- Email: [email protected]
Joint mobilization and manipulation of the elbow
Chapter
| 25 |
Joint mobilization and manipulation of the elbow Helen Slater, Ce´sar Ferna´ndez de las Pen˜as
CHAPTER CONTENTS Introduction Evidence-based decision-making Definitions and clinical applications Mobilization and manipulation techniques Mobilization in extension combined with adduction (varus mobilization) Mobilization in adduction and abduction (varus to valgus mobilization) Mobilization in pronation/supination combined with flexion Mobilization of the radio-humeral joint Lateral glide mobilization-with-movement (MWM) Manipulation in lateral glide of the elbow (varus thrust manipulation) Conclusion
328 328 329 330 330 331 331 332 332 332 333
INTRODUCTION Mobilization and manipulation interventions of the elbow joint are frequently used in clinical practice, and although the evidence for their use is as yet insufficient, it is growing (Vicenzino et al 2007). Systematic reviews in relation to the elbow refer mainly to specific elbow conditions such as lateral epicondylalgia (Smidt et al 2003, Assendelft et al 2004, Vicenzino et al 2007). Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions due to contradicting results, insufficient statistical power, and the low number of studies per intervention (Smidt et al 2003). More recent high quality studies
328
provide evidence that joint manipulation/mobilization directed at the elbow and wrist results in beneficial alterations in pain and the motor system (Vicenzino et al 2007). A meta-analysis of two randomized controlled trials showed that elbow mobilization improved pain-free grip strength and pressure pain threshold in comparison with placebo at short-term follow-up (Bisset et al 2005). A few cases reporting the use of specific mobilization interventions for elbow disorders have also been published, including a patient with ulnar tunnel syndrome (Lawrence & Humphreys 1997) and a patient with lateral epicondylalgia (Kaufman 2000). Given the low level of evidence for single case studies, clinicians are cautioned against making any conclusions from case studies alone.
EVIDENCE-BASED DECISION-MAKING In choosing joint mobilization as part of multimodal management, consideration must be given to interpreting the clinical (patient) manifestations of peripheral and central sensitization processes involved in musculoskeletal disorders. For example, in patients with unilateral lateral epicondylalgia, evidence of bilateral manifestations of deep tissue hyperalgesia indicates that peripheral sensitization alone is unlikely to explain the clinical presentation (Slater et al 2005, Fernandez-Carnero et al 2008, 2009). In the Slater et al (2005) study, evidence of widespread pain, referred pain and changes in somatosensory sensitivity raises the index of suspicion that patients with lateral epicondylalgia demonstrate alterations in the way in which the nervous system processes nociceptive and non-nociceptive information. Therefore, clinical management of patients with lateral epicondylalgia may need to extend beyond local tissue-based pathology, to incorporate © 2011 Elsevier Ltd. DOI: 10.1016/B978-0-7020-3528-9.00025-X
Chapter | 25 |
Joint mobilization and manipulation of the elbow
strategies directed at normalizing nervous system sensitivity. Changes in somatosensory function, manifested clinically by persistent musculoskeletal pain (Graven-Nielsen 2006), also impacts motor systems with changes in the drive to muscle and altered motor control (Arendt-Nielsen & Graven-Nielsen 2008). Management cannot therefore focus on the simple biomechanics of joint mobilization, but must incorporate the more recent findings on sensory– motor interactions in persistent musculoskeletal pain disorders. In considering the choice of joint mobilization as an intervention, clinicians should also consider the potential neurophysiologic and tissue mechanisms underlying the effects (positive and negative) of mobilization. Multiple interacting tissue and pain mechanisms are likely to contribute to pain modulatory effects of mobilization (Slater et al 2006, Vicenzino et al 2007). For a comprehensive review of putative mechanisms underlying the effects of mobilization readers are referred to Paungmali et al (2003), Bisset et al (2006), Vicenzino et al (2007) and Chapter 23 of this textbook. Where a patient’s elbow disorder appears mediated primarily by peripheral nociceptive mechanisms (dominantly peripheral sensitization), early and appropriate physiologic movements and functional activity should be encouraged. In such cases, while joint mobilization may offer benefits in terms of pain relief and restoration of joint mobility, the ultimate aim of such techniques is the restoration of function limiting the chance of sustained central nervous system facilitation (central sensitization). Seldom in clinical practice would a unimodal approach, using mobilization alone, be considered appropriate for the management of elbow disorders. More commonly, mobilization would be incorporated into a multimodal approach. For example, depending on the chronicity of the disorder and the associated level of impairment and disability, patients would be educated on optimizing normal functional movements and undertaking active and specific exercises to maintain gains in pain-free joint ranges. The use of appropriate soft tissues techniques to address soft tissue contributions at the elbow may also be explored (Chapters 32–36). If required, help may be sought through the patient’s doctor in regard to appropriate analgesics, the primary purpose of analgesia (acetoaminophen, non-steroidal anti-inflammatories) being to provide a therapeutic window for regaining function. Additional considerations may also be required when the elbow condition is compromised by contributing factors such as a loss of the normal dynamic control of the shoulder joint (Chapters 17, 18 and 21), or a compromise of wrist stability (Chapter 27). Such contributing factors need to be addressed in the overall management of the patient with elbow disorders if an optimal outcome is to be achieved. Equally, the possibility of intra-articular pathologies including loose bodies, osteochrondritis,
and other conditions such as osteoarthritis, valgus instability with ulnar nerve trauma in patients involved in throwing sports, or a covert postero-lateral pathology following a fall onto an outstretched hand, should all be given due consideration prior to any decision that manual techniques are indicated in management (Chapter 24). For all patients, reassessment of the outcome of any intervention, including joint mobilization should include a subjective inquiry as to the treatment effects (positive and negative), re-examination of key initial physical findings (for example, loss of joint range and associated pain provocation, mechanical hyperalgesia) and functional limitations. Where possible, the parallel use of relevant outcome measures to assess the response to treatment is consistent with current best clinical practice. Examples of outcome measures that could be used for elbow disorders include the Patient-Specific Functional Scale (PSFS) or the Disability of Arm, Shoulder and Hand (DASH) tool.
