See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/232746026 Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions Article in The Journal of manual & manipulative therapy · November 2011 DOI: 10.1179/106698111X13129729551985 · Source: PubMed CITATIONS READS 20 881 3 authors: Ana Isabel de-la-Llave-Rincón Emilio Louie Puentedura King Juan Carlos University Baylor University 38 PUBLICATIONS 1,040 CITATIONS 94 PUBLICATIONS 1,673 CITATIONS SEE PROFILE SEE PROFILE César Fernández-de-Las-Peñas King Juan Carlos University 605 PUBLICATIONS 13,077 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Guest Editor of Diagnostics View project Thoracic spine pain/dysfunction and rehabilitation View project All content following this page was uploaded by Emilio Louie Puentedura on 04 June 2014. The user has requested enhancement of the downloaded file.
Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions ´n 1,2 , Emilio J Puentedura 3 , Ce ´sar Ferna ´ndez-de-las- Ana Isabel de-la-Llave-Rinco ˜as 1,2 Pen 1 Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey ´n, Madrid, Spain, 2 Esthesiology Laboratory of Universidad Rey Juan Carlos, Alcorco ´n, Juan Carlos, Alcorco Madrid, Spain, 3 Department of Physical Therapy, School of Allied Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches. Keywords: Upper quadrant, Pain, Sensitization, Neck, Thoracic, Manual therapy abnormalities. 7 Pain symptoms in the neck, shoulder, Introduction In the twenty-first century, upper quadrant syndromes or arm, which are not based on acute trauma or are common and cause substantial pain and disability. underlying systemic diseases, have been defined as It has been estimated that 70% of the population ‘complaints of the arm, neck and/or shoulder region’. experience neck or arm pain at some time during their This term suggests that symptoms in the upper life. 1,2 In fact, musculoskeletal disorders represent the quadrant may have different causes. majority of occupational ill-health and upper quad- In this paper, we will discuss: (1) the relevance of rant pain is second only to back pain as a cause of the cervical and thoracic spine in upper quadrant work-related illness. 3,4 In addition, upper quadrant pain syndromes and their management with manual pain represents high costs for health care systems as up therapy; (2) the presence of common sensitization to 58% of patients will make use of healthcare within mechanisms in different local pain syndromes of the the next 12 months. 5 upper quadrant; and (3) manual therapies propos- Walker-Bone et al. found that pain experienced in ed for upper quadrant pain syndromes based on the upper quadrant region is frequently perceived in nociceptive pain rationale. the dominant arm and the neck. 6 Upper quadrant pain can arise from several widely different conditions. In The Cervical and Thoracic Spine in Upper fact, different terms, i.e. cumulative trauma disorders, Quadrant Pain cervicobrachial disorders, repetitive strain injury, and Any innervated structure in the cervical and thoracic work-related upper limb disorders, have been used spine can be a source of nociception and provide an to describe pain at different sites in the neck and input mechanism for the experience of upper quadrant upper limb with no confirmed pathoanatomical pain. However, just as with low back pain, identifying the exact anatomical sources of neck and arm pain is Correspondence to: Ce ´sar Ferna ´ndez-de-las-Pen ˜as, Facultad de Ciencias often not possible. Current research is encouraging a de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 paradigm shift in clinical decision making away from Alcorco ´n, Madrid, Spain. Email: cesar.fernandez@urjc.es � W. S. Maney & Son Ltd 2011 Journal of Manual and Manipulative Therapy 2011 VOL . 19 NO . 4 201 DOI 10.1179/106698111X13129729551985
´n et al. de-la-Llave-Rinco Manual therapy for upper quadrant musculoskeletal conditions The treatment-based algorithm as outlined by Fritz and Brennan. 12 MOI: mechanism of injury; MVA: motor vehicle Figure 1 accident; NDI: neck disability index. the traditional tissue-based (biomedical) models of approach demonstrated that subjects receiving pain towards a more comprehensive biopsychosocial matched interventions were found to experience model. 8,9 The biopsychosocial model encompasses better outcomes (neck disability scores and pain more than just the biological factors (anatomy, ratings) than individuals receiving non-matched interventions. 12 The current TBC system for patients physiology, and pathoanatomy) in upper quadrant function, by addressing psychological (thoughts, with neck and arm pain is composed of five subgroups. 12 emotions, and behaviors), and social (work and classification The classification sub- playing status, culture, and religion) factors known groups are: mobility, centralization, exercise and to play a significant role in upper quadrant function in conditioning, pain control, and headache. An algo- the context of injury or illness. A true biopsychosocial rithm has been proposed to aid the clinician in model includes a greater understanding of how the determining which appropriate classification sub- nervous system processes injury, disease, pain, threat, group their patient should be assigned to (Fig. 1). and emotions. 10 The interventions proposed as a match for the The limitations of a tissue-based approach for respective subgroups include combinations of joint managing upper quadrant pain have led to current mobilization and/or manipulation; therapeutic exer- best evidence advocating a treatment-based classifi- cises including neuromuscular reeducation, stretching cation (TBC) approach. 11,12 With such an approach, and strengthening, cervical retraction, and manual/ mechanical traction. 15 We propose that neuroscience less emphasis is placed on locating the probable tissue sources of upper quadrant pain. Instead, greater education (i.e. explaining the patient’s pain) is an emphasis is placed on matching the patient to optimal intervention that should be provided across all interventions based on the identification of signs and subgroups if physical therapists wish to follow a true symptoms collected during the interview and physi- biopsychosocial approach to the management of cal examination. 12–14 Preliminary studies of a TBC upper quadrant pain. 202 Journal of Manual and Manipulative Therapy 2011 VOL . 19 NO . 4
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