SYSTEMATIC REVIEW

The Utilization of Joint Mobilization As Part

of a Comprehensive Program to Manage
Carpal Tunnel Syndrome: A Systematic
Review
Josiah D. Sault, DPT, a Dhinu J. Jayaseelan, DPT, b John J. Mischke, DPT, c and Andrew A. Post, DPT d
ABSTRACT

Objective: The purpose of this review is to identify the role of joint mobilization for individuals with Carpal tunnel
syndrome (CTS).
Methods: A systematic search of 5 electronic databases (PubMed, CINAHL, Scopus, Cochrane Central Register of
Controlled Trials, and SPORTDiscus) was performed to identify eligible full-text randomized clinical trials related to
the clinical question. Joint mobilization had to be included in one arm of the randomized clinical trials to be included.
Two reviewers independently participated in each step of the screening process. A blinded third reviewer assisted in
cases of discrepancy. The PEDro scale was used to assess quality.
Results: Ten articles were included after screening 2068 titles. In each article where joint mobilization was used,
positive effects in pain, function, or additional outcomes were noted. In most cases, the intervention group integrating
joint mobilization performed better than the comparison group not receiving joint techniques.
Conclusion: In the articles reviewed, joint mobilization was associated with positive clinical effects for persons
with CTS. No studies used joint mobilization in isolation; therefore, results must be interpreted cautiously. This
review indicates that joint mobilization might be a useful adjunctive intervention in the management of CTS.
(J Manipulative Physiol Ther 2020;43;356-370)
Key Indexing Terms: Manipulation; Musculoskeletal Manipulations; Orthopedic; Pain

TAGEDH1INTRODUCTIONTAGEDEN literature reflects a more complex presentation with local

