Chiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients

Article (PDF Available)inJournal of chiropractic medicine 11(4):267-272 · December 2012with250 Reads
DOI: 10.1016/j.jcm.2012.07.001 · Source: PubMed
Abstract
The purpose of this case series is to describe the treatment and outcomes of a series of patients presenting with frozen shoulder syndrome who received a novel chiropractic approach (OTZ Tension Adjustment). The files of 50 consecutive patients who presented to a private chiropractic practice with frozen shoulder syndrome were reviewed retrospectively. Two primary outcomes were extracted from the files for initial examination and at final evaluation: (1) the 11-point numeric pain rating scale and (2) the percentage change in shoulder abduction. Each patient received a series of chiropractic manipulative procedures that focused on the cervical and thoracic spine. Of the case files reviewed, 20 were male and 30 were female; and all were between the ages of 40 and 70 years. The median number of days under care was 28 days (range, 11 to 51 days). The median change in Numeric Pain Rating Scale score was - 7 (range, 0 to - 10). Of the 50 cases, 16 resolved completely (100% improvement), 25 showed 75% to 90% improvement, 8 showed 50% to 75% improvement, and 1 showed 0% to 50% improvement. Most patients with frozen shoulder syndrome in this case series appeared to improve with the chiropractic treatment.
Chiropractic management of frozen shoulder syndrome
using a novel technique: a retrospective case series of
50 patients
Francis X. Murphy DC
a,
, Michael W. Hall DC, CCST, DABCN, FIACN
b
,
Louis D'Amico
c
, Anne M. Jensen DC, ICSSD, MSc, MSc
d
a
Chiropractor, Owner and Founder, OTZ Health Education Systems LLC, Dallas, TX
b
Professor, Department of Clinical Neurology, Parker University, Dallas, TX
c
Chiropractor, Vice President and Senior Trainer, OTZ Health Education Systems LLC, Dallas, TX
d
DPhil Candidate, Department of Primary Care and Department for Continuing Education,
University of Oxford, Oxford, UK
Received 15 August 2011; received in revised form 4 July 2012; accepted 23 July 2012
Key indexing terms:
Shoulder;
Adhesive capsulitis;
Chiropractic;
Musculoskeletal
manipulations
Abstract
Objective: The purpose of this case series is to describe the treatment and outcomes of a
series of patients presenting with frozen shoulder syndrome who received a novel chiropractic
approach (OTZ Tension Adjustment).
Methods: The files of 50 consecutive patients who presented to a private chiropractic practice
with frozen shoulder syndrome were reviewed retrospectively. Two primary outcomes were
extracted from the files for initial examination and at final evaluation: (1) the 11-point
numeric pain rating scale and (2) the percentage change in shoulder abduction. Each patient
received a series of chiropractic manipulative procedures that focused on the cervical and
thoracic spine.
Results: Of the case files reviewed, 20 were male and 30 were female; and all were between
the ages of 40 and 70 years. The median number of days under care was 28 days (range, 11 to
51 days). The median change in Numeric Pain Rating Scale score was 7 (range, 0 to 10).
Of the 50 cases, 16 resolved completely (100% improvement), 25 showed 75% to 90%
improvement, 8 showed 50% to 75% improvement, and 1 showed 0% to 50% improvement.
Conclusion: Most patients with frozen shoulder syndrome in this case series appeared to
improve with the chiropractic treatment.
© 2012 National University of Health Sciences.
www.journalchiromed.com
Corresponding author. 6211 W Northwest Hwy, Suite 159, Dallas, TX 75225. Tel.: + 1 214 3683030.
E-mail address: fxmdc@aol.com (F. X. Murphy).
1556-3707/$ see front matter © 2012 National University of Health Sciences.
http://dx.doi.org/10.1016/j.jcm.2012.07.001
Journal of Chiropractic Medicine (2012) 11, 267272
Introduction
Frozen shoulder syndrome (FSS) is a common
condition presenting to a variety of health care
practitioners including chiropractors, osteopaths, medi-
cal doctors, and physical therapists. Also referred to as
adhesive capsulitis, FSS remains one of the most poorly
understood shoulder conditions,
1
with its etiology and
pathogenesis largely disputed.