DEFINITIONS AND CLINICAL APPLICATIONS Joint mobilization is usually defined as low velocity, high amplitude passive motion inducing intra-capsular movement at different amplitudes (Hengeveld et al 2005, Takei 2005), whereas joint manipulation is defined as a high velocity, low amplitude thrust motion. Maitland (1986) described different grades of mobilization according to the amplitude of the motion and resistance offered by the surrounding tissues (Hengeveld et al 2005). Maitland (1986) previously described four different standard oscillatory grades of movement. The differentiation between oscillations relates to amplitude with grade I and IV referring to small amplitude oscillation, while II and III indicate large amplitude oscillation. Conventionally, mobilizations with grades I–II are usually used for patients where the pain is the dominant symptom and a patient’s disorder is considered irritable in nature. In contrast, grades III–IV are usually used in patients where the main symptom response relates to limitation of elbow joint range and this restriction is associated with some pain provocation. Grade V refers to high velocity manipulation. In order to regain range, joint mobilization is provided at the limit of range, and the therapist expects a pain response, which should settle immediately or within seconds of the mobilization being completed. In current clinical practice, the use of a grade I mobilization is rare. More commonly, acute nociceptive elbow pain is managed using a combination of simple analgesia if required and appropriate early active movement to regain function and minimize prolonged sensitization. If passive movement is indicated in such a presentation, then large amplitude mobilization performed short of pain provocation
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(grade II or III ) offers the patient the advantage of increasing range and reducing pain. Patients are encouraged to continue with appropriate analgesia and maintain gains in range with active movements. Where patients present with persistent elbow pain (for example, tendinopathy or osteoarthritis), management will require a combined approach with joint mobilization offering only limited benefit when used as a unimodal intervention. Treatment ‘dose’ (how long and how many) is decided based on the clinical presentation with 30–60 seconds followed by reassessment typical for more acute disorders (2–3 repetitions) and 60–180 seconds (4–5 repetitions) for more chronic hypomobility disorders. When choosing to mobilize the elbow joint, a skilled therapist typically uses a clinically reasoned process rather than a doctrinal or didactic approach. For example, the grade of a technique is typically guided by the patient’s clinical presentation, with due consideration of irritability (severity of disorder; nature of associated pathology or systemic disease if appropriate; the acute, subacute or chronic stage of the disorder; how easy it is to trigger symptoms; how long these symptoms then take to resolve or reduce to baseline; and any precautions or contraindications to manual interventions such as postero-lateral joint instability or significant neuropathic pain). Typically, symptoms that are localized, mechanically patterned (nociceptive) and with clearly identifiable aggravating factors and easing factors, appear most amenable to mobilization techniques. In such presentations, the choice of the technique is made by considering which articulation of the elbow joint is problematic (radiohumeral, radio-ulnar or humero-ulnar) and at which point in the joint range the symptoms occur. Most commonly mobilization will be used at the point in range where a loss of mobility occurs. Where an elbow disorder is more acute and hypomobility is evident through a large part of the joint range, physiological mobilization may be useful when performed throughout larger amplitudes of joint range. A good clinical example is the uncomplicated post fracture (out of cast) elbow, where large amplitude physiological joint mobilization helps to encourage joint mobility without compromising the fracture or exacerbating pain. Conversely, where joint mobility is lost at terminal extension or flexion or into abduction or adduction at terminal elbow extension, passive accessory joint mobilization performed at the point in range of restriction is most likely to be beneficial in restoring function. In summary, the use of clinical reasoning and current neurobiology of musculoskeletal pain to problem solve and assist in decision-making should lie central to clinical practice. For a comprehensive review of clinical reasoning in physiotherapy practice see Jones et al (2004). In the following part of the chapter, we describe some of the more commonly performed elbow mobilization/ manipulation interventions. For each technique, the optimal positions for patient relaxation and for the therapist
330
are described, however as with all manual techniques, appropriate positional modifications are to be considered and applied as required. For convenience, all technique descriptions relate to the right elbow. The combining of mobilization techniques with active movement (an approach described by Mulligan in 1989 as ‘Mobilizationwith-Movement’) may also offer alternatives or progressions of the basic techniques described here. The techniques outlined are not exhaustive. As with any technique, modifications and variations are worthy of consideration if a logical and scientific rationale can be provided. Additionally, given the bony configuration of the elbow joint, most clinical presentations where joint mobilization is indicated as part of management, involve pain provocation associated with hypomobility towards the end of joint ranges. These restrictions typically occur at terminal extension associated with a restriction of abduction and adduction, terminal extension with limitation of end range supination or pronation, and flexion limitation with restriction of pronation and supination. Often these patterns of restriction are associated with soft tissue limitations or heightened deep tissue sensitivity or trigger points (Chapter 32). For example, in patients with lateral epicondylalgia, terminal extension and adduction/ abduction can be provocative for pain however, supination performed in extension is also frequently limited. Careful examination may reveal a loss of tissue extensibility of the flexor and pronator muscle group and trigger points may exist in these tissues as well as in the extensor muscles. Techniques directed at normalizing this soft tissue limitation or heightened sensitivity should assist in restoring supination in extension (Chapters 32–36). Given the intimate anatomical and functional relationships in the upper limb kinetic chain, the techniques described in this chapter are complemented by techniques described in Chapters 20, 23 and 30.
