Orthopedic Manual Physical Therapy for the. Upper Extremity

Transcription

1 Orthopedic Manual Physical Therapy for the Upper Extremity

2 Introduction Who are we? Instructors Erik Gregersen, DPT, OCS, Fellow in Training Joe Kucksdorf, DPT, OCS, FAAOMPT Teaching Assistances Lauren Hogan, DPT, OCS, Fellow in Training Jeremiah Weber, DPT, OCS Lee Coleman, DPT, OCS Who are you?

3 Timeline 8:00 to 8:20 Intro, Objects, and Rules 8:20 to 8:45 PT UE Exam, and Cervical Screen 8:45 to 10:00 Shoulder Exam, Accessory/Treatment 10:00 to 10:15 Break 10:15 to 10:45 Mechanisms of MT/Regional Interdependence and Safety 10:45 to 12:00 Shoulder Accessory/Treatment 12:00 to 2:00 Lunch 2:00 to 2:30 Elbow Exam 2:30 to 3:15 Elbow Accessory/Treatment 3:15 to 3:30 Break 3:30 to 4:00 Elbow Accessory/Treatment 4:00 to 5:00 Wrist Exam, Accessory/Treatment

4 Objectives Understand what manual therapy (MT) is and how it is used Determine where and when MT may be utilized as a treatment intervention Safety using risk to benefit thought process Provide a 30,000 foot view of evidence-based mechanisms behind manual therapy with focus on Regional Interdependence Provide an overview of evidence supporting the use of MT in physical therapy (PT) practice for upper extremity conditions Improve our psycho-motor hand skills with select MT techniques for the lower extremity; Focus on getting better at a few of the key techniques commonly seen in the evidence

5 Hands On Lab Considerations Focus on those techniques commonly utilized in the literature Quality over quantity Getting really good at a few techniques rather than poor/adequate with many The best therapists do the basics really well Quality feedback Change up partners; different body shapes and sizes

6 Hands On Lab Considerations Practice Soft hands/relaxed body Focus on quality set up Work on creating a standard operating procedure Table Position Patient Position Therapists Position Hand Position Final minor adjustments Provide quality feedback

7 Rules for the Day Engage Have fun Lean Expect to provide and receive feedback Be open to constructive critique Discussion This is a safe place It is your individual responsibility to protect yourself Stop if you do not feel comfortable

8 Physical Therapy Examination and Treatment

9 Physical Therapy Examination and Treatment Treatment should always follow a complete examination An Evidence-Based, bio-psychosocial approach First step is to determine if the patient is appropriate for Physical Therapy; this will be greatly truncated for today If patient is appropriate we still need to make sure our treatment is appropriate

10 Physical Therapy Examination Red Flags: signs/symptoms indicating serious medical pathology= immediate referral Orange Flags: abnormal psychological or psychiatric factors suggesting diagnosable psychopathological= referral or consultation Yellow Flags: normal but unhelpful psychological reactions to musculoskeletal symptoms= possible consultation

11 Nicholas et al., PTJ, 2011

12 Differential Diagnosis/Red Flags to Consider for Upper Extremity Visceral/ Non-Mechanical Neurologic Vascular

13 Boissonnault and Fuller Visceral Referral Patterns

14 Visceral Causes of Upper Pulmonary Upper lobe pneumonia Pulmonary embolism Pneumothorax Pneumosoperitoneum Malignancy Pancoast tumor Metastatic cancer Abdominal Billary disease Pancreatitis Splenic injury Perforated viscus Extremity Pain

15 Neurologic and Vascular Causes of Upper Extremity Pain Neurological Cervical radiculopathy Upper trunk brachioplexopathy Neurologic amyotrophy Focal mononeuropathy Muscular dystrophy Vascular Cardiac ischemia Thoracic outlet syndrome Aortic disease Axillary thrombosis

16 Cervico-Thoracic Screen

17 Cervical Screen Cervical AROM Cervical AROM + OP Cervical Accessory Motion Assessment

18 Cervical Overpressure: Flexion Patient first moves actively into available motion If no symptom reproduction, add overpressure Stabilize upper thoracic spine, and apply pressure into more forward flexion

19 Cervical Overpressure: Extension Patient moves actively into available range If no symptoms reproduced, add overpressure into more extension Assess for symptom reproduction

20 Cervical Overpressure: Retraction Patient actively moves into available range. Slide head and neck straight back, keeping eyes level If no symptom reproduction, add overpressure and assess for symptoms Helps to isolate lower cervical and upper thoracic extension