2
Recently, a consensus
denition of FSS was reached by the American Shoulder
and Elbow Surgeons to be a condition characterized by
functional restriction of both active and passive shoulder
motion for which radiographs of the glenohumeral joint
are essentially unremarkable.…”
1
The prevalence of FSS is thought to be 2% to 5% of
the general population.
2,3
It occurs usually between 40
and 60 years of age,
3
is 3 to 7 times more prevalent in
women than men,
4
and can be classied as either primary
or secondary.
1
A diagnosis of primary (or idiopathic)
FSS is made if no causative factors are identied on
history or examination.
3
Secondary FSS is thought to
develop following some trauma or systemic condition.
1
For instance, there is a high comorbidity of FSS in
patients with diabetes, with incidence rates nearing
40%.
5
In addition, FSS is also commonly found in
those with Parkinson disease, cardiovascular disease,
thyroid disease, and stroke.
6,7
In the absence of other pathological processes, a
diagnosis of FSS is made if the following criteria are
present: an insidious onset, night pain, painful
restriction of passive scapulohumeral elevation causing
shoulder abduction of less than 100°, and shoulder
external rotation of less than half of normal.
3
The current medical paradigm divides the natural
history of FSS into 3 stages (Fig 1): (1) the freezing stage,
characterized by diffuse pain and loss of motion (2-9
months); (2) the frozen stage, where pain decreases and
stiffness has maximized (4-12 months); and (3) the
thawing stage, characterized by a gradual normalization
of mobility and function (4-12 months).
3,8
Reeves,
8
who
rst described the 3 stages of the condition, reported that
FSS usually lasts from 1 to 3.5 years with a mean duration
of 30 months. However, Shaffer et al reported that, after 7
years, 50% of the cohort they studied continued to have
residual pain and/or loss of shoulder function.
9
The underlying etiology of FSS is largely disputed;
but it is commonly thought that its origins lie in biologic
factors, mechanical stress, and/or neovascularization of
the shoulder joint complex.
3
However, it is hypothe-
sized that the etiology of FSS is not as the current
paradigm describes, but rather is neuromechanical in
nature, originating in the cervical spine, cranium,
occipitoatlantal joints, and/or cranial nerve 11 (CNXI)
and causing malfunction of the trapezius muscle
resulting in a breakdown of the entire dynamic shoulder
complex.
10
In fact, the literature well describes the most
common symptoms of CNXI injury as (1) reduced
shoulder abduction, (1) drooped shoulder (tie), and (3)
shoulder pain,
11
which are also common symptoms of
FSS.
1,3
The inference that CNXI might be related to
FSS is the next logical step.
Support for a chiropractic approach toward FSS is
currently limited to a small pilot study
12
and a number
of case reports.
13,14
Common medical approaches
toward intervention focus on addressing the medical
etiology, namely, the shoulder joint complex. These
include nonsteroidal anti-inammatory drugs,
3,15
ste-
roid injection,
2,15,16
and shoulder surgery.
2,17
Inter-
ventions that physical therapists frequently use include
moist heat, ultrasonography, passive stretching, and
shoulder mobilization.
18-21
In addition, there is some
evidence in the physical therapy literature to support
manipulation of the cervical spine or cervicothoracic
spine for shoulder complaints.
22-26
Patients may
experience resolution when treated by these various
methods, but some may have residual pain and reduced
shoulder function even several years after treatment.
3
It
is clear that a more durable intervention is needed.
The purpo se of this article i s to describe the
outcomes of patients with FSS presenting to a private
chiropractic practice that used a novel chiropractic
treatment, the OTZ Tension Adjustment.
Case series
Case les of 50 consecutive patients presenting with
medically diagnosed FSS between May 2007 and
Fig 1. The three phases of FSS, rst described by Reeves.
8
(Adapted from Hsu et al.
3
)
268 F. X. Murphy et al.
March 2008 were identied and reviewed retrospec-
tively. Institutional Review Board approval was
obtained for this retrospective case series (Parker
University IRB Approval # R03_11).
