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LITERATURE REVIEW
MANIPULATIVE AND MULTIMODAL THERAPY FOR UPPER
EXTREMITY AND TEMPOROMANDIBULAR DISORDERS:A
SYSTEMATIC REVIEW
James W. Brantingham, DC, PhD,
a
Tammy Kay Cassa, DC,
b
Debra Bonnefin, DC, MAppSc,
c
Mario Pribicevic, MChiro, PhD,
d
Andrew Robb, DC,
e
Henry Pollard, DC, MSportSc, PhD,
f
Victor Tong, DC, MBA,
g
and Charmaine Korporaal, MTech:Chiropractic, CCSP, ICCSD
h
ABSTRACT
Objective: The purpose of this study was to complete a systematic review of manual and manipulative therapy
(MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ).
Methods: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature,
PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database
(PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983
to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as
manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity
peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant)
temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale
in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete,
evidence grades of “A, B, C and I”were applied.
Results: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to
develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or
clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test
prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints
and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy,
carpal tunnel syndrome, and temporomandibular joint disorders, in the short term.
Conclusion: The information from this study will help guide practitioners in the use of MMT, soft tissue technique,
exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the
hierarchy of published and available evidence. (J Manipulative Physiol Ther 2013;36:143-201)
Key Indexing Terms: Chiropractic; Manual Therapy; Upper Extremity; Shoulder Pain; Elbow Joint; Wrist Joint;
Randomized Controlled Trials
The first systematic review of chiropractic treatment
for upper extremity conditions and disorders was
published in 2008
1
After this, a broader systematic
review of manual and manipulative therapy (MMT) for
shoulder pain was completed in 2011.
1-4
Extremity
manipulations, mobilizations, and MMT are found in
chiropractic textbooks including in and/or before 1906,
1910, and 1911.
5-9
Furthermore, the use of chiropractic
a
Adjunct Associate Professor, School of Chiropractic and
Sports Science, Murdoch University, Murdoch, Australia.
b
Private Practice, Calif.
c
Associate Professor, Texas Chiropractic College, Tex.
d
Private Practice, Sydney, Australia.
e
Clinical Faculty, Canadian Memorial Chiropractic College,
Ontario, Canada.
f
Adjunct Associate Professor, School of Exercise Science,
Faculty of Health Science, School of Medicine, The University of
Notre Dame (Sydney), Australia.
g
Private Practice, Rowland Heights, Calif.
h
Head of Department and Researcher, Department of Chiro-
practic and Somatology, Durban University of Technology,
Durban, South Africa.
Submit requests reprints to: James W. Brantingham DC, PhD,
Adjunct Associate Professor, 250 Whiteside Place, Thousand
Oaks, CA 91362 (e-mail: jimbrant2002@yahoo.com).
Paper submitted August 12, 2012; in revised form February 9,
2013; accepted February 20, 2013.
0161-4754/$36.00
Copyright © 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.04.001
143
manipulative therapy for extremity dysfunction and mus-
culoskeletal disorders in conjunction with multimodal
therapies, such as exercise, stretching, electromodalities,
heat, ice, nutrition, advice and other adjunctive modalities
dates back at least 100 years.
5-9
It should be noted that all
types of MMT (all grades of joint mobilization, manipu-
lation and or manual therapy including of the soft tissues)
are components of current chiropractic training and scope of
practice. Looking back historically, these therapies have
been used by the profession from its inception.
6,10-14
Currently, many doctors of chiropractic (DCs) manage
extremity conditions.
15,16
The percentage may vary
depending on the survey, whether the DC is a general,
sports or rehabilitation practitioner, the practice location,
extremity problems and/or interest and has been reported to
account from as low as 3.3% to as high as 20%.
4
Most DCs
managing extremity disorders use a broad multimodal
approach for elbow, wrist, hand, finger and TMD
disorders.
1-4,16,17
Multimodal treatments are a common form of manage-
ment and appear helpful for those: (a) who may not or
should not have surgery, (b) or those who may not or
should not use, or use long term, nonsteroidal anti-
inflammatory drugs (NSAIDs), and (c)forthosein
whom exercise alone has not been effective.
7,18-21
Research into the application of manual therapy techniques
has erupted, including intensive investigation by nearly all
professions that treat upper extremity disorders with
manual and manipulative therapy techniques. These in-
vestigations generally incorporate (with MMT) multimodal
or rehabilitative care, many exploring the most common
methods used by DCs, HVLA manual therapy or: grade V
manipulation/thrust technique.
18,22-28
Broadly revisiting MMT studies to review quantity,
quality, and types of research published, is needed; with the
goal of ranking, grading, and presenting common charac-
teristics. The purpose of this systematic review is to update
and expand upon previous reviews to include MMT
research for upper extremity problems including the
elbow, wrist, hand, finger and the (upper quadrant)
temporomandibular joint, joints, disorders, dysfunction
and disease within and without the chiropractic profession.
METHODS
Terminology
The term manipulative therapy is a general term
commonly used to denote any form of mobilization and
manipulation: all grades from grade I (II, III, and IV)
mobilizations through grade V manipulation(or thrust) and
may appear indistinguishable from modern definitions of
“manual therapy”and the current use and definitions of the
term adjustment or adjustive therapy by the chiropractic
profession.
10,12,16,29-32
Among those studying MMT for
musculoskeletal disorders, there is agreement in standard-
ization of terminology such as “manipulation, mobilization,
manual or manipulative therapy,”used in many texts and
publications. For example, the word “manipulation”is
defined as a high-velocity low-amplitude thrust.
10,12,16,30,31
Although “mobilization”generally describes a variety of
“manual”or in a few cases “instrument assisted”movement
of joints and/or associated joint and/or joint soft tissues with
lower velocity movements such as repetitive oscillation
and/or other types of movement, such as low-velocity, high-
amplitude oscillation, post-isometric stretch, pressure, and
friction.
10,12,16,30,31
Mobilization is applied movement at
either the beginning (grades I, II) or within and/or up to the
end range (grades III and IV) of normal physiological
motion (but, a term that generally does not describe a high-
velocity thrust (grade V manipulation or thrust) into the
“paraphysiological joint space—with and without
cavitation.”
10,12,16,30,31
However, perusal of PubMed
shows that though there may be agreement by academics
on the definition of these terms, standardization of
terminology is not apparent.
10,12,16,30
Therefore, for the purposes of this systematic review, the
term chiropractic has been replaced by the broadly
inclusive term “manipulative therapy”to facilitate inclusion
of similar, related, peer reviewed literature, to reflect agreed
upon definitions, and to more accurately reflect the practice
of the chiropractic profession.
1-4
“Manipulative therapy”
for this review (eg, “manipulation”in Medline) is therefore
inclusive of all “manual, manipulative or adjustive”joint
and soft tissue procedures and/or therapy (denoted by
“MMT”in this study) including all grades of mobilization
and mobilization techniques (including as modified by + or
−and/or ++, etc, as per Maitland or others) together with
grade V manipulation or, high-velocity low-amplitude
thrust, with and without adjunctive, instrument-assisted or
multimodal therapy—used to benefit health.
1,10,12,32-39
Search Strategy
For this systematic review a search of the literature was
conducted using the Cumulative Index of Nursing Allied
Health Literature (CINAHL), PubMed, Manual, Alterna-
tive, and Natural Therapy Index System (MANTIS);
Physiotherapy Evidence Database (PEDro); Index to
Chiropractic Literature, Google Scholar, and hand search
inclusive of literature dating from January 1983 to March 5,
2012. Search limits were set to include the English
language, abstract and human studies. The search included
MESH terms derived from words such as shoulder, elbow,
wrist, hand and finger manipulation, manipulation, mobi-
lization, spinal adjustment, spinal manipulation, peripheral
diagnosis or, diagnosis, and randomized clinical trials and/
or randomized controlled trials. Other search terms
including those MESH words, expressions and phrases
derived from these were one of the following: chiropractic,
144 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
osteopathic, orthopedic, musculoskeletal, physical thera-
pies and manual therapies. There were 84 citations retrieved
from CINAHL, 303 citations retrieved from PubMed, 197
citations retrieved from Index to Chiropractic literature; 374
citations from MANTIS; and 6 citations taken from PEDro.
Out of ultimately 764 citations initially chosen and
reviewed, 129 studies were deemed possibly to probably
useful, relevant and/or helpful to develop expert consensus.
From 81 total randomized controlled or clinical trials
(RCTs) that were located, 35 RCTs were ultimately
included—and, as an extension of a previous 2011 shoulder
systematic review, these RCTs and studies covered elbow,
wrist, hand, finger and TMD/TMJ joint disorders, dysfunc-
tion and/or disease. Five CTs were located, and 4 were
included. Fifty case series, reports and/or single-group pre-
test post-test prospective case series were located, but 32
were included; however, non RCT studies are in narrative
form and were not ranked.
1-3
A total of 32 case series,
reports, and/or single-group pre-test post-test prospective,
and/or other types of clinical studies were included and
although not ranked, all members of the team were directed
to read through these studies using the case series checklist
—the checklist was recommended and used in previous
reviews in determining the usefulness of including a
particular series or report.
3,17,40
These case series, reports,
and/or single-group pre-test post-test prospective, and/or
other types of clinical studies were considered as possibly
or probably constructive in helping develop a general but
restricted expert consensus for assessing MMT (generally
with multimodal therapy) in relation to the upper extremity
in relation to all the included types of studies and
incorporated as part of the overall Considered Judgment
On Quality of Evidence tool—todevelopanexpert
consensus in this review.
1-3,41
Only a few case reports (or
other studies from any of the other categories) were
included from the previous McHardy et al upper extremity
systematic review, as these studies (mostly case reports and
series) were felt to have been adequately analyzed and need
not be repeated. It is suggested that this study is an
extension and expansion of that previous review and the
Brantingham et al shoulder systematic reviews published in
2008 and 2011, respectively; and the reader is directed to
the McHardy review for additional case series and
reports.
1,3
Unlike the Brantingham et al systematic review
of the shoulder, this extension did not use the Whole
Systems Research (WSR) ranking system but, for the RCTs
used the PEDro ranking tool (addressed below).
Manipulative or manual therapy treatment of upper
extremity pain and disorders by DCs generally uses a
“multimodal”approach.
1
Multi-modal procedures com-
monly used in the treatment of upper (and lower) extremity
pain and disorders include not only the use of manipulation
but also and commonly mobilization, exercise, strengthen-
ing and stretching (or rehabilitation) along with numerous
soft tissue therapies, instrument assisted mobilization or
manipulation, proprioceptive neuromuscular facilitation,
splinting or orthoses, electrical and mechanical modalities
and other myofascial, functional and soft tissue
techniques.
1,4
Very few studies reviewed by McHardy et
al used what they labeled as the “classical”approach
(HVLA spinal or extremity manipulation only).
1
Multi-
modal practice appears commonplace with approximately
75% up to 85% of practicing DCs treating extremity
disorders using this approach.
42-44
Inclusion and Exclusion Criteria
Inclusion criteria was based upon previous published
reviews and required an upper extremity peripheral
diagnosis and some form of manipulative therapy with
and/or without multimodal or adjunctive therapy.
1,3,17
Articles were excluded when (1) pain was referred from
spinal sites (without a peripheral extremity diagnosis); with
a requirement of (at least) a minimal diagnoses such as,
“elbow, wrist, hand or temporomandibular pain and/or joint
dysfunction,”(2) there was referral for surgical intervention
(unless there was documented and/or apparent post-surgical
healing with or without rehabilitation), (3) the condition
was not amendable for manipulative therapy (RA, fracture,
ligament tear with instability, diabetes type I, etc), (4) a red-
flag diagnosis (signs of: infection, drug abuse, weight loss,
Very High Quality 9-10
High Quality 7-8
Medium Quality 4-6
Low Quality 1-3
Levels of Evidence were primarily derived from the recommendations
for evidence based guidelines by Harbour and Miller.
52-54
GRADE A: Good evidence from relevant studies.
•Studies with appropriate designs and sufficient strength to answer
the questions.
•Results are both clinically important and consistent with minor
exceptions at most.
•Results are free of significant doubts about generalizability, bias,
and design flaws.
•Negative studies have sufficiently large sample sizes to have
adequate statistical power.
GRADE B: Fair evidence from relevant studies.
•Studies of appropriate designs of sufficient strength, but
inconsistencies or minor doubts about generalizability, bias, and
design flaws, or adequacy of sample size.
•Evidence solely from weaker designs, but confirmed in separate
studies.
GRADE C: Limited evidence from studies/reviews.
•Studies with substantial uncertainty due to design flaws, or
adequacy of sample size.
•Limited number of studies weak design for answering the question
addressed.
GRADE I: No recommendation can be made because of
insufficient or non-relevant evidence.
No evidence that directly pertains to the addressed question either
because studies have not been performed or published, or are
non-relevant.
Fig 1. PEDro ratings in this systematic review are labeled.
1,20,48-51
145Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
age above 50 years, previous malignancy, chronic non-
mechanical pain, palpable deformities of bone/tissue,
widespread neurological symptoms, violent trauma, swell-
ing, pain at rest, night sweats, HIV, etc, was identified- also
see limitations below) or (5) there was a peripheral
diagnosis absent a description of management or
intervention.
23,45-47
In the current review, osteopathic,
physical therapy and other medical literature, including a
few peer-reviewed doctoral, masters and university theses
and/or dissertations were included; however, review-type
articles were excluded. Theses and/or dissertations were
included on the basis that they underwent blinded peer
review. Non–peer-reviewed literature, conference proceed-
ings, grand rounds, and discussion articles that did not
render treatment were excluded.
PEDro
Data were abstracted independently by a minimum of 3
of the authors (independent assessment and combined
agreement regarding the PEDro scores [Fig 1]). After
blinded review anonymous scores were shared with the
reviewers and input was solicited as to whether there was
agreement (or disagreement) with the mean PEDro number
or score; this was later shared with the full unblinded team
and input solicited before a final agreement on the PEDro
score. Most articles were acquired as electronic PDFs with a
few hard copy articles obtained and/or scanned and shared
from the CCCLA, Texas Chiropractic College, Durban
University of Technology, Logan University and Macquar-
ie University libraries.
First, relevant articles were read, reviewed and assessed
with the valid and reliable Physiotherapy Evidence
Database scale or PEDro ranking system.
55,56
PEDro uses
an 11-point scale (the first point being an eligibility criteria
not counted or included as part of the score, as it relates to
external validity); thus the score is ranked from “10 best,”to
“0 worst.”
55,56
The PEDro methodological scores of RCTs
are ranked as follows: 9 to10 is considered excellent, 6 to
8 good, 4 to 5 as fair, and 3 or below as representing poor
methodological quality.
49,50
However, for this review, we
have used guideline and scoring recommendations per
Harbour and Miller, and Brantingham et al 2011.
17,52,57,58
It is suggested that such slightly modified PEDro rankings
may more rigorously clarify the terminology for scoring
used in this review: a very high-quality RCT (VHQ) is
assigned if the score is 9 to 10 with a very low risk of bias, a
High-quality RCT (HQ) is assigned if a score is 7 to 8 with
low risk of bias, a Moderate Quality (MQ) is 4 to 6 with a
high risk of bias, and low- or poor-quality RCTs (LQ) are
rated 1 to 3 with very high risk of bias (Fig 1).
17,52,57,58
The
use of a modified PEDro score, and/or alteration of this
ranking system has been commonly used with various
authors having adopted adjusted point scales adapted from
and anywhere from 8 up to a 12 point maximum.
59-62
Physiotherapy Evidence Database
As part of our desire to survey a broad evidence base, the
previous shoulder review used the Whole Systems
Research (WSR) ranking tool felt relevant to observational
study of “body-based”usual practice, studies—difficult to
blind.
3,63
WSR assessment was developed to analyze
complementary and alternative medicine and for commonly
used, but minimally researched treatments or therapies.
64,65
However, although research into WSR is progressing and it
may be, or may have recently become, a useful ranking tool
—it appears that it remains non-validated and it was
decided for this reason it would not be continued and used
in this review.
63,64,66-70
Using the PEDro guidelines, a number of select earlier
MMT RCTs (including a number of the earliest peer-
reviewed chiropractic MMT RCTs of the upper extremity
ever published) used mechanical and manual randomization
and concealed allocation, and scores derived from these
procedures were in some circumstances assigned a slightly
or significantly decreased score or weight in this
study.
3,4,19,48,49,71-75
In particular PEDro states randomization is achieved
if…“a study is considered to have used random allocation if
the report states that allocation was random. The precise
method of randomization need not be specified. Procedures
such as coin-tossing and dice-rolling should be considered
random.”
49,71,75-77
PEDro Guidelines consider concealed allocation suc-
cessful if “the person who determined if a subject was
eligible for inclusion in the trial was unaware, when this
decision was made, of which group the subject would be
allocated to.”This study also considered intention to treat
analysis (ITT) as per PEDro guidelines “an intention to treat
analysis means that, where subjects did not receive
treatment (or the control condition) as allocated, and
where measures of outcomes were available, the analysis
was performed as if subjects received the treatment (or
control condition) they were allocated to.”Furthermore, it is
outlined in these guidelines that “this criterion is satisfied,
even if there is no mention of analysis by intention to treat,
if the report explicitly states that all subjects received
treatment or control conditions as allocated.”While ITT is
now a requirement and has broad general acceptance, it is
nevertheless true that this was not so in the past (and much
standard care grew from and/or continues because of similar
or lesser studies).
71,78-80
Thus randomization, concealed
allocation and ITT per the PEDro guidelines as outlined
above, were carried out in a few of the included earlier
studies using these older, acceptable methods; some of
which continue to be used in smaller sample sized
research.
26,76,81,82
After reviewing abstracts, research was placed into 3
broad categories (see Table 1 for Definitions and Acronyms).
Category 1 (Randomized Controlled and Clinical Studies
and Clinical Trials) included randomized controlled or
146 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 1. Terminology and definitions including acronyms
Lateral Epicondylopathy or Tennis Elbow or Epicondylosis or Epicondylitis.
Pain over the lateral elbow that increased on palpation of the lateral epicondyle, gripping, resisted wrist, or second or
third finger extension (including such tests Cozen's and Mill's tests and other resisted extension tests), usually N6
weeks and N18 years
LE
Carpal Tunnel Syndrome.
Pain or paresthesia in the median nerve distribution and/or clinical examination findings (+ Phalen's, + Tinel's,
decreased maximum grip or pinch strength) and/or electrodiagnostic or electromyographic (EMG) abnormalities and other findings
consistent with CTS usually N12 weeks.
CTS
Thumb Osteoarthritis or Carpometacarpal Osteoarthritis CMOA
Temporomandibular Joint Dysfunction and Disorders.
Includes a variety of conditions, syndromes and disease associated with pain and dysfunction of the
temporomandibular joint and the masticatory muscles (see below)
TMD/TMJ
Rotator Cuff Injuries Disease or Disorders RCID
Shoulder Complaints, Dysfunction, Disorders and/or Pain SCPD
Frozen Shoulder/Adhesive Capsulitis FS
Soft Tissue Disorders of the shoulder ST
Neurogenic Shoulder Pain NSP
Randomized Controlled Trial (treatment vs placebo) RCT
Randomized Clinical Trial
Treatment vs another treatment; usually comparative treatment
Showed superior to placebo or standard care and/or multiple treatments: experimental vs placebo vs standard care vs
wait and see, etc
RCT^
Controlled or Clinical Trial with systematic assignment.
Pseudo- or partial randomization and/or non-randomization) but with inclusion, exclusion, controlled, independent and
dependent variables vs placebo and/or comparative treatment.
CT¥,
N3 mo duration shoulder pain, N3 on 0-10 pain scale with active abduction or ext rot + a + impingement test/Complete rot
cuff tear with + drop arm and substantial weakness ruled out (see Bennell, K 2010 for inclusion/exclusion details)
RCID
↓or painful shoulder range of motion (ROM)/+ impingement test with magnetic resonance imaging (MRI) confirmation SIS
Secondary to: Cervical/Thoracic and adjacent Rib dysfunction and/or disorders C-T-rib Manual Therapy (MT) only…no
glenohumeral (GH) MT; defined as: “shoulder pain”from base of neck to elbow.
SCDP
Manual or Manipulative Therapy.
Grades I-IV++ mobilization and grade V high-velocity–low-amplitude (HVLA) manipulation; as well as soft tissue procedures
(trigger point therapy, transverse friction massage, therapeutic massage, proprioceptive neurofacilitation techniques, etc).
MMT
Shoulder = For this article, denotes the GH joint and/or also the acromioclavicular (AC) joint and sternoclavicular (SC) joint.
Shoulder girdle is defined in various ways and is not standardized but in this article often refers to studies that defined it as the
cervical and thoracic spines and upper rib joint dysfunction causing pain from the base of the neck to the elbow
(see individually cited studies).
MMT applied to all the above defined under MMT and shoulder girdle or shoulder, including C-T-spines, upper ribs and/
or GH, AC, and SC joints and/or as well as the entire upper extremity, including through the elbow, wrist and hand.
FKC
Soft Tissue disorders of the shoulder.
Trigger points and/or pressure/tender points and/or taut muscle or fascial and/or myofascial bands with local or referred
pain without or with applied pressure into the involved muscles and fascia in and/or around the shoulder/shoulder
girdle or FKC; also known as myofascial pain and dysfunction syndrome (MPDS and/or similar terminology).
ST
Minor referred neurogenic shoulder pain is also known as minor peripheral nerve injuries and/or disorders NSP
Serious neurological pathology from diabetes or other neurological disease must be ruled out and referred to the
appropriate practitioner.
MPNID
Manual Therapy MT
Grade I, II, III, IV Mobilization mbl
Manual Physical Therapy MPT or MT
Intention to Treat ITT
Proprioceptive Neuromuscular Facilitation PNF
Shoulder Pain and Disability Index SPADI
Patient Perceived Global Rating of Change Likert
Health Related Quality of Life Measure AQoL
Transverse Friction Massage TFM
Neer Functional Assessment Questionnaire Neer FAQ
Soft Tissue ST
Constant-Murley Functional Score C-MFS
Additional Manual Therapy AMT
Usual Care or Standard Care from general practitioner UC or SC
Shoulder Pain Score SPS
Shoulder Dysfunction SD
Myofascial Pain and Dysfunction Syndrome MPDS
(continued on next page)
147Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
clinical trials (RCTs) with MMT that included adjunctive or
multimodal therapy most commonly exercise and/or
rehabilitation, modalities, NSAIDs, and/or activity
modification.
1,2,17
The Category 1 evidence table included;
(1) randomized controlled trials (RCT) indicating studies
which were placebo controlled; (2) randomized clinical trials
(RCT^) denoting a comparative study (treatment vs another
treatment; usually either a “standard treatment”or a treatment
with evidence superior to placebo); and/or (3) controlled or
clinical trials (CTs) a lesser level of evidence, generally
including pseudo or non-randomized allocation such as
systematic or purposive allocation; these older studies were
included because of prospectively controlled variables,
accurate peripheral diagnosis, and usually a highly planned
manipulative therapy protocol vs placebo, comparative
treatment or both; and also (4) studies that were prospective
and generally included valid and reliable outcome measures
with appropriate statistical analyses
17
(Table 2).
Category 2 (Case Series and/or Case Series often
designated as Single Group Pre-test Post-test Designs or
Studies) included case series including 3 or more patients
per study and single-group pre-test post-test studies or
designs (SGPPDs) a sophisticated case series methodology.
Single-group pre-test post-test designs often use a signif-
icantly more rigorous methodology with innovation or
improvements in design believed by some to produce a
higher level of research hierarchy evidence, due to
strengthened evidentiary results
112-114
(Tables 3-10).
Category 3 (Case Reports) included case reports of 2 or
less patients. However, only a few case reports (or other
studies from any of the other categories) were included
from the previous McHardy et al and/or Brantingham et al
upper extremity systematic reviews, as these studies
(mostly case reports and series) were already adequately
analyzed and need not be repeated in this systematic
review
1,3
(Tables 3-10). This study is an extension of the
McHardy et al and Brantingham et al reviews (the
Brantingham et al systematic review was limited to the
shoulder); and the reader is directed otherwise to McHardy
et al and Brantingham et al.
1,3
Before listing levels of evidence certain definitions will
be given. For this study the “shoulder”includes only the
glenohumeral joint; the “shoulder girdle”includes the
glenohumeral joint, thoracic spine, cervical spine, upper
ribs and/or the acromioclavicular (AC) and sternoclavicular
(SC) joints; the upper extremity including all the above and
the elbow, wrist and hand joints and associated muscles,
ligaments and fascia. The upper quadrant (or quarter)
includes: the occiput (and associated structures such as the
mandible), the cervical and upper thoracic spines, shoulder
girdle, the upper extremities, associated soft tissues, and
related nerve and blood vessels.
143
Upper extremity full
kinetic chain treatment (FKC) includes all of the above and
any indicated upper extremity joint and associated muscles,
ligaments and fascia.
Within each of these categories studies were further
grouped according to the condition or conditions
investigated in each study. This review used these
diagnostic groupings: Lateral epicondylopathy (LE) to
include lateral epicondylitis, epicondylosis, epicondylal-
gia, tennis elbow, etc; carpal tunnel syndrome (CTS) or
median nerve neuropathy, neuralgia or neuritis; thumb
osteoarthritis (thumb carpometacarpal OA or TCOA) is a
new category along with inclusion of Temporomandibular
Joint Disorders or Dysfunction (TMJ/TMD) often called
craniomandibular disorder or disease, jaw joint disorders
or disease, pain and dysfunction. A few miscellaneous
RCTs and/or CTs are covered dealing with a singular or
uncommon diagnosis (such as MMT for postoperative
Colle's fracture or systemic sclerosis), but these generally
isolated studies were not given or placed in individual
sections nor was there a suggested level of evidence
rating beyond their individual PEDro score (see below
and Tables 2-10).