and regional degenerative joint changes,3,4 potential cer-
The term carpal tunnel syndrome (CTS) encompasses a
vical spine involvement,5-7 and signs of central sensitiza-
diverse constellation of symptoms considered to arise from
tion including nonmedian hand symptoms,8 proximal
compression of the median nerve at the wrist.1 Traditional
pain,9,10 local and widespread pain sensitivity,11-14 and
symptoms include numbness, tingling, pain, and muscular
cortical reorganization.15-17
dysfunction in the region innervated by the median nerve
The incidence of CTS has been reported as 10.4 per
distal to the level of compression2; however, the
1000 person-years, and it is more common in women.18
The 6-year economic cost to an individual with CTS can be
a $45,000 to $89,000 owing to unpaid leave and functional
University of Illinois Hospital and Health Sciences System,
Chicago, Illinois.
loss.19 Surgical costs exceed $2 billion annually in the
b
Department of Health, Human Function and Rehabilitation United States, costing $2149 to $9927 per case.20 Although
Sciences, The George Washington University, Washington, DC. total costs of surgical versus nonsurgical interventions tend
c
School of Physical Therapy and Rehabilitation Science, Uni- to be similar, with nonsurgical intervention being more
versity of Montana, Missoula, Montana. cost effective for those who do not progress to surgical
d
Department of Physical Therapy and Rehabilitation Science,
University of Iowa, Iowa City, Iowa.
intervention,21 surgical intervention carries with it the
Corresponding author: Dhinu J. Jayaseelan, DPT, 2000 Penn- inherent risks associated with surgery, ranging from postoper-
sylvania Ave. NW, Suite 2000, Washington, DC 20006. ative pain to infection to complex regional pain syndrome.22
(e-mail: dhinuj@gwu.edu). Nonsurgical intervention options for CTS include
Paper submitted February 13, 2019; in revised form October manual therapy (joint, neurodynamic, and soft tissue mobi-
23, 2019; accepted February 5, 2020.
0161-4754
lizations), exercises (tendon gliding, exercise, stretching),
© 2020 by National University of Health Sciences. passive modalities (ultrasound, extracorporeal shockwave
https://doi.org/10.1016/j.jmpt.2020.02.001 therapy, diathermy, pulsed radiofrequency, laser),
Journal of Manipulative and Physiological Therapeutics
Volume 43, Number 4
splinting, acupuncture, and pharmacologic interventions
(nonsteroidal anti-inflammatory drugs, injections).1,23-30
Despite a litany of nonsurgical treatment options, current
medical management guidelines for CTS31 recommend sur-
gical intervention over nonoperative strategies, categoriz-
ing “therapy” with other conservative options including
splinting and corticosteroid injections, the long-term effi-
cacy of which is in question.32,33 A recent systematic
review and meta-analysis of comparing surgical with non-
surgical interventions for CTS concluded that surgical
interventions were superior, but highlighted the higher
associated risks and recommended further research into
manual therapy interventions for CTS.34 A recent random-
ized clinical trial comparing surgical intervention with mul-
timodal manual therapy showed similar long-term results
between groups, whereas short-term results favored manual
therapy.35
Manual therapy techniques can target joint, soft tissue,
nerve, and other diverse structures. Several reviews exam-
ined manual therapy interventions for CTS in recent
years23-26,34 and specifically neurodynamic mobiliza-
tion,23-25 yet none specifically focused on joint mobiliza-
tion. Joint mobilizations and manipulations are applied by
a health care practitioner in a joint’s accessory or physio-
logic plane of motion. Locally, joint mobilization and
manipulation is meant to address impairments in intra-artic-
ular or immediate extra-articular tissues (eg, the capsule or
ligaments) to restore the joint’s normal pain-free range of
motion (ROM).36 Other forms of manual therapy, such as
soft tissue or neurodynamic mobilizations, can involve
movement of a joint, but they are designed to selectively
affect the overlying soft tissue or nerve. Trials examining
other chronic conditions show that joint mobilizations can
improve local range of motion37,38 and mechanosensitiv-
ity,39 reduce spinal cord hyperexcitability,40,41 and facilitate
centrally mediated conditioned pain modulation.42 Further-
more, systematic reviews have found that joint mobilization
alone or in conjunction with other therapies can address both
pain and function in conditions involving pain and central
sensitization.43-45 Considering evidence that individuals
experiencing symptoms consistent with CTS exhibit both
local and regional joint findings and central sensitization, it
seems reasonable to further examine the efficacy of joint
accessory mobilization and manipulation in a complex con-
dition such as CTS.
The aim of this systematic review was to evaluate the
current available literature examining the comparative clin-
ical usefulness of joint mobilization as part of a treatment
plan for individuals with CTS.
TAGEDH1METHODSTAGEDEN
The authors followed the PRISMA guidelines in the
creation of this manuscript.46
Sault et al 357
Joint Mobilization for CTS
Identification of Studies
A comprehensive and systematic literature search of
PubMed, CINAHL, Scopus, Cochrane Central Register
of Controlled Trials, and SPORTDiscus electronic data-
bases was conducted to identify articles relevant to the
clinical question. All articles published from database
inception through May 25, 2019, were considered. To be
included, articles had to be a randomized clinical trial
(RCT) that involved adult human participants with a pri-
mary diagnosis of CTS, published as a peer-reviewed
full-text in English, and had at least one group receiving
a joint mobilization technique. Articles were included,
even if cointerventions were provided, to more closely
apply to clinical practice. The search terms used (alone
or in combination) were: joint, carpal, manual therapy,
mobilization, mobilisation, manip*, physical therapy,
physio, physiotherapy, PT, conservative, osteopath*,
chiro*, occupational therap*, rehabilitation, carpal tun-
nel syndrome, carpal tunnel. The Appendix details
search strings used for each database. Articles were
excluded if they did not demonstrate any identifiable
joint directed accessory or physiologic mobilization tech-
nique or addressed other wrist or hand diagnoses not specific
to CTS. Pilot studies of RCTs were also excluded. Primary
outcomes of pain and function were prioritized; however,
any outcome related to the intervention of joint mobilization
was considered.
Selection of Studies
Two reviewers independently screened the titles and
abstracts for eligibility using the criteria determined a pri-
ori. After the preliminary search of the above databases,
any article that included joint mobilization in the interven-
tion of CTS was retained for further analysis. When details
of the intervention was unclear, the study’s corresponding
author was contacted for additional information. For the
articles in which disagreement occurred, the final decision
for inclusion was made by a third author blinded to previ-
ous voting. The same two individuals who performed ini-
tial screening reviewed the abstracts, and a consensus was
reached to obtain the full article to be included in this sys-
tematic review.
Data Extraction
Descriptive data regarding the participants, interven-
tions, outcomes, and results were extracted using a stan-
dardized form created for this study (Table 1). When
reporting allowed, numeric data including group means
and standard deviations were extracted. Between-group
effect sizes were calculated when possible, using the
mean difference between groups divided by the pooled
standard deviation.
 358
Joint Mobilization for CTS
Sault et al
Table 1. Description of Studies
Frequency and Duration
Primary Author Participants Intervention Comparison of Joint Mobilization Outcome Assessment Timeline Primary Outcome Measures and Results
Davis54 n = 91 (45 exp, 46 comp) Manipulation of the soft tissues Ibuprofen and noc- 1-3 times/wk Baseline, posttreatment, 1 mo (1) Function: CTOA-P, CTOA-M
Exp mean age: 36 § 6 y; and bony joints of the upper turnal wrist splints 9 weeks for 16 total follow-up (2) Impairments: vibrotactile sensibility
comp mean age: 38 § 5 y extremities and spine, ultra- treatments (3) Electrophysiological variables
Primary diagnosis: CTS sound over the carpal tunnel, Results: Significant improvements noted in
nocturnal wrist splints self-reported physical and mental distress
and neurophysiological measures for both
groups. No statistically significant differen-
ces between groups in outcome measures.