MOBILIZATION AND MANIPULATION TECHNIQUES Mobilization in extension combined with adduction (varus mobilization) The aim of this mobilization technique is to improve the lateral glide of the elbow region, particularly of the radiohumeral joint, where pain or restriction is associated with active extension. Therefore, the clinical presentation would require limitation of terminal elbow extension and adduction and pain provocation in this position is likely and probably most evident at the lateral elbow, although medial joint pain can also be elicited. For this technique, the patient is lying supine with their elbow extended (Fig 25.1). To maximize stabilization, the therapist’s left elbow contacts the anterior part of the
Chapter | 25 |
Joint mobilization and manipulation of the elbow
Fig 25.1 Mobilization in extension combined with adduction (varus mobilization). Black arrows show the stabilizations at the shoulder and the elbow of the patient and the white arrow shows the direction of the mobilization force.
Fig 25.2 Mobilization in adduction and abduction (varus to valgus mobilization). White arrows show the direction of the medial or lateral mobilization force.
patient’s shoulder. Medial rotation of the whole arm allows the use of a gravity-assisted medial (varus) mobilization. The therapist’s left hand supports the patient’s elbow immediately proximal and medial to the elbow joint. The therapist’s right hand grasps the patient’s wrist with the therapist’s fingers placed over the dorsum of the hand. The technique consists of applying an appropriately graded oscillatory mobilisation into adduction (varus). The technique would be performed at the point in range prior to the onset of pain (acute, grade II or III ) or at the limitation of range (chronic, III–IV). Symptoms should be monitored and the grade of movement adjusted if required.
adduction (varus). The technique would be performed at the point in range prior to the onset of pain (acute, grade II or III ) or at the limitation of range (chronic, III–IV). Symptoms should be monitored as the grade of movement adjusted if required.
Mobilization in adduction and abduction (varus to valgus mobilization) The aim of this mobilization technique is to improve the lateral glide of the elbow region, specifically the radiohumeral and humero-ulnar joints, at the limitation of extension range. Therefore, the clinical patient presentation would require limitation of terminal elbow extension and abduction. Pain provocation in this position is likely and probably most evident at the medial elbow, although lateral joint symptoms may also occur. For this technique, the patient is lying supine with their elbow extended (Fig 25.2). The hands of the therapist grasp the forearm of the patient in close proximity to the elbow, with stabilization provided medially and laterally at the elbow. The tips of both thumbs are placed against the radial head anteriorly, whereas the remaining fingers spread medially/laterally around the patient’s forearm. The technique consists of applying a graded oscillatory lateral mobilization into abduction (valgus) or
Mobilization in pronation/supination combined with flexion The aim of this mobilization technique is to improve the pronation/supination rotational glide/spin of the radiohumeral joint where the limitation occurs in a flexion position. Therefore, the clinical presentation would require limitation of elbow flexion and pronation, functionally one of the most important positions to be able to attain. Pain provocation in this position is likely and probably most evident at the radio-humeral joint laterally or at the anterior joint line (common post fracture). For this technique, the patient is supine with the right elbow flexed and the forearm pronated. The therapist’s left hand is positioned with the dorsum of the fingers lying proximal to the elbow joint and the thumb distal to the elbow and making contact with the radial head. The proximal contact helps control the internal rotation of the patient’s humerus that occurs with forearm pronation. The therapist’s right hand grasps the patient’s right wrist at the dorsum of the distal radio-ulnar joint. The technique consists of applying an oscillatory mobilization force combining pronation and flexion (Fig 25.3). This technique may be also performed with the forearm in supination and at the limitation of flexion (Fig 25.4), although this is less commonly used in clinical practice. Symptoms should be monitored and the grade of movement adjusted if required.
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Fig 25.3 Mobilization in pronation combined with flexion. The white arrow shows the direction of the flexion force. A rotational mobilization in pronation of the forearm is applied with the other hand placed over the radio-humeral joint.
Fig 25.5 Mobilization of the radio-humeral Joint. The white arrow shows the postero-anterior glide applied over the radial head laterally.
range where there is pain provocation or joint hypomobility. The pads of both thumbs are placed against the radial head posteriorly whereas the remaining fingers spread comfortably proximally and distally around the patient’s forearm. The technique consists of applying oscillatory posterior-anterior glides of the radial head using an appropriate grade of movement. Symptoms should be monitored and the grade of movement adjusted if required.