21 Cervical Overpressure: Side Patient moves into available range of sidebending without rotation If no symptoms produced, add overpressure into more sidebending and assess for symptoms Bending

22 Cervical Overpressure: Rotation Ask patient to actively move into available range. Apply over pressure into rotation Therapist stabilizes trunk with arm on back of shoulder If no symptoms reproduced, add overpressure and assess for symptom reproduction

23 Cervical Overpressure: Spurling s Test Screen for Cervical Radiculopathy (CPR) Seated patient, therapist side bends the neck toward the affected side and applies roughly 7kg of compression force directly downward + Test is reproduction of symptoms

24 Cervical Overpressure: Quadrant Patient Seated Actively rotate fully to the side and extend looking over the shoulder first then Therapist approximates the scapula posterior while exaggerating cervical rotation and extension if needed + for symptom reproduction Test

25 Thoracic Overpressures

26 Treating the Cervical and Thoracic Spine for UE Problems Evidence exists to supporting treating the cervical spine, thoracic spine and rib cage for UE problems Regional Interdependence May be the first line of treatment for highly severe and irritable symptoms

27 Shoulder Examination

28 Shoulder Subjective What are the key questions we want for shoulder pain complaints? Reaching, lifting, pushing, pulling, carrying Hand behind back, hand behind head Functional Outcome Scale- Quick DASH

29 Shoulder Physical Exam Observation/ Functional Tests Reaching Lifting Pushing Pulling Palpation Flexibility* Strength* Neurodynamics

30 Shoulder Physical Exam AROM PROM, PROM w OP Accessory Special Tests Many (probably too many to know them all), consider in clusters, and what they mean clinically

31 Passive Shoulder Flexion Patient supine, arm at edge of table Therapist grasps patient s forearm with one hand and humorous with other hand Therapist takes patients shoulder into full physiologic shoulder flexion

32 Passive Shoulder Flexion with Glenohumeral Isolation Patient supine, arm at edge of table Therapists uses one hand to block lateral boarder of the patient s scapula (before elevating the arm) and grasps at the arm at the distal humorous Therapist takes shoulder into end-range flexion blocking the scapula for upward rotation looking to isolate gleno-humeral flexion Alternate hooked handhold can be used to stabilize the scapula (shown)

33 Passive Shoulder Abduction Patient supine, arm at edge of table Therapist grasps patient s forearm with one hand and humorous with other hand Therapist takes patients shoulder into full physiologic shoulder abduction

34 Passive Shoulder Abduction with Gelnohumeral Isolation Patient supine, arm at edge of table Therapists uses one hand to block lateral boarder of the patient s scapula (before elevating the arm) and grasps at the arm at the distal humorous Therapist takes shoulder into end-range abduction blocking the scapula from upward rotating looking to isolate glenohumeral flexion Alternate hooked handhold can be used to stabilize the scapula

35 Passive Shoulder External Patient supine, arm at edge of table, elbow bent to 90 degrees Therapist uses one arm to grasp the elbow and other arm to grasp the distal arm Therapist moves the shoulder into external rotation Various positions of elevation can be assessed Rotation

36 Passive Shoulder Internal Patient supine, arm at edge of table, elbow bent to 90 degrees Therapist grasp the patient s distal arm with one hand and places the other at the anterior shoulder The therapist may rest the patients elbow on their thigh or use the table for support Therapist moves the shoulder into internal rotation as they block the shoulder from moving anterior Various positions of elevation can be assessed Rotation

37 Passive Shoulder Horizontal Adduction Patient supine, arm at edge of table The grasps the patient's distal arm with one hand and blocks the lateral scapula with the other The therapist moves the shoulder into horizontal adduction blocking the scapula from moving into abduction

38 Passive Shoulder Extension Patient supine, arm off edge of table The grasps the patient s elbow with one hand and stabilizes the patient s anterior shoulder with the other Therapist moves the shoulder into extension blocking the shoulder from moving anterior

39 Shoulder Accessory Motion Examination can become treatment

40 Accessory Mobility Testing Compare to opposite side Looking for pain vs. resistance-this will guide your grade of mobilization if needed Assessment and treatment are the same Does everyone know the difference between physiological and accessory motion?