Dinarvand49 n = 37 (19 exp, 18 comp) AP and PA glide of scaphoid Wrist splinting in 3 times/wk for 8 wk Baseline, posttreatment, 10 wk (1) Pain: VAS
Exp mean age: 49.22; comp and hamate and wrist splinting neutral (2) Function: BCTQ
mean age: 46.36 y in neutral (3) Electrophysiological variables
Mean symptom duration: Results: Both groups demonstrated signifi-
14.3 § 7.1 mo cant improvement in pain function, and
Primary diagnosis: CTS electrophysiological variables. No signifi-
cant between group improvement in
median sensory peak latency or median
motor onset latency. Significant between
group improvement in pain and function
favored mobilization group.

Fernandez-de-las-penas35 n = 120 (60 each group) Desensitization maneuvers of Open or endoscopic 1 time/wk for Baseline, 1, 3, 6, and 12 mo (1) Pain: NPRS mean pain, worst intensity
Exp mean age: 47 § 10 y; the CNS (STM and tendon/ decompression and 3 wk for pain
comp mean age: 46 § 9 y nerve gliding exercises directed release of the carpal 3 total treatments (2) Function: BCTQ, GROC
Mean symptom duration: at anatomical sites of potential tunnel Results: Both groups experienced signifi-
Exp: 3.1 § 2.7 y median nerve entrapment), cant and clinically important improve-
Comp: 3.5 § 3.1 y cervical lateral glides ments from baseline to follow-up in all
Primary diagnosis: CTS outcomes. The physical therapy group had
greater symptom and functional improve-
ment at 1 and 3 mo, while longer term fol-
low-up outcomes were equivalent between
groups.

Journal of Manipulative and Physiological Therapeutics

Fernandez-de-las-penas55 n = 94 (47 each group) Cervical lateral glides, CPA
Exp mean age: 46 § 9 y mid-cervical; STM scalenes,
comp mean age: 47 § 8 y costoclavicular space, pec
Mean symptom duration: minor, biceps brachii, bicipital
Exp: 2.8 § 1.6 y; aponeurosis, pronator teres,
comp 3.1 § 1.8 y transverse carpal ligament,
Primary diagnosis: CTS palmar aponeurosis, lumbricals;
cervical stretching; patient
education
Endoscopic decom- 1 time/wk for Baseline, 1, 3, 6, and 12 mo (1) Function: BCTQ
pression and release 3 wk (2) Impairments: Pinch-tip grip force and
of the carpal tunnel cervical ROM
Results: Improvements in self-reported
function and pinch grip force were similar
between the groups at 3, 6, 12 mo. Both
groups reported improvements in symptom
severity that were not significantly differ-
ent at all follow-up periods. No significant
changes were observed in pinch-tip grip
force on the less symptomatic side. No
changes in cervical ROM noted.