The patients initially presented with active shoulder
abduction restricted to 90° or less in the affected shoulder.
Two primary outcomes were extracted from the patient
records at 2 points in time, upon initial examination and at
the nal evaluation: (1) the 11-point verbal Numeric Pain
Rating Scale (NPRS; 0 = no pain to 10 = worst pain
possible), which has been shown to be a valid and reliable
measure in patients with shoulder pain,
27
and (2) the
percentage change in active shoulder abduction, with
100% improvement meaning the patient achieved the
norm of 180° of pain-free active abduction.
28
Shoulder
abduction was measured twice, at the initial and nal
visits, by the same assessor using a wall goniometer
(Fig 2) with the patient's humeral head positioned in the
center of the circle. Each patient received a series of
chiropracti c manipulation treatments, by the same
practitioner, focusing on the cervical and thoracic spine.
The manipulation included an adjustment called the
One-to-Zero (OTZ) Tension Adjustment (OTZ Health
Education Systems, Dallas, TX). The OTZ Tension
Adjustment aims to correct occipitoatlantal articular
dysfunction (C0-C1 chiropractic subluxation).
29
It is
theorized that the technique identi es aberrant align-
ment of the occipitoatlantal articulation through visual
inspection and motion palpation.
29
In the procedure,
the doctor is seated at the head of the supine patient and
rst performs a specic skull glide to determine the
exact orientation of the dysfunctional joint
10
(Fig 3). A
high-velocity, low-amplitude thrust is delivered at the
level of the dysfunctional C0-C1 joint into the direction
of maximal restriction. The general line of drive is
posterior to anterior, lateral to medial, and slightly
superior to inferior (Fig 4).
10
After the adjustment is
made, the skull glide palpation is performed again to
conrm correction of the dysfunction.
Results
Of the 50 case les reviewed, 40% were male (n =
20) and 60% were female (n = 30); and all were
between the ages of 40 and 70 years. The median
number of days in the treatment program was 28 days,
with a range of 11 to 51 days, and interquartile range
(IQR) of 12.5 days. The median initial NPRS score
was 9 out of 10 with a range of 7 to 10 and an ICQ of
1.0. The median nal NPRS score was 2 with a range
of 0 to 10. The median change in NPRS score was 7
with a range of 0 to 10. Of the 50 cases, 16 resolved
completely, regaining 180° of pain-free active shoul-
der abduction (and 0 NPRS score). Anot her 25
showed 75% to 90% improvement in active abduc-
tion, 8 showed 50% to 75% improvement, and 1
showed 0% to 50% improvement (Table 1).
Fig 2. Example of one patient with FSS before (left) and after (right) an OTZ Tension Adjustment. (Color version of gure is
available online.)
269Frozen shoulder
Discussion
Frozen shoulder syndrome is a common condition of
insidious onset affecting middle-aged persons, yet its
etiology is still unclear. The current medical approach
is slow to show progress; and also, there is presently
little evidence to support chiropractic management of
this condition. The results of this case series are
encouraging in that many of these patients complaints
seemed to improve or resolve within 1 month of
presentation, whereas, in general, it is thought that FSS
symptoms can persist for 2 years or more.
8
It is speculated that the etiology of FSS lies in altered
neuromechanical fun ction of the trapezius muscle.
Increased hypertonicity of the upper bers of the upper
trapezius and sternocleidomastoideus (SCM) creates an
adverse positioning of the occipitoatlantal articulation.
30
It is posited that forward head posture results in this
abnormal tonus and may therefore cause dysfunction in
the spinal accessory nerve and/or trapezius and/or SCM.
This dysfunction may then cause the inability of the
trapezius to properly position the scapula in preparation
for shoulder abduction greater than 90°. This will
produce the rst hallmark of FSS: a decrease in shoulder
range of motion (ROM). Improper positioning of the
scapula may result in the humeral head compressing
sensitive tissue in the subacromial space, which would
cause the second hallmark of FSS: pain on scapulohum-
eral elevation. This biomechanical alteration will result
in inammation and, over time, in inter- and intraarti-
cular adhesions and brosis, often seen in long-standing
disease and evidenced by radiographic or arthroscopic
examinations.