41 Accessory- Posterior Patient supine, arm off edge of table Therapists uses distal hand to support the patient s arm at the humerous/elbow and holds the forearm against their body with their elbow Therapists uses proximal hand eminance/heel of hand to apply an posterior force (and slightly lateral) to the patient s proximal humeral head The patients shoulder can be moved into various positions based off symptoms and response

42 Shoulder Accessory- Posterior, Alternate Patient supine, arm off edge of table Therapists uses distal hand to support the patient s arm at the humerous/elbow, holding the forearm against their body with their elbow Therapists uses both hands to grasp the shoulder applying a posterior force (and slightly lateral) to the patient s proximal humeral head with the length of both thumbs The patients shoulder can be moved into various positions based off symptoms and response

43 Shoulder Accessory- Inferior Patient supine, arm off edge of table Therapists uses one hand to support the patient s arm at proximal humorous and holds forearm against their body with their elbow Therapists uses proximal hand web space to apply an inferior force to the patient s proximal humeral head The patients shoulder can be moved into various positions based off symptoms and response

44 What is Manual Therapy?

45 Manual Therapy Manual therapy techniques are skilled hand movements and skilled passive movements of joints and soft tissue and are intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or retraction. Technique may include manual lymphatic drainage, manual traction, massage, mobilization/manipulation, and passive range of motion. Guide to Physical Therapy Practice 3.0, American Physical Therapy Association

46 Manual Therapy Physical therapists select, prescribe, and implement manual therapy techniques when the examination findings, diagnosis, and prognosis indicate use of these techniques to decrease edema, pain, spasm, or swelling; enhance health, wellness, and fitness; enhance or maintain physical performance; increase the ability to move; or prevent or remediate impairment in body functions and structures, activity limitations, or participation restrictions to improve physical function. Guide to Physical Therapy Practice 3.0, American Physical Therapy Association

47 How does MT work?

48 Bialoski et al., JOSPT, 2018

49 Coronado et al., JMMT, 2017

50 The successful use of manual therapy depends on a comprehensive understanding of the complex interplay between multiple inputs, including the patient, the provider, and the environment. Relying simply on biomechanical mechanisms is a recipe for failure. We feel strongly that manual therapy is a useful intervention to facilitate pain-free functional movement. But it is just one treatment option for us to consider, in what should be an ever-evolving skillset. Paul E. Mintken, Jason Rodeghero & Joshua A. Cleland (2018) Manual therapists Have you lost that loving feeling?!, Journal of Manual & Manipulative Therapy, 26:2, 53-54, DOI: /

51 May Require a Paradigm Shift

52 Using MT Practically What technique do you apply when? Many apply techniques based off biomechanical models Most lack efficacy Most hypothetical Seems to have a large neuro-physiological component Still, we are not exactly sure how to use mechanisms to prescribe treatment

53 Using MT Practically We would propose You may initially apply based off your treatment paradigm Do not box yourself in Utilize extreme caution against detailed explanations for you patients related to biomechanical or patho-anatomical causes of pain and/or mechanisms behind treatment Let Test-Re-Test related to a meaningful, patient-specific comparable sign guide you Apply based off current understanding of pain neuroscience principles and mechanisms of manual therapy

54 Using MT Practically Manual therapy is a means to an end May create a Window of opportunity Fisher BE, Piraino A, Lee Y-Y, et al. The Effect of Velocity of Joint Mobilization on Corticospinal Excitability in Individuals With a History of Ankle Sprain. Journal of Orthopedic & Sports Physical Therapy. 2016;46(7): Mitigate pain to help facilitate active intervention Calm stuff down to allow us to build stuff up Greg Lehrman:

55 Regional Interdependence What is it?

56 Wainner et al., JOSPT, 2007 Old definition: (a) concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient s primary complaint.

57 Paradigm Shift in RI Discussion Wainner et al., 2007 editorial Discussed RI mechanism as musculoskeletal/biomechanical perspective Bialosky et al., 2008 response editorial Argued RI mechanism likely have larger neurophysiological than biomechanical Suecki et al., 2013 editorial Revised mechanism discussion to include multiple mechanisms

58 Suecki et al., JMMT, 2013 New definition: the concept that a patient s primary muscusloskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s).