Neck Disability Index NDI
Numerical Pain Rating Scale NRS
Short-form McGill Pain Questionnaire SFMPQ
Algometry ALG
Patient Specific Function Scale PSFS
Present Pain Index PPI
Minor Peripheral Neurogenic Shoulder (arm) Pain or Minor Peripheral Nerve Injuries and/or Disorders MPNID
Exercise Therapy ET
Pain Free Grip Strength PFG
Maximum Grip Strength MaxG
Corticosteroid Injection STiNJ
Glenohumeral Internal Rotation Deficit/Dysfunction GIRD
Mulligan's technique or Mobilization with Movement MWM
Tennis Elbow Function Scale TEFS
Therapeutic Touch TT
Pain Pressure Threshold PPT
Muscle Energy Technique MET
Upper Limb Tension Test mobilization ULTT
Table 1. (continued)
148 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 2. Trials of lateral epicondylopathy; carpal tunnel syndrome; thumb osteoarthritis; temporomandibular joint disorder or dysfunction
Author Condition Methodology Intervention Outcome measures/results PEDro
Bisset L
2006
24
Lateral Epicondylitis (LE)
Inc Criteria:
Lat elbow pain ↑with palpation of the lat
epicondyle, gripping, resisted wrist or
second/third finger ext.
18-65 y/o, pain ≥6wk.
Exc Criteria:
Any elbow pain tx last 6 months, bilateral
elbow symptoms, cervical radiculopathy,
elbow joint pathology, peripheral nerve
involvement, elbow surgery, hx of elbow
fracture/dislocation or tendon rupture,
systemic/neurological disorders,
shoulder, wrist, hand pathology, and
contraindications to corticosteroids.
Randomized Controlled Trial (RCT)
Random Concealed Allocation
Intention to Treat Analysis
(ITT) ~ Adequate
N=198
Group 1 n = 66
Group 2 n = 65
Group 3 n = 67
8 txs over 6 wk
Baseline equivalency
Group 1: Physiotherapy protocol (PT):
Mulligan's mobilization with movement
(MWM) + exercise and postural
correction including resisted exercises
and stretching + self-manipulation.
MWM: Generally MWM is performed
by applying a sustained mobilization
while the patient performs the painful
movement—gripping, pronating,
extending etc, up to but not in the painful
range. In the case of the elbow it is
generally applied with the elbow in
extension and forearm pronated while the
therapist applies a lateral glide while the
patient performs a grip up to but not in
the painful range. Each author applied it a
little differently in subsequent studies
cited where MWM is used.
Group 2: Corticosteroid injections (StInj)
Up to 2 injections over a 2 week period
Group 3: Wait and see group
Told to use analgesics, heat, cold or
braces as needed.
All groups received advice that this is
generally a self-limiting disorder,
counseled to be as active as possible
without doing aggravating activities. All
received an information booklet on the
disorder of LE.
Outcomes Measures:
Baseline, 3, 6, 12, 26 and 52 weeks
Global Improvement:
Completely recovered and much
improved = success—Likert-like scale
Visual Analogue Scale (VAS) 0-100:
Assessor's Rating of Severity
Results:
Group 1 = PT
6 weeks significantly ↑Control group
52 weeks no difference
Group 2 = StInj
6 weeks favored over other 2 groups
52 week worse on all outcomes than PT
group
StInj had the most recurrences.
Groups 2 and 3 sought the most not per
protocol treatments.
8
Smidt et al 2002
83
LE
Inc Criteria:
Pain at the lat side of elbow ↑with
pressure on the lat epicondyle and with
resisted wrist dorsiflexion
Exc Criteria:
Tx in last 6 months to the lateral elbow,
bilateral elbow symptoms, duration b6
weeks, condition other than LE,
deformities of the elbow, dislocation,
tendon ruptures or fractures in preceding
12 months, systemic musculoskeletal or
neurological condition, contraindications
to corticosteroids.
RCT
Random Concealed Allocation
ITT ~ Adequate
Fully powered
N = 185
Group 1 n = 66
Group 2 n = 65
Group 3 n = 67
Age:18-70 years old
6 wk active protocol
Baseline differences:
The injection group largest
number of concomitant neck
pain, largest number who
had previous elbow episodes,
Group 1: 9 tx over 6 wk of Physiotherapy
Pulsed ultrasound, Deep friction massage
(not specified), and an Exercise program
once pain ↓
Ultrasound 20% duty cycle, 2 W/cm
2
for
7.5 minutes. Frequency was not
identified.
Physical therapists provided and taught
pts to do slow, progressive, repetitive
wrist and forearm stretching, muscle
conditioning, and occupational exercises,
intensified in 4 steps. Home exercise
equipment and instruction book supplied.
Group 2: Up to 3 corticosteroid
injections. Tender site was injected until
Outcomes Measures:
Before and 3 weeks after randomization
and at 6, 12, 26 and 52 weeks.
General Improvement on a 5 point scale:
(Completely recovered and much
improved were counted as success.)
Numerical Pain Rating Scale (NRS):
severity of main complaint, pain
during the day, inconvenience of elbow
complaints and severity of elbow pain.
Pain-free function (PFF) using a
modified pain-free function questionnaire
A research physiotherapist also rated the
overall severity of elbow complaints on
an 11 point scale from the hx and pe.
7
(continued on next page)
149Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
lowest max grip strength and
a slight difference in the cause
of their injuries. The authors
state the differences were
slight and had little effect on
the outcome. The unadjusted
analysis is therefore given.
there was pain-free resisted wrist
extension. The amount injected to reach
this pain-free state was recorded and the
amount of solution to reach the pain-free
state increased between the first and third
injection. Provoking activities were to be
avoided
Group 3: Wait and see; subjects assured
in most cases problem would clear up in
1 year; asked to be normally active but
avoid aggravation with activities and/or
active daily living (ADL) and use
drugs (acetaminophen, nonsteroidal
anti-inflammatory drugs [NSAIDs]), heat,
cold, brace as needed.
All groups given info booklet on disorder
of LE. All co-interventions were
discouraged other than pain medication if
necessary.
Secondary outcomes were pain free grip
strength (PFG), maximum grip strength (MaxG)
and algometry pressure pain threshold (PPT)
Patient satisfaction rated on 11 pt scale.
Adverse Effects:
47% ~ primarily mild ↑pain post tx Nin
PT and StInj than control group.
Results:
Imp between groups analyzed by
analysis of variance (ANOVA).
Multivariate analysis of variance
(MANOVA) used for analysis
of potential effect ofdiffbetweengroups
on prognostic indicators at baseline.
StInj: Best outcome short term, worst at
52 wk with highest rate of recurrence.
PT and Control: Best outcomes at one
year with PT better than control,
difference was not significant at one year.
Langen-Peters
2003
84
LE
Inc Criteria:
RCT and Masters dissertation from
author ~ +Mill's,
Pain or tenderness near lat epicondyle,
pain over lat elbow that ↑with palpation,
gripping, resisted wrist or 2nd/3rd finger
ext, Age 32-64 with pain ≥6 weeks
Exc criteria:
Hx of inflammatory arthritis, no previous
tx for LE and not of traumatic origin
RCT
Random Allocation,
ITT ~ Adequate
No blinding of subjects,
therapist or assessors
Low power N = 13
Group A n = 7
Nfem and mean duration of sx
Group B n = 6
12 tx's over 6 wk with some
having a longer period of
treatment due to US unit failing.
Group A: chiropractic manipulative
therapy (CMT) and exercise. CMT to
humeral-radial or humeral-ulnar joints.
Exercise = resisted motions of the elbow
and wrist.
Group B: Ultrasound (US) direct gel
method, continuous, 3MHz, 1.5 W/cm
-2
,
5 minutes to lateral epicondyle and
extensor muscles distal to lateral
epicondyle.
Each pt received an informational leaflet
on “tennis elbow”based on a publication
from the Arthritis Research Campaign.
The section on recommended treatments
was omitted to avoid biasing the
participants toward their treatment.
Outcomes Measured:
Baseline, 3rd week, after treatment.
Objective:
PFG: Jamar
dynamometer
Subject standing with arm hanging by the
side in elbow extension. while squeezing
until discomfort.
Subjective:
VAS: Pain
PFF: 8-item tennis elbow questionnaire
Verbal Rating System (VRS) : Overall
improvement with a 5-point
(Much worse, Worse, No change,
Improved, Complete recovery)
Results:
Both groups had significant
improvement in VAS, PFG and PFF at
the final evaluation
US statistically better than CMT
5
Blanchette 2011
38
LE
Dx Criteria:
+ Cozen's and Mill's
Exc Criteria:
Bleeding disorders, anticoagulants, hx
thrombosis or thrombophlebitis, any
RCT
Random, Concealed Allocation
No ITT
Low power N = 27
Group 1 n = 15
Group 2 n = 12
Group 1: Experimental Group (EG):
Augmented Soft Tissue Mobilization
(ASTM)—Graston
Group 2: Control group (CG): Advice
about the natural history of LE, (self-
limiting pathology with pain decreasing
Outcomes Measures:
Baseline, 6 weeks, 3 months post 6 wk
Patient-Rated Tennis Elbow Evaluation
(PRTEE)
VAS
PFG
5
150 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
condition that weakens the skin, diabetic,
kidney disease, uncontrolled
hypertension, infection, hx elbow
surgery, diffuse pain syndrome,
inflammatory arthritis affecting the wrist
or elbow, carpal tunnel
syndrome (CTS),
radiculopathy from neck,
fx of the upper limb with
residual deformity, pending
litigation settlement (other
than work comp)
for elbow problem,
SInj preceding 30 days.
Tx: 2× wk for 5 weeks
Follow-up out to 3 months after
treatment.
the mechanical stress on the extensor
muscles as a protective mechanism. This
group also received computer station
ergonomic advice, stretches for the
extensor and flexor muscles (30s hold
6×'s/d) and analgesics consisting of ice
and generic anti-inflammatory medicines.
1° outcome chosen was PRTEE due to it
being more sensitive, measuring function
and ADL's as well as pain.
Results: PRTEE and VAS
Group 1 significant ↓(Pb.001) after
6 wk and through follow-up
Group 2 significant ↓(Pb.002)
at follow-up.
3 month follow-up no difference between
PRTEE and VAS were analyzed using
ANOVA with α= .05
After ANOVA determined a significant
difference a post hoc Tukey test was
performed α= .05
Struijs 2003
25
LE
Inc Criteria:
Pain on the lat elbow that is worse with
pressure on the lat epicondyle and with
resisted ext of the wrist, sx ≥6 wk and
≤6 mo.
Exc Criteria:
No ↓range of motion (ROM), bilateral
complaints, ↓in pain over the last 2 wk,
severe neck or shoulder problems, tx for
the current episode, inability to fill out
questionnaires
RCT
Random Concealed Allocation
No ITT
Low power N = 31
Group 1 n = 15
Group 2 n = 16
Baseline Equal α= .05
Tx: 9 txs over 6-7 wk
Group 1:
Manipulation of the scaphoid from dorsal
to ventral while moving the wrist in
extension. multiple times with either
passive extension or resisted extension.
No limitation to daily activities was given.
Group 2:
Pulsed ultrasound at a 20% duty cycle,
2 W/cm
2
, 7.5 minutes. Ten minutes of
friction massage.
Exercise intervention: based on
Pienimaki which included muscle
stretching and strengthening exercises.
Resisted and rotational motions and
occupational exercises. Progression
based on patient being able to progress if
all exercises could be performed without
pain. To be performed at home 2×'s daily.
Activities were limited to pain threshold.
Outcomes Measures:
Baseline, 3 and 6 weeks
Primary: A Likert scale that measured
“global measure of improvement”on a
6-point scale (1 = completely recovered,
2 = much improved, 3 = slightly
improved, 4 = not changed, 5 = slightly
worse, and 6 = much worse). A
successful outcome was deemed as
completely recovered or much improved.
Secondary: 11-point NRS of severity of
complaint, pain during the examination,
pain during the day, and inconvenience
during daily activities. 0 = no complaints
to 10 = very severe complaints.
Objective measures:
PFG, MaxG, Pressure Pain Threshold
(PPT) with an algometer, ROM of wrist
flexion/extension.
Results:
3 weeks:
GI: Group 1 was superior (Pb.05) but
effect was lost at 6 weeks (P= .40).
NRS: No difference between groups
6 weeks:
Pain during the day: Group 1 significant
P= .03
Otherwise, no difference between groups
7
Dreschler 1997
85
LE
Inc Criteria:
None given
Exc Criteria:
Cervical, shoulder, elbow or
RCT
Stated randomized but no
description given Allocation
not concealed
No blinding,
NT Group: Mobilization of radial nerve
with upper limb tension test (ULTT).
Unclear if performed in office +
at home or only at home. Nerve
mobilizations prescribed at 10 reps
Outcomes Measures:
Baseline, 6 weeks and 3 months
Self-report questionnaire assessing
recreational and occupational activities
“status.”Unclear if assessing function
4
(continued on next page)
151Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
wrist pathology other than LE
or hx of systemic or nervous
system disease
No ITT
Interrater reliability interclass
correlation coefficient (ICC)
adequate: N.90
N=18
NT group n = 8
PT group n = 10
Age: 30-57 Mean 46
Tx: 2× wk for 6 wk
Baseline differences: Found in
all outcome measures…
radial head treatment and non
radial head treatment were
found for grip strength and
occupational status.
1×/ day over time this could be increased
to 2× per day. Radial head mobilizations
if hypo-mobile per “Maitland”
assessment technique.
PT Group: Ultrasound, TFM ~3-1 month
sessions + stretching and strengthening
wrist extensors. Unclear if performed in
office as well as at home. Home exercise
program strengthening and stretching.
The patients who had radial head
mobilization were compared against the
group that did not.
or pain.
Maximal grip strength, ULTT IIb,
resisted third finger extension for “pain
or no pain.”
Radial head mobility (Maitland method ~
supine anterior to posterior (A-P)
radio-humeral glide with max
elbow ext compared to uninvolved side
Elbow ROM in extension
Results:
Most sig difference found for radial head
mob performed when hypomobility
found for recreational status
measure only.
NT: ULTT had significant difference
from pretest at 6 wk and follow-up
Authors: combination of neural tension
tech and radial head mob was found to be
superior to the standard treatment.
No difference found between neural
tension treatments with out radial head
mob and standard treatment group.
One-way ANOVA neural tension vs
standard and radial head mob vs no radial
head mob.
Within-group ANOVA with post hoc
testing using Tukey test.
Kochar
2002
86
LE
Inc Criteria:
Hx pain and tenderness at lat epicondyle
↑with gripping and wrist ext, relieved
by rest.
+ Cozen's or wrist extension, + Mill's
test or passive stretching, + tender point
at the tenoperiosteal junction. Full elbow
ROM, Normal x-ray
Exc Criteria:
Cervix spine (C/S) dysfunction,
Neuromeningeal involvement,
Radial tunnel syn,
Posterior interosseous syn, Arthritis,
Bursitis
Ligamentous sprain, Bilateral LE
Recurrent, Golfer's elbow, Painful
shoulder, Prior arm fractures, Pregnancy,
Clinical Trial (CT)
Partial randomization—
MWM + US while Control
made up of pts who did not
rec assigned treatments.
Allocation was not concealed
No Blinding
No ITT
N=66
Group 1 n = 23
Group 2 n = 23
Group 3 n = 2
Age 23-71, Mean 41
Baseline similar
Tx: 10 sessions over 3 wk
followed by 9 wk exercise
intervention
Group 1: MWM + US* +
exercise therapy (ET^),
10 txs over 3 wk alternate days
followed by 9 weeks ET
MWM: See Bisset This was performed
3×'s each session
Group 2: US* + ET^, 10 txs over 3 wk
alternate days followed by 9 wk ET
*3 MHz, 1.5 W/cm
2
, pulsed 20%, 5 minutes.
Group 3: Control group not able to
comply with treatments; No
treatments received
^Exercise Therapy:
Stretching: Pt applied pas stretch of
extensor group
Progressive Resistive Exercises (PRE):
Isometric contractions of the wrist
extensors—5-10 s hold. Starting elbow
Outcomes Measures:
Baseline, 1, 2, 3 and 12 weeks
VAS for the last 24 hours,
Weight test: Ability to lift only wt of own
hand and then progressive amounts of
1 kg, 2 kg, 3 kg with wrist and elbow ext
and forearm supported and pronated in a
pain free range.
Grip strength:
Patient Assessment: Pain worse,
unchanged, slightly improved, improved,
good or excellent over last 24 hours.
Results:
Group 1 improved each assessment sig
more than 2 or 3; even at 12 weeks.
VAS: Group 1 ↓significantly (Pb.05)
more than 2 or 3 from the first assessment
through the end of the study. Group 2 had
5
152 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Neurological abnormalities.
Infection, Malignancy
Treatment prior 3 wk, StInj 6 months
flexed, forearm supinated, progressing to
forearm pronated.
Active concentric and eccentric wrist
extension exercises with arm on table
hand hanging off the table; Weight is
added as pain decreases
All exercises10 rep 3 ×/ day in pain free
range. Increase level of res if possible
without adding pain. Exercises were
reviewed every 2 weeks.
sig improvement (Pb.01)
Patient Assessment: Group 1sig
improvement through end of study
(Pb.05). Group 2 did not sustain
improvement past 3 week period.
Weight test:
Group 1 appeared to ↑sig and earlier and
at all stages and end Pb.05 and lift
heavier weights.
Group 2 ↑sig Pb.05 from 2nd week on.
Group 3 did not show a sig difference.
Grip Strength:
Group 1 ↑first wk (Pb.05), third wk
(Pb.01) and end of study (Pb.01).
Group 2 ↑second wk onwards (Pb.05)
but not sig different from Group 3 from
third week (Pb.05).
Stasinopoulos
2006
26
LE
Inc Criteria:
Palpatory pain on lat epicondyle,
Less pain during resistance of sup with
elbow flex to 90° vs ext, Pain with 2 of
following tests:
Res wrist ext, Res 3rd finger ext, Mill's,
Grip Test (Dynamometer)
Exc Criteria:
Dysfunction of the shoulder, C/S,
thoracic spine (T/S),
Arthritis, Radial nerve entrapment,
Bilateral LE ↓arm functions, Pregnancy
Pacemaker, Previous elbow surgery,
Conservative care last 4 weeks for LE
CT
Sequential Allocation to groups
ITT ~ met
Blinding of assessor.
N = 75; number needed
to treat (NNT) assessed at
25/
group met
Similar at baseline
Mean age = 40 years
Mean duration of symptoms
5 months.
Tx: 3×/wk over 4 wk
Follow-up through 28 weeks.
Group A: Cyriax TFM 10 minutes +
HVLA (Mill's manipulation).
Group B: Supervised ET; static
stretching of extensor carpi radialis
brevis (ECRB) tendon 3× before
and 3× after slow progressive eccentric
exercises of wrist extensors (3 sets of 10
repetitions 1 min rest interval between
each set.) If pain free progressive
increase in weight added.
Group C: Light therapy.; Polarized,
polychromatic non-coherent light
(Bioptron light)
Directions to all groups:
Avoid aggravating activities (spelled out)
Use arm
Avoid NSAIDs
Diary to be kept
Outcomes Measures:
Baseline, 4, 6, 8, 28 weeks
VAS (pain -24 hours before evaluation);
VAS “Function”(0 = no function, 100
full function—24 hours before
evaluation);
PFG
Results:
VAS: Group B sig ↓over other 2 groups
Pb.05 from first assessment through to
28 weeks Pb.05
VAS Function and PFG: sig ↑between
Group B and other 2 groups Pb.05) with
Group B showing largest effect
6
Struijs 2004
87
LE
Inc Criteria:
Lat elbow pain ↑by pressure on lat
epicondyle and resisted dorsiflexion
wrist.
Exc Criteria:
Bilateral complaints,
↓of complaints over the last 2 weeks, tx
last 6 months, unable to fill out the
questionnaires.
Randomized Clinical Trial (RCT^)
Randomized Concealed
Allocation
Blinded Assessor
ITT Analysis
ANOVA, ITT and per-protocol
changes in scores over time was
calculated, dichotomous
outcomes were expressed in a
relative risk (RR) an absolute
risk reduction (ARR) and a
number needed to treat NNT
Group A:
TFM for 5-10 minutes. + US 7.5 months
pulsed per protocol by Binder + ET 10
reps, 2-3 sets, 4-6 × per day; partially
supervised and home component
consisting of stepwise progression
starting with isometrics and stretching,
then progressing to isotonic exercises and
stretching ending with an occupational
therapy (OT) program.
Group B: Brace only with instructions
given with brace and again the next
Outcomes Measures:
Baseline, 6 and 52 weeks with a
26 weeks questionnaire
Primary:
Global Measure of Improvement
compared to baseline on a 6 point scale
(1 completely recovered, 2 much
improved, 3 little improved, 4 not
changed, 5 little worse, 6 much worse)
Dichotomized with “success”defined as:
completely recovered or much improved.
NRS 11-point scale
7
(continued on next page)
153Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
N = 180
Group A n = 51
Group B n = 61
Group C n = 51
Baseline Similar
Tx: 9tx over 6 wk
Follow-up to 52 wk
week. Continuous wear during the day
for 6 weeks. Discouraged from
performing activities that caused pain
while wearing the brace. (Epipoint brace
from Bauerfeind, Zeulenroda, Germany)
Group C: Group A and B treatments
combined
NRS 11 point pain intensity scale
Modified Pain Free Function
Questionnaire (PFFQ):
10 activities frequently affected with LE
Each activity was rated 0 to 4; total score
ranging from 0 to 40 with 40 worst
Secondary:
11-point scale for inconvenience ADL
Reported as ratios of unaffected side:
PFG, MaxG, PPT
Results:
Primary: “success rate,”no statistically
significant differences between groups
Secondary:
Group 1 NGroup 2: Decrease in pain,
Group 2 NGroup 1: PFFQ and
satisfaction., ADL and less
inconvenience
Group 3 NGroup 2: Statistically sig on
severity of complaints, PFFQ and
satisfaction. No other outcome measures
differed significantly.
Group 3 NGroup 2: Statistically sig
difference in ↑PPT; (MD, 13; 95%
Confidence Interval (CI), 1-25).
Conclusions:
Beneficial effects of Group A were found
for pain, disability, and satisfaction but
only short term. Group B superior in the
short term ↓inconvenience ADL;
otherwise no other outcomes showed
a difference.
Manchanda 2007
88
LE
Inc Criteria:
Age 25-55, Sx at lat epicondyle
1-3 months,
+ Cozen's or Mill's
Exc Criteria:
Trauma hx, surgery, acute infections or
systemic disorders, StInj in last 30 days
in elbow jt, C/S dysfunction, radial
tunnel syndrome (RTS) or posterior
interosseous nerve syndrome (PINS)
RCT^
Random Assignment
No Concealed Allocation
No ITT
No Blinding
N=30
Group A n = 10
Group B n = 10
Group C n = 10
Similar at Baseline
Tx: 15 tx over 3 wk
Group A:
MWM 3 sets of 10 + US 3 MHz, 20%
duty cycle, 1.2 W/cm
2
, 5 minutes and ET
stretching of wrist extensors, isometric
contractions of wrist extensors for 15×
for 5-10 sec start with forearm pronated
to forearm supinated and ↑resistance
Group B:
Manipulation ~ 3× 10 mob dorsal to
volar light thrust or mob grade IV of
scaphoid (navicular) and wrist into ext
(not described fully)
US and ET same as Group A
Outcomes Measures:
Baseline, days 5, 10 and 15
VAS worst pain over the last 24 hours
Weight test: Progressed 0 kg, 1 kg, 2 kg,
3kg without pain with wrist and elbow
ext with forearm pronated and supported
Functional Pain Scale for LE:
10 activities rated on a 5 point scale for
pain on performance
0 = no discomfort
1 = slight discomfort
2 = moderate discomfort
3 = quite a bit of discomfort
3
154 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Group C:
US and ET same as Groups A + B
4 = extreme discomfort
Groups A and B equally effective or sig
superior to Group 3 as it relates to VAS,
Strength and functional pain scale (FPS)
with no statistical sig difference
between Groups A and B
Paired ttest for ↑within groups
Student ttest for between group analysis
ANOVA and Bonferroni post hoc
analysis for dependent variables of the 3
Nagrale 2009
27
LE
Inc Criteria:
Lat epicondyle tenderness to palpation,
pain with gripping, pain with pas wrist
flex with elbow ext, pain with resisted
wrist ext, Age 30-60, symptoms
≥1 month
Exc Criteria:
Bilateral elbow pain, previous surgery or
trauma, med epicondylagia,
supracondylar variety of lat
epicondylalgia tenderness 3-5 mm above
lat epicondyle, cervical radiculopathy,
StInj last 6 months, peripheral
nerve entrapment (PNE)
RCT^
Random Allocation,
Blinding of assessor
Effect sizes were calculated
N=60
Mean age = 39 years
Baseline similar with the
exception of age
Tx: 3×/wk over 4 wk
Follow-up to 8 weeks
Group A:
Phonophoresis which consisted of
Ultrasound + Voveran Emulgel a topical
NSAID + ET
US = continuous 1 MHz, 0.8 W/cm
2
,
5 minutes
ET = static stretching of the ECR 30-45 s
3× pre and post strengthening, Eccentric
strengthening of the wrist extensors with
3 sets of 10 reps. When pain-free weights
were added.
Group B:
Cyriax TFM to lat epicondyle for 10 min
followed by a single HVLA Mills*
*Mill's manipulation: Arm @90° of
abduction (abd) with int rot so
the olecranon face up.
Wrist in full flex and pronation stabilized
by indifferent hand of therapist, an
HVLA thrust then at olecranon.
