Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

Abstract

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

Keywords: Manual therapy; Neck; Pain; Sensitization; Thoracic; Upper quadrant.

Figures

Figure 1

The treatment-based algorithm as outlined by Fritz and Brennan. MOI: mechanism of injury; MVA: motor vehicle accident; NDI: neck disability index.

Figure 2

Supine middle to lower thoracic spine thrust manipulation. The therapist uses the manipulative hand to stabilize the inferior vertebra of the motion segment targeted and uses the body to push down through the patient’s arms to perform a high-velocity, low-amplitude thrust.

Figure 3

Supine upper thoracic on mid-thoracic spine thrust manipulation in cervico-thoracic flexion. The therapist uses the manipulative hand to stabilize the inferior vertebra of the motion segment targeted and uses the body to push down through the patient’s arms, to perform a high-velocity, low-amplitude thrust.

Figure 4

Seated thoracic spine distraction thrust manipulation. The therapist places the upper chest at the level of the patient’s middle thoracic spine and grasps the patient’s elbows. A high-velocity distraction thrust is performed in an upward direction.

Figure 5

Cervical spine thrust joint manipulation. The therapist uses the manipulative (left) hand to localize the motion segment targeted and uses both hands to perform a high-velocity, low-amplitude thrust into rotation, which was directed up towards the patient’s contra-lateral eye.

Figure 6

Manual therapy techniques addressing trigger points (TrPs) in the forearm muscles. One hand of the therapist stabilizes the skin of the patient and the other hand performs a longitudinal stoker over the TrP taut band.

Figure 7

Elbow joint mobilization/manipulation. The patients’ forearm is supinated at the point of hypo-mobility. The pad of the thumb is placed posteriorly against the radial head. The technique consists of applying a posterior–anterior glide of the radial head.

Figure 8

Shoulder joint mobilization. Both hands of the therapist cup the humeral head of the patient. The therapist applies a lateral–medial or posterior–anterior glide of the humerus along joint plane of glenoid fossa.

Figure 9

Trigger point (TrPs) manual therapy to the shoulder. The fingers grasp the taut band from both sides of the TrP and strokes centrifugally away from the TrP.

Figure 10

Manual therapy technique targeting the carpal tunnel. The therapist places his thumbs on the region of the carpal tunnel and flexes the index fingers over the back of the wrist forming a clamp. Holding the patient’s wrist, the therapist applies a three-dimensional traction while slightly extending the wrist.

Figure 11

Neurodynamic technique targeted to the median nerve: (left) shoulder girdle depression, gleno-humeral abduction and lateral rotation, supination of the forearm, elbow flexion and wrist, thumb, and finger extension; (right) shoulder girdle depression, gleno-humeral abduction and lateral rotation, supination of the forearm, elbow extension and wrist, thumb, and finger flexion.

Figure 12

Mobilization with movement applied over the elbow region. One hand of the therapist is used to glide the proximal forearm laterally, while the other hand fixed the distal end of the humerus while the patient performed a pain-free gripping action. Ten repetitions are performed with an approximate 15-second rest interval between repetitions.

Figure 13

Dry needling of active trigger points (TrPs) in the infraspinatus muscle.