Lateral glide mobilization-withmovement (MWM)
Fig 25.4 Mobilization in supination combined with flexion. The white arrow shows the direction of the flexion force. A rotational mobilization in supination of the forearm is applied with the other hand over the radio-humeral joint.
Mobilization of the radio-humeral joint The aim of this technique is to improve the anterior glide of the radio-humeral joint (Edmond 2006) where there is associated joint restriction and pain provocation. Radio-ulnar joint mobilization in the posterior-anterior medial direction can be performed effectively at 60 through 90 of flexion. For this technique, the patient is supine with the right elbow flexed to the point of restriction (Fig 25.5). The forearm may be supinated or pronated at the point in
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Despite the findings of human and animal studies, the specific mechanisms underlying the effects associated with the mobilization/manipulation techniques remain largely putative. The beneficial effects associated with the specific lateral glide-MWM are likely to relate to multiple and potentially interacting mechanisms and these are discussed in more detail elsewhere (Slater et al 2006, Vicenzino et al 2007). For a detailed description of this technique, see Chapter 23.
Manipulation in lateral glide of the elbow (varus thrust manipulation) The patient is supine or seated with the elbow extended. For patients where no contraindications exist, joint manipulation can be an effective treatment progression. As with any manipulative technique, due care must be taken to exclude any contraindication to high velocity thrust. Screening questions that contraindicate joint manipulation include evidence of, or suspicion of, intra articular pathologies, fracture, compromised bone density, prolonged use of corticosteroids or anti-coagulant medication, pain dominant disorders and young children
Chapter | 25 |
Joint mobilization and manipulation of the elbow
Fig 25.6 Manipulation in lateral glide of the elbow (varus thrust manipulation). The black arrow shows the therapist’s lateral stabilizing hand placed distal to the radio-humeral joint. The white arrow shows the varus direction of the high-velocity low-amplitude thrust.
elbow. Slight external rotation of the patient’s whole arm allows a gravity-assisted thrust. Ensure that the elbow joint is not locked in full extension, but approximately 5 short of full extension as this avoids a painful and unsuccessful thrust. Examine the position of restriction to establish the direction that is restricted by gently guiding the joint laterally (varus force). It is important that the therapist’s right (thrusting) arm is placed perpendicular to the patient’s elbow joint. Inform the patient to soften their arm and relax. Inform your patient that you will now provide a rapid thrust and this may be associated with an audible clicking or popping sound. Reassurance that this popping sound is expected and simply indicates a joint cavitation, is helpful advice for patients. The technique then consists of applying a high-velocity low-amplitude thrust (grade V) force directed in a medio-lateral direction. Post manipulation, joint range and pain provocation should be reassessed.
CONCLUSION where bone maturity is incomplete. Once the decision is made to proceed to manipulation, clear succinct information should be provided to the patient with risks and benefits discussed. As a minimum, verbal consent and a record in the patient notes indicating agreement to proceed with manipulation is recommended. The therapist’s left hand is placed just distal to the patient’s right radio-humeral joint extending over the lateral part of the elbow joint (Fig 25.6). The therapist’s right hand grasps the patient’s forearm medially at the
There is increasing evidence that when used appropriately, joint mobilization and manipulation techniques can help to alleviate pain and assist in restoring function in patients with musculoskeletal elbow disorders. Clinicians need to understand the putative neurophysiologic and tissue mechanisms underlying elbow joint mobilization (including placebo analgesia) and recognize that these techniques typically contribute only a small part of a more comprehensive evidence-based management approach.
REFERENCES Arendt-Nielsen, L., Graven-Nielsen, T., 2008. Muscle pain: sensory implications and interaction with motor control. Clin. J. Pain 24, 291–298. Assendelft, W., Green, S., Buchbinder, R., Struijs, P., Smidt, N., 2004. Tennis elbow. Clin. Evid. 11, 1633–1644. Bisset, L., Paungmali, A., Vicenzino, B., Beller, E., 2005. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br. J. Sports Med. 39, 411–422. Bisset, L., Beller, E., Jull, G., et al., 2006. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 333, 939.
Edmond, S.L., 2006. Joint mobilization/ manipulation. 2nd ed. Mosby Elsevier, London, pp. 86–87. Fernandez-Carnero, J., Fernandez-delas-Pen˜as, C., de la Llave-Rincon, A.I., Ge, H.Y., Arendt-Nielsen, L., 2008. Bilateral myofascial trigger points in the forearm muscles in patients with chronic unilateral lateral epicondylalgia: a blinded, controlled study. Clin. J. Pain 24, 802–807. Fernandez-Carnero, J., Fernandez-de-LasPenas, C., de la Llave-Rincon, A.I., Ge, H.Y., Arendt-Nielsen, L., 2009. Widespread mechanical pain hypersensitivity as sign of central sensitization in unilateral epicondylalgia: a blinded, controlled study. Clin. J. Pain 25, 555–561.