59 Sueki et al., JMMT, 2013 Any condition or disorder initiates a series of responses that involves multiple systems of the body. Musculoskeletal Neurophysiological Somatovisceral Biopsychosocial

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61 McDevitt et al., JMMT, 2015 The interplay between these theoretical mechanisms may maximize patient outcomes when the clinician includes treating anatomical sites sometimes remote from the site of the patient s symptoms. Treating the thoracic spine for patients with shoulder or cervical dysfunction Treating the cervical spine in patients with lateral epicondyalgia or carpal tunnel syndrome Treating the hip in those with lumbar spinal stenosis or visa versa Treating the hip and lumbar spine for those with knee pain

62 When is MT appropriate? A risk : benefit model can provide a simple framework for decision-making through consideration of risk factors, predicted benefit of OMT intervention, and analysis of possible action. Rushton et al.,

63 Making The Best Decision Risk to Benefit Ratio Identify the likely benefit Acute LBP CPR for manipulation Flynn et al., 2002, Childs et al., 2007, Cleland et al., 2009 Neck pain CPR for cervical manipulation Putendura et al., JOSPT, 2012 Identify the likely risk Contraindications and precautions

64 Making The Best Decision The clinician must accept that the clinical decision is made in the absence of certainty and that the aim of the assessment is to make a decision based on a balance of probabilities. It is the responsibility of the clinician to make the best decision regarding treatment in these situations using their clinical reasoning skills and consideration of patient preferences. Rushton et al., 2013

65 Contraindications and Precautions Articular derangements Arthritides: acute inflammation, RA, ankylosing spondylitis Hypermobility: dislocation/subluxation, Down syndrome, CP, etc. Circulatory disturbances Aneurysm Anticoagulant therapy Clotting disorders Atherosclerosis VBI/CAI Ligamentous rupture, spondylolisthesis Bone weakening Fracture Malignancy Osteoporosis/penia Osteomyelitis TB Progressive neuralgic deficit Disc herniation Infections disease Pregnancy Active growth plates Spasticity PETERSEN, C. and FOLEY, R. (2002). Active and passive movement testing. New York: McGraw-Hill.

66 Accessory- GH Lateral Distraction Patient is supine, arm off edge of table Therapist s distal arm supports patient distal humorous and elbow Therapist s proximal grasps the medial aspect of the humorous, up into the axillary region providing a lateral force to the humorous

67 Accessory- GH Lateral Patient is supine, arm off edge of table Therapist sits alongside patient and supports the R UE at 90 flexion, neutral rotation Grasping as distal on the humerous as you can traction, distract laterally and slightly posterior with a scooping motion

68 Accessory- GH Long Axis Patient is supine, arm off edge of table Therapist s grasps the patient s distal elbow, trapping the distal arm between their arm and body Therapist s proximal thenar eminence blocks the patient s scapula in the axilla Therapist provides a long axis distraction pulling thought the distal humerous

69 Accessory- Acromioclavicualr Inferior Patient supine Therapist at head of the table Dummy thumb position Therapist places dummy thumb on distal end of clavicle with opposite heel of hand over dummy thumb Therapist applies a inferior force to the clavicle The patients shoulder/arm can be moved into various positions based off symptoms and response

70 Accessory- Sternoclavicualr Posterior Patient supine with arm at edge of table Therapist s distal arm supports patient distal humorous and elbow Therapist s heel of proximal provides a posterior/lateral force to the sternal portion of the clavicle Therapist can provide distraction to the arm at the same time The patients shoulder/arm can be moved into various positions based off symptoms and response

71 Accessory- Calvicular Wiggles Patient supine with arm at edge of table Therapist to side of patient Therapist grasps clavicle with both hands between thumbs and fingers providing a oscillatory anterior to poster/posterior to anterior rotation to the clavicle oscillation or Wiggle

72 Accessory- Scapulo-Thoracic Anterior Position Patient side lying PT holds antero-superior shoulder with one hand and with other reaches under scapula with lumbrical grip Therapist mobilizes scapula in various directions: rotation up/down, ABD/ADD, elevation/depression and distraction Therapist may provide thrust

73 Accessory- Scapulo-Thoracic Posterior Position Patient side lying PT holds antero-superior shoulder with one hand and with other reaches under scapula with lumbrical grip Therapist can be posterior or anterior to the patient Therapist mobilizes scapula in various directions: rotation up/down, ABD/ADD, elevation/depression and distraction Therapist may provide thrust

74 Mobilize this shoulder?

75 Special Tests Many special tests exist Probably to many to remember much less perform correctly or know the supporting research (or not) We suggest Very few tests are great in isolation. Consider entire exam and use testes in clusters Use those with the most research Choose tests that are a reflection of your hypothetical-deductive process