Outcomes Measures:
Baseline, 2, 4 and 8 weeks
VAS, PFG, tennis elbow function scale (TEFS)
Results:
4 weeks: Both groups sig ↑in all
outcome scores. Sig ↓between wk 4 and
8. Overall ↑between Baseline and 8 wk.
Group B superior outcomes to Group A
for all outcomes at each collection point
with exception of VAS collected at
week 0
Effect sizes favoring Group B found for
all outcomes.
Mean differences with shoulder
dysfunction (SD) was calculated
for all outcomes.
ANOVA for between and within-group
differences
7
Nourbakhsh 2008
89
LE
Inc Criteria:
Pain at lat epicondyle, Cozen's, Mill's
and 3rd finger ext tests also used
Exc Criteria:
Proximal upper extremity (UE) or
neck sx, hx of cervical pathology,
nerve entrapment syndrome (NES),
nonunion fractures, surgery for LE,
StInj for elbow pain prior
6 months, Sx N3 month
RCT
Random Concealed Allocation
Blinding of assessor
No ITT
N=23
Group A n = 11
Group B n = 12
Ages 24-72
Baseline Similar
Tx: 6 tx over 2-3 wk
Follow-up at 6m for Group A
of Patient Specific
Functional Scale (PSFS) and NRS
only: not
identified as face to face with
evaluator or by mail
Group A:
All tender points near elbow treated by
oscillating energy manual therapy
(OEMT)* lasting approximately 20-30
minutes per treatment
*OEMT = Tender point tx or therapeutic
touch tx based on oscillating energy
between therapists fingers located on
either side of epicondyle—osteopathic
based.
Group B:
Sham OEMT ~ Pressure applied away
from tender points with no oscillations
Outcomes Measures:
Baseline and it appears at 2 weeks.
Measurement points are not clearly
identified.
Grip Strength (GS)
PSFS—patient identifies
3 activities most affected by
their injury and rates them for
level of difficulty.
NRS for pain in the last 24 hours
Results:
Group A sig difference for ↑GS (P=
.04), ↓pain (P= .000), functional
abilities (P= .004); and in limited
activity due to pain (P= .000).
Sig difference in GS (P= .03), pain
intensity (P= .0006), limited activity due
6
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155Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
to pain (P= .025) and functional level
(P= .003) was found between groups.
Follow-up: (Group A only) 91% of the
subjects maintained improved function
and 73% remained pain free (amount of
change is not identified).
Baseline independent ttests used to
compare baseline between groups.
Repeated measure analysis to compare
pretest and post-test data for all outcomes
for within-group analysis.
MANOVA and Tukey post hoc analysis
was performed to compare between
group outcomes.
Paungmali 2003
90
LE
Inc Criteria:
Pain over lat elbow provoked by
palpation of lat epicondyle and gripping
tasks. Pain with resisted wrist ext or
stretching of forearm extensor muscles.
Exc Criteria:
C/S or upper limb (UL) problems,
neurological impairments, neuromuscular
diseases, cardiovascular disease,
health conditions that would preclude
tx, recent StInj, prescription meds
such as β-adrenoceptor blocking
agents or anti-inflammatory or
analgesic drugs, aversion to manual
contact and previous therapy for
the elbow joint.
RCT
Placebo controlled, repeated
measures (each subject received
3 randomly assigned treatments
3 × 24 = 72 treatments,
randomly allocated by drawing
lots
Blinding of Assessor
ITT ~ Adequate
N=24
Mean age = 48.5 years
Mean sx 9 months
MWM: See Bisset or the study for the
specific treatment given ~ 10 reps with
15s rest between
Placebo: Firmly contacting the patients
elbow while they performed a pain-free
gripping action with no loading across
the joint.
Control: Pain-free gripping action only
no manual contact by the therapist.
Outcome Measures:
Pre- and post-treatment of each of the
3 treatments each subject received.
2 Categories:
Pain-related measures:
PFG
PPT
Thermal Pain Threshold (TPT) using
Thermotests System. Patient responds
when the heat first becomes painful.
3 measurements are used with a 30s rest
interval
Sympathetic Nervous System Function:
Cutaneous blood flux ~ monitors tissue
blood flow
Skin conductance indicates sweat gland
activity
Skin Temperature
Blood Pressure
Heart Rate
Results:
MWM superior at PFG at P≤.01.
sympathetic nerve system (SNS)
cutaneous measures, heart rate and blood
pressure were all activated for the MWM
whereas no changes were observed for
the placebo and control treatments.
2 way ANOVA for differences in
outcomes pre- and post-treatment. 3 way
within subjects ANOVA was used for
skin conductance and skin temperature
7
156 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
(affected/unaffected limb).
PFG was also analyzed using Tukey
Honestly Significant Difference. Paired
ttest with Bonferroni correction for type
I error rate was used for multiple
comparisons of pre and post-treatment data.
ANOVA comparing differences among
conditions and ANOVA comparing
differences among days were both run.
Stratford 1989
91
LE
Inc Criteria:
Discomfort at or about lat epicondyle,
tenderness over origin of the ECRL or
ECRB tendons, ECRB at the tendon
body, ECRB extending from the origin to
the tendon body, pain at lat aspect of
elbow during wrist ext and radial dev
during elbow extension.
Exc Criteria:
Combined lesions, bilateral elbow
problems, hx elbow surgery, injection
within 6 months.
N = 40 RCT^
Random Allocation,
No concealed allocation,
No ITT
Similar at baseline other than
pre-pain VAS (PVAS)
9 tx over 3 wk
Follow-up within 5 wk
1. US + placebo ointment with no TFM
2. US + placebo ointment + TFM
3. Phonophoresis (US + steroid
coupling agent)
4. Phonophoresis (US + steroid coupling
agent) + TFM
Cyriax TFM for 10 minutes
US dosage: patient dependant between
1.3 W/cm
2
continuous output to .
5 W/cm
2
pulsed 25% duty cycle,
6 minutes
Phonophoresis element was
hydrocortisone and therapist was blinded
to whether the gel had the steroid or not.
Instructions to all: avoid aggravating
activities
and NSAIDs or meds.
Outcome Measures:
Primary: Simple dichotomous success or
failure. Success is ability of patients to
progress to pain-free strengthening for
wrist extensors, performed with elbow
extended and no regression within 4 wk
Pain VAS
Function VAS scale (FVAS)
PFF—an 8 item pain-free function scale
PFG
Results:
No difference between US and
Phonophoreses or between TFM and
no TFM
Suggested no treatment better than the
other at 5 weeks; thus the most cost
effective treatment is US.
Note only a post hoc power analysis done
Dichotomous outcomes measured with
χ
2
tests. Analysis of covariance
(ANCOVA) on the rest of the
outcomes. Stepwise multiple regression
analysis for the some variables.
Contingency table analysis performed for
other variables.
6
Verhaar 1996
92
LE
Inc Criteria:
Lat elbow pain, tenderness over forearm
extensor origin, pain at lat epicondyle
with resisted wrist dorsiflexion.
Exc Criteria:
Lat elbow operation, arthritis,
neurological disorders of involved
extremity, N3 m, local StInj within 6 m,
previous Cyriax tx at site of injury.
RCT^
Much of methodology is not
clearly delineated. Random
allocation was stated but if at
6 wk tx was unsuccessful a
different method was chosen.
The number of pts who received
both treatments is not clear;
dilutes 1 yr measure as
number of pts received both
treatments and for which group
those results were reported is
not known.
Group 1: CorticoSteroid Injections
(StInj), 1 ml of Triamcinolone acetate
suspension (1% diluted with 1 ml of
lidocaine 1%) into the tendinous origin of
the ECRB and extensor digitorum.
2-3 injections over 2-4 weeks.
Instructions: do not provoke pain with
activities.
Group 2: TFM and Cyriax Mill's
manipulation, 12 treatments over
4 weeks, followed by 2 weeks of
restricted activities.
Outcomes Measures:
Baseline, 6 and 52 weeks
Grip Strength
Patient Assessment and Result Rating:
Excellent, Good, Fair, Poor. See study
for descriptions of each group.
It appears that at follow-up there were a
number of outcomes assessed
(apparently no baseline taken before
intervention given). Other outcomes:
occurrence and severity of pain,
subjective loss of grip strength, time of
return to work and they performed
5
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157Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
No Concealed Allocation
No ITT
No Blinding
N = 106 53 per group
Mean sx 33 wk
Mean age = 43 years
resisted dorsiflexion of the wrist and
middle finger. Local tenderness and
increase in grip strength was
also assessed.
Results:
6 weeks Group 1 better statistically all
areas but at 52 weeks no difference
52 weeks 50% of the patients regardless
of group had received only the initial
treatment prescribed, 30% had received
surgery and 20% had received both
treatments.
Vicenzino 2001
93
LE
Inc Criteria:
Pain over lat epicondyle provoked by
palpation and gripping a hand
dynamometer, one of these test had to be
painful: resisted static contraction of the
wrist extensors, or ECRB or stretching of
the extensor muscles,
unilateral LE N6wk
Exc Criteria:
Concomitant problems in C/S or UL,
neurological impairments, previous
CMT to elbow joint, aversion to manual
contact, health conditions which preclude
CMT and concurrent use of medications
such as analgesic or anti-inflammatory
RCT
N=24
Age 34-66
Mean 46.43
Symptom 2-36 months, Mean
8.33 months
Placebo controlled, double blind,
repeated measures: (each received
3 assigned txs 3 × 24 = 72 txs)
randomly allocated by drawing
lots, blinding of the assessor
and patient (the authors feel they
accomplished this by recruiting
patients who have never had
CMT)
3 independent variables:
1-treatment condition
2-side (affected/unaffected)
3-time (PFG pre-/during/post-
treatment—PPT pre- and
post-treatment)
Treatment: MWM 6 repetitions were
performed with a 15 s rest interval
between reps.
Placebo: Firm contact over the subject's
elbow at the joint on both sides.
Control: Patient placed in the same
position as the treatment position and the
placebo position but no manual contact
was applied.
All patients instructed to avoid any
activity that could interfere with pain
perception.
Outcomes Measures:
Just before the treatment, during
treatment (PFG) and after treatment
PFG
PPT
Results:
PFG: Treatment group showed a
significant increase for the affected side.
The unaffected side showed a decrease
during and after treatment, whether it was
the treatment, placebo or control group.
PPT: Significant difference between the
Treatment and Placebo or Control
favoring treatment.
3-way within subjects ANOVA, PFG
data during and following treatment were
assessed as a percent change from
pre-application data.
2-way within subjects ANOVA to
analyze the PFG data. A one-way within
subjects ANOVA for the main treatment
conditions for the percentage change in
PPT. Statistical significance was
determined at the α-level of 0.05.
7
Vicenzino 1996
94
LE
Inc Criteria:
Lat elbow pain provoked by at least 3 of
the following:
Palpation over lat epicondyle region,
stretch of the forearm extensor muscles,
resisted static contraction of wrist
extensors or ECRB or static contraction
in grip
RCT
N=15
Age 22 -62
Mean 44y
Symptom 2-36 m Mean 8 ± 2 m
Repeated measures design: each
subject received 3 randomly
assigned treatments 3 × 24 = 72
treatments
Treatment: Cervical contralateral (to the
side of the LE) lateral glide (CLG) at
C5/6
Placebo: Reproduced the set-up for the
CLG but no lateral glide motion
Control: Subject's arm was resting in the
same position as the treatment group.
No manual contact
Outcomes Measures:
Immediately before and after the
assigned treatment; with the exception of
the 24 hour measure of pain. It appears
these are the only data collection points.
ULTT2b, PFG, PPT, VAS for current
resting pain and worst pain in the last
24 hours, VAS function (no function =
arm in a sling) and full function were the
7
158 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Exc Criteria:
Bilateral elbow symptoms, Sequel of
previous pain, dysfunction or impaired
sensation in the forequarter necessitating
treatment.
Blinding of assessor and subjects
No ITT
No concealed allocation.
extremes at each end of the VAS.
Results:
Treatment: Statistically significant effect
for ULTT2, PFG, PPT and 24 h pain
scores (Pb.0.01), compared to placebo
and control.
No significant difference was found for
VAS function between the groups.
Tyler 2010
95
LE
Inc Criteria:
Positive response to all 3 tests: Pain on
palpation of lat epicondyle,
Pain resisted wrist ext, Pain resisted
middle finger ext, Sx
N6 wk, unilateral
Exc Criteria:
Hx of fracture, dislocation, surgery,
bilateral pain, C/S pathology, osteoarthritis
(OA), StInj b6 weeks prior
RCT^
Random non-concealed
allocation
Blinded assessor
No ITT
N=21
Standard Care Group (SCG) n = 10
Eccentric Group (EG) n = 11
Tx:9-10tx/7wk
Study terminated early to
allow SCG to receive EG tx a
s results were so strong in favor
of EG. This only allowed 11
participants to receive intended
tx which left study
underpowered. Calculated 80%
power if 15 subjects per group.
Both groups received PT consisting of
TFM + US + heat + ice + wrist extensor
stretching and the intervention (either
isotonic exercises or eccentric exercises.
SCG performed home isotonic wrist
extensor strengthening
EG performed home isolated eccentric
wrist extensor strengthening using a
Thera-Band
FlexBar from the Hygenic Corp
Involved hand starts full ext while
uninvolved hand flexes bar, involved
hand slowly controls untwisting. 15 reps
with 30 s rest between 3 sets. Progression
provided with stiffer bar as pain dec
Compliance of home therapy unknown
for either group
Outcomes Measures:
Appear to be baseline and 7 weeks.
Disabilities of the Arm, Shoulder &
Hand Questionnaire (DASH)
VAS for pain during their primary
provocative activity
Grip strength in wrist extension
(dynamometer)
Resisted middle finger extensor strength
(dynamometer):
PPT measured distal to lateral epicondyle
Results:
EG: Significant difference and in favor
DASH P= .01, VAS P= .002, PPT
P= .003
EG: Improvement in both strength
assessments but no statistical significant
difference between groups
ANOVA with Bonferroni corrections for
subsequent pairwise comparisons for
eccentric training on all dependent
variables
5
Carpal Tunnel Syndrome ~ CTS
Bonebrake 1993
96
1990
97
(data combined)
CTS
Some had co-morbidities such as ulnar
nerve entrapment, radial nerve palsy,
scalenus anticus syndrome and various
thoracic outlet syndromes, etc.
CT
No randomization–but purposive
allocation to tx of CTS and a
“control group”and intragroup
No ITT
Baseline differences existed
between groups for strength,
(males stronger than females
Pb.05); pinch strength (stronger
for those below 40 and
controls); grip strength stronger
for controls for flexion grip
strength in elbow flexion and
extension (Pb.05)
N=28
Tx: 3-96 mean of27 over
First only 1990 covered:
Study 1: N = 41
CTS n = 38, Control (no CTS) n = 13
Study 2: N =28 …CTS patients who
completed treatment
Post treatment measurements of CTS
patients compared against Study 1
Baseline, The controls and pain and
distress questionnaire (PAD)
was compared against baseline, controls
and another group of chronic pain
patients in a study of PAD by Zung.
Treatments: Average number 27 (range,
3-96), average period of treatment
45 days (range, 4-162 days). Most treated
daily 5×/week. A few 2× 5 ×/ week.
Outcome Measures:
Baseline, Post Treatment and at 1 year
Measures of anthropometry, strength,
EMG, ROM, Task performance and
PAD
1990 Results:
Within:
Strength: Significant ↑all compared to
controls (male and female) all Pb.05
Grip strength at 90° elbow flex and ext
P= .0001 with overall sig imp with
↑25.67 kg
Pinch Strength: Thumb to index finger
Pb.05 with overall sig imp ↑12.30 Kg
Between:
No essential diff with controls for grip
2
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159Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
6 months mean 45 days Treatments for Group 1 (with dx of
CTS): Full Kinetic Chain Treatment (FKC)
upper, lower extremities and
spine, ST treatment applied to FKC; for
some dietary modifications and
supplements; All (it appears) got exercise
therapy for wrists, Thumbs and neck to
increase flexibility. Ultrasound for a few
cases. Treatments were thus generally
tailored to individual needs. Pre-post
intragroup measurement for Group 1 =
study “2.”
Control or Group 2 (no CTS) no
treatment. Measurements only.
strength, pinch strength, pronation or
supination strength; except for grip
strength in elbow extension in favor of
control group P= .0001
ROM: overall sig ↑sagittal dorsiflexion
and trans palmer all P= .05
CTS:
Grip Strength overall sig imp ↑25.67 kg
Pinch: Thumb to index and ring fingers
pinch strength Pb.05 with thumb to
index overall sig imp ↑12.30 kg
Forearm supination strength in frontal
and sagittal planes Pb.05
PAD: ↓7 pts, 15%, sig P≤.01
Task: no sig diff p = .427
EMG: sig for radialis and ulnaris muscles
during grip strength for CTS P= .0001
no sig diff between groups
1993: Within group results at 6 months:
Strength: Grip strength sig sup to
pre-treatment level all at 6 months all
Pb.0001
Pinch strength of thumb to ring finger sig
sup at 6 months Pb.0002
EMG: sig sup ↑in all areas Pb.0001
ROM: Flex and Ext were sig ↑Pb.05
Task: no diff
PAD: Pb.001
CTS essentially no “tingling”or
abnormal paresthesia
Blankfield 2001
98
CTS
Inc Criteria:
CTS diagnosis (no other info given)
confirmed by electrodiagnostic with a
median motor nerve distal latency
N4.2 ms using portable
electroneurometer.
RCT
Random allocation, cross over
with a 6 weeks wash-out period
(6/group)
No ITT
Baseline:
Narthritis (P= .02) and previous
splint use (P= .05) in 1
N=21
Group 1 n = 11
Group 2 n = 10
Tx: 1×/wk for 6 wk
Group 1 Therapeutic Touch (TT)
Therapist uses the hands in a nontactile
manner to direct an energy exchange
toward a healing effect
Group 2 Placebo Group: Sham TT
provided
The therapist concentrated on counting
backward from 100 during the treatment.
Outcome Measures:
Pre- and post-treatment each sessions
Median motor nerve distal latency
VAS—pain/discomfort
VAS -State of relaxation for the last 13
subjects only
No stat sig ↓but some pos changes after
tx and crossover—particularly in
relaxation and they suggest that slight
imp of ↑in speed of median motor nerve
distal latency might be simply due to A).
Relaxation = warmth or increased blood
flow which increased n speed or B) the
sham group inadvertently received TT
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160 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Burke 2007
99
CTS
Inc Criteria:
Electrodiagnostic to confirm distal
latency of median nerve sensory
(N3.60 ms) and/or motor latency
N4.20 ms. Pain + paresthesia in median n
distr, Ratings of the Katz hand diagrams
indicating classic or probable, VAS pain
rating ≥33 mm and
2 of 8 PE findings:
Nocturnal paresthesia, Mean symptom
severity score at least 3/5, Mean
functional-status score at least 3/5,
Tinel's, Phalen's
Strength deficits,
Sensory deficits of touch, ↓ROM.
Exc Criteria:
N50 years, CTS surgery, hx wrist trauma,
underlying disease process, hx
musculoskeletal medical conditions, no
pending lawsuits or insurance claims,
electrodiagnostic studies inconsistent
with CTS.
RCT^
Random allocation
No ITT
Blinding of assessor
N=36
Group GISTM n = 14
Group soft tissue mobilization
(STM) n = 12
Tx: 2×/wk for 4 wk, then
1×/ wk for 2 wk
Then monthly phone contact
for 3 months.
Graston Instrument Assisted Soft
Tissue Mobilization (GISTM) Group:
Warm up exercise (12 min riding
stationary bicycle or treadmill walking),
Graston tx, stretching, strengthening
and ice.
STM Group:
Warm up exercise (12 min riding
stationary bicycle or treadmill walking),
Manual (therapists hand) soft tissue tx
designed to break down scar or fascial
restrictions hand, wrist or forearm.
Appears same post tx stretch, strengthen,
ice protocol and the pre-treatment
Both groups received at home stretching
and strengthening exercises of UE
closed kinetic chain (CKC).
All instructed to refrain using wrist
splints and anti-inflammatory
medications during the 6 wk
Outcomes Measures:
Baseline, within 1 wk after final tx ,
3 months
5 Subjective:
Katz hand diagram classifications;
Functional wrist/hand status—ability to
perform ADL's
Pain VAS;
Severity of CTS symptoms—11
questions …pain, paresthesia, numbness,
weakness, nocturnal sx and overall
functional
Patient satisfaction rating
9 Objective:
Distal sensory latency (DSL);
Distal motor latency (DML);
ROM flexion/extension;
Grip and pinch strength;
2 point discrimination first bi-lat 3 digits
Pressure sensitivities first bi-lat 3 digits
(Semmes-Weinstein monofilaments [SWM]);
Phalen's and Tinel's.
Results:
Distal latencies not sig changed for motor
or sensory either group.
Both Groups ↑subjective but GISTM N
in functional ability and symp severity.
Pt satisfaction did not reach stat sig
Both Groups grip strength ↑; slightly
NGISTM but not clinical sig
Both Groups ↑ROM, grip strength and
pinch strength.
Sensory function tests, Phalen's Test and
Tinel's Test did not show improvement.
5
Bialosky 2009
100
CTS
Inc Criteria:
Pain or paresthesia in median n distrib
and/or clinical examination consistent
with CTS,
Sx ≥12 weeks, NRS pain/sx ≥4/10
Exc Criteria:
Non–English-speaking, CTS surgery,
prior treatment with neurodynamic
technique (NDT), pregnancy, dx
of systemic disease that cause peripheral
neuropathy, current or hx chronic pain or
CTS 2° to fx.
RCT
Random Concealed Allocation
Blind assessor at the 3 week
follow-up only
No ITT
N = 40 females
Group 1 n = 20
Group 2 n = 20
Fully powered TPT
68% bi symptoms (dominant
or worst used for comparisons)
Baseline not sig diff
Tx: 2×/wk for 3 wk
Group 1:
Bi-Lat NDT—manual technique to stress
median n through specific positioning of
UE followed by passive wrist and finger
flexion and extension over 6 s. First 3 txs,
5 sets of 10 cycles, txs 4-6, 7 sets of
10 cycles.
Group 2:
Bi-Lat Sham—minimized stress to the
median nerve through positioning
and motion.
After baseline testing all subjects
received a prefabricated wrist splint and
Outcomes Measures:
Baseline, first tx only for mechanical
visual analog scale (MVAS), PPT
and TPT, 3 wk and 3 wk follow-up.
Patient-Centered Outcome Questionnaire
(PCOQ): quantifies the usual, desired,
and expected levels of pain, fatigue,
emotional distress, and interference with
ADLs associated with pain. PCOQ also
used to assess a successful treatment and
the self-perceived importance of
improvement in pain, fatigue, emotional
distress, and interference with ADLs;
7
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161Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
Mean tx 4.7 instructed to wear while sleeping and
performing painful activities
MVAS: Mechanical pain rating scale;
PPT;
TPT –Thermal pain assessment at the
thenar eminence for when the sensation
changed from warm to painful;
Quick DASH;
Grip Strength—MaxG;
Sensation (Semmes-Weinstein
monofilament) testing;
Electrodiagnostic testing (nerve
conduction study [NCS]) median
n (motor and sensory testing).
Results:
Group 1 superior TPT at 3 wk follow-up;
Otherwise no diff NDT or Sham (PN.05)
Group 1:
Paired t tests indicated mean ↓of self-
report of temporal summation pain of
−8.8 (SD, 14.7; P= .02; Cohen's
d = 0.35) compared to sham ↑of +4.2
(SD, 16.0; P= .26; Cohen's d = 0.13) at
3-wk follow-up.
All showed sig imp in measures of
clinical pain intensity, UE disability and
grip strength (MaxG) at 3 wk follow-up.
No tx effect noted for nerve conduction
—motor or sensory.
Study showed manual therapy (MT)
regardless of type was effective for
↓pain, perceived disability and grip strength.
Hains 2010
37
CTS
Inc Criteria:
20-60 years, numbness in hand affecting
thumb, index, and partial ring finger,
daily for 3+ months, agree to 15 txs,
Tinels, Phalens, Sleep problems due to
CTS symptoms.
Exc Criteria:
UL or neck surgery, pregnant, systemic
pathologies related to CTS.
RCT
Random allocation, cross-over
of 13 from sham to experimental
group (no wash-out period)
Pts blind to treatment
ITT applied
Baseline not sig diff
N=55
Group 1 n = 37
Group 2 n = 18
Tx: 3×/wk over 5 wk
Group 1: Experimental Group
Ischemic Compression (IC) of “noxious”
trigger points (TrPs) in 4
areas—biceps, biceps aponeurosis,
pronator teres muscle and
axilla subscapularis
Group 2: Sham Group:
IC was applied to TrPs in deltoid, supra
and infraspinatus, biceps, biceps
aponeurosis, pronator teres, axilla
TrP treated 15 seconds
Both groups instructed to refrain from
other tx
Outcomes Measures:
Baseline, 5 wk, experimental group and
cross-over group at 1 and 6 months
follow-up
NRS to rate perceived improvement
CTS Pain and Function Questionnaire
Results:
Group 1 ↓in symptom and function
scores stat sig in favor over Group 2
(Pb.0001)
Sig diff in perceived imp score noted in
favor of Group 1 (Pb.021)
Crossed over (n = 13) sig imp after cross
over tx (Pb.001)
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162 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Repeated measures one-way ANOVA,
post hoc Tukey test, ttests to compare
perceive imp % between groups set at
Pb.05
Moraska 2008
101
CTS
Inc Criteria:
Documentation from an Doctor of
Medicine (MD), Doctor of Osteopathy
(DO) or Doctor of Chiropractic (DC),
Dx ≥6 months
Exc Criteria:
Surgery on involved limb, pregnancy,
smokers, persons with diabetes
RCT^
Random Allocation
No ITT
No Blinding
N = 28 (1 did not complete the
study )
Baseline Group A
stronger (+ males) dealt with by
ANCOVA
Tx: 12 txs over 6 wk
Group A:
General Massage (GM): a typical
relaxing massage focused on ↓muscular
tension and ↑circulation to UE, back and
neck for 30 min
Group B:
Targeted Massage (TM): Designed to
(1) ↓vol of fluid in carpal tunnel region,
(2) ↓connective tissue restriction and
(3) ↓contractile tissue hypertonicity or
potential pts of n entrapment along
brachial plexus and median n
30 min of very specific protocols—
see study.