May 2020
(continued)

Table 1. (Continued)
Primary Author Participants
Gunay50 n = 40 (20 each group)
Exp mean age: 52.4 § 1.82 y
comp mean age: 47.7 § 2.06 y
Mean symptom duration:
Exp: 34.3 § 6.5 mo;
comp: 41.2 § 8.8 mo
Primary diagnosis: CTS
Tal-Akabi51 n = 21 (7 per group)
Mean age: 47.1 § 14.8 y
Mean symptom duration:
2.3 y
Primary diagnosis: CTS
Talebi52 n = 30 (15 exp, 15 comp) Exp
mean age: 49 § 10.18 y;
Comp mean age: 50.17 §
10.16 y Mean symptom dura-
tion: Exp: 32.25 § 31.21 mo;
comp: 28.66 § 24.57 mo Pri-
mary diagnosis: CTS
Intervention
10 min/d carpal bone mobiliza-
tion (Dorsal-palmar glide at the
radiocarpal joint and midcarpal
distraction) and volar wrist
splint at night
Carpal bone mobilization (PA
and/or AP) and flexor retinacu-
lum stretch
Carpal bone mobilization,
transverse carpal ligament
release, palmar fascia release,
STM of the forearm, neurody-
namic mobilization (median
nerve)
Volume 43, Number 4
Journal of Manipulative and Physiological Therapeutics
Frequency and Duration
Comparison of Joint Mobilization Outcome Assessment Timeline Primary Outcome Measures and Results
Volar wrist splint at 3 times/wk for Baseline, 3 mo (1) Pain: NPRS
night 10 total treatments (2) Function: BCTQ
(3) Impairments: Pinch-grip and handgrip
strength
(4) Electrophysiological variables
Results: Experimental group showed sig-
nificant improvements in all clinical varia-
bles. There was also an improvement in
distal sensory latency and sensory nerve
action potential. Comparison group only
improved in BCTQ symptom severity and
night/day pain intensity. BCTQ functional
status and pinch grip strength were only
between-group significant differences in
experimental group vs comparison group
at 3mo.
(1) ULTT2a mobili- 9 sessions over 3 wk Baseline, posttreatment, few (1) Pain: VAS, Modified Pain Relief Scale
zation months of follow-up (2) Function: Functional Box Scale
(2) Control group (no (3) Impairments: Wrist ROM, ULTT2a
treatment) Results: Statistically significant improve-
ment in pain, ROM, and ULTT for treated
groups, as compared to control group (no
improvement). No statistical difference in
functional outcomes at follow up or
between groups. Fewer subjects in the
manual therapy groups went on to surgery
than the control group.
TENS, ultrasound 3 times/wk for Baseline, immediately after final (1) Pain: VAS
4 wk; 12 total treatments treatment (2) Function: BCTQ
(3) Impairments: Neurodynamic mobility
of median nerve
Results: Both groups had improvement in
pain and symptom severity subscale of
BCTQ. Comparison group did not improve
functional subscale or neurodynamic
mobility, while the manual therapy group
did. Manual therapy group had a statisti-
cally significantly greater improvement in
functional and impairment-based
Joint Mobilization for CTS
outcomes.
(continued)
Sault et al
359
 360
Joint Mobilization for CTS
Sault et al
Table 1. (Continued)
Frequency and Duration
Primary Author Participants Intervention Comparison of Joint Mobilization Outcome Assessment Timeline Primary Outcome Measures and Results
Wolny47 n = 140 (70 exp, 70 comp) Neurodynamic mobilization Laser, contact ultra- 2 times/wk for Baseline, immediately after final (1) Impairments: Static 2PD
Exp mean age: 53.1 § 8.7 y; (median nerve), functional mas- sound (both at trans- 10 wk; 20 total treatment Results: Both interventions had a statisti-
Comp mean age: sage (trapezius muscle), wrist verse carpal ligament treatments cally significant effect on improving 2PD
51.5 § 10.3 y mobilization area of wrist) in symptomatic CTS. There was no signifi-
Primary diagnosis: CTS cant difference between the two treatments.

Wolny48 n = 140 (70 exp, 70 comp)
Exp mean age: 53.1 § 8.7 y;
Comp mean age:
51.5 § 10.3 y
Primary diagnosis: CTS
Neurodynamic mobilization
(median nerve), functional mas-
sage (trapezius muscle), wrist
mobilization
Laser, contact ultra- 2 times/wk for Nerve studies: baseline, (1) Pain: NPRS
sound (both at trans- 10 wk; 20 total 1 mo after final treatment (2) Function: BCTQ
verse carpal ligament treatments (3) Electrophysiological variables
area of wrist) Pain and function: baseline, imme- Results: Experimental group had a statisti-
diately after treatment cally significant positive effect on median
nerve conduction velocity with comparison
group showing no change after treatment.
Both groups had significant positive effects
on motor latency. While both groups
showed significant improvements, pain
reduction, improved functional status and
subjective symptoms were greater in the
experimental group.