3
However, it is hypothesized that the
brosis and adhesions are the sequelae of neurobiome-
chanical alterations involving forward head posture and
trapezius and scapulocostal articulation dysfunctions,
and not the cause of the syndrome itself (Fig 5).
It is further hypothesized that the OTZ Tension
Adjustment restores normal function of C0-C1, trape-
zius, and SCM, thereby restoring normal glenohumeral
mechanics, improving shoulder ROM, and reducing
pain on elevation of the arm.
Conservative (ie, nonsurgical) medical interventions
for FSS include nonsteroidal anti-inammatory drugs,
steroid injections and oral steroids, nerve blockades,
hydrodilatation, heat therapy, stretching, and manipu-
lation under anesthesia.
3
The evidence suggests that,
after 3 or more months of traditional treatment, patients
experience a reduction in pain and improved function.
3
In addition, although manipulation under anesthesia
has been extensively described in the medical literature,
it is routinely only performed on the shoulder joint
Fig 3. OTZ specic skull glide example positioning.
(Color version of gure is available online.)
Fig 4. OTZ Tension Adjustment setup positioning. (Color
version of gure is available online.)
Table 1 Prole of patients in study (N = 50)
Age range (y) 40-70
Male:female 20:30
Median # days in treatment (IQR) 28 (12.5)
Median # treatments (IQR) 7 (4.0)
Median treatment frequency: #/mo (IQR) 8 (2.0)
Median initial NPRS score (IQR) 9 (1.0)
Median nal NPRS score (IQR) 2 (2.0)
Median change in NPRS score (IQR) 7 (2.0)
Percent improvement in active abduction
(n)
90%-100% 16
75%-900% 25
50%-75% 8
Less than 50% 1
NPRS: 0 to 10 (with 0 = no pain, 10 = worst pain ever). IQR,
interquartile range.
Percentage improvement in active shoulder abduction of
affected shoulder at nal assessment.
270 F. X. Murphy et al.
complex, does not involve any spinal joints, and has
also been associated with a number of serious
iatrogenic complications.
3
A safer and more immediate
conservative therapy is needed.
It has been previously shown that some shoulder
complaints resolve after practitioner-applied manipula-
tion.
18,22-26,31-33
However, with regard to the efcacy
of chiropractic adjustments specically for shoulder
complaints, the current evidence is limited,
34
consisting
of one small pilot study,
12
a qualitative study,
35
and a
number of case reports
13,14,34,36
(such as this one). It is
clear that additional efcacy research is needed.
In this case series, patients presented with medically
diagnosed FSS; however, they all exhibited some
degree of shoulder pain and reduced shoulder abduc-
tion. Because syndrome diagnoses are often vague and
confusing, there is currently a trend away from many
shoulder diagnoses, such as FSS or adhesive capsulitis,
and toward a more descriptive term such as shoulder
pain or shoulder pain and dysfunction.
24,31
Future
research should follow this trend.
Limitations and future research
Because there have been no studies yet published on
this technique, a case series format was the logical place
to start. As a result, the limitations of this study are those
for any case series, such as that the management of these
patients occurred within a private chiropractic practice,
which was not controlled.
37
Another limitation is the use
of a measure that itself lacks evidence of validity. A more
accepted measure of joint ROM would have strength-
ened our ndings, as would the use of continuous rather
than discrete data. The inclusion of additional clinical
information, such as duration of symptomatology before
presentation and number of adjustments given, would
have also strengthened this case series.
Caution is urged when drawing denitive conclusions
from these resu lts or when generalizing to other
patients.
37
This study would have been strengthened
by the reporting of the length of time the patients had
the FSS symptoms before presentation. As well, long-
term follow up to identify if there was reoccurrence is
suggested for future studies.
Future research could include a 2-pronged approach.