Instructed not to receive other tx and to
only take non-prescription pain relievers
Outcomes Measures:
Baseline 1, Baseline 2 (immediately
before treatment), 2 days following the
7th and 11th massage sessions and a final
follow-up 4 weeks after the 12th massage.
MaxG, Pinch strength (both
dynamometers), Perceived symptom
severity with the Symptom Severity
Scale (SSS), Functional Status Scale
(FSS)—difficulty performing daily
activities, Grooved Pegboard Test.
Results:
MaxG: Both groups ↑Group B sig N
Group A (P= .04)
Pinch Strength: Both groups ↑over time
(P= .001) and was maintained through
follow-up with no sig diff between
groups (P= .11)
SSS: MT ↓sx severity and maintained
through follow-up (P= .001); no
difference between protocols (P= .80)
FSS: TM group had progressively imp
(P= .016) as compared to GM group.
Pegboard: No difference between
2 groups (P= .41)
Repeated measures ANOVA with post
hoc Bonferroni analysis. Alpha set at
α= 0.05
5
Tal-Akabi 2000
102
CTS
Inc Criteria:
+electrodiagnostic test, Phalen, Tinel's,
ULTT2a, with dx CTS by surgeon
indicating pt was a surgical candidate,
from a surgery waiting list
Exc Criteria:
Known psychosocial problems, diabetes,
herpes zoster, rheumatoid arthritis (RA),
pregnancy, hyperthyroidism, known
congenital abnormality nervous system,
C or T spine origin of symptoms
RCT
Random Allocation
No Blinding
No info given on num of tx (as
they wrote “grade of treatment,
amplitude or mobilization, and
progression of treatment was
based on an individual basis
depending on irritability and
severity of symptom”), length
of study or when outcomes taken
Kruskal-Wallis Test, ttest for
within-group pre and post-test
analysis
N=21
Group 1 n = 7
Group 1:
Neurodynamic mobilization (NDM) used
“mobilization technique”ULTT2a (per
Butler 1991)
Group 2:
Carpal bone mobilizations (CBM) A-P or
P-A and flexor retinaculum stretch (per
Maitland 1991 p 205). Grade of
mobilization (I-IV; no grade V/HVLA)
and progression tx from lesser grades
such as II or III, to grade IV; and strength,
amplitude or force used oscillating mob
based on irritability and severity of
individual's symptoms and response to
tx. Often applied as 2 sets of ≥10-30
1 second oscillating mob or as indicated
Outcome measures:
24 hr diary for duration and frequency of
symptoms, VAS for severity of
symptoms, Functional Box Scale score
(FBS), Pain Relief Scale (PRS), ROM
(wrist flex/ext), ULLT2b Test
ULLT2b: Slight GH shoulder girdle
depression, elbow ext, lat rot of whole
arm, wrist, thumb and finger ext and
finally GH abd; taken to end ROM (= R2)
or to point at which sx first appear (= PI)
Results:
VAS:
Group 1 sig ↓(P= .02)
Group 2 sig ↓(P= .001)
Group 3 not sig ↓(PN.05)
5
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163Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
Group 2 n = 7
Group 3 n = 7
Baseline similar
Age range 29-85 Mean 47.1
Sx range 1-3 y
Mean duration 2.3 y
Tx: 3 weeks
per individual (see Maitland 1991).
Group 3:
Control Group—no treatment
Surgery:
Group 1 (NDM): 5 out of 7 did not have
Group 2 (CBM): 6 out of 7 did not have
Group 3 (Control): 1 out of 7 did
not have
FBS: (ability or disability to button or
unbutton shirt) no diff between 3 groups
PN.05 but Group 2 intragroup changed
52%, Group 1 17% (both Pb.05)
PRS: sig for Groups I and II (0 worst
5 best) Group 1 mean: 3.14, Group II
mean
3.71(Pb.05).
ROM: sig ↑flex for Group 1 Pb.05
(about an increase of 10 degrees); no sig
diff between groups (PN.05) ANOVA
ULTT2b: more “negative”now in group
1 (5/2) and group 2 (4/3).
Ultimately: no diff between 2 MT tech
both seemed helpful short term.
Very short-term and small sample size
does not allow for extrapolation.
Davis 1998
103
CTS
Inc Criteria: Phalen/Tinel's, grip strength
and pinch grip testing, Semmes-
Weinstein monofilament test, ortho and
neuro tests for CTS and possible spinal
involvement,
21-45 y, self-reported symptoms of CTS
(numbness and tingling), sx of median
n distr
Exc Criteria:
Current tx for CTS, pregnancy, relevant
systemic condition, wrist surgery, current
anti-inflammatory or B6 use, prescriptive
use of wrist brace or electrodiagnostic
abnormalities inconsistent with CTS or
indicating axonal degeneration.
RCT^
Random Concealed Allocation
Blinding of assessor
No ITT with sig loss of subjects
(25)
Repeated measures MANOVA.
Statistical significance was set at
P= .00833
Baseline similar
N=91
Group 1 n = 46
Group 2 n = 45
Tx: Avg 27 over 6 wk follow-up
1 month
Group 1: Medical Group
Ibuprofen (800 mg 3× a day for 1 wk,
800 mg 2× a day for 1 wk and 800 mg as
needed to a max daily dose of 2400 mg
for 7 wk) and nocturnal wrist splints
Group 2: Chiropractic Group
HVLA UE and spine. 16 treatments
(3×/wk for 2 wk, 2×/wk for 3 wk 1×/wk
for 4 wk). Soft tissue tx, nocturnal wrist
splints and ultrasound (1/2 the visits)
Outcomes Measures:
Baseline, 6 and 10 wk
Carpal Tunnel Outcome Assessment—
physical distress (CTOA-P), Carpal
Tunnel Outcome Assessment—mental
distress (CTOA-M) self-reports of
physical and mental distress,
Vibrometric thresholds of finger
sensation of third digit affected
hands (primary assessment), NCS
of median motor and sensory components
for digits 3-4 and palm/wrist segment.
Results:
Sig imp in self report (SR) physical and
mental distress, Vibrometry and NCS
but not in favor of one group over
the other.
Conclusions:
CTS assoc with median n demyelination
but not axonal degeneration may be
treated with commonly used components
of conservative medical or chiropractic
care.
Verbatim from study:
“Subjects in both treatment groups
improved significantly; they felt better,
their nerve conduction velocities
increased and their finger sensation
7
164 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
improved. Overall improvement for both
treatment groups indicated by self-
reported physical and mental distress,
NCS and the vibrometer can be
considered clinically meaningful. That
these results are based on both subjective
and objective measures strengthens this
interpretation.”
Nevertheless, because there were no a
priori equivalence criteria established,
the present research neither “proves”the
equivalence of conservative medical with
chiropractic treatment of CTS nor do the
results indicate that either treatment is
more efficacious than “watchful
waiting.”Such conclusions may be
possible after more definitive research
is conducted.
Wrist, Hand and Fingers
Varsha 2007
104
Post-op Colles Fracture
Inc Criteria:
Dx dis radial fx on x-ray, Post-surgical
(external fixation removed after
2 months.)
Exc Criteria:
Conservative tx of colles fracture, any
other fx in ipsilateral limb, osteopenia,
previous colles fx, pre-existing
inflammatory joint condition, Sudeck's
dystrophy
RCT^
Random Assignment
No ITT
No Blinding
N=30
Group A n = 15
Group B n = 15
No baseline measures given
Analyzed using ttests and
Mann-Whitney U Test
Pb.05
manual or manipulative therapy (MMRT)
treatment was only after a minimum of
8 weeks after fracture with full healing.
Group A:
Maitland and moist heat. Tx grades 1 and
2 first week and grades 3 and 4
second week.
Group B:
Mulligan (pain-free) and moist heat.
Both groups were not allowed to lift
heavy weights during the treatment
period.
Outcomes measured at end of 2 weeks of
MMT treatment:
VAS for pain
ROM (goniometer)
Thumb Motion Scale
Functional Assessment Tool (no validity
or reliability shown for this outcome)
Results:
VAS: Group B Sup with 0.8 sig than A
P= .029
Group A (-3.93 ± 1.09) vs Group B
(-4.73 ± 1.03)
Wrist flex sig imp in Group A P= .020
Thumb Motion Scale superior in
Group B
Functional Assessment Tool did not
show any sig changes for either group
3
Bongi 2009
28
Systemic Sclerosis (for the hand and
finger treatment)
RCT^
Random Concealed Allocation
ITT
No Blinding
Baseline Similar
N=40
Group A n = 20
Group B n = 20
Mean age = 57.8 ± 11.8 years
Symptom 9.0 ± 3.8 y
Group A: Combined Group
Connective tissue massage (total time =
10-15 minutes), Mc Mennell jt man and
home exercises of daily mvt of fingers,
wrists and forearm, with out resistance
Group B: Control Group
Daily home exercise program
All patients continued their medications
Outcomes Measures:
Baseline, 9 weeks, 9-wk follow-up
Physical Synthetic Index and Mental
Synthetic Index from the SF-36 (Italian
version)
Hand Assessment: Hand Mobility in
Scleroderma (HAMIS) test, the Cochin
hand functional disability scale and ROM
(hand opening and fist closing
only)
7
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165Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
Tx: 2×/wk for 9 wk Results:
Group A: Fist closure, HAMIS test and
Cochin hand functional disability scale
imp sig (Pb.0001) through follow-up.
Group B: Fist closure at end of tx only
(Pb.0001)
Repeated measures of ANOVA, post hoc
Bonferroni, P= .05
Villafane 2012
105
Thumb Osteoarthritis (Thumb
carpometacarpal OA or TCOA)
Inc Criteria:
X-ray, OA of dominant hand, stage III –
IV of Eaton-Littler-Burton
Classification, preserved cognition
according to age, ex-factory workers and
housewives whose use of the dominant
hand was common and systematic.
Exc Criteria:
CTS, arthritis, surgery of
trapeziometacarpal jt, finger spring or de
Quervain's, neuro conditions pain
perception altered
RCT
Random Allocation
Blinding of Assessors
ITT
Baseline Similar
N=28
Group 1 n = 14
Group 2 n = 14
70-90 y with clinical pathology
N10 years
Tx: 2×/wk for 2 wk
Group 1: Maitland's mobil to dominant
hand (P-A gliding of thumb for 3 min
with a 1 min pause 3×)
Group 2: Sham
Pulsed US 0 with cm
2
No NSAID's or anti-inflammatory
medications could be taken 24 hours
before each session.
Outcomes Measures:
Baseline, pre-treatment and post-
treatment, 1 wk after tx, and 2 wk after tx
PPT at the carpometacarpal (CMC), Hamate
and Scaphoid Pinch Strength (tip pinch
and tripod pinch)
MaxG
Results:
PPT: Group 1 sig diff passive jt mob of
thumb metacarpal joint over Group 2
P≤.001 and clin sig (N15%)
No sig diff for scaphoid or hamate
Tip and Tripod Pinch and Grip Strength:
no differences between groups PN.05 or
clinically meaningful changes
8
Villafane 2011
106
Thumb Osteoarthritis
Dx Criteria:
Medical hx and radiographic evidence of
Stage III of Eaton-Littler-Burton Class,
Preserved condition according to age,
ex-factory workers and housewives
whose use of dominant hand was
common and systematic
Exc Criteria:
CTS, arthritis, surgery of CMC joint,
finger spring or de Quervain's, neuro
conditions pain perception was altered.
RCT
Random Allocation
ITT not met: all completed tx
and assessment but 7 were
excluded from analysis as they
had no x-ray
Baseline Similar
N = 29 Females
Group 1 n = 14
Group 2 n = 15
70-90y with clinical pathology
N10 years of secondary CMC
jt OA of the dominant hand
Tx: 6 txs over 2 weeks
Group 1: Kaltenborn's Mobilization
P-A gliding of CMC with grade 3
distraction (grade 3 = joint separation)
for 3 min with a 1 min pause 3×'s
Group 2: Sham
Non-therapeutic pulsed US
Outcomes Measures:
Pre-treatment, post-treatment, 1 wk end
tx and 2 wk end tx
PPT
Pinch Grip (tip pinch and tripod pinch)
MaxG
Results:
PPT: Group 1 immediate stat sig ↑in
favor at the CMC joint (Pb.05)
At Scaphoid (Pb.05) there was sig diff
between pre and post-treatment Group 1
(P= .023); not at follow-up
Tip Pinch: Sig diff for time (P= .02)
through follow-up
Post hoc analysis did not detect sign diff
between the time points (PN.05)
6
Temporomandibular disorders
(TMD/TMJ)
Minakuchi et al
2001
107
TMD
Anterior disc displacement without
reduction
RCT
N=69
Blind Assessment
ITT inadequate
Baseline, 2,4, and 8 weeks
Mobilization 20 minutes by a dentist:
mobilization not described and no
reference for technique given.
Three groups
Control
Outcome Measures:
Mouth opening calipers ROM.
VAS pain.
Daily activity limitation (using a Likert
scale)
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166 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Treatment 1: self-care/NSAID group
Treatment 2: appliance/mobilization
group
No significant differences between
groups at all assessments through 8 weeks
all P N.05
Kalamir A et al
2012
108
TMD RCT
N=93
Concealed Allocation
Blind Assessment
ITT
Group 1 Intra-oral myofacial
therapy (IMT)
Group 2 IMT education, self-care,
and home care exercises (IMTSCE)
Waiting list control
ST MMT intraoral myofascial therapy
for the TMD
Outcome Measures:
VAS Pain
VAS pain rest
VAS pain open
VAS clench
Global rating scale
ROM calipers
Essentially all outcome measures
changed significantly in favor of MMT
(at 1 year) all P≤.05
8
Nicolakis 2001
109
TMD-OA or CMD (Craniomandibular
disorder).
Inc Criteria:
Radiological signs of OA of the TMJ,
pain ≥3 months.
CT
No randomization
ITT inadequate
N=20
Mean age = 48.8 ± 14.9 years
Mean sx 2.7 years
Stats:
MONOVA
Wilcoxon
χ
2
Control group of a waiting list vs the
same group of patients during treatment.
Waiting: Mean 35.4 days (5-120 range)
Tx: Mean 10.8 tx (range, 5-18) over
mean of 45.5 day (range, 10-86)
Exercise therapy by PT.
30 min of exercise with passive and
active jaw movements, correction of
body posture (see study), and relaxation
tech; massage of painful muscles, muscle
stretching, gentle isometric
strengthening, guided opening and
closing exercises, MT joint distraction,
disk condyle mobilization. Home
exercises
Outcomes Measures:
Measures 1-4 were measured at baseline,
immediately before, immediately after
and 6 months after exercise therapy.
Measures 5 and 6 were assessed at the
2nd, 3rd and final examination.
1. VAS pain at rest; maximal pain over
2 days; (0-100 with “no pain and worst
possible pain”).
2. VAS for: impairment in daily life
(chewing, speaking, yawning) with “no
impairment and worst possible impairment.”
3. Mouth opening in mm (from 1st right
incisal of the upper and lower jaw) with
mouth as wide open as possible.
4. Patient perceived improvement of jaw
pain using apparent Likert like scale.
6. Perceived improvement of jaw
function in contrast to baseline on a
7 point scale.
Results:
Baseline: 20 pain on chewing, 16 pain at
rest, 12 an impaired mouth opening,
20 high VAS impairment.
Control: No statistical changes (all
outcome measures PN.05).
After Treatment: 80% experienced an
excellent or distinct imp in pain Pb.001.
20% reported excellent and 65% reported
distinct imp of jaw function Pb.001.
Incisal edge clearance imp sig P= .057.
6 month follow-up: Pain ratings and jaw
function continued to imp in contrast to
incisal opening which did not improve.
3
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167Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 2. (continued)
Author Condition Methodology Intervention Outcome measures/results PEDro
17 tx was effective = 85% success rate.
MANOVA at 6 months for all VAS (pain
at rest, at stress, impairment) and for
improved incisal clearance (or increased
mouth opening): all P= .001
Varrie N
2003
110
TMJ/TMD
Signs and Symptoms:
Pain and tenderness at TMJ, or muscles
of mastica, Popping, clicking or crepitus
with mastica during condylar movement,
Limited jaw joint movement, Headaches,
facial or neck pain and/or vertigo,
tinnitus, masticatory muscle spasm,
bruxism, malocclusion, earache and/or
locking of the TMJ
Inc Criteria:
≥3 of above symptoms + the 2 knuckle
test: a testing of Gross ROM + TrP
tenderness (marked) in the lat pterygoid
(intra- orally) or in masserter or
temporalis muscles. Vernier Callipers at
all measurements and then put down as a
Visual ROM or VROM in mm's
(0-150 mm is range)
RCT
Random Allocation
No Blinding
No ITT
N=30
Per Group n = 10
Low power
Mean Age:
Group A 24.2
Group B 28.9
Group C 31.2
Tx: 6 txs over 3 weeks
Follow-up 1 month
Group A: Chiropractic adjustments only
Motion palpation and adjusting
technique per Schafer and Faye (1990).
Assessed for TrPs. MT for restricted
medial to lateral and superior to inferior
motion at TMJ for restricted (with a
light HVLA “inferiorly”or downward and
medial light thrust of TMJ; for other
restrictions see Shafer and Faye (1990).
Group B: Soft tissue therapy only
3× per day self-exercise and stretch. Soft
tissue per TrP with gentle post stretch and
heat if necessary and exercise alone and
stretched gently into opening, retraction,
protrusion and laterotrusion for 20
seconds, PIR resistance for 10 seconds
with post-isometric stretch in all
directions with resistance by researcher
then stretched
Group C: Combination of Groups A
and B
MT and Exercise
Outcome Measures:
Baseline, after 3rd and 6th tx and at
1 months follow-up
Symptom Questionnaire:
1. pain in jaw (0-10 etc)
2. when talking
3. during or after chewing
4. Headaches
5. Clicking
6. Locking
and other questions on Pain, Noise,
Movements and Associated symptoms
such as clenching, bruxism, etc (see
Varrie N et al 2003)
ROM: Assessed with V Callipers for
opening, protrusion and laterotrusion
(Valid and reliable).
ROM: Group C stat and sig better
(ANOVA and Student-Newman- Keul
test) with p≤0.05, ↑jaw joint opening
Symptom questionnaire: All groups had
stat sig (ANOVA and Student-Newman-
Keul test) within-group imp and changes
at the 6th tx and 1 month FU (P≤.01)
with none sig diff from other
Group A ↓24%
Group B ↓27.5%
Group C ↓33%
ttests, paired and unpaired, and Mann-
Whitney U were also used
4
Kalamir 2010
111
TMJ/TMD
Inc Criteria:
18-50 y, daily periauricular pain with or
without jt sounds ≥3 months with dx of
myogenous caused
Exc Criteria:
Previous pt at clinic, edentulous
applicant, hx of malignancy ≤5 years,
other physical contraindications
(inflammatory arthritieds, fxs,
RCT
Random Concealed Allocation
ITT
Baseline Similar
N=30
Group 1 n = 10
Group 2 n = 10
Group 3 n = 10
Tx: 2×/wk for 5 weeks
Follow-up at
Group 1: IMT
Intra-oral temporalis, med and lat
pterygoid muscle release tech and intra-
oral sphenopalatine ganglion tech
Group 2: IMT, education, self-care and
home care exercises 2× per day
(IMTSCE)
Education = TMJ anatomy,
biomechanics, psychosocial factors,
para-functional activities
Outcome Measures:
Baseline, 6 weeks and 6 months
Research Diagnostic Criteria (RDC) a
comprehensive diagnostic tool. Assesses
psychosocial, physiological and
palpatory information on TMD's.
Categorizes TMD as to myogenous,
discal or arthritic.
Graded chronic pain scale (GCPS):
11-point NRS scale for resting,
8
168 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
dislocation or known instability of jaws
or neck metabolic diseases, connective
tissue and rheumatologic disorders and
hematological disorders.
6 months Self Care = Mandibular body-condylar
cross-pressure chewing technique
Exercises = Post-isometric relaxation
stretches and resisted closing of mandible
Group 3: Control group
Wait list; could receive tx at end of
follow-up
maximum opening, and clenching pain.
Inter-incisal opening range.
Results:
6 weeks: no sig diff between groups in
primary outcomes of pain at rest and
on opening
Pain on clenching opening range showed
stat sig changes between groups (Pb.01
and Pb.01, respectively) in favor of
Groups 1 and 2.
6 months: Groups 1 and 2 were superior
in all outcome measures compared to
control (Pb.01) (Kruskal Wallis test and
ANOVA like test).
Pain at opening and clenching was sig for
Groups 1 and 2.
No diff between Groups 1 and 2.
Greatest relief overall in clenching pain
for both groups.
Outcomes of Groups 1 and 2 suggest
IMT with or without education and self-
care may be of benefit in treating
myogenous TMD. Notes small pilot
study, etc, No statement of effectiveness
can be made.
169Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 3. A summary of research on shoulder case series and reports
Author Diagnosis Treatment/Management Reported Outcome
Hidalgo Lozano A
et al 2010
115
Case Series
Rotator cuff injuries, diseases, or disorders
(RCID) and soft tissue (ST) disorders (or
apparent)
Myofascial pain and dysfunction
syndrome (MPDS)
N=12~7♂/5 ♀
Mean age = 25 years
12 consecutive pts with a dx of unilateral
impingement syndrome stage l
(acute inflammation and either
tendonitis or bursitis)
Mean duration of shoulder pain:
8.7 ± 4.8 months (95% Confidence
Interval [CI] CI 5e12.4)
Mean intensity of
pain experienced during arm
active elevation:
5.1 ± 1.9
(95% CI 3.9e6.4)
Positive Neers, Hawkins and passive
int rotation
Manual trigger point pressure release
over identified muscles by the treating
practitioner. Pressure was applied over
trigger points (TrPs) until an increase
in muscle resistance (barrier) was
perceived by the clinician and
maintained until the clinician
perceived release of the taut band.
The patients also received a
neuromuscular technique over the
effected muscles where the thumb of the
therapist was placed over
the taut band and longitudinal strokes
were applied slowly
with moderate pressure which was not
painful for the patient.
Tx: 4 sessions over 2 weeks
Outcome Measures:
Pain during arm elevation (visual
analogue scale, VAS) and Pressure
pain thresholds (PPT) using a
mechanical pressure algometer over
levator scapulae, supraspinatus,
infraspinatus, pectoralis major, and
tibialis anterior muscles.
Pain assessed pre-intervention and
1-month follow-up
PPT assessed pre- and post-treatment,
and 1-month follow-up.
Patients experienced a significant
(Pb.001) reduction in pain after
treatment (mean ± SD: 1.3 ± 0.5) with
a large effect size (d N1).
Patients experienced a significant
increase in PPT immediate after the
treatment (Pb.05) and 1 month after
discharge (Pb.01), with effect sizes
ranging from moderate (d = 0.4)
to large (d N1)
Krenner, BJ
2005
116
Shoulder impingement syndrome (SIS)
and for treatment of ST disorders or
associated MPDS.
(secondary to RCID with –see Krenner
2005 discussion)
Patient 1: ♀29 years
shoulder injury: volleyball 8-10 years
ago, later ↑at work in deli/overhead
work.
Mild to mod general shoulder pain and
could not lift arm over head. 1st Dx: Rot
Cuff. Rx'd Ibuprofen.
2nd Dx via doctor of chiropractic (DC):
SIS …↓abduction (ABD) ROM,
↓Cerv spine ROM, weak supraspinatus,
infraspinatus, teres minor, and
subscapularis (SITS) muscles (MMs),
+Hawkins-Kennedy (H-K),
Painful Arc ABD (P-ARC), TrPs,
joint dysfunction C-spine and GH joint
Patient 2: ♂20 years shoulder injury due
to overhead shoulder press exercises 18
months ago
Mild to mod A-Sup shoulder pain when
arm overhead.
Cerv comp tests—palp of
acromioclavicular (AC) join and passive
ABD of GH joint with inf press
to clavicle elicited chief complaint,
+H-K, Painful Arc of ABD with “hiking,”
TrP subscap and subclavius MM, tender
biceps tendon at SITS tendons. MM
strength ↓SITS 4/5, Restricted T2/3,
Hiking on shoulder press.
Dx: SIS
Patient 1…MT:
1. high-voltage, low-amplitude
chiropractic manipulative therapy
(HVLA CMT) to glenohumeral
(GH) and cervical spine (C/S) as
indicated by restricted movement
(generally described).
2. Soft tissue technique (specifically used
the “Trigenics™”strengthening or the
“TS”method) to the left teres major,
infraspinatus, supraspinatus
TS: specialized technique of applying
digital manual pressure (see Krenner
2005).
3. Post 4th tx: strengthening exercise
program rx'd: 2 lb dumbbell—Ant
deltoid raise, lat deltoid raise,
supraspinatus raise,
Rowing exercise bringing dumbbell up to
axilla. 12× each. 1× per day
Tx: 5 sessions
Patient 2 …MT:
1. HVLA CMT to Upper thoracic, left
GH , sternoclavicular (SC), and AC joints
(general description)
2. Trigenics, TS to SITS MMs and the left
pectoralis minor (a form of lengthening/
stretching for the pectoralis).
3. Stretches: pectoralis and rotator cuff
MMs before tx, light SITS strengthening
exercises (without weights). At 4th visit
shoulder press exercises (with 8 lb
dumbbell) performed with ease with no
shoulder hike. External and Internal
rotation strengthening (sidelying with 3 lb).