Wolny53 n = 189 (102 exp, 87 comp) Neurodynamic mobilization Control 2 times/wk for Baseline, immediately after (1) Pain: NPRS
Exp mean age: (median nerve), functional mas- 10 wk; 20 total treatment (2) Function: BCTQ
52.6 § 9.3 y sage (trapezius muscle), wrist treatments (3) Overall health status: SF-36
Comp mean age: mobilization (4) Electrophysiological variables
53.1 § 8.9 y Results: Experimental group had signifi-
Primary diagnosis: cant improvement in all physical and men-
CTS tal components in overall health status
when compared to the control group.

AP, anterior to posterior; BCTQ, Boston carpal tunnel questionnaire; CNS, central nervous system; Comp, comparison group; CTOA-M, carpal tunnel outcome assessment−mental distress; CTOA-P, carpal tun-
nel outcome assessment−physical distress; CTS, carpal tunnel syndrome; Exp, experimental group; GROC, global rating of change; PA, posterior to anterior; ROM, range of motion; SF-36, short-form health
survey; STM, soft tissue mobilization; TENS, transcutaneous electrical neuromuscular stimulations; ULTT2a, upper limb tension test median nerve biased; VAS, visual analogue scale.

Journal of Manipulative and Physiological Therapeutics

May 2020
Journal of Manipulative and Physiological Therapeutics Sault et al 361
Volume 43, Number 4 Joint Mobilization for CTS

Quality Assessment of Studies
Each of the authors were randomly assigned, and each one
independently assessed the quality of studies using the Phys-
iotherapy Evidence Database (PEDro) scale.14 Two authors
were assigned to each article for quality assessment. As the
PEDro scale delineates, 1 point was assigned whenever the
criterion was clearly described in the article. These items
assess the internal validity of a trial by scoring the following
items as yes or no: eligibility criteria, random allocation,
concealed allocation, baseline similarity, blinding of par-
ticipants, blinding of therapists, blinding of assessors,
follow-up >85%, intention to treat analysis, between-
group comparisons, and reporting of both point estimates
and measures of variability for at least one key outcome
measure. Any disagreement was resolved by a third reviewer
who was blinded to previous voting.
TAGEDH1RESULTSTAGEDEN
Ten eligible studies were identified through the database
searches after filtering 2068 titles (Fig 1). In total, data
were analyzed and reported for 752 participants. In one
Identification
case, the authors used the same sample population while
reporting outcomes separately in different manuscripts.47,48
The scores on each of the 11 PEDro scale criteria and total
scores for each study are presented in Table 2. PEDro
scores ranged from 4 to 8 out of 10, with an average score
of 6.3. The primary outcomes of interest were pain and func-
tion, although additional impairment-based and electrophysi-
ological outcomes were considered as well. Between-group
treatment effects for pain and function were calculated and
are presented in Tables 3 and 4, respectively. None of the
included studies used joint mobilization in isolation; rather,
cointerventions such as soft tissue mobilization (STM),
neural mobilizations, stretching, and wrist splints were
integrated in the experimental group.
Of the 10 articles reviewed, 7 articles examined pain as
a primary outcome using either the visual analogue scale or
numeric pain rating scale.35,48-53 In 6 of the studies, statisti-
cally significant improvements in pain levels were noted
for the groups receiving joint mobilization as part of their
intervention. In 4 of the 6 studies, the group receiving
joint mobilization as part of their intervention had signifi-
cantly greater improvement than the comparison groups

Records idenfied through Addional records idenfied

database searching through other sources
(n = 2059) (n = 9)

Records aer duplicates removed

(n = 1678)
Screening

Records screened Records excluded

(n = 1678) (n = 1642)
Eligibility

Full-text arcles assessed Full-text arcles excluded

for eligibility (n = 26)
(n = 36)
Not appropriate study
design (n = 18)