Graven-Nielsen, T., 2006. Fundamentals of muscle pain, referred pain, and deep tissue hyperalgesia. Scand. J. Rheumatol. 122, 1–43. Hengeveld, E., Banks, K., Wells, P., 2005. Maitland’s peripheral manipulation, fourth ed. Elsevier Health Sciences, London. Jones, M.A., Rivett, D.A., Twomey, L., 2004. Clinical Reasoning for Manual Therapists. Elsevier Science Ltd, Butterworth-Heinemann, London. Kaufman, R.L., 2000. Conservative chiropractic care of lateral epicondylitis. J. Manipulative Physiol. Ther. 23, 619–622. Lawrence, D.J., Humphreys, C.R., 1997. Cubital tunnel syndrome: a case report. Chiropractic Techniques 9, 27–31.
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Maitland, G.D., 1986. Vertebral manipulation, fifth ed. ButterworthHeinemann, London. Mulligan, B., 1989. Manual Therapy ‘NAGS’, ‘SNAGS’, ‘MWMs’ etc. Plane View Services, Wellington, New Zealand. Paungmali, A., Vicenzino, B., Smith, M., 2003. Hypoalgesia induced by elbow manipulation in lateral epicondylalgia does not exhibit tolerance. J. Pain 4, 448–454.
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Slater, H., Arendt-Nielsen, L., Wright, A., Graven-Nielsen, T., 2005. Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness. Pain 114, 118–130. Slater, H., Arendt-Nielsen, L., Wright, A., Graven-Nielsen, T., 2006. Effects of a manual therapy technique in experimental lateral epicondylalgia. Man. Ther. 11, 107–117.
Smidt, N., Assendelft, W.J., Arola, H., et al., 2003. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann. Med. 35, 51–62. Takei, H., 2005. Joint mobilization for bone and joint disease. Phys. Ther. Sci. 20, 219–225. Vicenzino, B., Cleland, J.A., Bisset, L., 2007. Joint manipulation in the management of lateral epicondylalgia: a clinical commentary. J. Man. Manip. Ther. 15, 50–56.
| 25 |
Joint mobilization and manipulation of the elbow Helen Slater, Ce´sar Ferna´ndez de las Pen˜as
CHAPTER CONTENTS Introduction Evidence-based decision-making Definitions and clinical applications Mobilization and manipulation techniques Mobilization in extension combined with adduction (varus mobilization) Mobilization in adduction and abduction (varus to valgus mobilization) Mobilization in pronation/supination combined with flexion Mobilization of the radio-humeral joint Lateral glide mobilization-with-movement (MWM) Manipulation in lateral glide of the elbow (varus thrust manipulation) Conclusion
328 328 329 330 330 331 331 332 332 332 333
INTRODUCTION Mobilization and manipulation interventions of the elbow joint are frequently used in clinical practice, and although the evidence for their use is as yet insufficient, it is growing (Vicenzino et al 2007). Systematic reviews in relation to the elbow refer mainly to specific elbow conditions such as lateral epicondylalgia (Smidt et al 2003, Assendelft et al 2004, Vicenzino et al 2007). Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions due to contradicting results, insufficient statistical power, and the low number of studies per intervention (Smidt et al 2003). More recent high quality studies
328
provide evidence that joint manipulation/mobilization directed at the elbow and wrist results in beneficial alterations in pain and the motor system (Vicenzino et al 2007). A meta-analysis of two randomized controlled trials showed that elbow mobilization improved pain-free grip strength and pressure pain threshold in comparison with placebo at short-term follow-up (Bisset et al 2005). A few cases reporting the use of specific mobilization interventions for elbow disorders have also been published, including a patient with ulnar tunnel syndrome (Lawrence & Humphreys 1997) and a patient with lateral epicondylalgia (Kaufman 2000). Given the low level of evidence for single case studies, clinicians are cautioned against making any conclusions from case studies alone.
EVIDENCE-BASED DECISION-MAKING In choosing joint mobilization as part of multimodal management, consideration must be given to interpreting the clinical (patient) manifestations of peripheral and central sensitization processes involved in musculoskeletal disorders. For example, in patients with unilateral lateral epicondylalgia, evidence of bilateral manifestations of deep tissue hyperalgesia indicates that peripheral sensitization alone is unlikely to explain the clinical presentation (Slater et al 2005, Fernandez-Carnero et al 2008, 2009). In the Slater et al (2005) study, evidence of widespread pain, referred pain and changes in somatosensory sensitivity raises the index of suspicion that patients with lateral epicondylalgia demonstrate alterations in the way in which the nervous system processes nociceptive and non-nociceptive information. Therefore, clinical management of patients with lateral epicondylalgia may need to extend beyond local tissue-based pathology, to incorporate © 2011 Elsevier Ltd. DOI: 10.1016/B978-0-7020-3528-9.00025-X
Chapter | 25 |
Joint mobilization and manipulation of the elbow
strategies directed at normalizing nervous system sensitivity. Changes in somatosensory function, manifested clinically by persistent musculoskeletal pain (Graven-Nielsen 2006), also impacts motor systems with changes in the drive to muscle and altered motor control (Arendt-Nielsen & Graven-Nielsen 2008). Management cannot therefore focus on the simple biomechanics of joint mobilization, but must incorporate the more recent findings on sensory– motor interactions in persistent musculoskeletal pain disorders. In considering the choice of joint mobilization as an intervention, clinicians should also consider the potential neurophysiologic and tissue mechanisms underlying the effects (positive and negative) of mobilization. Multiple interacting tissue and pain mechanisms are likely to contribute to pain modulatory effects of mobilization (Slater et al 2006, Vicenzino et al 2007). For a comprehensive review of putative mechanisms underlying the effects of mobilization readers are referred to Paungmali et al (2003), Bisset et al (2006), Vicenzino et al (2007) and Chapter 23 of this textbook. Where a patient’s elbow disorder appears mediated primarily by peripheral nociceptive mechanisms (dominantly peripheral sensitization), early and appropriate physiologic movements and functional activity should be encouraged. In such cases, while joint mobilization may offer benefits in terms of pain relief and restoration of joint mobility, the ultimate aim of such techniques is the restoration of function limiting the chance of sustained central nervous system facilitation (central sensitization). Seldom in clinical practice would a unimodal approach, using mobilization alone, be considered appropriate for the management of elbow disorders. More commonly, mobilization would be incorporated into a multimodal approach. For example, depending on the chronicity of the disorder and the associated level of impairment and disability, patients would be educated on optimizing normal functional movements and undertaking active and specific exercises to maintain gains in pain-free joint ranges. The use of appropriate soft tissues techniques to address soft tissue contributions at the elbow may also be explored (Chapters 32–36). If required, help may be sought through the patient’s doctor in regard to appropriate analgesics, the primary purpose of analgesia (acetoaminophen, non-steroidal anti-inflammatories) being to provide a therapeutic window for regaining function. Additional considerations may also be required when the elbow condition is compromised by contributing factors such as a loss of the normal dynamic control of the shoulder joint (Chapters 17, 18 and 21), or a compromise of wrist stability (Chapter 27). Such contributing factors need to be addressed in the overall management of the patient with elbow disorders if an optimal outcome is to be achieved. Equally, the possibility of intra-articular pathologies including loose bodies, osteochrondritis,
and other conditions such as osteoarthritis, valgus instability with ulnar nerve trauma in patients involved in throwing sports, or a covert postero-lateral pathology following a fall onto an outstretched hand, should all be given due consideration prior to any decision that manual techniques are indicated in management (Chapter 24). For all patients, reassessment of the outcome of any intervention, including joint mobilization should include a subjective inquiry as to the treatment effects (positive and negative), re-examination of key initial physical findings (for example, loss of joint range and associated pain provocation, mechanical hyperalgesia) and functional limitations. Where possible, the parallel use of relevant outcome measures to assess the response to treatment is consistent with current best clinical practice. Examples of outcome measures that could be used for elbow disorders include the Patient-Specific Functional Scale (PSFS) or the Disability of Arm, Shoulder and Hand (DASH) tool.
DEFINITIONS AND CLINICAL APPLICATIONS Joint mobilization is usually defined as low velocity, high amplitude passive motion inducing intra-capsular movement at different amplitudes (Hengeveld et al 2005, Takei 2005), whereas joint manipulation is defined as a high velocity, low amplitude thrust motion. Maitland (1986) described different grades of mobilization according to the amplitude of the motion and resistance offered by the surrounding tissues (Hengeveld et al 2005). Maitland (1986) previously described four different standard oscillatory grades of movement. The differentiation between oscillations relates to amplitude with grade I and IV referring to small amplitude oscillation, while II and III indicate large amplitude oscillation. Conventionally, mobilizations with grades I–II are usually used for patients where the pain is the dominant symptom and a patient’s disorder is considered irritable in nature. In contrast, grades III–IV are usually used in patients where the main symptom response relates to limitation of elbow joint range and this restriction is associated with some pain provocation. Grade V refers to high velocity manipulation. In order to regain range, joint mobilization is provided at the limit of range, and the therapist expects a pain response, which should settle immediately or within seconds of the mobilization being completed. In current clinical practice, the use of a grade I mobilization is rare. More commonly, acute nociceptive elbow pain is managed using a combination of simple analgesia if required and appropriate early active movement to regain function and minimize prolonged sensitization. If passive movement is indicated in such a presentation, then large amplitude mobilization performed short of pain provocation
329
Part | 4 |
The elbow region
(grade II or III ) offers the patient the advantage of increasing range and reducing pain. Patients are encouraged to continue with appropriate analgesia and maintain gains in range with active movements. Where patients present with persistent elbow pain (for example, tendinopathy or osteoarthritis), management will require a combined approach with joint mobilization offering only limited benefit when used as a unimodal intervention. Treatment ‘dose’ (how long and how many) is decided based on the clinical presentation with 30–60 seconds followed by reassessment typical for more acute disorders (2–3 repetitions) and 60–180 seconds (4–5 repetitions) for more chronic hypomobility disorders. When choosing to mobilize the elbow joint, a skilled therapist typically uses a clinically reasoned process rather than a doctrinal or didactic approach. For example, the grade of a technique is typically guided by the patient’s clinical presentation, with due consideration of irritability (severity of disorder; nature of associated pathology or systemic disease if appropriate; the acute, subacute or chronic stage of the disorder; how easy it is to trigger symptoms; how long these symptoms then take to resolve or