4. TS applied to infraspin and teres min, by
6th visit shoulder press 8 lb repeated
30× with no pain, later with 10 lb.
Tx: 6 sessions
Patient 1:
1. Range of motion (ROM)
improved (especially ABD),
otherwise within normal
2. Ortho test (H-K) negative
3. Other SITS MM tests normal,
no pain-weakness
Patient 2:
1. Overall 90% improvement reported
by patient
2. Ortho test (H-K) 50% less painful
3. ABD full and painless
4. Shoulder Press with 10 lb possible
Caldwell C et al
2007
117
RCID (SIS) and shoulder complaints,
dysfunction, disorders and/or pain (SCDP)
Based on the MSI diagnosis, the patient
was educated to avoid positions and
Outcomes measures:
VAS to assess pain intensity at rest and
170 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 3. (continued)
Author Diagnosis Treatment/Management Reported Outcome
Movement System Impairment (MSI) in
a patient with shoulder pain.
No tissue in lesion Dx provided
Female 46 years
The patient presented with a 2 month Hx
of recurrent right sided shoulder pain
with varying intensity but gradually
increasing over time. The pain limited
her ability to ride her bicycle and in
reaching activities
Dx: The examination consisted of
direction-specific tests of movements and
alignments, during which, pain was
monitored and judgments were made
regarding alterations relative to a
kinesiological
standard. Functional movements that
were painful were simulated by the
patient and analyzed by the
examiner. The abnormal alignment
findings included an anterior humeral
head, glenohumeral joint resting in
extension, and anteriorly tilted and
adducted scapula.
Manual muscle testing of the right
middle and lower trapezius revealed
weakness, with the serratus anterior
graded at 4/5.
Short pectoralis minor and teres major
muscles were identified.
movements that promoted excessive
humeral anterior glide and to increase
scapular upward rotation with overhead
motions.
Treatment consisted of instruction
in a home exercise program (HEP),
practice correcting functional
movements, and patient education.
Specific exercises included in the
program were passive shoulder
horizontal adduction, and shoulder
internal rotation and active shoulder
external rotation.
Exercises for the trapezius and serratus
muscles were prescribed in the prone
position and quadruped, respectively.
Finally the patient was instructed in an
exercise to stretch pectoralis minor.
Tx: 4 sessions over 6 weeks
with use, overall percentage decrease in
pain, frequency of pain with activities,
ROM of passive medial rotation and
horizontal adduction and strength of
scapula muscles.
The patient was pain free with all
activities at 1 month and there was no
recurrence of symptoms 3 years after
the last physical therapy visit.
Haddick E
2007
118
SCDP and Neurogenic Shoulder Pain (NSP)
Shoulder pain secondary to neural tissue
mechanosensitivity
Female 45 years
Research scientist presenting with
intermittent sharp pain felt deeply in the
Rt A shoulder ↓ability to use her Rt
upper extremity (UE) for activities of
daily living (ADL). The 24-hour
symptom behavior was described
as gradually worsening over course
of the day, with frequent sleep
disturbances (2 to 3 hours/night) related
to position changes.
Examination: Impairments of the C/S and
upper limb (UL) neural tissue. Standard
shoulder orthopedic evaluation was neg.
UL tension testing reproduced pain at
45° of shoulder abd and ↑with C/S
contralateral sidebending.
Cervical spine mobilization directed
toward the impaired motion segment at
right C5-6 level.
A posterior to anterior pressure was
applied to the spinal segment for 3 bouts
of 30 seconds.
Tx: 1 session per wk over 5 weeks
Outcomes Measures:
The shoulder Pain and Disability Index
(SPADI) which was administered at
baseline and at the beginning of each
subsequent visit.
ROM of the shoulder was also
measured with a goniometer.
The patient's SPADI score improved
from 83% to 1.5% over the course
of treatment.
Active ROM of shoulder flexion
improved from 50° to 155° over this
period.
A 6-month follow-up revealed a full
return to usual activity and a SPADI
score of 0%.
Gemmell H et al
2011
119
SCDP and MPDS
Non specific shoulder pain
Report of 3 cases
Case 1 Male 43 years
Hx of Lt Ant shoulder pain
Dx of glenohumeral hypomobility with a
myofascial trigger point in the left
subscapularis and biceps brachii, and
weakness of left biceps due to pain.
Case 2 Male 44 years
1-week hx of lt shoulder pain related to
yacht sanding. Dx of GH hypomobility
Mobilization treatment
using the Spencer technique,
followed by subscapularis kinetic release
and scapulothoracic stabilisation with
active arm movements as described by
Mulligan.
Trigger point release to the involved
muscles was also added to the therapeutic
management.
Rx frequency: 4-12 visits over a 6 week
period, average 2 per week.
Case 1 × 4
Outcomes Measures:
Subjective pain, ROM and orthopedic
tests.
Case 1: The patient felt he was 60%
improved after the first visit, 70% after
the third visit and nearly 100%
improved with full function of the
shoulder after the fourth visit.
Case 2: The patient felt he was 80%
Better at 2 weeks. At the sixth visit, the
patient was still 80% better, but had not
improved further.
(continued on next page)
171Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
For evaluation of case series, reports and SGPPDs
(category 2 and 3 studies), assessment and group consensus
were used placing more weight on the value of appraising
simple model validity generally in relation to a previous
unblinded Case Series Checklist used in earlier systematic
reviews for example: does the study give a clear rationale or
suggest the importance of the study; how does the patient(s) fit
into the representative population of the disorder, disease or
dysfunction; was diagnostic or inclusion and exclusion criteria
discussed; is/are the case(s) adequately described, and
pertinent patient data included, and in case series was the
duration and severity described, and/or was there any follow-
up, side-effects and/or adverse reactions described; were valid
and reliable outcome measures used; and were strengths
weaknesses and possible implications of this study described,
and did the authors describe the directions for future
investigations or management?
3,4,40,65
All authors were to
read these studies and were given time and asked to give input
pro or con into including, excluding or discussing case series
and reports in narrative report. Many treatments delivered in
private practice and complementary and alternative medicine
therapies combine a wide range of modalities to provide
individualized treatment. The complexity of these interven-
tions and their potential synergistic effects require a second
look and evaluation if their future innovative use and
usefulness is to be uncovered.
17,19,40,48,64,65,67,144
After blindly ranking each study by PEDro all authors
independently reviewed inclusion of RCTs, CTs, Case Series,
Reports and SGPPDs and their listing within the Considered
Judgment on Quality of Evidence document.
17,40,57
An
overall rating was applied to the reviewed materials first by
the primary author and then, the final rating was reviewed,
discussed, agreed upon and/or changed through group
consensus.
7,17,40,57
The aggregate evidence for each condi-
tion was then given a score as either a level A, B, C,or “I.”Ior
“Insufficient”was used in place of the earlier designation of
“D”as outlined in the Handbook for the Preparation of
Explicit Evidence-Based Clinical Practice Guidelines (Fig 1:
Levels of Evidence).
1,2,11,18,27,40,144
RESULTS
Out of 764 citations, 129 studies were deemed useful,
relevant and/or helpful to develop expert consensus. From
81 total RCTs, 35 RCTs were ultimately included—and, as
an extension of the previous 2011 shoulder systematic
review, these studies covered elbow, wrist, hand, finger,
and TMD/TMJ joint disorders, dysfunction and/or disease
not covered before. Four CTs were included. Thirty-two
case series, reports and/or single-group pre-test post-test
prospective case series were included; non RCT studies are
in narrative form and are not ranked
1-3
(Tables 2-10).
Levels of Evidence
Lateral Epicondylopathy “Tennis Elbow,”Lateral Epicondylitis, Etc.
There is a fair or (B) level of evidence for MMT for short-term
treatment (≤3-6 months) for LE to the elbow joint and/or full
kinetic chain generally combined with exercise, soft tissue
and/or myofascial treatment, advice, education, and home
exercise also known as multimodal therapy. Evidence level
was based on MMT randomized controlled or clinical studies
of the elbow and/or FKC combined with exercise and/or
multimodal therapy including multiple high- and medium-
quality RCTs (Tables 2-10).
24-27,83-95, 110,145,146
There is also a large body of additional lower level
evidence regarding a variety of case series (CS) and reports
(CR) of MMT for short-term treatment of Lateral
Epicondylopathy, some previously noted in reviews such
as McHardy
1
et al and other newly incorporated studies in
this review. Representative examples in this update of such
work are in Tables 2 and 7.
123,127,147-149
Carpal Tunnel Syndrome (CTS) and MMT.There is a fair or (B)
level of evidence for MMT, particularly soft tissue/
myofascial MMT and/or carpal bone mobilization for
short-term treatment (≤3-6 months) of Carpal Tunnel
Syndrome or CTS (combined most applicably with splints)
and ultrasound followed by advice, education on prognosis
and modification of activities of daily living, etc) also
known as multimodal therapy for Carpal Tunnel Syndrome
Table 3. (continued)
Author Diagnosis Treatment/Management Reported Outcome
with scapular dyskinesis and active
supraspinatus and infraspinatus TrPs
Case 3 Male 55 years Greater than 12
months hx of rt shoulder pain located
over ant aspect of shoulder and biceps
muscle. Unable to relate onset to any
injury or unusual activity.
Dx: glenohumeral hypomobility with
inhibition of the lower
scapular stabilisers, stiff thoracic spine,
scapular dyskinesis and tight gleno-
humeral internal rotators.
Dx by orthopedic evaluation and
palpatory findings.
Case 2 × 10
Case 3 × 12
Case 3: The patient reported a 50%
improvement after the 6th visit, and at
the 12th visit the patient felt he was
nearly 100% improved and full
function of the shoulder girdle had
been restored.
172 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
(Table 2). Evidence level was based on MMT randomized
controlled or clinical studies of the wrist and/or FKC
combined with exercise and/or multimodal therapy includ-
ing 2 high and multiple medium RCTs and, a LQ RCT per
PEDro ratings (2 HQ RCTs, 5 MQ RCTs and 1 LQ
RCT).
37,71,96,98-103
There is also a large body of additional
lower level evidence regarding a variety of case series (CS)
and reports (CR), some previously noted in reviews such as
McHardy
1
et al 2008, with additional lower level evidence
added to this review
129,131,150-153
(Tables 2 and 8).
Wrist, Hand, and Finger.There is Insufficient or an (I) level
of evidence for MMT + multimodal treatment of the
listed Wrist, Hand and Finger disorders (Carpal tunnel
syndrome excepted—see separate CTS data and informa-
tion above) such as Post-op Colles Fracture MMT,
Systemic Sclerosis (for the hand and finger), and
Thumb Osteoarthritis (Thumb carpometacarpal OA/
TCOA) and De Quervains' tenosynovitis.
There are very few RCTs covering Wrist, Hand and Finger
conditions. The work of Villafane et al (2010 and 2010)
regarding Thumb osteoarthritis and of Bongi et al 2009 for
Systemic Sclerosis (affecting the hands) is valuable and
commendable and appears to have been methodologically
well conducted with a range of RCTs from moderate to high
quality, with supportive case series and reports published
through the efforts of Villafane et al 2011.
28,105,106,138
Furthermore, this work is supported by case series and reports
in the earlier work of McHardy et al.
1
Nevertheless, as of this
time there is simply—a numerically insufficient and/or a
broad enough number and/or a large enough cross section of
studies to allow a statement of evidence beyond
Insufficient
1,28,105,106,138
(Tables 2 and 8-10).
However, there is a growing number of apparently
positive and supportive studies emerging in these areas and
these subjects are beginning to be assessed using MMT
management for conditions such as metacarpophalangeal
joint pain, disorders and dysfunction, post Colle's (see
below) fracture or De Quervains' tenosynovitis, disease
and/or disorder, and other upper extremity soft tissue
dysfunction and disorders.
1,128,132,135,154,155
TMD/TMJ or Craniomandibular Disorders (of the Upper Quadrant).
There is a limited or a (B) level of evidence that MMT may
be helpful in the short-term (≤3-6 months) treatment of
TMJ/TMD disorders (and/or generally combined with
Table 4. A summary of research on miscellaneous case series regarding frozen shoulder
Author Diagnosis Treatment/Management Reported outcome
Wies J
2005
120
Frozen Shoulder (FS)
Adhesive Capsulitis
N=8~2♂/6 ♀
Patients referred from a
Rheumatologist at a shoulder clinic
Showed painful, restricted active range
of motion and passive range of motion;
capsular pattern of restriction;
no glenohumeral (GH) arthritis
as confirmed by radiography
and symptom duration for at
least 3 months.
Soft tissue mobilization treatment
techniques, used in combination with a
home exercise program.
The specific techniques
used included effleurage, cross-fiber
friction, sustained
pressure, and prolonged soft tissue
approximation.
These techniques were applied to the
areas of soft tissue restriction, or areas
adjacent to the restrictions.
The home exercise program consisted of
stretching the posterior aspect of the
shoulder and strengthening the shoulder,
initially with isometric exercises and
progressing to resisted exercises through
range of motion, using commercially
available elastic bands.
Tx: 10 (shoulder dysfunction (SD) 1/4 2)
visits over a mean of
14 (SD 1/4 3) weeks.
Outcome Measure:
Active range of motion (ROM) for
shoulder flexion, abduction and
external rotation assessed using a
handheld goniometer.
The mean initial outcomes:
Glenohumeral flexion was
94°SD (13), and the final value
was 131° (5),
Pb.001.
Abduction 73° (26) at baseline, and
final value 120° (11), P= .0004.
External rotation 13° (14)
at baseline,
and final value of 34° (14), P= .006.
Mean improvement were:
1. Shoulder flexion 37° (SD = 12:4;
P= .0001
2. Shoulder abduction 47° (SD = 30;
P= .0004
3. Shoulder external rotation 21°
(SD = 9; P= .006
Murphy FX 2012
116
FS Adhesive Capsulitis
N = 50 patients
N = 50 ~ 20 ♂/30 ♀
Age Range: 40-70 years
Manual or manipulative therapy (MMT)
to Cervical and Thoracic spine with a
specialized upper cervical adjustment
called the “One to Zero (OTZ) tension
adjustment”*see study for details
No Shoulder or Glenohumeral of
shoulder girdle MMT
Median number of days: 28 days
with a range of 11 to 51 days and
interquartile range (IQR) of 12.5
Median number of treatments: 8
With IQR 2.0
Numeric Pain Rating Scale: Median
↓−7
16 with 100%, 25 with 75% to 90%,
8 with 50% to 75% and 1 with 0% to
50% improvement
Active Shoulder
Abduction Improvement:
16 with 100%, 25 with 75% to 90%,
8 with 50% to 75% and 1 with 0% to
50% improvement.
173Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
multimodal therapy with exercise or rehabilitation in clinic,
interdisciplinary clinics and/or at home) in decreasing pain,
increasing oral opening, improving muscle length and
strength, in a select number of acute disk and/or acute
myofascial pain TMJ/TMD patients.
108,111
TMJ/TMD problems also known variously as “temporo-
mandibular joint disorder,”“temporomandibular dysfunction,”
“craniomandibular disorders,”and “mandibular dysfunc-
tion,”etc, (hereafter all labeled TMD) may affect 10% to
40% of the general population within their lifetime.
111,156
TMD/TMJ is a condition associated with many comorbid-
ities: such as tension headache, whiplash, fibromyalgia,
tinnitus, vertigo, hearing loss, abnormal swallowing, hyoid
bone tenderness, and otalgia.
111,156
MMT for temporomandibular disorders or TMD is now
supported by an evidence level based on randomized
controlled or clinical studies per PEDro ratings with
minimally 2 high-quality, 2 medium-quality, and 1 low-
Table 5. A summary of related and miscellaneous shoulder case reports
Author Diagnosis Treatment/Management Reported outcome
Charles E
2011
121
Parsonage-Turner Syndrome
A neurogenic shoulder pain (NSP)
and soft tissue (ST) disorders
(or apparent)
Myofascial pain and dysfunction
syndrome (MPDS)
Additional diagnoses:
Acute Brachial Neuritis and
Myofascial Pain Syndrome
(trigger points/myofasciopathy) in the
right scalenes; pectoralis minor; and the
biceps muscles
Male 30 y/o presented with rt arm
contracture, atrophy, weakness with
general paralysis of the forearm and
index finger after nerve entrapment
release surgery.
Presented with rt forearm, wrist, and
hand in full flex and unable to ext rt
forearm…burning, stabbing, numbness,
and pins and needles sensations along the
C6, C7 dermatomes. Orthopedic tests
Adson and Wright were positive for
sensory findings on the right. There was
loss of grip strength that could not be
measured on a handgrip dynamometer.
chiropractic manipulative therapy (CMT)
to the 5th cervical segment.
Deep tissue therapy and spray and stretch
directed to release fascial adhesions.
Rehabilitative therapy including rubber
ball and band exercises for finger flexors
and extensors.
Tx: 12 sessions
Outcome measures:
Active range of motion, and grip
strength measured with a dynamometer
Restoration of full range of motion
after 8 sessions.
Restoration of grip strength of
12 sessions.
Three year follow-up patient reported
full daily activities with arm fully
functional and pain free.
Daub C
2007
122
NSP (or minor peripheral neurogenic
shoulder (arm) pain or minor peripheral
nerve injuries and/or disorders (MPNIDs))
and ST disorder (or apparent) MPDS
Shoulder pain presentation caused by
foraminal encroachment and C6
radiculopathy, followed by an
infraspinatus myofascial pain syndrome
(MPS) with referred shoulder
pain 18 months later
Female 44 years
Two separate presentations
She described the pain as starting in her
neck and shoulder on the right and
radiating down her right arm to her
fingers. She also complained of tingling
and numbness of her right lateral forearm
and hand as well as loss of grip strength.
Orthopedic tests: Positive Spurlings on
right…arm abduction provided relief
of symptoms.
Spinal palpation revealed grade II
tenderness at C4-6.
Films confirmed advanced disccogenic
spondylosis at C5/6 with associated
CMT of the restricted
segments, post-isometric relaxation to
the hypertonic
musculature and manual long axis
traction of the cervical spine (c/s)
above the level of the
suspected nerve root involvement.
As the radiculitis lessened and the
severity of the patient's symptoms
decreased she was also instructed on
neuromobilization techniques to decrease
possible nerve root adhesions.
For the second complaint treatment
focused on manual trigger point therapy,
including both ischemic compression and
post-isometric relaxation, as
well as functional postural correction.
Due to the chronic
nature of the condition active
rehabilitation included cervical
retraction and mid/lower trapezius
strengthening exercises. Cervical and
thoracic spinal manipulation was also
used to address segmental joint dysfunction
Tx: 18 sessions over 7 weeks
Outcome measures:
Subjective reduction of presenting
symptoms, and negative orthopedic
tests after the treatment period.
The patient was significantly better for
all subjective outcome variables after
the treatment period.
18 months later she reported similar but
less severe symptoms. All orthopedic
tests were negative except digital
palpation of the right infraspinatus
muscle exacerbated the chief complaint
and of shoulder pain and paresthesia of
the lateral forearm and hand
174 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 6. A summary of case reports and case series for the elbow
Author Diagnosis Treatment/Management Reported outcome
Ekstrom RA 2002
123
Radial Tunnel Syndrome (RTS) ~ Chronic lateral
elbow pain with nerve entrapment and/or radial
tunnel syndrome
43 ♀secretary 4 months lateral elbow pain
mostly attributed to long computer work and
gripping motions
Symptoms: burning pain over radial tunnel and/
or at the lateral epicondyle.
Dx: RTS deep radial n. entrapment near or at
elbow via history.
Both median and radial nerve tension tests
taken into pain then backed off to just before the
pain: at that point range of motion (ROM) was measured
There was ↑pain over radial tunnel and ↓ROM
with the radial test
Max Grip Force (MGF) with dynometer was
14 kg on painful side (28 kg normal)
There was tenderness to palpation of lateral
epicondyle but acute pain at the radial tunnel.
Neural mobilization techniques,
theoretically using movements similar to
the “radial nerve test”and “median”
nerve test (with modification) it
mobilizes and “frees”nerves allowing
greater movement and ↓symptoms (see
study for details of technique). These
were also done daily at home per
instructions.
Ultrasound strengthening and stretching
exercises were also delivered
Tx: 14 sessions over 10 weeks.
Outcome Measures:
Visual Analogue Scale (VAS): 1 to 6 depending on activities
ROM with neural tension tests
MGF
ROM with the median nerve:
Initial 8 txs
Left Right Left Right
Shoulder depression (cm) 3.5 2.5 4.0 4.0
Shoulder abduction (°) 60 40 90 90
Lateral (extern) rotation (°) 49 12 90 90
Wrist extension (°) 75 40 75 75
Elbow extension (°) -32 -64 -10 -20
ROM with the radial nerve:
Initial 8 txs
Left Right Left Right
Shoulder depression (cm) 3.5 2.5 4.0 4.0
Forearm pronation (°) 85 85 85 85
Elbow extension (°) 0 -20 0 0
Wrist flexion (°) 65 0 65 65
Shoulder abduction (°) 85 47 65 65
VAS: “0”= no pain, “10”the “most severe pain imaginable”
Initial (Baseline) 1.0 6.0
Week 8 0.0 2.0
4 months follow-up 0.0 0.0
Conclusion:
Ability to exercise with increased free weights improved, muscle
grip strength (MGS) improved to 39 kilograms and a more
ergonomic work station appears to help decrease pain in her elbow.
At discharge: minimal symptoms, pain-free At 4-month follow-up:
no elbow pain of any type and resumed all normal activities of daily
life (ADL)
Hudes K 2011
124
Medial Epicondylosis
Male 35 years
Right forearm and medial elbow pain
4–6 weeks duration—worsened after playing
Squash. An avid player, playing approximately
5–6 times per week for over 1 year. Worked in
Fascial stripping, cross friction massage,
and ischemic compression of the medial
epicondyle and pronator teres muscle.
General mobilization of the carpals,
specifically the scaphoid, and the elbow.
Ice elbow and forearm 4 times after tx for
The patient verbally reported a 50% improvement after the 4th visit.
Two week follow-up:
Continued to participate in his exercise program almost daily and he
attempted to play one game of squash which increased his
symptoms
slightly.
(continued on next page)
175Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 6. (continued)
Author Diagnosis Treatment/Management Reported outcome
oil industry in desert where he could not receive
medical care. He reports pain and weakness to
his grip but continued to play. Rested for
2 weeks but no improvement.
On examination VAS (verbal) 3/10. Palpation
revealed tenderness and a tender point in the
pronator teres muscle. Palpation at the medial
epicondyle revealed pain and reproduced
symptoms. Neurological testing was normal.
Resisted pronator teres test +, Mills test + (see
study for variation), pain on passive elbow
extension, combined with wrist supination and
extension, and the resisted medial epicondylitis
test (actively resists elbow flexion and pronation).
pain control.
Eccentric exercises daily using a 1 pound
weight 3 sets of 15 repetitions 3 times per
day with the forearm flexed and
supinated.
Tx: 4 sessions in 1 week
8 and 18 week follow-ups:
Reported he no longer had pain on a daily basis.
Robb A et al
2009
125
Posterior Interosseous Neuropathy
(elbow pain and dysfunction)
Elite baseball pitcher Insidious
onset of pain, fatigue, and altered
sensation of the rt posterior forearm
of 1-week duration. Pain 6/10 VAS
described as a deep ache in the radial,
posterior compartment of the forearm.
Pain subsided upon cessation of
throwing. An altered sensation
reported over the dorsum of the thumb
and index finger, and the wrist and
finger extension felt “weaker and
more fatigable”since the onset of
the pain.Dx: Palpation of supinators
markedly tender. Tinels sign was
elicited by palpating over radial
nerve branches. Upper Limb Tension
Test (ULTT) for the radial nerve trunk
was positive. Cozens and Modified
Cozens reproduced pain.
MT:
Active Release Techniques,
augmented by soft
tissue mobilization technique
(Graston Techniques).
Neural gliding was also used
for the radial nerve.
chiropractic manipulative therapy (CMT)
administered to the radiocapitellar and
ulnotrochlear joints.
Rehabilitation exercises followed by a
sport specific rehabilitation program of
the core and throwing shoulder were
initiated after the initial 6 treatments.
Instructions to avoid pitching
during the treatment period were also
implemented.Tx: 6 sessions over 2 weeks
followed by 4 sessions after a 10 day
break from the last session.
Outcome Measures:
VAS pain, and return to pre-treatment activities
At the end of the last treatment (38 days after first visit), the patient
experienced a pain free throwing motion.
The patient no longer reported any stiffness in the elbow, wrist
extensor strength was powerful and absent of fatigability during
dumbbell testing, and his pitches were regularly measured at speeds
over 90 mph which was a velocity previously achieved before
injury.
Radpasand, M
126
2009
Lateral Epicondylitis (LE)
(“Tennis Elbow”)
Female 57 years
Elbow pain (from arm all the way down to the
elbow)
duration 5 months
1st Rx nonsteroidal anti-inflammatory
drugs (NSAIDs) with heat—helped some then
aggravated with activities; then 3 steroid
injections over 2 weeks and more NSAIDs, a
CMT, high-voltage pulse galvanic
stimulation (HVPGS), bracing, ice,
and exercises, along with restricted
use of the affected elbow
Begin with 3×/week for 2 wk. high-
voltage–low-amplitude (HVLA) to
elbow with thumb over radial head start
with the elbow slightly flexed, take to full
ext and thrust at end range while
extending elbow and pronating forearm.
Outcome Measures:
Patient-Rated Tennis Elbow Evaluation (PRTEE): Baseline, each
visit and 10 and 13 weeks.
Looking at the mean overall, mean pain, mean specific activity, and
mean usual activity, there was exacerbation of pain between
weeks 4 and 7
to 8; probably due to addition of exercises and less use of the brace
or also due to HV galvanic. Resolved.
For the PRTEE:
Overall, there is a systematic reduction of pain
176 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
sling and ice; appeared to help but then 2 weeks
after tx ended carrying groceries caused severe
pain.