No joint mobilizaon
performed (n = 7)
Studies included in
Included

qualitave synthesis No full-text available

(n = 10) (n = 1)

Fig 1. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) flow diagram.
 362
Joint Mobilization for CTS
Sault et al
Table 2. Physiotherapy Evidence Database (PEDro) Scores
Primary Author 1 2 3 4 5 6 7 8 9 10 11 Total
Davis54 + + + + − − + − − + + 7

Dinarvand49 + + − + + − + + + + + 9

Fernandez-de-las-penas35 + + + + − − + + + + + 9

Fernandez-de-las-penas55 + + + + − − + + + + + 9

Gunay50 − + − + − − + + − + + 6

Tal-Akabi51 + + − + − − − + − + − 5

Talebi52 + + − + − − + + − + + 7

Wolny47 − + − + − − + + − + + 6

Wolny48 + + + − − − + + − + + 7

Wolny53 + + − + − − + − − + + 6
+, yes; −, no.
1. Eligibility criteria were specified.
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received).
3. Allocation was concealed.
4. The groups were similar at baseline regarding the most important prognostic indicators.
5. There was blinding of all subjects.
6. There was blinding of all therapists who administered the therapy.
7. There was blinding of all assessors who measured at least one key outcome.
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups.
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated, or where this was not the case, data for at least one key outcome was analyzed by “intention

Journal of Manipulative and Physiological Therapeutics

to treat.”
10. The results of between-group statistical comparisons are reported for at least one key outcome.
11. The study provides both point measures and measures of variability for at least one key outcome.

May 2020
 Volume 43, Number 4
Journal of Manipulative and Physiological Therapeutics
Table 3. Between-Group Treatment Effects for Pain Outcomes for Persons With Carpal Tunnel Syndrome According to Treatment and Comparison Groups and Time Point
Treatment Group Comparison Group
Authors Outcome Measure Treatment Group Versus Comparison Group Time Point Mean (SD) Mean (SD) Mean Difference Effect Size
Dinarvand49 VAS Carpal joint mobilization and wrist splinting vs splinting alone Baseline 5.44 (2.35) 6.36 (1.16) 0.92 −0.5

Carpal joint mobilization and wrist splinting vs splinting alone 10 wk 1.94 (1.34) 3.52 (2.06) 1.58 −0.9

Fernandez-de-las-penas35 NPRS (average) Cervical lateral glides, STM and neurodynamic techniques vs Baseline 4.8 (1.5) 4.9 (2.2) 0.1 −0.05
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 1 mo 1.4 (1.9) 3.4 (2.3) 2.0 −0.95
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 3 mo 1.1 (1.8) 2.5 (2.1) 1.4 3.07
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 6 mo 1.1 (1.6) 1.8 (2.5) 0.7 −0.33
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 12 mo 1.2 (1.8) 1.3 (1.9) 0.1 −0.05
surgery

NPRS (worst) Cervical lateral glides, STM and neurodynamic techniques vs Baseline 6.6 (1.7) 7.0 (2.0) 0.4 −0.22
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 1 mo 2.5 (2.7) 5.4 (2.7) 2.9 −1.07
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 3 mo 2.3 (2.6) 4.3 (3.0) 2.0 2.14
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 6 mo 2.2 (2.5) 3.3 (3.3) 1.1 −0.37
surgery

Cervical lateral glides, STM and neurodynamic techniques vs 12 mo 2.0 (1.6) 2.7 (1.9) 0.7 −0.40
surgery

Tal-Akabi51 VAS Carpal joint mobilization vs control Baseline 2.29 (0.95) 2 (1.29) 0.29 0.26

Carpal joint mobilization vs control After intervention 0.71 (0.76) 2.4 (0.69) 1.69 −2.33

52
Talebi VAS Carpal joint mobilization, STM and neurodynamic techniques vs Baseline 7.08 (1.56) 6.58 (1.37) 0.5 0.34
electrophysical modalities

Carpal joint mobilization, STM and neurodynamic techniques vs After intervention 3.75 (2.22) 4.41 (1.31) 0.66 −0.36
electrophysical modalities

Joint Mobilization for CTS

Wolny48 NPRS Wrist mobilization, STM, and neurodynamic techniques vs electro- Baseline 5.72 (1.49) 5.25 (1.75) 0.47 0.29
physical modalities

Wrist mobilization, STM, and neurodynamic techniques vs electro- After intervention 1.47 (1.20) 3.58 (1.93) 2.11 −1.31

Sault et al
physical modalities

NPRS, numeric pain rating scale; SD, standard deviation; STM, soft tissue mobilization; VAS, visual analogue scale.

