muscle. The muscle originates from the transverse carpal ligament and tubercle of the trapezium bone. This maneuver stretches the muscle and transverse carpal ligament, releasing pressure within the carpal tunnel and unloading pressure on the median nerve.

• The physician performs this technique by grasping the hypothenar region of the patient and then using his or her other hand to grasp the patient's thenar area. The physician gradually pulls the patient's thenar area laterally while simultaneously moving the thumb into extension to create traction. In addition, the abductor pollicis brevis is extended and abducted. A progressive phase of stretch further extends and abducts the opponens and abductor muscles.This technique is especially useful as patients can be educated on how to self-perform the opponens roll maneuver by using the contralateral hand to grasp and extend the thumb.
  
• Carpal Bone: 
• High-velocity, low-amplitude technique (mobilization with impulse)—The physician's hands grasp the patient's hand and wrist with the thumb contacting the dorsal aspect of the dysfunctional carpal bone (Figure 11A). The physician uses the thumb of the other hand to reinforce the dysfunctional carpal bone while the index fingers grasp the anterior aspect of the carpal bones (Figure 11B). A dorsiflexion barrier is then engaged, and the physician applies a mobilization with impulse thrust moving the patient's wrist toward the floor in a whipping motion (Figure 11C). A palmar flexion barrier is then engaged, and the physician applies a mobilization with impulse thrust by moving the patient's wrist in the opposite direction.
  

• Metacarpophalangeal Joint: 
• High-velocity, low-amplitude technique (mobilization with impulse)—The physician grasps an individual phalanx with his or her index fingers and palm (Figure 12A). Traction is then applied to the metacarpophalangeal joint, and a mobilization with impulse thrust is applied distally in an axial manner. The same technique is applied to the remaining untreated metacarpophalangeal joints.
  
• Carpometacarpal Joint: 
• High-velocity, low-amplitude technique (mobilization with impulse)—With the physician's thumb contacting the dorsal aspect of an individual metacarpal, the index fingers grasp the dorsal aspect of the metacarpal48 (Figure 12B). Mobilization occurs by gently applying a downward force with the thumb until a barrier is engaged and subsequently applying an upward force with the index fingers. The remaining untreated metacarpals are then mobilized in the same fashion.
  
• Posterior radial head dysfunction:
• High-velocity, low-amplitude technique (mobilization with impulse) —The physician places his or her thenar eminence on the patient's posterior radial head using his or her index fingers to grasp the patient's medial elbow. The patient's forearm is then rotated into supination until the restrictive barrier is reached. The forearm is then extended and a mobilization with impulse 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. Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome. J Am Osteopath Assoc. 1994; 94(8): 647-63.

6. Siu G, Jaffe JD, Rafique M, Weinik MM. Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome. J Am Osteopath Assoc. 2012; 112(3): 127-139.