Presented to chiro clinic: pain over lateral
epicondyle and pain to resisted extension of
middle finger
High voltage (HV) galvanic for 10 min
over lateral epicondyle. Elbow brace
(see study) with instructions. Ice after 3rd
week 2 ×/wk for 2 weeks. Wk 4:
exercises for forearm supinator and
pronator muscles (MMs) with
imbalanced adjustable dumbbell free-wt.
For the forearm extensor and flexor
muscle exercise used a free-standing
dumbbell
Forearm ext MM exercise with
isometric contraction at end ROM:
free-standing dumbbell (approximate
weight, 500 g), duration per rep 10 sec
with 10 repetitions each. This is repeated
with ulnar and radial deviation and with
flex and at end ROM hold flex and
squeeze as tight as possible and with flex
combined with radial deviation
For supinator and pronator MMs used
imbalanced adjustable dumbbell weight
(a hammer) with a max wt of 700 g.
Repeat as above. All exercises can be dec
to 5 reps and then inc if necessary. Week
5: 1 ×/wk to week 8: remove brace at
home. Began therapeutic putty exercises:
arm and forearm at 90° angle wrist
extended, while holding the putty: putty
pushed toward the thenar surface of the
palm of the hand flexing the 4 digits of 2
to 5 as hard as possible, holding it 10
seconds, releasing, then waiting a few
seconds. This is repeated 5 times. Goal
10× holding 10 seconds each. Began to
use hand for normal activities after
8 weeks. Follow-up @ 2 and 10 weeks,
one add tx with final follow-up @ 12
weeks.
(92.86%), and improvement in specific activity (100%), and
usual activity (96.87%).
It appears that a 30% change in the overall PRTEE occurred so,
appears to have had clinically meaningful improvement
Gonzalez-Iglesias J et al
2011
127
LE
Prospective Case Series of rock climbers
N=9~6♂/3 ♀
Mean symptoms duration:
3 weeks, shoulder dysfunction (SD) 1.7
Mean weekly hours of rock
climbing: 10.4, SD 3.1.
Rx frequency: participants
HVLA CMT directed at the C5/C6
vertebral level. Mobilisation with
movement as described by Mulligan to
glide the proximal forearm laterally.
Ten rep performed with approx 15-sec
rest interval between rep
Manipulation of wrist, by grasping
the scaphoid bone between thumb and
Outcome Measures: Baseline, Final Visit,
2 month follow-up
Primary: PRTEE
Secondary: Pain pressure threshold levels (PPT) and Pressure
Algometer: over extensor carpi radialis longus, extensor carpi
radialis brevis, brachioradialis, and supinator
There was an improvement in all outcome measures at both the final
visit and 2-month follow-up period.
(continued on next page)
177Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 6. (continued)
Author Diagnosis Treatment/Management Reported outcome
received 3 treatment sessions
over a3 consecutive weeks.
index finger, in a palmar direction and
repeated 15 times at each treatment
session.
Trigger point dry needling of active
trigger points (TrPs) in extensor carpi
radialis brevis (ECRB) muscle which
reproduced symptoms.
Kinesio taping applied with 50% tension
over the ECRB muscle.
Patients in this case series experienced dramatic improvements in
the PRTEE at the
final visit (29.6; 95% confidence interval [CI], 21.1-39.1) and the 2-
month follow-up period (36.0; 95% CI, 26.7-45.3).
PPT for the ECRB at baseline 2.2(.3) increased to
2.7 (0.5) after the final visit and 2.8 (0.4) at the 2 month follow-up.
The respective difference between baseline and final visit was 0.5;
95% CI (0.01-0.9) and baseline and 2 month follow-up was 0.51;
95% CI (0.01-0.9)
Oskay D et al
2010
128
Cubital Tunnel Syndrome
Case Series N = 7
Mean duration of symptoms 5 weeks
Age range 35-70 years
Dx based on physical exam: Mild numbness
primarily at the ulnar part of fingers 4 and 5. It
was observed that numbness ↑with the
elbow flex test (holding elbow at
full flex for 1 min.
Symptoms were aggravated by overhead
throwing activities, carrying a heavy bag,
using a computer for more than 1 hour, and
writing for a long time.
Intervention 4 stage process:
(1) reduction of overload, pain, and
inflammation (2) promotion of total
arm strength and normal joint
arthrokinematics (3) interval return to full
activity (4) maintenance First stage: pts
treated with pulsed US at an intensity of 1
W/cm
2
5 min for 10 sessions 3 ×/wk
Stage 2: neurodynamic mobilisation in
the form of sliding techniques to slide the
ulnar nerve without creating tension.
Applied 5 times per visit. This
technique also given as active sliding
exercises at home 10× per day. This
treatment program was applied 3× a
week over 8 weeks. At 2 wk gentle
strengthening exercise were applied as
sxs allowed. In wrist flex, ext, forearm
pron and sup. Frequency of 3 × 15 per
day wk 2 and 4 and 3 × 30 wk 4 and 8.
Followed by home exercise program
including progressive resistance
strengthening exercises with an elastic
therapeutic band for all upper extremity
musculature and nerve mobilization
exercises.
Outcome Measures:
Before treatment, Final visit, 12 month follow-up
Grip dynamometer; Palmar gripping with a Pinchmeter; Pain VAS,
Tinel sign, sensibility with Semmes-Weinstein monofilaments, and
functional status of the patients with the Turkish version of the
Disability of Arm, Shoulder, and Hand Index
Between the first, second and third assessments decreased pain,
Disabilities of the Arm, Shoulder & Hand Questionnaire (DASH)
and Tinel sign scores were obtained, as well as increased grip and
pinch scores.
All variables showed statistical significance with
Pb.05.
178 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 7. Summary of case reports and case series for CTS
Author Diagnosis Treatment/Management Reported outcome
De Leon RP et al
2002
129
Carpal Tunnel Syndrome (CTS)
Male 58 years
Hx of right-handed
burning pain ranging from the right
elbow down toward the right hand and
fingers, especially the right
middle finger.
High-voltage, low-amplitude chiropractic
manipulative therapy (HVLA CMT)
directed toward the thoracic
and cervical spines, manipulation of the
wrist and elbow, flexion/distraction,
ultrasound, cryotherapy, muscle
stimulation, deep tissue massage, wrist
supports and vitamin/mineral
supplements to aid the regenerative
process. Tx: 2 visits per week for 4 weeks
Outcome Measures:
Purely subjective in nature, in terms of
the presence of pain in the wrist and
fingers, presence of pain at night and
presence of pain when lifting heavy
objects. Complete resolution of patient
presenting symptoms after completion
of treatment as reported by the patient.
Craft GJ et al
2011
130
Work related upper limb disorder with
CTS complicated by ganglion cysts
Female 47 years 2-year
chronic Hx of progressively worsening
bilateral wrist pain, loss of range of
motion (ROM), weakness and paresthesia
described as numbness and tingling.
Goniometric assessment found the wrist
range of motion to be diminished in
all planes bilaterally, most notably
upon extension and flexion. Phalen,
Reverse Phalen, and Tinel tests
reproduced paresthesia into the
anterior first 3 digits on the left hand
Pinch test was a grade 3/5 revealing
weak flexor pollicis longus (FLP) and
flexor digitorum profundus (FDP)
Diagnostic confirmation with
electrodiagnostic studies and
magnetic resonance imaging (MRI).
Diversified HVLA CMT to the lunate,
scaphoid, and elbow joint
Pulsed ultrasound (50%, 3 MHz,
5 minutes) and electrical muscle
stimulation (1-150 Hz for 15 minutes)
were applied over the forearm flexors,
extensors, and carpal tunnel to facilitate
healing and was combined with ice or
heat.
Myofascial release over forearm flexors
and extensors.
Home stretching and strengthening
exercises.
Treatment frequency 3×s per week
tapering to once a week over 3 months
At the conclusion of care:
Initial verbal reporting scale pain rating
of 6-7/10 reduced to 1-2/10
At rest and at times increased to 3-4/10
with provocative activities.
Subjective complaints of hand
paresthesia and muscle weakness also
improved with respect to intensity and
frequency. All measured ranges of motion
improved for both wrists at the end of
treatment. Orthopedic tests were negative
at the end of treatment. Grip strength
improved from 3/5 to +4/5 bilaterally.
George et al 2006
131
Case Series
CTS
N=5~4♂,1♀Duration of
symptoms:1 to 6 weeks. Mean age:
48.2 shoulder dysfunction (SD) ± 16.7
Cervical spine association excluded
along with diabetes mellitus (DM),
pregnancy, prior
surgery or wrist splint tx, or median
n. trauma or thenar atrophy.
Soft Tissue Technique or Active Release
Technique (ART).
Baseline, 3×/week for 2 weeks
ART treatments were delivered for the
median nerve at the thenar muscles,
carpal tunnel, flexor digitorum
superficialis, pronator teres, and ligament
of struthers. Each site was treated with
ART 3 times. ART treatment takes tissue
to a shortened position manually, and
then while maintaining the contact, the
subject actively attempts to lengthen the
tissue.
Outcome Measures:
Boston Questionnaire (BQ): a self-
administered questionnaire (valid and
reliable) specifically for CTS for symptom
severity (SS) and functional status (FS)
SS scale: 11 questions with 1 = mild
5=severe
(55 worst)
FS scale: 8 activities with 1 = mild
5=severe
(40 worst)
EMG: pads placed at the flexor carpi radialis
(FCR) and extensor digitorum (ED) …
No significant change (ttest or analysis of
variance (ANOVA) tests [all PN.05])
OnetailedpairedttestsoftheBQ,SS
and FS showed significant decreases
(Pb.05) Mean pre (SD) Mean post (SD)
p2.87 (1.03) 1.73 (0.16) 0.03* 2.63
(0.89) 1.48 (0.32) 0.02* In this study ART
cause no EMG change but significantly
improved symptom severity and functional
status in 5 CTS post tx. This suggests that
ART may be an effective conservative
management strategy for CTS patients.
randomized controlled or clinical trials
(RCTs) are needed.
179Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 8. Summary of case reports and case series for wrist and hand disorders
Author Diagnosis Treatment/management Reported outcome
Anderson M et al
1994
132
De Quervains Disease (Tenosynovitis)
Female 41 years book-keeper with
long hours on the computer involving
repetitive pronation and supination tasks.
Chronic Hx of intermittent, sharp and
shootingpaininleftwrist,bandlikepain
in upper arm near deltoid insertion and
posterior scapula pain described as
tightness.
Left wrist flexion and extension revealed
manual muscle test weakness of 4/5.
Range of motion (ROM) was reduced in
flexion and extension with overpressure
causing pain
Finkelstein test elicited a sharp shooting
pain that radiated along the radius, and to
the carpometacarpal (CMC), thumb.
Palpation revealed tenderness and
thickened tendons at the extensor
retinaculum
Week 1: Mobilization to the lower
cervical and upper thoracic spines.
Week 2: Mobilization to the carpal
bones in addition. Friction techniques
to the abductor pollicis brevis (APL),
extensor pollicis brevis (EPB)
tendons. Stretching of upper trapezius,
biceps, triceps and levator muscles.
Tx: 3× per week for 3 months, 2×
per week for 2 months, and 1× weekly
for 1 month.
Progress was reviewed every 6 weeks
The patient reported subjective
improvement over time in terms of
improved range of motion,
decreased pain and improved strength.
Finkelstein test negative at the end
of the treatment period.
Emary PC
2010
133
Third metacarpophalangeal (MCP)
arthropathy ~ MCP osteoarthritis
Male 62 years
5 year Hx of insidious and progressive
pain and stiffness in left hand described
as a dull ache and intermittent throbbing
pain graded with a severity of visual
analogue scale (VAS) 4/10.
ROM was stiff and decreased with
respect to the right hand.
Examination of the left hand revealed
bony enlargement, severe tenderness to
palpation, and limited flexion of the third
MCP joint.
Dx was confirmed via radiographs
revealing severe osteoarthritis of the third
MCP joint.
30 minutes in hydrotherapy performing
active and passive wrist extension
exercises.
Ring toss, ball throwing and volleyball
played with a beach ball followed.
After hydrotherapy 5 layers of wax
were applied by placing hands in
paraffin bath and then wrapping in a
towel for 20 minutes. After the wax
was removed the carpal bones manually
realigned by distracting the wrist joint
and applying a dorsal mobilization
force through the volar aspect of the
proximal carpal row.
Followed by pas ext exercises. A cast
was applied with optimal alignment of
the wrist and kept for 72 hours.
After removal of the cast PROM wrist
exercises were performed by the pt,
including wrist extensor strengthening.
This was performed for 3-4weeks under
supervision 3×/wk.
A home program was then initiated
including pas wrist ext stretches and act
wrist ext and progressing wrist active
ext strengthening exercises.
A working splint was also used during
activities of daily life (ADL).
Follow-up:
Three and 14 months from baseline
Both patients showed significant
increases in wrist extension range
of motion and grip strength which
were maintained at the 14 month
assessment period.
Gonzales-Iglesias J
et al 2010
134
Radial wrist pain secondary to de
Quervains Disease and Tenosynovitis
and local neuropathy Male 57 years
bartender Initial symptoms 6 months duration
which started insidiously and consisted
of pain and stiffness in the radial side of
the wrist. Pain was burning and electrical
shock like when carrying items at work.
Dx was based on examination findings
with a positive Finkelstein test on the
right, and upper limb tension testing with
a radial bias. Symptoms were
exacerbated by shoulder depression and
contralateral sidebend.
Initial Rx involved wrist and hand
immobilization for 2/52 in neutral, and
then a further 4/52 in a short arm
circumferential cast.
Hand therapy consisted of protective
splinting and active ROM of MCP,
and IP joints 8/52 post injury. Each hand
therapy session began with a 10 min
period of hydrotherapy followed by
active and passive ROM assessments,
ROM exercises, resisted extensor and
flexor gliding exercises with the brace
as the patient progressed.
Outcomes Measures:
VAS and patient specific functional
scale (PSFS) with follow-up at
1, 3, 6 months
Baseline: VAS 5.4 and PSFS his
ability to lift at 2.9 and pour
drinks at 3.1.
10 Weeks: Full range of motion
12 Weeks: strengthening exercises
were initiated
24 Weeks: full strength achieved
VAS decreased to 1.3 at session
2 (day 4) and maintained at
zero levels for session 3, and 1, 3
180 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
Table 8. (continued)
Author Diagnosis Treatment/management Reported outcome
Passive neural slider techniques
specifically targeted at the superficial
radial nerve completed over 15 to 20
minutes, 4 sets of 5 minutes each, with
a 1-min rest between sets. Speed and
amplitude of movement were adjusted
such that no pain was produced.
Home exercise: 3× per day, 10 reps
with speed and amplitude so that pain
was not produced.
Tx: 3 visits over 1 wk
and 6 month follow-ups.
PSFS for the ability to lift ↑to 7.1
at session 2 and further increased
and maintained at 10 for sessions
3, and 1, 3 and 6 month follow-ups.
PSFS for the ability to pour drinks
↑to 7.8 at session 2, and further ↑
and maintained at 10 for sessions 3,
and 1,
3 and 6 month follow-ups.
Walker MJ
2004
135
Radial wrist pain secondary to de
Quervains Disease or Tenosynovitis
Female 55 years 2-year hx of chronic rt
wrist pain aggravated 6 wk before
PT appt. Pain was constant aching, burning,
and a pulling sensation that varied in
intensity, activity dependent. Symptoms
began near the base of her rt thumb,
radiated proximally to radial forearm.
Previous tx consisted of nonsteroidal
anti-inflammatory medications and an
occupational therapy (OT) regimen of
short arm thumb spica splinting, first
CMC joint arthritis splinting, and stretching
exercises.
VAS 7/10 (PSFS), ability to lift at
3/10, wash dishes at 5/10, and push or
pull at 4/10.
Dx based on motion testing causing pain
at end range flex, radial deviation and
ulnar deviation. Radial nerve tension
testing ↑radial pain. Finkelstein test +
with reproduction of the pain.
Low-level laser therapy, MCP joint
mobilization, and finger-stretching
exercises.
Tx: 8 physical therapy sessions over
4 weeks
The pain severity, MCP joint
tenderness, and range of motion
remained unchanged. The patient
experienced subjective, short-term
relief only.
Kissel P
2009
136
Carpal Bossing
Male 18 years
Elite hockey player after hitting the
boards with the dorsal aspect of his right
wrist first contacting the boards while
flexed. The subsequent addition of his
mass and that of the opposing player
further compressed the wrist between the
boards and the players own body.
Primary complaint was poorly localized
to the dorsal aspect of the right wrist over
the second and third carpometacarpal
joints, and the length of the second and
third metacarpals. The player rated the
intensity of pain as 8 out of 10.
AROM was limited by 50% in flexion;
end range extension caused pain with
PROM causing similar pain.
Resisted muscle testing was graded 5/5
and grip strength at 4/5.
Dx was confirmed as an os styloideum
on radiographic imaging.
Soft tissue massage of the forearm and
wrist mobilization.
Active Release Technique (ART)
of extensor carpi radialis brevis (ECRB)
and the extensor
retinaculum.
Initial modification of work related
activities
Tx: 2 visits for 2 weeks.
Outcomes Measures:
VAS pain, AROM and PROM.
One week from the injury the player
rated his pain at 0/10, and was only
symptomatic with full AROM and
PROM in flexion of the wrist
combined with direct pressure over
the bony prominence.
Able to play the final 2 months of
the season without re-aggravation.
6 weeks post injury good function
of the wrist.
Walker MJ
2004
135
Radial wrist pain secondary to de
Quervains Tenosynovitis
Female 55 years
2-year hx of chronic rt wrist pain
aggravated 6 wk before PT appt. Pain
AP and ulnar transverse-glide
mobilizations of the rotator cuff (RC)
joint to
treat pain and hypomobility symptoms.
This was followed by scaphotrapezium
Post initial treatment session:
Decreased VAS from 7/10 to 4/10
Increased PSFS average of 4/10
to 8.2/10.
At treatment completion:
(continued on next page)
181Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
quality RCT.
107-111,156,157
There is large body of mixed
high-, moderate- and lower-level evidence from a variety of
studies such as RCTs, systematic reviews
18,107,156,158,159
Case Series,
160
Case Reports
139-142,161
and single-group
pre-test post-test studies or designs that, along with RCTs
and CTs support this limited rating
141,160
(Tables 2 and 10).
DISCUSSION
Recently a comprehensive summary was published
focusing on the scientific evidence regarding effectiveness
of manual therapy in the management of a broad spectrum
of common musculoskeletal conditions seen by DCs
including disorders of the upper extremities.
18
Included
was an appraisal of randomized controlled and/or clinical
trials (RCTs), regarding manual therapy for the elbow, wrist
and the temporomandibular joints.
18
However, the authors
were very restrictive in their selection of evidence and did
not consider lesser evidence level research nor other types
of studies that did not meet their stringent criteria.
18,71
For
practical purposes, we suggest that ignoring other types of
research does not appear to fully align with Evidence Based
Medicine as conceived by Sackett et al and others.
18,71,162
Full patient and practitioner preferences cannot be taken
into account solely through RCTs; yet many of these
variables are often uncovered in different degrees in a
variety of other types of studies.
18,71,81,162-168
Historically,
flaws are discovered and disclosed over time in most types
of research and research designs; one must be cognizant of
these established limitations and interpret findings cau-
tiously and judiciously, not discount all findings outside the
currently “latest, best designed,”most stringent
RCTs.
18,71,81,162-168
Therefore, in the interest of painting
a broad view of the existing MMT evidence, this review
accepted a wider range of RCTs, CTs, as well as single-
group pre-test post-test designs (SGPPDs), case series and
case reports combined finally, analyzed and given an expert
consensus opinion.
18,71,81,162-168
Expert consensus opinion
—is still needed in the context of a larger review as a vital
component in guiding the delivery of “best patient care”and
to facilitate the development of new lines and areas of
research in medicine and chiropractic.
18,71,81,162-168
Sackett et al originally developed evidenced-based
medicine to improve practice and best patient care; which
were never intended to be derived solely from RCTs, rather
derived from “tracking down the best external evi-
dence.”
162,169
Regrettably, one large, apparently well
designed RCT can be misleading, skew and distort
knowledge, and do much harm when used unscrupulously
out of context.
170,171
In this regard it has been suggested “the
hierarchy of evidence has done nothing more than glorify the
results of imperfect experimental designs on unrepresenta-
tive populations in controlled research environments above
all other sources of evidence that may be equally valid or far
more applicable in given clinical circumstances.”
170
Some have suggested that a substantial amount of the
practice of medicine, is based on sources with lesser levels of
evidence than large, high- or very high-quality and
methodologically faultless, RCTs.
22,71,162,163,169,172
If the
highest level of evidence does not fully support a treatment,
this does not prevent the practice of medicine nor the practice
of other limited licensed professionals for a particular disorder
or condition. However, lower levels of evidence may
reasonably but fairly lead to restricting quantity of treatment
delivered or may limit reimbursement unless altered by new
research. Where then, or from what other research or studies,
can such types of evidence be found: information “to improve
practice and best patient care…for each individual, taking into
account singular, individual clinical characteristics, co-
Table 8. (continued)
Author Diagnosis Treatment/management Reported outcome
was constant aching, burning, and a
pulling sensation that varied in intensity,
activity dependent. Symptoms began
near the base of her rt thumb, radiated
proximally to radial forearm. Previous
tx consisted of nonsteroidal anti-
inflammatory
medications and an OT regimen of short
arm thumb spica splinting, first CMC
joint arthritis splinting, and stretching
exercises.
VAS 7/10 (PSFS), ability to lift at
3/10, wash dishes at 5/10, and push or
pull at 4/10.
Dx based on motion testing causing pain
at end range flex, radial deviation and
ulnar deviation. Radial nerve tension
testing ↑radial pain. Finkelstein test +
with reproduction of the pain
Intercarparal joint anterior to posterior
(ICJ A-P) glides.
Mobilization techniques were
based on Maitland's text on
peripheral joint manipulation.
4th session EPB and APL stretches
were introduced and wrist radial
deviation mobilisations.
The patient was also prescribed at
home exercises including
self-mobilization procedures to
reinforce clinic treatments.
Tx: 8 PT sessions over 4 wk
VAS 0/10
PSFS 9.8/10
Results were maintained
at 10 month follow-up.
182 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
morbidities and personal values and preferences for each
particular individual”?
14,169
A variety of reviews and research looking at current
interventions and how many interventions are actually
“evidenced based”have been forced to admit there is a
significant lack of RCTs, especially high-quality RCTs in
most disorders, and that ultimately consensus based, expert
opinion is still required for the development of best evidence
guidelines.
167,170,173-175
However, just as RCTs, systematic
reviews and meta-analyses may initially be praised as
rigorous and of high-quality but later be significantly
demoted, discounted and condemned as biased, so too can
“expert opinion”be lauded and later shown to be biased and
wrong; caution and humility are mandatory.
48,167,170,172-183
And, it must still be acknowledged that, although it appears
to be improving, there is as of yet no comprehensive
consensus of internationally accepted and fully agreed upon
gradated levels of evidence based care.
48,166,167,184-188
How is it ethical then to practice without RCTs, or to
develop a linear understanding of literature gaps, or to develop
research to fill those gaps and develop better designed trials
and studies to improve best patient care, without listing or
reviewing all levels of evidence?
19,22,66,72,169,172
Most
diagnoses have no RCTs undergirding them to guide
practitioners.
72
Indeed, 2 of the RCTs listed in Brantingham
et al published in 2011 and Brantingham et al published in
2012 were developed directly and indirectly from the
McHardy et al and Brantingham et al reviews, and were
further dependent on information generated through earlier
included case series and reports which now are often and/or
generally excluded.
1-3,189,190
The answer is that at this time
particularly for the chiropractic profession, all levels of
evidence as intended by Sackett et al and others, must be
brought together and considered.
17,29,71,165,166,191
DISCUSSION OF STUDY FINDINGS
Lateral Epicondylopathy (LE) MMT and Pain
In the methodologically “high-quality”MMT LE RCT
by Bisset et al, one of the methodologically best MMT
RCTs studied, after 8 treatments over 3 weeks, the
“physical therapy group”which included MMT (Mulligans
Mobilization with Movement or MWM, plus extensive
exercise, rehabilitation, home exercise and self-mobiliza-
tion) including clinically delivered occasional HVLA
elbow manipulation—had “VAS pain”decrease by a
mean of −10.7 mm.
24
In another methodologically “high-
quality”MMT RCT, the Smidt et al “Physiotherapy”for LE
consisted of 9 treatments of pulsed ultrasound, deep friction
massage or “soft tissue”MMT combined with an exercise
program over 6 weeks. The authors found that at 3 weeks
“VAS pain”decreased by 11 mm or points, and at 6 weeks
pain decreased by 26 mm or points.
83
However, in the
“medium-quality”MMT LE RCT of Langen-Peters et al at
3 weeks (12 treatments over 6 weeks; averaging 6
treatments at 3 weeks) the “VAS pain”decreased by 25
mm at 3 weeks ; at 6 weeks Bisset et al had a “VAS pain”
decrease of 23.7 mm; Langen-Peters at 6 weeks had a VAS
decrease by 29 mm.
24,84,145
The “medium-quality”MMT
LE RCT of Blanchette MMT consisted of “augmented soft
tissue mobilization”(ASTM), using the recommended
ASTM technique or protocol and instruments manufactured
by Graston Technique, Falmouth, MA. This study also used
VAS as an outcome and found that at 6 weeks the ASTM
MMT had decreased “VAS pain”by 30 mm; the control
group changes were not significant.
38
In Bisset et al and Smidt et al although corticosteroid
injection achieved the quickest, highest levels of “VAS pain”
relief in the short-term, by 12 weeks corticosteroid injection
was not superior to MMT in either study. In fact MMT
consisting of physical therapy or exercise with MMT alone,
achieved significantly superior long-term outcomes for a
greater number of subjects in both studies.