reduce to baseline; and any precautions or contraindications to manual interventions such as postero-lateral joint instability or significant neuropathic pain). Typically, symptoms that are localized, mechanically patterned (nociceptive) and with clearly identifiable aggravating factors and easing factors, appear most amenable to mobilization techniques. In such presentations, the choice of the technique is made by considering which articulation of the elbow joint is problematic (radiohumeral, radio-ulnar or humero-ulnar) and at which point in the joint range the symptoms occur. Most commonly mobilization will be used at the point in range where a loss of mobility occurs. Where an elbow disorder is more acute and hypomobility is evident through a large part of the joint range, physiological mobilization may be useful when performed throughout larger amplitudes of joint range. A good clinical example is the uncomplicated post fracture (out of cast) elbow, where large amplitude physiological joint mobilization helps to encourage joint mobility without compromising the fracture or exacerbating pain. Conversely, where joint mobility is lost at terminal extension or flexion or into abduction or adduction at terminal elbow extension, passive accessory joint mobilization performed at the point in range of restriction is most likely to be beneficial in restoring function. In summary, the use of clinical reasoning and current neurobiology of musculoskeletal pain to problem solve and assist in decision-making should lie central to clinical practice. For a comprehensive review of clinical reasoning in physiotherapy practice see Jones et al (2004). In the following part of the chapter, we describe some of the more commonly performed elbow mobilization/ manipulation interventions. For each technique, the optimal positions for patient relaxation and for the therapist
330
are described, however as with all manual techniques, appropriate positional modifications are to be considered and applied as required. For convenience, all technique descriptions relate to the right elbow. The combining of mobilization techniques with active movement (an approach described by Mulligan in 1989 as ‘Mobilizationwith-Movement’) may also offer alternatives or progressions of the basic techniques described here. The techniques outlined are not exhaustive. As with any technique, modifications and variations are worthy of consideration if a logical and scientific rationale can be provided. Additionally, given the bony configuration of the elbow joint, most clinical presentations where joint mobilization is indicated as part of management, involve pain provocation associated with hypomobility towards the end of joint ranges. These restrictions typically occur at terminal extension associated with a restriction of abduction and adduction, terminal extension with limitation of end range supination or pronation, and flexion limitation with restriction of pronation and supination. Often these patterns of restriction are associated with soft tissue limitations or heightened deep tissue sensitivity or trigger points (Chapter 32). For example, in patients with lateral epicondylalgia, terminal extension and adduction/ abduction can be provocative for pain however, supination performed in extension is also frequently limited. Careful examination may reveal a loss of tissue extensibility of the flexor and pronator muscle group and trigger points may exist in these tissues as well as in the extensor muscles. Techniques directed at normalizing this soft tissue limitation or heightened sensitivity should assist in restoring supination in extension (Chapters 32–36). Given the intimate anatomical and functional relationships in the upper limb kinetic chain, the techniques described in this chapter are complemented by techniques described in Chapters 20, 23 and 30.
MOBILIZATION AND MANIPULATION TECHNIQUES Mobilization in extension combined with adduction (varus mobilization) The aim of this mobilization technique is to improve the lateral glide of the elbow region, particularly of the radiohumeral joint, where pain or restriction is associated with active extension. Therefore, the clinical presentation would require limitation of terminal elbow extension and adduction and pain provocation in this position is likely and probably most evident at the lateral elbow, although medial joint pain can also be elicited. For this technique, the patient is lying supine with their elbow extended (Fig 25.1). To maximize stabilization, the therapist’s left elbow contacts the anterior part of the
Chapter | 25 |
Joint mobilization and manipulation of the elbow
Fig 25.1 Mobilization in extension combined with adduction (varus mobilization). Black arrows show the stabilizations at the shoulder and the elbow of the patient and the white arrow shows the direction of the mobilization force.
Fig 25.2 Mobilization in adduction and abduction (varus to valgus mobilization). White arrows show the direction of the medial or lateral mobilization force.
patient’s shoulder. Medial rotation of the whole arm allows the use of a gravity-assisted medial (varus) mobilization. The therapist’s left hand supports the patient’s elbow immediately proximal and medial to the elbow joint. The therapist’s right hand grasps the patient’s wrist with the therapist’s fingers placed over the dorsum of the hand. The technique consists of applying an appropriately graded oscillatory mobilisation into adduction (varus). The technique would be performed at the point in range prior to the onset of pain (acute, grade II or III ) or at the limitation of range (chronic, III–IV). Symptoms should be monitored and the grade of movement adjusted if required.
adduction (varus). The technique would be performed at the point in range prior to the onset of pain (acute, grade II or III ) or at the limitation of range (chronic, III–IV). Symptoms should be monitored as the grade of movement adjusted if required.