First, a randomized controlled clinical trial could be
conducted to ascertain if a cause-and-effect relationship
exists between the OTZ Tension Adjustment and relief
of FSS symptoms. Second, basic science research could
be applied to determine if neurological dysfunction
(including CNXI) is involved in FSS pathogenesis.
Future research is warranted and should consist of
experimental clinical trials testing the effectiveness of
the OTZ Tension Adjustment in a controlled setting.
Conclusion
This retrospective case series of the outcome of
chiropractic treatment for patients with FSS using the
OTZ Tension Adjustment for FSS was reported with
encouraging preliminary results.
Funding sources and potential conflicts
of interest
No funding sources were reported for this study.
Francis Murphy and Louis D'Amico are principals and
owners of OTZ Health Education Systems.
References
1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus
definition. J Shoulder Elbow Surg 2011;20(2):322-5.
Fig 5. One hypothesized mechanism of the etiology of FSS.
271Frozen shoulder
2. Favejee MM, Huisstede BMA, Koes BW. Frozen shoulder: the
effectiveness of conservative and surgical interventions
systematic review. Br J Sports Med 2011;45(1):49-56.
3. Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA.
Current review of adhesive capsulitis. J Shoulder Elbow
Surg 2011;20:502-14.
4. Paget SA, Gibofsky A, Beary J, Sculco TP. Hospital for special
surgery manual of rheumatology and outpatient orthopedic
disorders: diagnosis and therapy. 5th ed. New York: Lippincott
Williams & Wilkins; 2006.
5. Tighe CB, Oakley WS. The prevalence of a diabetic condition and
adhesive capsulitis of the shoulder. South Med J 2008;101(6):
591-5.
6. Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petrova DR,
Finestone A. Risk factors for idiopathic frozen shoulder. Isr
Med Assoc J 2008;10(5):361-4.
7. Wong PLK, Tan HCA. A review on frozen shoulder. Singapore
Med J 2010;51(9):694-7.
8. Reeves B. The natural history of the frozen shoulder syndrome.
Scand J Rheumatol 1975;4(4):193-6.
9. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term
follow-up. J Bone Joint Surg-Series A 1992;74(5):738-46.
10. Murphy FX. Frozen shoulder syndrome diagnosis & treatment.
Dallas: OTZ Health Education Systems; 2009.
11. Aziz NH, Shakespeare DT. Blunt injury to the spinal accessory
nerve. Injury 1989;20(6):381-2.
12. Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A
prospective clinical trial comparing chiropractic manipulation
and exercise therapy vs. chiropractic mobilization and exercise
therapy for treatment of patients suffering from adhesive
capsulitis/frozen shoulder. J Am Chiropr Assoc 2008:12-28.
13. Gleberzon B. Successful chiropractic management of a
centenarian presenting with bilateral shoulder pain subsequent
to a fall. Clin Chiropr 2005;8(2):66-74.
14. Pribicevic M, Pollard H, Bonello R, De Luca K. A systematic
review of manipulative therapy for the treatment of shoulder
pain. J Manipulative Physiol Ther 2010;33(9):679-89.
15. Alvado A, Pélissier J, Bénaim C, Petiot S, Hérisson C. Physical
therapy of frozen shoulder: literature review. [Les traitements
physiques dans la rétraction capsulaire de l'épaule: revue de la
littérature.]. Ann Readapt Med Phys 2001;44(2):59-71.
16. Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A, et al.
Effectiveness of corticosteroid injection in adhesive capsulitis.
Clin Rehabil 2008;22(6):503-12.
17. Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of
current treatment. Am J Sports Med 2010;38(11):2346-56.
18. Camarinos J, Marinko L. Effectiveness of manual physical
therapy for painful shoulder conditions: a systematic review.
J Man Manipulative Ther 2009;17(4):206-15.
19. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder:
a prospective study of supervised neglect versus intensive
physical therapy in seventy-seven patients with frozen shoulder
syndrome followed up for two years. J Shoulder Elbow Surg
2004;13(5):499-502.
20. Leung MSF, Cheing GLY. Effects of deep and superficial
heating in the management of frozen shoulder. J Rehabil Med
2008;40(2):145-50.