24,83
Approxi-
mately one-half (or more) of the steroid subjects improved
but in both studies approximately one-third to one-half of all
subjects that received steroid injections relapsed to a near
complete or a complete relapse not simply a diminished
improvement as seen in the MMT groups.
24,83
Acombina-
tion of MMT and/or soft tissue MMT, such as transverse
friction massage plus multimodal advice (see below), may
ultimately deliver the best short and long-term outcome.
Karlsson and Sundqvist (in a peer-reviewed thesis and
systematic review) using a modified PEDro score assessing
the Shaik and Myburg MMT LE study of: transverse friction
massage (TFM or “soft tissue”MMT) vs Mill's HVLA
manipulation plus TFM determined that, there was a
statistically significant decrease in “NRS pain”in both.
Using a modified PEDro rating Karlsson and Sundqvist
awarded this study a 6 which was equivalent to the MMT
studies of Nagrale et al Verhaar et al, and higher than that
awarded to the RCT of Stasinopolous and Stasinopolous
(awarded a PEDro 5).
62,192,193
They stated TFM combined
with other physiotherapy may help reduce LE pain and
improve grip strength.
32
Taken all together this reasonably
suggests that for short- and “long-term”continued improve-
ment or a decrease in LE pain as seen at 12 weeks, 6 months,
and 12 months in Bisset et al, Schmidt et al and similar
studies may have more to do with extensive multimodal care.
In this case multimodal care includes a continued and
extensive home exercise program, education, self-mobiliza-
tion, advice on how to limit aggravations, exacerbations or
flair-ups and appropriate advice and education given at the
initial and follow-up clinical treatments—than in the short-
term delivery of any particular manipulative or manual
therapy and/or exercise protocol (Table 2).
24,83
LE and Function
Bisset et al and Smidt et al again showed significantly
faster and apparently superior short-term outcomes in other
183
Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 9. Summary of case reports and case series for finger disorders
Howitt S
et al
2006
137
Trigger Thumb
Male 42 years
Moderately painful right
thumb with restricted motion.
Gradual onset over a number
of weeks.
Inability to actively flex and
extend the right thumb,
passive motions consistently
produced pain and clicking.
Palpation of the A1 pulley
and joint play of the distal
interphalangeal joint
reproduced/exacerbated the
reported pain. Palpable
adhesions were noted in the
flexor pollicis longus tendon
of his right thumb.
Dx was confirmed by an
ultrasound revealing a severe
tenosynovitis of the flexor
pollicis longus (FPL) and
prominent thickening of the
A1 pulley measuring 5 mm.
Active Release Technique (ART)
and Graston technique by a
certified provider.
Advised to self mobilize the t
henar eminence (see Yagi M,
2000)
Tx: 8× over 4 week
Outcomes Measures:
Range of motion (ROM)
and subjective
pain as reported by the
patient. Muscle strength
evaluation of FPL.
Post first treatment
increased ROM, with
moderate pain.
Post third treatment
minimal pain and full ROM.
Post sixth visit full pain free
ROM with strength testing
of the FPL rated at 4/5.
Eighth treatment there was
no pain and only slight
irritation at the capsule in
full flexion when forced.
There was mild weakness
(4/5) present as noted in the
previous visit but no
palpable adhesions were
present. Full normal range
of motion restored in the
right thumb
with no pain. The subject
was given “theraputty”
and released with thumb
exercises
Guly HR et al
1982
111
Locked finger
Case 1
Male 59 years
Rising from kneeling position
when he put his hand on his
closed fist. Unable to move rt
middle finger. Presents to the
Accident and Emergency department with the
finger held in a position of
semi flexion at the metacarpophalangeal
(MCP) joint and full extension at the IP
joint.
Case 2
Female 78 years
Caught rt index finger while
lifting a door latch. Presents
to the A and E department
with the finger held in a
position of semi flexion at the
MCP joint and full extension
at the interphalangeal (IP) joint. The last
20 degrees of extension was
not possible at the MCP joint,
and there was no difficulty
in flexing the MCP and
IP joints.
Case 3
Female 68 years
Insidious inability to
straighten lt middle finger.
Presents to the A and E
department, was unable to
actively or passively extend
the MCP joint of the middle
finger through the last 30 degrees.
Digital nerve block where
the joint was manipulated in
the line of deformity with
alternated medial and lateral
rotation.
The finger was
simultaneously extended
(see Yagi M, 2000)
Tx: Single intervention
Outcome Measures:
ROM and Pain levels
Immediate improvement in
range of motion and
significant pain reduction.
Three month follow-up
review recorded full
extension and further
episodes of joint locking.
184 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
subjective and objective functional scales with steroid
injection; however, as before—the same number of subjects
had complete, or near complete, functional relapse from
approximately 12 weeks or more—whether there was
improvement in pain free grip (PFG), increase in grip
strength (GS), or any other functional evaluation.
24,83
Similar subjective and objective functional improvement
findings in favor of MMT were also seen in MQ RCTs such
as Blanchettes et al LE RCT which showed superior, short-
term subjective, objective, and functional improvement at 6
weeks and 3 months using the Patient Reported Tennis
Elbow Evaluation (PRTEE) scale which has been found to
be valid and reliable for LE.
38
Specifically and further
along these lines, Bisset et al improved from baseline to 6
weeks a + 1.6 kg in PFG strength, yet in MQ RCTs similar
short-term improvements were also noted; for example, in
Langen-Peters, from baseline to 6 weeks PFG strength
improved + 3.4 kg and Blanchette PFG improved from
baseline to 6 weeks a + 2.0 kg of strength.
24,38,84,145
Again,
there would appear then to be no reason that similar
adjunctive, multimodal care (exercise, self-mobilization,
education, advice, etc) could not be integrated into any or
all MMT LE protocols—no matter the MMT technique
used. As stated in Bisset et al 2006, “combining elbow
manipulation and exercise was superior to wait and see in
the first 6 weeks and to steroid injections in the long term (at
3, 6, and 12 months) and may be recommended over
corticosteroid injections.”
24
However, Blanchette points
out that it appears that 80% to 90% of those who had LE
will heal spontaneously without treatment in 1 to 2 years.
38
It would appear that the benefit of MMT comes in adding it
to a multimodal package of care to include exercise, advice,
education, etc. This combination appears to give faster pain
and functional relief than placebo or wait and see and/or no
care and, may allow a patient to immediately exercise with
less pain. MMT and multimodal treatment appears to be best
Villafane JH
2011
138
Case Series
Secondary Thumb
Carpometacarpal
Osteoarthritis
N=15~2♂/13 ♀
Mean age = 81.9 ± standard deviation
6.51 years
Referred by primary care practicioner (PCP)
with dx of thumb
metacarpal OA
obtained via medical history
and x-ray
detection of stage III and IV thumb
osteoarthritis (TCOA)
according to the
Eaton-
Littler-Burton Classification.
Median nerve mobilization
sliding technique which
consists of a series of
combined movements of at
least 2 joints in which 1
movement lengthens the
nerve bed, thus increasing
tension in the nerve, while
the other movement
simultaneously decreases
the length of the nerve bed,
which unloads the nerve itself.
In this study the sliding
technique consisted of
the alternation of elbow
extension (loads the median
nerve) and wrist flexion
(unloads the median nerve),
with elbow flexion (unloading)
and wrist extension (loading).
Tx: 4 sessions over 2 weeks
Outcome Measures:
Baseline, 5 min post Tx and
1 and 2 wk post Tx
PPT measured by
mechanical pressure
algometer at the
trapeziometacarpal (TM)
joint, tubercle of the
scaphoid bone, the unciform
apophysis of the hamate
bone
Tip and tripod pinch
strength was also measured
by using a mechanical pinch
gauge.
Grip strength was measured
by a grip dynamometer.
PPT: Baseline 3.54 ± 0.04
kg/cm
2
…Post treatment
↑4.38 ± 0.04 kg/cm
2
(Pb.01) and maintained at
first (4.27 ± 0.04 kg/cm
2
,
Pb.02) and second follow-
up (4.08 ± 0.04 kg/cm
2
.
No differences were noted
in other studied structures
including the scaphoid and
the hamate.
Tip and tripod pinch
strength remained without a
change after the
intervention.
Grip strength: Baseline
10.77 ± 0.18 kg, ↑to
11.55 ± 0.16 kg (Pb.05)
post-tx and maintained at
first and second follow-up,
respectively (11.73 ± 0.18
kg, Pb.02) and (11.2 ±
0.17 kg, Pb.05).
Table 9. (continued)
185Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
Table 10. Summary of case reports/series for TMD/TMJ
Author Diagnosis Treatment/Management Reported outcome
Furto ES 2006
Case Series
Temporomandibular Disorder (TMD)
N=15
Dx: local dentists,
ear-eye-nose-throat
physicians, and/or
general practitioners with
a diagnosis of TMD or
orofacial
pain
Average Treatments: 4.3
Manual Physical
Therapy Interventions,
Iontophoresis and
exercise
Accessory motion and
joint play of the temporomandibular
joint (TMJ), cervical spine (c/s)
and thoracic spine (T/S)
Long axis distraction,
Medial glide and Lateral
glide of the TMJ as
described by Rocabado
Capsular mobility of the
TMJ was assessed by
applying a long axis
distraction through the
mandible for 6 repetitions.
Acupressure techniques
applied to lateral
pterygoid musculature
Outcome Measures:
Patient specific functional
scale (PSFS), TMD Disability
Index (higher scores
better), Global Rating
of Change -7 worst to
+7 best
2 week follow-up
Mean TMD Disability
Index:
Baseline: 32.1% and
18.3% 2 wk with
an improvement of
13.9% (confidence interval [CI]
8.2%, 19.5%) (Pb.05)
Global Rate of Change
(GROC, a patient satisfaction
scale): Eleven patients
(73%) reported they
were somewhat better to a
very great deal better on the
GROC Pb.05
PSFS: ↑3.1 points (CI: 2.3, 3.9)
(Pb.05)
with improvements in:
difficulty chewing,
yawning, talking, and
opening the jaw
Alcantara J
2002
139
TMD
Female 41 years
Presents with bilateral
ear pain, tinnitus,
vertigo, decreased
hearing acuity and
chronic headaches with
TMJ pain while talking
or chewing
Gonstead soft tissue (ST) with
chiropractic manipulative therapy (CMT)
directed at the level of
the atlas
Tx: 9 treatments over a
2.5 month
No reported outcomes
Purely subjective in
terms of reduction in
presenting symptoms.
1 year follow-up:
Resolution of
headaches and no
symptoms associated
with the TMJ
DeVocht et al
140
2005
Temporomandibular
Disorder
Female 30 years
Daily unremitting jaw
pain for 7 years. Pain
radiated from TMJ into
shoulder and
accompanied by
headaches, tinnitus,
decreased hearing, and
congestion in right ear.
Medical and dental
treatment did not reduce
the symptoms.
Mechanically assisted
manual therapy using the
Activator Methods
protocol and adjusting
instrument (Activator
Methods, International,
Phoenix Arizona)
Tx: 18 during the first
2 months, and another
10 for the next 3 months.
Outcome Measures:
Subjective symptoms,
TMJ measured pain on
a numerical scale rated
from 0-100, active
mouth opening
measure in mm.
Visual Analogue Scale (VAS):
Baseline 60 to 2
months 25 to 5
months 9
Nonsteroidal anti-inflammatory
drugs (NSAIDs) was ↓from 2
to 1 tablet per day
headaches frequency ↓with a
sig ↓in intensity
Active mouth opening
↑from 22-28 mm
13 months follow-up:
Active mouth opening at 32 mm
VAS 13
Headaches
significantly ↓with no
tinnitus
20 month follow-up
186 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
practice and the safest practice in the short and long term for
treatment of LE at this time. Steroid injection might be
considered not as the first line of “conservative”care for LE
but as a second line of conservative care if MMT and
extensive multimodal care (emphasizing exercise therapy,
education and self-care) fails.
Carpal Tunnel Syndrome and MMT
Doctors of chiropractic regularly use a variety of MMT
treatments in the management of CTS. This review found
higher and lower level research to support MMT of CTS.
There are methodologically strong myofascial MMT RCTs
and/or carpal bone mobilization RCTs and, to a lesser
degree, a variety of local or FKC MMT with or without
FKC thrust techniques that show short-term relief for
CTS
1,18,37,71,103,129,131,150-153,192,193
In addition, there are
other systematic reviews and studies that support the use of
MMT principally carpal joint mobilization, usually citing
the Tal-Akabi et al 2000 RCT.
18,102,192,195-198
Yet,
although MMT, particularly carpal bone mobilization, is
recognized as one of a number of conservative, effective
Table 10. (continued)
Author Diagnosis Treatment/Management Reported outcome
patient symptom free
Houle S et al
141
2009
Temporomandibular
Disorder
(TMD) with a patient
with spinal muscular
dystrophy
Male 35 years
Masseter muscle pain
and mouth-opening
restriction with pain 5/10
Aggravating factors
included long speeches,
mastication, eating, and
fatigue.
Relieved by celecoxib
100 mg, a nonsteroidal
anti-inflammatory drug,
and rest.
TMJ range of motion (ROM)
revealed restricted
opening
(11 mm interincisival)
Muscle palpation
detected tenderness and
hypertonicity of the
masseter muscle, the
anterior fibers of the
temporalis, lateral
pterygoid, and digastric
and suboccipital muscles
on both sides of the joint.
Joint mobilization and
AROM of the TMJ in
distraction, protrusion,
retrusion and lateral
deviation.
Myofascial therapy
including PNF, active
stretching and TP
therapy for masseter,
temporalis, lateral
pterygoid, digastric and
suboccipital muscles
performed at each visit to
address jaw stiffness and
muscular hyper-tonicity.
Light spinal
mobilizations upper
cervical spine and
cervicothoracic junction.
Tx: 2× weekly for
4 weeks
4 month evaluation:
ROM showed active
opening of 12 mm with
absence of pain and
muscle tenderness of
the jaw.
DeVocht et al
142
2003
Temporomandibular
Disorder
Prospective Case series
N=8~1♂/7 ♀
Median age = 27 years
Activator Adjusting
Instrument II (AAI) and
protocol prescribed by
advanced protocol of
Activator Methods,
International.
Tx: 2-3× per week over
2 wk with ↓frequency,
depending on the
progress of individual
participant.
Participants released
from care when treating
clinician determined
maximum
improvement had been
reached.
Outcome Measures:
VAS for TMJ pain
Maximum Active
Mouth Opening
without pain (MAMO)
VAS:
Baseline: 65 mm with
median VAS decrease
of 45 mm (range,
21-71); all experienced
improvement.
MAMO:
Baseline: 38 mm with
median increase of
9 mm (range, 1-15); all
showed improvement.
187Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
short-term treatments that manual therapists and DCs
frequently use, a number of authors treat carpal bone
mobilization MMT as if it is not a normal part of
chiropractic practice, and on that basis exclude “chiroprac-
tic”as an available or acceptable short-term conservative
treatment of CTS. This conclusion is wrong and appears to
be because some practitioners are unaware that DCs readily
use this form of MMT, especially in regards to extremity
and carpal joint treatment and believe wrongly (or from
ignorance of our training and scope) that all “chiropractic
care”is solely grade V manipulation or a “forceful”HVLA
thrust technique to the spine and other joints. This subject
was adequately covered above, and lack of knowledge,
misconceptions, and unfamiliarity with chiropractic MMT
training, practice, and scope prevents patients from getting
effective chiropractic management of CTS.
1,3,12,195
Liter-
ature search easily and quickly uncovers that “carpal bone
mobilization”is a regularly applied therapy, often delivered
in conjunction with splinting, with and without ultrasound
or other multimodal care, by DCs for CTS.
1,193,194
According to high-quality systematic reviews by Ash-
worth, Goodyear-Smith and Arroll, Muller et al, Ibrahim et
al, Piazzini et al, and Cranford et al, the best conservative
(non-surgical) treatments that have the strongest level of
evidence for effectiveness in the “short-term”treatment of
CTS were steroids for the short term (3-6 months) and a few
other treatments covered below.
24,83,195,196,199-203
Howev-
er, Muller et al and Ibrahim et al nor any of the above
authors address fully the significant levels of relapse (30%-
50%) commonly seen in distal musculoskeletal disorders or
fully discuss the side-effects or adverse events from local
CTS steroid injection or treatments which appear similar to
that seen in elbow injection and are readily locatable in the
literature.
24,83,195,196,199-205
In spite of this, Ashworth et al, Muller et al, Ibrahim et al,
Piazzini et al, and Cranford et al note common use of and
moderate evidence in support of splints, and relatively less
but limited support for ultrasound in short-term treatment
of CTS—again 2 treatments routinely offered by
DCs.
193,194
Practitioners must be aware that as yet, no
reviews cite “high”level RCT evidence for any CTS
treatment.
24,83,195,196,199-203
Ashworth et al state that
steroid injection is “likely to be beneficial”but like other
conservative care interventions has not been shown to be
effective longer than ≤3 to 6 months, and state beyond this
that the long-term CTS outcome for steroids remains
unclear.
199
Ashworth et al note that in one observation
study of CTS patients, 34% spontaneously remised within 1
year, but Goodyear-Smith et al noted in 2004 that, of those
who had received steroid injection (from a variety of
studies), 50% had opted for surgery—a 50% failure
rate.
199,200
Ashworth et al further note that in fact there is
insufficient evidence to assess whether surgery is more
effective than no treatment and, although surgery appears
superior compared to wrist splints, it is as yet unknown
whether surgery is as effective as local corticosteroid
injections.
199
Surgeons suggest that CTS resistive to
conservative care should have surgery by 6 months (after
diagnostic determination) but not longer than 3 years after
diagnosis.
200
Yet with local MMT management of CTS
there are no reported serious adverse reactions beyond
occasional minimal and temporary soreness, stiffness and/
or temporary aggravation; bruising and/or soreness from
soft tissue MMT. Such bruising and soreness caused only
one subject to leave treatment in the Burke et al study
99
and none in the vigorous ST MMT (trigger point therapy)
CTS study of Hains and Hains.
37
There are then almost no
reports of serious adverse reactions (permanent disability
or death) and minimal to nearly no side-effects reported
for ultrasound, splinting, mobilization of the carpal bones,
and/or upper extremity FKC MMT in treatment of
CTS.
37,96,98-103,129,131,150-153
Manual and manipulative
therapy with splinting and other multimodal care, advice,
and exercise would appear a reasonable first choice as best-
practice, evidenced-based care and used before steroid
injection, a secondary line of conservative care and surgery,
if these fail or there is severe neurological and/or functional
degeneration. This treatment should be delivered by DCs
and/or other practitioners trained to deliver such care.
CTS Outcome Changes: Conservative Treatments
It is quite difficult to compare outcomes in CTS research
as there is minimal use of the same objective and subjective
valid and reliable outcome and/or treatment measures.
199
For example Ashworth et al states that the best conservative
treatment of CTS is local corticosteroid injection. In the first
RCT, Ashworth et al strongly imply corticosteroid in-
jections are superior to splinting, ultrasound, and mobili-
zation. In a study reviewed by Ashworth, one group
received injection of steroid (vs no treatment) and was
followed up a total of 6 weeks. In this RCT (N = 84),
Ashworth et al found that both low- and high-dose
hydrocortisone significantly increased the proportion of
people with improved symptoms at 6 weeks, compared with
no treatment (all P≤.05).
199
However, Ashworth et al note
that the findings in this RCT should be viewed with caution
because terms such as “better”or “much better”were not
quantified, nor did they describe changes in mean
individual symptoms.
199
In the second RCT cited as one
of the best studies (N = 32), Ashworth et al note that it does
not compare between the 2 groups but compares only
within-group differences between baseline and follow-up
for both groups, yet at the 2 month follow, the steroid
treatment is clearly denoted superior to the “other”placebo
injection.
199
Ashworth et al go on to note significant
differences between baseline and the 2-month follow-up in
favor of the steroid injection for improvement in paresthe-
sia, pain, and motor deficit (all P≤.05) and improvement
for both treatments at 2 months for a decrease in nocturnal
188 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
paresthesia (P≤.05) but no significant improvement in
hypoesthesia and weakness for either the corticosteroid or
placebo injection groups (PN.05).
199
This RCT measured
CTS signs using a subjective scoring system of 0 to 4
(where 0 = absent signs or symptoms and 4 = marked signs
or symptoms). Ashworth et al notes that these intragroup
findings must be viewed cautiously.
199
However, such
intragroup comparisons are routinely attacked, ignored;
not allowed or impugned if performed by certain
practitioners.
179,206,207
In another RCT that used oral
steroids vs oral placebo (N = 60), a Global Symptom
Score scale (using Confidence Intervals) was reported as
significantly in favor of oral steroids after 8 and 12 weeks
(GSS 8 weeks: -7.2, 95% CI –11.5 to –2.9; 12 weeks: –7.0,
95% CI –11.6 to –2.4).
199
Ashworth et al, though, are
careful to note that there are still not enough studies to know
which steroid dose to use (low or a high dose) and cautions
that the outcomes in this high-quality RCT reflect poorly
delineated subjective ordinal measurements.
199
Interesting-
ly they also looked at an RCT that compared oral
prednisone (N = 40) vs a neutral wrist splint (advised to
be worn at night and, as much as possible, during the day)
using the SSS. Using this symptom severity and functional
status scale CTS was assessed using a 5-point scoring
system (1 = no symptom or no difficulty to, 5 = severe
symptoms preventing activity). Symptom severity incorpo-
rated 11 items (eg,, relating to pain, nocturnal symptoms,
numbness, tingling, and weakness) and functional status
assessed 8 items associated with daily tasks (eg, difficulty in
writing, opening jars, and holding a book). The SSS was
found significantly in favor of steroids at 1 month (P= .01)
but there was no significant difference between the groups
with the SSS at 3 months (comparing steroid vs splint).
199
Notably, they state that these findings too must be viewed
with caution since this study, despite repetitive treatments
and measurements, had no correction for multiple statistical
testing.
199
Only one of 3 RCTs studied by Ashworth et al
looked at ultrasound (vs placebo) in the treatment of CTS
and was included because it assessed subjects up to or
longer than one month (N = 45). This study compared
ultrasound (15 minutes, 5 times weekly for 2 weeks
followed by twice weekly for 5 weeks, given at an intensity
of 1.0 W/cm
2
) vs placebo. It found that ultrasound
treatment significantly increased the proportion of wrists
with “satisfactory improvement”or “complete remission”
of CTS symptoms at 6 months (all P≤.05). However, there
was no apparent “intention to treat”statistical analysis and
the terminology “satisfactory improvement”and “complete
remission”were not clearly defined.
199
These are the “best”
studies according to Ashworth et al and these short-term,
generally small studies are forwarded as significantly better
than all other conservative treatments.
199
Muller et al
performed a systematic review of treatments for CTS and,
came to a similar decision as this review. After looking at 9
RCTs of splinting for CTS, they found that splinting
achieved a level of “B”evidence (using Sacketts' Levels of
Evidence: “A”being highest, “D”the lowest rating).
196
In
the 9 RCTs of splinting assessed by Muller et al for CTS
nearly every study used different outcome measures though
the SSS was used twice.
196
Similarly, Muller et al gave
ultrasound an evidence level of “B,”but again, the studies
generally all had different outcome measures, although both
looked at pre and post EMG findings (ultrasound delivered
at a frequency of 1 MHz, and 1.0 W/cm
2
).
196,208
Muller et
al gave 2 MMT RCTs a level of “B”evidence.
196
All MMT
RCTs in Muller et al used different outcome measures
(generally all outcomes were significant at P≤.05) but a
further evidence level was determined and used in this
review: the Structured Effectiveness Quality Evaluation
Scale or for splinting, ultrasound and MMT.
196
MMT Conservative Treatment of CTS
The data show 33% to 50% of all subjects that receive
steroid injections undergo near complete to complete
relapse, not simply diminished improvement common to
other conservative upper extremity treatments, and up to
50% of injected CTS patients opted for surgery. With this
in mind, is it reasonable to state these minimal to
moderate level studies should be claimed markedly
superior to MMT and other conservative therapies in the
short term, particularly since they have not yet been
adequately compared to MMT combined with multimodal
care?
1,24,83,107,111,156,195,196,199-203
Yet, when the methodology and outcomes of a variety of
earlier and more recent MMT RCTs for CTS, and other
studies using carpal bone, myofascial and full kinetic chain
MMT are scrutinized, they appearto have achieved similar or
greater methodology and outcomes. For example, when you
compare overall percent improvement in functional change
and/or overall decrease in pain, as did the one small
methodologically medium-quality RCT by Tal-Akabi et al
published in 2000 (quoted to justify short-term use of carpal
bone mobilization) and cited in the O'Connor et al Cochrane
systematic review, Muller et al systematic review, and
the Ibrahim et al systematic review, it appears MMT is
as effective or even in some cases has superior
outcomes.
101,195-197,208
Pain relief in these older and/or
more recent RCTs, CTs using myofascial mobilization and/or
MMT, carpal and/or FKC MMT, have had similar significant
decreases in pain using the VAS/NRS, or pain from use of the
functionalPAD (pain and distress) scale from the very earliest
studies; noted as significant for example by an improvement
or change of 15.3% (PAD) in the low-quality Bonebrake et al
CT, to as much as a 51.7% (VAS) and 67%, (NRS) decrease
in pain in the recent medium-quality RCTs by Burke et al and
Hains et al studies, respectively (all Pb.05). In the latest
MMT RCTs it has been shown that there are significant
functional improvements such as a decrease in paresthesia,
numbness, weakness, and nocturnal symptoms using
various CTS symptom severity scales ranging from an
189
Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
improvement in the Symptom Severity Scale (SSS) of 43%
(Burke et al) after the first treatment to up to 63% decrease
in the SSS at the end of care. Haines et al showed
improvement in decreasing severity of symptoms and
improvement in functional status of 42% after 15 treatments
45% at follow-up of 3 months and 36% at 6 months (all Pb
.05 to a P≤.0001). Davis showed a functional
improvement of 26% in the CTO-P (CTS outcome physical
distress score) and an overall 40.2% overall functional
change or improvement in CTO-M (mental distress score,
both P= .01) by the end of care. Most of these MMT
studies of CTS also showed small but significant increases
in grip and pinch strength too (all P≤.05).