76 Special Tests Consider tests in context of clinical management Special tests may allow us to name the problem, but will it guide our treatment at PTs? Example: Shoulder Sub-Acromial Impingement Patients don t care if we can name it, they care if we can change it! Use special tests to help us determine if patient has a possible significant pathological tissue lesion which may change our plan of care Significant pathological rotator cuff tear Significant pathological labral tear with instability

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78 Shoulder Evidence Bang & Deyle et al., 2000 Camarinos, J. and Marinko, L. (2018). Effectiveness of Manual Physical Therapy for Painful Shoulder Conditions: A Systematic Review. Rhon DI e. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder imping... - PubMed - NCBI. Ncbinlmnihgov Available at:

79 Elbow and Forearm Examination

80 Elbow and Forearm Subjective What are the key questions we want for shoulder pain complaints? Reaching, lifting, pushing, pulling, carrying Functional Movement Functional Outcome Scale- Quick DASH

81 Elbow and Forearm Physical Exam Observation/ Functional Tests Palpation Flexibility* Strength* Neurodynamics

82 Elbow and Forearm Physical Exam AROM PROM, PROM w OP Accessory Special Tests Many (probably too many to know them all), consider in clusters, and what they mean clinically

83 Passive Elbow Flexion- Three Direction Patient supine, arm on table Therapists grasps the patient s distal humerous with one hand and wrist with the other Patient moves the elbow into straight flexion, ADD flexion, and ABD flexion Follow the thumb Note, stabilizing hands changes hand grasping humerous does so from medial side with some relative ER of the humerous for ADD flexion hand grasping humerous does so from the lateral side with some realxive IR of the humerous for ABD flexion

84 Passive Elbow Flexion- Three Direction

85 Passive Elbow Extension- Three Direction Patient supine, arm on table Therapists faces patient s feet and grasps the patient s posterior elbow with their posterior fingers/hand against the table using the same forearm to block the patient s anterior shoulder Therapist grasps the patient s wrist with the other Patient moves the elbow into straight extension, ADD extension, and ABD extension Follow the thumb

86 Passive Elbow Extension - Three Direction

87 Accessory- Humeroulnar Distraction With patient s humerus stabilized on the table, therapist flexes patient s elbow to approximately 60 o and places one hand over the proximal ulna while supporting the distal forearm with other hand. Therapist then applies a distraction force to the ulna and assesses the mobility and symptom response

88 Accessory- Posterior Humeroulnar Patient supine, arm at edge of table Therapists grasps patient s proximal ulna and traps the forearm between their elbow and body Therapists grasps the patient s distal humerous with their posterior hand/fingers against the table Therapist applies a posterior force to the ulna

89 Accessory- Proximal Radioulnar Posterior and Anterior Patient supine, arm at edge of table Therapists grasps patient s proximal radius with lumbrical grip with one hand and proximal ulna with lumbrical grip with other hand Therapists stabilizes the radius or ulna providing a anterior or posterior force stabilizing the opposite direction with the opposite hand

90 Accessory- Distal Radioulnar Posterior and Anterior Patient supine, elbow resting on the table Therapists grasps patient s distal radius with lumbrical grip with one hand and distal ulna with lumbrical grip with other hand Therapists stabilizes the radius or ulna providing a anterior or posterior force stabilizing the opposite direction with the opposite hand

91 Accessory- Distal Radioulnar Supination Patient supine, elbow flexed on the table, forearm supinated Therapists grasps the distal ulna with one hand and distal radius with the other using a lumbrical grip Therapist moves the radius dorsally stabilizing the ulna mobilizing the distal radiocarpal joint into supination

92 Accessory- Distal Radioulnar Pronation Patient supine, elbow flexed on the table, forearm pronated Therapists grasps the distal ulna with one hand and distal radius with the other using a lumbricle grip Therapist moves the radius volar, stabilizing the ulna mobilizing the distal radiocarpal joint into pronation

93 Radial Head Manipulation Patient standing, arm slightly abducted from body with forearm pronated, elbow and flexed Therapist grasps patient s distal arm/wrist with inside hand Therapist grasps proximal forearm with other arm placing thumb at posterior radial head applying anterior pressure Therapist moves wrist into flexion and elbow into about 10 degrees from full extension Therapist maintains the anterior force to the posterior radial head as they quickly moving wrist to full extension (NOT BEYOND) Picture shows ending position of thrust, not starting position