21. Buchbinder R, Youd JM, Green S, Stein A, Forbes A, Harris A,
et al. Efficacy and cost-effectiveness of physiotherapy
following glenohumeral joint distension for adhesive capsulitis:
a randomized trial. Arthritis Care Res 2007;57(6):1027-37.
22. Bergman GJ, Winter JC, Van Tulder MW, Meyboom-De Jong
B, Postema K, Van Der Heijden GJ. Manipulative therapy in
addition to usual medical care accelerates recovery of shoulder
complaints at higher costs: economic outcomes of a random-
ized trial. BMC Musculoskelet Disord 2010;11:200.
23. Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G,
Hicks M, et al. Manipulative therapy for shoulder pain and
disorders: expansion of a systematic review. J Manipulative
Physiol Ther 2011;34(5):314-46.
24. McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D,
Agur A. Mobilizations of the asymptomatic cervical spine can
reduce signs of shoulder dysfunction in adults. Man Ther
2009;14(4):369-74.
25. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M,
Whitman JM. Some factors predict successful short-term
outcomes in individuals with shoulder pain receiving cervi-
cothoracic manipulation: a single-arm trial. Phys Ther 2010;
90(1):26-42.
26. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate
effects of thoracic spine and rib manipulation on subjects with
primary complaints of shoulder pain. J Man Manipulative Ther
2009;17(4):230-6.
27. Mintken PE, Glynn P, Cleland JA. Psychometric properties of
the shortened disabilities of the Arm, Shoulder, and Hand
Questionnaire (QuickDASH) and Numeric Pain Rating Scale in
patients with shoulder pain. J Shoulder Elbow Surg 2009;18(6):
920-6.
28. Bates B. A guide to physical examination and history taking.
5th ed. Philadelphia: J.B. Lippincott; 1991.
29. Murphy FX, Hall MW, Jensen AM. OTZ Tension Adjustment
for frozen shoulder syndrome: a retrospective case series of 50
cases. In: Johnson C, editor. World Federation of Chiropractic
Congress; Rio de Janeiro, Brazil; April 6-9, 2011.
30. Liebenson C. Rehabilitation of the spine: a practitioner's
manual. 2nd ed. Los Angeles: Lippincott, Williams & Wilkins;
2007.
31. Bergman GJ, Winters JC, Groenier KH, Meyboom-de Jong B,
Postema K, van der Heijden GJ. Manipulative therapy in addition
to usual care for patients with shoulder complaints: results of
physical examination outcomes in a randomized controlled trial.
J Manipulative Physiol Ther 2010;33(2):96-101.
32. Bergman GJD, Winters JC, Groenier KH, Pool JJM,
Meyboom-De Jong B, Postema K, et al. Manipulative therapy
in addition to usual medical care for patients with shoulder
dysfunction and pain: a randomized, controlled trial. Ann
Intern Med 2004;141(6):432-9+I-27.
33. Ylinen J, Kautiainen H, Wirén K, Häkkinen A. Stretching exercises
vs manual therapy in treatment of chronic neck pain: a randomized,
controlled cross-over trial. J Rehabil Med 2007;39(2):126-32.
34. McHardy A, Hoskins W, Pollard H, Onley R, Windsham R.
Chiropractic treatment of upper extremity conditions: a system-
atic review. J Manipulative Physiol Ther 2008;31(2):146-59.
35. Thiel HW, Bolton JE. Predictors for immediate and global
responses to chiropractic manipulation of the cervical spine.
J Manipulative Physiol Ther 2008;31(3):172-83.
36. Polkinghorn BS. Chiropractic treatment of frozen shoulder
syndrome (adhesive capsulitis) utilizing mechanical force,
manually assisted short lever adjusting procedures. J Manip-
ulative Physiol Ther 1995;18(2):105-15.
37. Green BN, Johnson CD. How to write a case report for
publication. J Chiropr Med 2006;5(2):72-82.
272 F. X. Murphy et al.
  • [Show abstract] [Hide abstract] 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.
    Full-text · Article · May 2013