Mobilization in adduction and abduction (varus to valgus mobilization) The aim of this mobilization technique is to improve the lateral glide of the elbow region, specifically the radiohumeral and humero-ulnar joints, at the limitation of extension range. Therefore, the clinical patient presentation would require limitation of terminal elbow extension and abduction. Pain provocation in this position is likely and probably most evident at the medial elbow, although lateral joint symptoms may also occur. For this technique, the patient is lying supine with their elbow extended (Fig 25.2). The hands of the therapist grasp the forearm of the patient in close proximity to the elbow, with stabilization provided medially and laterally at the elbow. The tips of both thumbs are placed against the radial head anteriorly, whereas the remaining fingers spread medially/laterally around the patient’s forearm. The technique consists of applying a graded oscillatory lateral mobilization into abduction (valgus) or
Mobilization in pronation/supination combined with flexion The aim of this mobilization technique is to improve the pronation/supination rotational glide/spin of the radiohumeral joint where the limitation occurs in a flexion position. Therefore, the clinical presentation would require limitation of elbow flexion and pronation, functionally one of the most important positions to be able to attain. Pain provocation in this position is likely and probably most evident at the radio-humeral joint laterally or at the anterior joint line (common post fracture). For this technique, the patient is supine with the right elbow flexed and the forearm pronated. The therapist’s left hand is positioned with the dorsum of the fingers lying proximal to the elbow joint and the thumb distal to the elbow and making contact with the radial head. The proximal contact helps control the internal rotation of the patient’s humerus that occurs with forearm pronation. The therapist’s right hand grasps the patient’s right wrist at the dorsum of the distal radio-ulnar joint. The technique consists of applying an oscillatory mobilization force combining pronation and flexion (Fig 25.3). This technique may be also performed with the forearm in supination and at the limitation of flexion (Fig 25.4), although this is less commonly used in clinical practice. Symptoms should be monitored and the grade of movement adjusted if required.
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Fig 25.3 Mobilization in pronation combined with flexion. The white arrow shows the direction of the flexion force. A rotational mobilization in pronation of the forearm is applied with the other hand placed over the radio-humeral joint.
Fig 25.5 Mobilization of the radio-humeral Joint. The white arrow shows the postero-anterior glide applied over the radial head laterally.
range where there is pain provocation or joint hypomobility. The pads of both thumbs are placed against the radial head posteriorly whereas the remaining fingers spread comfortably proximally and distally around the patient’s forearm. The technique consists of applying oscillatory posterior-anterior glides of the radial head using an appropriate grade of movement. Symptoms should be monitored and the grade of movement adjusted if required.
Lateral glide mobilization-withmovement (MWM)
Fig 25.4 Mobilization in supination combined with flexion. The white arrow shows the direction of the flexion force. A rotational mobilization in supination of the forearm is applied with the other hand over the radio-humeral joint.
Mobilization of the radio-humeral joint The aim of this technique is to improve the anterior glide of the radio-humeral joint (Edmond 2006) where there is associated joint restriction and pain provocation. Radio-ulnar joint mobilization in the posterior-anterior medial direction can be performed effectively at 60 through 90 of flexion. For this technique, the patient is supine with the right elbow flexed to the point of restriction (Fig 25.5). The forearm may be supinated or pronated at the point in
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Despite the findings of human and animal studies, the specific mechanisms underlying the effects associated with the mobilization/manipulation techniques remain largely putative. The beneficial effects associated with the specific lateral glide-MWM are likely to relate to multiple and potentially interacting mechanisms and these are discussed in more detail elsewhere (Slater et al 2006, Vicenzino et al 2007). For a detailed description of this technique, see Chapter 23.
Manipulation in lateral glide of the elbow (varus thrust manipulation) The patient is supine or seated with the elbow extended. For patients where no contraindications exist, joint manipulation can be an effective treatment progression. As with any manipulative technique, due care must be taken to exclude any contraindication to high velocity thrust. Screening questions that contraindicate joint manipulation include evidence of, or suspicion of, intra articular pathologies, fracture, compromised bone density, prolonged use of corticosteroids or anti-coagulant medication, pain dominant disorders and young children
Chapter | 25 |
Joint mobilization and manipulation of the elbow
Fig 25.6 Manipulation in lateral glide of the elbow (varus thrust manipulation). The black arrow shows the therapist’s lateral stabilizing hand placed distal to the radio-humeral joint. The white arrow shows the varus direction of the high-velocity low-amplitude thrust.
elbow. Slight external rotation of the patient’s whole arm allows a gravity-assisted thrust. Ensure that the elbow joint is not locked in full extension, but approximately 5 short of full extension as this avoids a painful and unsuccessful thrust. Examine the position of restriction to establish the direction that is restricted by gently guiding the joint laterally (varus force). It is important that the therapist’s right (thrusting) arm is placed perpendicular to the patient’s elbow joint. Inform the patient to soften their arm and relax. Inform your patient that you will now provide a rapid thrust and this may be associated with an audible clicking or popping sound. Reassurance that this popping sound is expected and simply indicates a joint cavitation, is helpful advice for patients. The technique then consists of applying a high-velocity low-amplitude thrust (grade V) force directed in a medio-lateral direction. Post manipulation, joint range and pain provocation should be reassessed.
CONCLUSION where bone maturity is incomplete. Once the decision is made to proceed to manipulation, clear succinct information should be provided to the patient with risks and benefits discussed. As a minimum, verbal consent and a record in the patient notes indicating agreement to proceed with manipulation is recommended. The therapist’s left hand is placed just distal to the patient’s right radio-humeral joint extending over the lateral part of the elbow joint (Fig 25.6). The therapist’s right hand grasps the patient’s forearm medially at the
There is increasing evidence that when used appropriately, joint mobilization and manipulation techniques can help to alleviate pain and assist in restoring function in patients with musculoskeletal elbow disorders. Clinicians need to understand the putative neurophysiologic and tissue mechanisms underlying elbow joint mobilization (including placebo analgesia) and recognize that these techniques typically contribute only a small part of a more comprehensive evidence-based management approach.
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