94 Elbow Mobilization w Movement Patient sitting, standing or supine Therapist grasps patient s lateral distal humerous laterally with outside hand and medial proximal ulna with inside hand Therapist places arms parallel applying therapist applies a lateral mobilizing force with medial hand while stabilizing with lateral hand Patient performs repeated gripping or wrist extension exercise while force is maintained. Adjust technique until grip has significant reduction in pain

95 Vinenzino et al., 2009 Derivation CPR of LE patient s likely to respond to elbow mobilization with movement Less than 49 years old Affected painfree grip strength >112 N (about 25 lbs) Unaffected painfree grip strength <336 N (about 75 lbs) Vicenzino, Bill, et al. Development of a Clinical Prediction Rule to Identify Initial Responders to Mobilization with Movement and Exercise for Lateral Epicondylalgia. Manual Therapy, vol. 14, no. 5, 2009, pp , doi: /j.math

96 Bisset & Bicenzino et al., 2015 Topical Review of Lateral Epicondylalgia In summary, manual therapy techniques to the elbow, wrist and cervicothoracic spine may reduce pain and increase painfree grip strength immediately following treatment, although in many instances, meta-analysis was not possible due to heterogeneity between manual therapy techniques and timing of follow-up assessment. There was insufficient evidence of any long-term clinical effects for manual therapy alone. Bisset, Leanne M, and Bill Vicenzino. Physiotherapy Management of Lateral Epicondylalgia. Journal of Physiotherapy, vol. 61, no. 4, 2015, pp , doi: /j.jphys

97 Wrist and Hand Examination

98 Wrist and Hand Subjective What are the key questions we want for shoulder pain complaints? Reaching, lifting, pushing, pulling, carrying Functional Movement Functional Outcome Scale- Quick DASH

99 Wrist and Hand Physical Exam Observation/ Functional Tests Palpation Flexibility* Strength* Neurodynamics

100 Wrist and Hand Physical Exam AROM PROM, PROM w OP Accessory Special Tests Many (probably too many to know them all), consider in clusters, and what they mean clinically

101 Accessory- Radiocarpal Flexion Patient supine, sitting or standing, lower arm supinated Therapist grasp s the patients hand/wrist at proximal row of carpals; fingers dorsal, thumbs volar at carpals Therapist mobilizes the radiocarpal joint into flexion with or without applying a co-current dorsal glide to the carpals

102 Accessory- Radiocarpal Patient supine, sitting or standing, lower arm pronated Therapist grasp s the patients hand/wrist at proximal row of carpals; fingers volar, thumbs dorsal at carpals Therapist mobilizes the radiocarpal joint into extension with or without applying a co-current volar glide to the carpals Extension

103 Radiocarpal Joint-Pronation Proximal Hand-stabilize distal radio-ulnar joint (DRUJ) w thumb on posterior ulna and index finger on anterior radius Distal Hand-Grasp around posterior proximal carpal rowthumb hooks anterior triquetrum, index finger on posterior scaphoid Mobilize proximal carpal row into pronation w thumb and index finger of distal hand Stabilize w proximal hand to prevent further pronation at DRUJ

104 Radiocarpal Joint- Supination Proximal Hand-stabilize DRUJ w thumb on posterior radius and index finger on anterior ulna Distal Hand-Grasp around posterior proximal carpal rowthumb hooks anterior scaphoid, index finger on posterior triquetrum Mobilize proximal carpal row into supination w thumb and index finger of distal hand Stabilize w proximal hand to prevent further supination at DRUJ

105 Accessory- Radiocarpal Joint Posterior Patient supine, elbow flexed on table, forearm neutral supination/pronation Therapist uses one hand to stabilize patient s posterior DRUJ with heel of hand Therapist uses other hand to grasps patient s anterior hand and firm contact on anterior proximal carpal row with heel of hand Stabilize DRUJ with proximal hand, applying an equal and opposite counterforce while mobilizing the proximal carpal row posteriorly

106 Accessory- Radiocarpal Joint Anterior Patient supine, elbow flexed on table, forearm neutral supination/pronation Therapist uses proximal hand to stabilize patient s anterior DRUJ with heel of hand Therapist uses distal hand to grasps patient s posterior hand and firm contact on posterior proximal carpal row with heel of hand Stabilize DRUJ with proximal hand, applying an equal and opposite counterforce while mobilizing the proximal carpal row anteriorly