37,97,99,101,102
DCs routinely use splints and ultrasound in the treatment
of carpal tunnel syndrome, forearm, wrist and other distal
entrapment injuries.
1,24,100,102,103,131,195,196,199,201-203,209
Carpal MMT or carpal bone mobilization or MMT of the
FKC as in Davis et al and even Biolosky et al may decrease
mechanical pressure and/or entrapment of the median nerve,
disperse intraneural edema, increase vascularization to the
vasa vasorum relieving ischemic effects and decreasing
swelling while relieving symptoms and promoting
healing,
90,100,102,103
and there is much additional lower
level evidence (case series and reports) that MMT including
soft tissue MMT combined with night splints, ultrasound,
and/or multimodal care is effective in the short-term treatment
of CTS
1,24,100,102,131,151,195,196,199,201-203,209
(Tables 2 and 8).
It appears prognostically that only 34% of people with
idiopathic CTS that do not receive treatment, have
complete resolution of symptoms (or remission) within 6
months of diagnosis.
37,199
Otherwise, many may still have
symptoms 1 year later.
37,199
Some with untreated CTS
may still have symptoms up to 8 years later
37
with those
who are older having bilateral symptoms, a (+) Phalen's,
and symptoms of more than 3 to 6 months in duration
having a poorer prognosis.
37,199
There seems to be a consensus that a period of
conservative treatment is indicated before invasive surgery
for CTS.
199,210
The most common standard care for CTS by
family and general medical practitioners is use of a wrist
splint, rest or change in daily activities, and concurrent
prescription of NSAIDs, although systematic reviews are
beginning to suggest acetaminophen.
37,210
However, Ash-
worth and Hamamoto et al recommend local steroid injection
first, oral systematic steroids second but not NSAIDs as the
first conservative choice.
199,210
Common reasons given for
surgery are chronicity of more than 6 months of unrelieved
hand and finger night pain, unrelieved hand numbness, and
paresthesia for relief of functional daytime pain.
37
Other disease causing neuropathy (diabetes, chronic
polyarthritis, myxoedema, acromegaly, pregnancy and or
cervical radiculopathy, brachial plexopathy, and/or CNS
disorders such as multiple sclerosis or cerebral infarction)
must be ruled out.
37,195,199,211
But if pain persists for N6
months after treatment, if there is increasing hand and finger
pain, weakness and/or numbness (pain, paresthesia,
hypoesthesia and/or motor loss/weakness) then referral for
neurological evaluation with EMG confirmation of a
decreased distal latency of median sensory, motor, and
nerve velocity conduction strengthens the justification for,
or need of, surgery.
37,195,199,211
Left untreated, these
changes may lead (for some) to permanent pain, weakness
and atrophy of the thenar eminence, abductor pollicis
brevis, and opponens pollicis muscles with chronicity of
neurological symptoms and loss of hand and finger
function.
37,195,199,211
However, although subjective and
objective examination changes occur with conservative and
surgical care, post-surgical EMG and median nerve
findings and pathology often remain.
100,212
Application of Mobilization for Carpal or Extremity Joints
It should be noted that mobilization, especially carpal
bone mobilization and mobilization in general, is frequently
and initially applied with lesser grades of amplitude or force.
For example, grade II and III will initially be performed
progressing to grade IV, with grade V manipulation or thrust
infrequently used.
1,4,12,35,102,150,155,213
Often mobilization
is applied for longer periods or duration than manipulation:
for example mobilization is more commonly applied in 2
sets (from as low as) 10 oscillations per setup to ≥30 one
second (or faster) A-P or P-A oscillations, performed per
visit with a ≥10 second rest between sets as opposed to one
or only a few grade V high-velocity low-amplitude
manipulations.
1,4,12,35,102,150,155,213
MMT as Conservative, Multimodal, and/or Adjunctive Treatment of
TMD/TMJ
The following therapies overall produced short-term
statistically significant differences in improved range and/
or quality of motion, decreased pain while resting, opening,
and clenching scores (Pb.05): intraoral myofascial therapy
(IMT), post isometric relaxation, manual distraction, and
self-mobilization in conjunction with a variety of exercises
and gentle, high-velocity (very) low-amplitude manipula-
tion, soft tissue MMT, or extra-oral soft tissue mobilization
alone or as multimodal care.
109-111,141,156-158,160,161
MMT for TMD added to exercise and/or multimodal
therapy (and/or home exercise, postural, and relaxation
training, EMG, proprioceptive neurofacilitation re-educa-
tion, and other modalities) may be helpful in the short-term
treatment of TMD particularly in decreasing pain, increasing
oral opening and in improving muscle stretching,
and strengthening; and/or possibly helpful in decreasing
short-term pain in acute disk and/or acute myofascial
pain.
109-111,141,156-158,160,161
MMT (including chiropractic
delivery of MMT for TMD/TMJ) may be of additional
value in decreasing pain, increasing function and in
producing an increase in oral opening, alone or in
190 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
combination as part of interdisciplinary dental care and
treatment (see above and Table 2). Working in conjunction
with DCs offers an additional choice for dental pro-
fessionals and patients.
107,109-111,141,156-161
The short-term
(8-week trial) RCT of Minakuchi et al published in 2001 is
cited as evidence that MMT is of no value in the treatment of
TMD/TMJ.
107
The mobilization performed (for 20 minutes)
was delivered by a dentist; no apparent chiropractic input or
care was involved; no chiropractic or physical therapy text
or reference is apparently referenced describing any form or
type of manipulation, mobilization or myofascial/soft tissue
MMT.
107
Newly completed, longer-term peer-reviewed
research needs to be taken into account in addition to
previous TMD/TMJ MMT research.
108,111,156,158
LIMITATIONS
This systematic review of MMT for upper extremity
and upper quadrant pain and disorders has presented a
broad review of research to help in the determination of
evidenced based care. It is hoped that this will cautiously
provide practitioners, particularly within the context of
their clinical expertise and training, and patient prefer-
ence, more choice of interventions and a more compre-
hensive picture of the existing evidence supporting a
variety of MMT therapies that may be useful alone or
also in interdisciplinary management of additional
common upper extremity neuromusculoskeletal disorders
beyond the shoulder.
1,3
MMT with multimodal treatment appears to be an
efficacious approach for many common upper extremity
conditions (Tables 2-10). This review has shown that MMT
(primarily as part of multimodal care) should be considered
for inclusion in the treatment of many common upper
extremity conditions and disorders; and may be applied
appropriately and safely for the benefit of, and to improve
the effectiveness of TMJ/TMD treatment. Regarding MMT,
some believe that FKC evaluation of spinal, glenohumeral,
elbow, wrist, hands and fingers joints including other joints
such as the acromioclavicular, sternoclavicular, and upper
ribs (or full kinetic chain) should be assessed for range of
motion, accessory glide and end-range play, feel or
accessory motions. However, the efficacy or effectiveness
from the application of FKC MMT is unclear. All grades of
MMT from mobilization including lesser grades, I-IV up to
IV + or IV++ should then be applied when appropriate
following an adequate diagnosis and ruling out any
contraindications. Gentle (lower force) HVLA manipula-
tion may also be of benefit but it is recommended it be used
cautiously, judicially and later in care as upper extremity
mobilization and soft tissue MMT for the elbow, wrist,
hand, finger and TMD simply has a greater level of
evidence at this time (see above). The average and range of
treatments as used in the RCTs and CTs analyzed in this
review is given in Table 11. Additional case series or
reports, including some comprising the shoulder (otherwise
not covered in RCTs analysis) along with the elbow, wrist,
hand, fingers, and the TMJ/TMD are outlined in Table 12.
From the results of this review the clinician should be
guided to additionally consider and in some cases evaluate
the cervicothoracic spine and ribs when treating upper
extremity disorders (including the elbow, wrist, etc). For
example, in the treatment of elbow pain a number of MMT
trials or studies treated the cervicothoracic spine and or
wrist only and reported good outcomes.
25,94,146
The
segmental fixation (or restricted motion) of the cervicothor-
acic spine may refer pain to the upper extremity (from the
neck to the hand) or may be partially responsible for
inhibition or altered biomechanics eventuating in shoulder
or upper extremity pain.
155,214-216
Rarely in clinical practice is there one diagnosis for a
given upper extremity condition. Often myofascial soft
tissue involvement will be accompanied with joint
restrictions and neuromuscular movement dysfunction,
which over time may cause tissue injury or failure
resulting in a primary joint disorder. Travell and Simons
have revealed pain referral patterns into the upper
extremity as a result of myofascial trigger points (patterns
that appear partially supported by the work of Hains and
Hains regarding CTS and shoulder pain).
37,217,218
How-
ever, the full impact of myofascial adhesions and
restrictions (and their treatment) on upper extremity
function, pain and dysfunction needs more research but
may have far reaching effects on function and pain.
37,217-220
However, since the 2011 study
3
which outlined a number of
shoulder studies that used only myofascial MMT in
treatment
217,221
this updated and expanded review has added
more studies of upper extremity disorders whose MMT was
solely myofascial rather than boney mobilization or
manipulation.
37,38,91,98,99,101,111,132,136,137,149,151,153,217-219,222
For example, the work of Kibler suggests that myofas-
cial scapular dyskinesis (an alteration in the normal position
or motion of the scapula during coupled scapulohumeral
myofascial movement) is very often present in the most
painful shoulder conditions; according to Kibler rotator cuff
injuries have scapular dyskinesis present in 68% of cases,
labral tears 94%, and there is scapular dyskinesis in
glenohumeral instability in nearly 100% of cases.
215
Scapular stabilization exercise or rehabilitation is develop-
ing into an essential component of shoulder rehabilitation
(which may require myofascial MMT of the scapula or
shoulder girdle) for success. Our previous review found
scapular stabilization (retraction and inferior setting and/or
holding) was one of the most common exercises prescribed
in the shoulder studies reviewed in 2011.
3
Boney and
myofascial MMT + multimodal or exercise therapy make
up the core of shoulder rehabilitation and to this a few
additional shoulder case series, reports, etc, have been
added in this review (Table 12 for a description of the most
191
Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
common exercises prescribed in the previous shoulder
review). These shoulder disorders were: rotator cuff
injuries, disease or disorders (RCIDs); shoulder complaints,
dysfunction, disorders and/or pain (SCDP); frozen shoulder
(FS); soft tissue disorders of the shoulder (ST shoulder = a
myofascial shoulder disorder)—also known as a myofascial
pain and dysfunction syndrome of the shoulder (MPDS
and/or similar terminology); (minor referred) neurogenic
shoulder pain (NSP); and finally osteoarthritis of the
shoulder or shoulder OA.
3
Levels of evidence for MMT
in treatment of these conditions were presented in
Brantingham et al (the initial part of this 2-part series).
3
X-Ray and Imaging Limitations
One aspect not covered in detail was the use of imaging.
Generally like the use of radiology and imaging for spinal
disorders and spinal manipulation, the use of imaging for
upper extremity disorders has the same concerns: to exclude
first “red flag”disorders.
47
Experts differ on what
constitutes a red flag finding in spinal, extremity or
musculoskeletal disorders but it is common to see lists
which include trauma, age, history of cancer, fever, chills,
night sweats, weight loss, recent infection, immunosuppres-
sion, rest/night pain, saddle or upper extremity anesthesia,
bladder dysfunction, and/or upper or lower extremity
neurological deficit.
223
Pathology such as a high riding
humerus, calcific tendinitis, various and/or previous surger-
ies, osteoarthritis or suggestion of meaningful osteoporosis,
boney deformities, subacromial or periarticular and/or
significant osteophytes; a type 3 hooked acromion, previous
fractures such as a Hills-Sachs lesion and/or other upper
extremity fracture and/or signs of systemic, inflammatory,
or neoplastic disease, congenital or acquired deformities,
dislocation, other sundry fracture or secondary evidence of
tendon ruptures (and similar) for the elbow, wrist, hand,
fingers and/or TMD must be considered but is beyond the
scope of the review (for specialized imaging of TMD see
tables and/or listed studies).
24,47,83,100,224-228
Diagnostic Terminology and Generalization Limitations
Currently many diagnostic entities and terminology have
been challenged and musculoskeletal terminology is
disputed, fluid and unstable.
224,229,230
Certainly there are
very few RCTs, sophisticated prospective case series, and/
or cost-effectiveness studies that clarify most upper
extremity neuromusculoskeletal diagnoses.
230
When it
comes to x-ray, magnetic resonance imaging and other
imaging modalities this is even more so; imaging presents
extreme parsing of musculoskeletal diagnoses. So, many
apparent common conditions not yet subjected to MMT
RCT studies such as SLAP (superior shoulder labrum tears
from anterior to posterior) or Bankart lesions (an inferior
labral tear due to dislocation or instability) were not covered
in this review.
231
Many diagnoses have not been included
in the elbow (collateral sprains), wrist (sprain, ganglion
cyst), hand (Keinbock's disease or avascular necrosis), or
finger and TMD sections (also lacking MMT RCTs) for the
same analysis and reasons. Accordingly there is no
inclusive claim that this systematic review has covered
the full and larger body of diagnoses DCs and other manual
therapists come in contact with, diagnose, treat or refer.
Many older common musculoskeletal disorders and
syndromes have recently been dissected, divided and
transposed into virtual diagnostic conundrums with termi-
nology distrusted, questioned, and confused.
229,230
How-
ever, many of the above disorders may be safe to treat
without x-ray for a short period with an associated
unremarkable examination and no red flags. Yet many
may need immediate x-rays as in the case of older, frail
patients with positive orthopedic tests, severely limited
function and/or associated marked pain or for those who
respond slowly or poorly. X-ray or other imaging may then
elucidate an otherwise undetected causative fracture,
osteophyte or boney deformity (such as a subacromial
osteophyte or a type 3 hooked acromion) and require further
diagnostic tests, imaging, and/or orthopedic or surgical
referral.
229,232
Standardization Limitations
One difficulty and limitation uncovered in doing this
review was the confusion surrounding the lack of
standardization for many terms such as “shoulder girdle”
or “tennis elbow.”“Shoulder girdle”for example has been
defined variously by different authors at different times and
in the past has been outlined as a combination of the
Table 11. Average no. of treatment sessions per week with corresponding ranges for reviewed studies
Region Condition
Average no. of
Treatments
Range for Treatment
Sessions
Duration of
Treatment Plans
Average
Txs Overall
Elbow Lateral Epicondylopathy
(epicondylosis/epicondylitis)
2.3 sessions per week 1 to 12 treatments 2 to 6 weeks 8
Wrist Carpal Tunnel Syndrome 2.0 sessions per week 1 to 27 treatments 5 to 6 weeks 10
Post Colle's Fracture Post Colle's Fracture 7 sessions per week 15 txs over 3 weeks 3 weeks 15
Hand and Fingers Systemic Sclerosis 2 sessions per week 18 treatments 9 weeks 18
Thumb Thumb Metacarpal OA 2.5 sessions per week 2 to 6 treatments 2 weeks 7
Temporomandibular Joint ⁎TMJ/TMD-OA 2.0 sessions per week 6 to 10 treatments 5 to 7.7 weeks 9
OA, osteoarthritis; TMJ/TMD-OA, temporomandibular joint dysfunction/tempotomandibular disorder osteoarthritis.
192 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
glenohumeral, acromioclavicular including scapular glide
and sternoclavicular joints and/or including the axial spine
(cervical and thoracic spines). Some authors now describe
the “Shoulder Girdle”as encompassing the cervical and
thoracic spines and upper ribs while others do not—and
have used the previously more common definition given
above. Others have defined “the shoulder”as restricted to
the glenohumeral joint and there are similar problems with
the rest of the upper extremity. This confusion and lack of
standardization cannot be resolved in this study and the
reader is directed to each particular study cited and Tables 2-
10 for clarification.
233
When should one use MMT for the
spine and not the glenohumeral, elbow or wrist joint, or
MMT for the spine only to relieve elbow pain? This is
explicated in a minor way in Tables 2-10 but again the
reader is directed to the cited studies.
The PEDro ranking tool or scale and the PEDro Web site
with the official Physiotherapy Evidence Database expla-
nation was provided to all assessors, along with additional
written material and explanations from the first author sent
to all assessors doing blind assessment and to all members of
the team for comprehension of the RCTs.
50
For example the Tal-Akabi et al study of MMT for CTS,
an RCT ranked highly by some official guidelines and
systematic reviews, used a random number placed in a “hat”
and the hat had a dual purpose of completing randomi-
zation and concealing allocation (see further discussion
below).
102,197,198
The PEDro scale was used as per the
fundamental instructions given in and by the Physiotherapy
Evidence Database, a ranking tool that is considered valid
and reliable.
49,50,55,56
Although many others have modified
the PEDro scale, reporting scores from 8 to 11 or even
12,
59-62
it is not clear that the use of a slightly modified scale
adds tangible value beyond the validated PEDro score itself.
Ultimately the same 3 blind assessors were used in the vast
majority of PEDro rankings (approximately 93%) of the
included RCTs. In a few rankings (of RCTs) individuals
varied from these particular 3 individuals with some potential
lessening of validity. There may also have been inadvertent
“unblinding”of a few studies which may include in total 1.5%
to up to 3% of all the included RCTs in this review. It should
be noted that not all agreed on what constituted “best”
methodology in each and every issue (such as) “concealed
allocation, intention to treat, or randomization.”So PEDro
scores differed per these reviewers affecting the final score.
Ultimately the PEDro ratings were followed with a synthesis
and evaluation by the considered judgment on quality of
material document, whereby the authors scored all the
evidence considered together (for best practice) with grades
of “A, B, C, and I,”as outlined in the Handbook for the
Preparation of Explicit Evidence-Based Clinical Practice
Guidelines.
48,71,78-80,181,216,234
The “considered judgment on
quality of evidence”was applied to all reviewed materials,
including newly added SGPPDs, case series and
reports.
1,2,17,41,52,57
Clearly different people reading and
discussing the same instructions (and in good faith) can
interpret the reporting of methodologies diversely and come
up with divergent scores.
4,49,66,73,77,102,109,146,235-238
Table 12. Exercises for specific, common shoulder and elbow conditions summarized from Brantingham et al 2011, Vicenzino et al
2003, and Bisset et al 2006
Condition Exercise
Frozen Shoulder (FS) (after Brantingham et al 2011) Anterior capsule restriction (stretches), Posterior capsule restriction: Pendulum exercise
Shoulder impingement
Syndrome (RCID)s
a
Rotator cuff injuries,
disorders, dysfunction,
and/or disease
(after Brantingham et al 2011)
Shoulder serratus dynamic hug, Shoulder depression, Long-sitting row, Serratus press, Shoulder external rotation,
Shoulder flexion, Shoulder extension, Shoulder adduction,
Shoulder scaption, Internal rotation, Thoracic extension mobilization, Dynamic stabilization of the entire kinetic
chain including Scapular stabilization and PNF patterns
Lateral Epicondylopathy (after Vicenzino et al 2003 and Bisset et al 2006)
Recondition forearm ± upper cervical/thoracic/shoulder muscles (MMs) if necessary with proper alignment:
Minimally rehabilitate pain free grip and extensor muscles; and/or mms used in activities of daily life (ADL)
including–mms for flexion,
supination, pronation, radial and ulnar deviation.
A diversity of resistance and loads may be used such as elastic bands, free weights, manual resistance, isokinetic or
isometric exercise; pain free putty gripping, and seated:
forearm extensor and flexor, supination and pronation, radial and ulnar (supination, etc with adjustable dumbbell) mms
strengthening, modified bench press, (bent over)
rowing, unilateral shoulder press in the scapular plane begun at 90/90°, seated biceps, and supine triceps mms
strengthening.
Stretches after exercise may decrease pain sensitivity 3-5 reps, 20-30 sec hold.
Avoid aggravation by ADL or exercise (particularly wrist extension in pronation
For base reconditioning perform with good posture at all times and do not exercise into or exacerbate pain; perform 2-3×/week, 3 sets or 8-12 repetitions ↑
and ↓as appropriate to age, fitness and condition; begin with less reps in severely deconditioned and perform exercises slowly over 6-8 seconds.
⁎TMJ (temporomandibular joint), TMD (temporomandibular dysfunction or disorder), OA (osteoarthritis).
a
Many authors suggest Kinesiotape in conjunction with the above exercises for RCID and LE—see individual studies. For wrist, hand and finger
exercise and rehabilitation see individual studies.
193Brantingham et alJournal of Manipulative and Physiological Therapeutics
Upper Extremity Systematic ReviewVolume 36, Number 3
This review is essentially limited to recommendations
for short-term treatment described as ≤3 to 6 months. There
are a growing number of RCTs assessing outcomes at 3
months—approximately 30% of the overall studies listed
but—still very few RCTs, or any type of study, have
assessed MMT for these or many other upper extremity
disorders (for example for treatment of a post Colle’s
fracture and similar) for up to or longer than 6
months.
23,24,37,83,92,104,119-122,124-126,130,133,139,140,142,
189,217,224,235,239-243
There are a few RCTs (in some of the
categories) that have extended a follow-up to ≥1 year (or a
few ≥6 months) such as Bisset et al and Smidt et al for
lateral epicondylopathy.
24,83
Of course much more MMT
research is needed for all the upper extremity disorders
covered in this review.
Case Series, Reports, and Other Studies
A few additional MMT case series, reports and other
types of MMT studies have been added to this review
revisiting shoulder conditions as noted in the previous
systematic review including, in regards to RCIDs or similar,
the blinded diagnostic study of Trigger Points and increased
pain pressure threshold (PPT) in patients with shoulder
impingement syndrome (more trigger points and an
increase in PPTs was found in those with RCID as
compared to controls) in Hidalgo-Lozano et al; in a case
report of 2 patients Krenner described MMT of 2 shoulder
patients each with a combination of RCID and SCDP
diagnoses with thoracic and cervical spine MMT, gleno-
humeral MMT and the use of a specialized myofascial
MMT that was used along with exercise and rehabilitation
with apparently good outcomes for both subjects. Similarly
we have included the case report of Caldwell et al (for
RCID and SCDP); a case report of a patient with combined
SCDP and NSP by Haddick; a case series by Gemmell et al
of shoulder patients with a combination of SCDP and
MPDS; Wies case series of FS; and the FS case series of 50
consecutive patients by Murphy et al which appears
supportive of the work of Bergman et al in the treatment
of SCDP
3,115,134
; a look at chiropractic management of a
shoulder condition called the Parsonage-Turner syndrome
(that appears to be a combination NSP and MPDS); a case
report of a shoulder patient with cervical radiculopathy and
MFPD in the shoulder by Daub; additionally added were
case series, reports and other studies looking at MMT
applied to a variety of elbow, wrist, hand, finger and upper
quadrant TMJ/TMD disorders.
106,116-119,122,124-126,130-
133,135-137,139-142,147,148,151,154,155,160,242-245
Almost without
exception all of these upper extremity or upper quadrant
disorders and conditions in both the RCT, CT, case series
and reports sections were treated by a combination of MMT
and multimodal care or rehabilitation (MMT and multi-
modal care = mobilization, manipulation, soft tissue or
myofascial therapy; and exercise, stretching, advice,
education and/or in an interdisciplinary setting including
medication, etc)
1,2
(Tables 3-10).
CONCLUSION
There is a Fair (B) level of evidence for MMT treatment
of lateral epicondylopathy (LE) (“tennis elbow”) in the
short term (≤3-6 months) using: MMT to the elbow and/
or including the full kinetic chain combined generally with
exercise and/or multimodal therapy. There is a Fair (B)
level of evidence for the MMT treatment of carpal tunnel
syndrome and similar disorders in the short term (≤3-6
months) using: MMT to the wrist, myofascial MMT,
splinting and/or including MMT applied to the full kinetic
chain combined generally with exercise and/or multimodal
therapy. There is a Fair (B) level of evidence for the MMT
treatment of temporomandibular joint disorders in the short
term (≤3-6 months) using: MMT to the jaw joint, cervical
spine, myofascial MMT and/or including MMT to the full
kinetic chain combined generally with exercise, multi-
modal therapy and/or interdisciplinary care. There is
Insufficient or an (I) level of evidence, and insufficient
numerical studies of MMT + multimodal treatment of
other sundry Wrist, Hand and Finger disorders (carpal
tunnel syndrome excepted) in the short term (≤3-6
months). In particular MMT must be used alone or
combined with other multimodal treatment only when it is
safe, appropriate and there are no contraindications.
Generally MMT is used to enhance commonly indicated
exercise or rehabilitative therapy as these remain overall
the standard of care. For the clinician, this study is
intended to help guide in the appropriate use of MMT, soft
tissue technique, exercise and/or multimodal therapy for
the treatment of a variety of upper extremity complaints in
the context of the entire hierarchy of published and
available evidence.
ACKNOWLEDGMENTS
The authors thank Cheryl Hawk, DC, PhD, as well as the
Council on Chiropractic Guidelines and Practice Parame-
ters (CCGPP) for their help and support. The CCGPP
provided a grant for completion of this study.
Practical Applications
•MMT with exercise and/or multimodal therapy is
efficacious in short-term care (≤3-6 months) of
common upper extremity NMS disorders.
•MMT appears comparable with other conserva-
tive or standard care (such as steroid injection)
with exercise and/or multimodal therapy
194 Journal of Manipulative and Physiological TherapeuticsBrantingham et al
March/April 2013Upper Extremity Systematic Review
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
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