107 Fernandez-de-las-penas et al., 2017 Single-blinded, randomized control trial 100 women with CTS; clinical and EMG findings Random allocation to manual therapy or surgery groups Manual Therapy: 3 sessions, 30 minutes in duration Cervical spine, shoulder, elbow, wrist, and fingers Stretching exercises targeted at cervical spine Surgery: endoscopic release Outcomes measured: Boston Carpal Tunnel Questionnaire, pinch-grip, and cervical ROM At one month significant improvements in function and pinch grip favoring MT Three, six and twelve months no difference between groups Fernández-De-Las-Peñas C, Cleland J, Palacios-Ceña M, Fuensalida-Novo S, Pareja JA, Alonso-Blanco C. The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(3): doi: /jospt

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109 Accessory- Radiocarpal Medial Patient position, elbow extended with wrist off table, thumb up Therapist s proximal hand grips around patient s distal radius and ulna, knuckles resting on table Therapist s distal hand grips around pateint s proximal carpal row with first web space placed around scaphoid Therapist mobilizes proximal carpal row medially (toward floor) using arm and shoulder of distal hand Transverse Glide

110 Accessory- Radiocarpal Lateral Transverse Glide Patient position, elbow extended with wrist off table, thumb down Therapist s proximal hand grips around patient s distal radius and ulna, knuckles resting on table Therapist s distal hand grips around pateint s proximal carpal row with first web space placed around triquetrum Therapist mobilizes proximal carpal row laterally (toward floor) using arm and shoulder of distal hand

111 Accessory- Inter-Carpal Joint Patient supine, sitting or standing Therapist identifies the joint to be assessed, stabilizes one bone with the thumb and digit of one hand and with the thumb and digit of the other hand, grasps the adjacent bone Therapist glides one bone in either of palmar or dorsal direction relative to the adjacent stabilized bone

112 Carpal Palpation Distal Row of Carpals Dorsal view of right hand, use Capitate as Key Stone Follow 3 rd Metacarpal to Capitate Move laterally off Capitate to Trapezoid Proximal to based of 2 nd Metacarpal Move laterally again off Trapezoid to Trapezium Proximal to base of 1 st Metacarpal Starting back at Capitate move medially off Capitate to Hamate Proximal to base of off 4 th and 5 th Metacrapal Proximal Row of Carpals Starting at Capitate move proximally to Lunate Move laterally off Lunate to Scaphoid Starting back at Lunate move medially to Triquetrum Palmar and slightly lateral to Triquetrum is Pisiform

113 Intercarpal Joint-Horizontal Extension Patient supine, elbow flexed resting on table, forearm pronated Therapist at head of table holds patient s hand from the back with thumbs or thernar eminance positioned centrally over the metacarpals/carpals and fingers positioned around the pisiform and CMC joint Therapist uses both thumbs or thenar eminance as a fulcrum, pulling posteriorly/laterally and the medial and lateral margins of the carpal rows, creating and anterior force at the fulcrum point

114 Should Physical Therpists Be Treating Elbow, Hand, and Wrist?

115 Thank You! Contact Information:

116 Bonus Material

117 Upper Limb Tension Testing For all UE symptoms, neurodynamics need to be considered and treated if necessary Uses specific combinations of active or passive movements that aim to reduce nerve mechanosensitivity and restore symptom-free function.

118 Nee et al., JOSPT, 2012 Median Nerve

119 Median Nerve Sensitization maneuver with cervical side-bending

120 Nee et al., JOSPT, 2012 Ulnar Nerve

121 Ulnar Nerve

122 Nee et al., JOSPT, 2012 Radial Nerve

123 Radial Nerve

124

125 Who is most likely to respond? Absence of neuropathic pain descriptions Older age Smaller deficits in median nerve neurodynamic test rage of motion (elbow extension) Absence of hard neurologic findings (myotome weakness, DTR changes, upper motor neuron lesions, etc.)

126 Treatment Considerations Treatment sequence Start proximal and move distal Local manual therapy (treat the container) Sliders: Movement that lengthens the corresponding nerve bed is counterbalanced by another movement that shortens the nerve bed. When the targeted nerve segment is between the two moving joints, sliding techniques produce significant nerve excursion with minimal increases in nerve strain. Tensioners: Only involves movements that lengthen the nerve; produced significant nerve excursion and nerve strain. Careful to provoke symptoms Nee et al., Contemp Clinical Trials, 2011