363
 364
Joint Mobilization for CTS
Sault et al
Table 4. Between-Group Treatment Effects for Functional Outcomes for Persons With Carpal Tunnel Syndrome According to Treatment and Comparison Groups and Time Point
Treatment Group Comparison Group
Primary Author Outcome Measure Treatment Group Versus Comparison Group Time Point Mean (SD) Mean (SD) Mean Difference Effect Size
Davis 54
CTOA (physical) Soft tissue and joint manipulation of the extremities Baseline 12.47 (8.07) 14.66 (9.89) 2.19 −0.24
and spine and wrist splinting vs anti-inflammatory
medication and wrist splinting

Soft tissue and joint manipulation of the extremities After intervention 9.25 (8.14) 5.74 (6.28) 3.51 0.48
and spine and wrist splinting vs anti-inflammatory
medication and wrist splinting

CTOA (mental) Soft tissue and joint manipulation of the extremities Baseline 28.94 (11.69) 33.61 (12.02) 4.67 −0.39
and spine and wrist splinting vs anti-inflammatory
medication and wrist splinting

Soft tissue and joint manipulation of the extremities After intervention 17.29 (13.24) 14.94 (11.33) 2.35 0.19
and spine and wrist splinting vs anti-inflammatory
medication and wrist splinting

Dinarvand49 BCTQ (function) Joint mobilization and wrist splinting vs splinting alone Baseline 2.33 (0.81) 2.61 (0.57) 0.28 −0.40

Joint mobilization and wrist splinting vs splinting alone 10 wk 1.4 (0.35) 1.76 (0.45) 0.36 −0.89

BCTQ (severity) Joint mobilization and wrist splinting vs splinting alone Baseline 2.58 (0.57) 2.52 (0.4) 0.06 0.12

Joint mobilization and wrist splinting vs splinting alone 10 wk 1.46 (0.37) 1.81 (0.44) 0.35 −0.86

Fernandez-de-las-penas35 BCTQ (function) Cervical lateral glides, neurodynamic techniques and STM vs surgery Baseline 2.3 (0.5) 2.4 (0.6) 0.1 −0.18

Cervical lateral glides, neurodynamic techniques and STM vs surgery 1 mo 1.5 (0.4) 2.3 (0.7) 0.8 −1.40

Cervical lateral glides, neurodynamic techniques and STM vs surgery 3 mo 1.5 (0.5) 1.8 (0.7) 0.3 −0.49

Cervical lateral glides, neurodynamic techniques and STM vs surgery 6 mo 1.5 (0.5) 1.6 (0.6) 0.1 −0.18

Journal of Manipulative and Physiological Therapeutics

Cervical lateral glides, neurodynamic techniques and STM vs surgery 12 mo 1.5 (0.5) 1.5 (0.6) 0 0.00

BCTQ (severity) Cervical lateral glides, neurodynamic techniques and STM vs surgery Baseline 2.5 (0.7) 2.7 (0.6) 0.2 −0.31

Cervical lateral glides, neurodynamic techniques and STM vs surgery 1 mo 1.6 (0.5) 1.7 (0.5) 0.1 −0.20

Cervical lateral glides, neurodynamic techniques and STM vs surgery 3 mo 1.6 (0.6) 1.6 (0.4) 0 0.00

Cervical lateral glides, neurodynamic techniques and STM vs surgery 6 mo 1.6 (0.6) 1.5 (0.5) 0.1 0.18

Cervical lateral glides, neurodynamic techniques and STM vs surgery 12 mo 1.5 (0.5) 1.5 (0.5) 0 0.00

Fernandez-de-las-penas55 BCTQ (function) Cervical lateral and PA glides and STM vs surgery Baseline 2.1 (0.5) 2.2 (0.5) 0.1 −0.20

May 2020
(continued)
 Volume 43, Number 4
Journal of Manipulative and Physiological Therapeutics
Table 4. (Continued)
Treatment Group Comparison Group
Primary Author Outcome Measure Treatment Group Versus Comparison Group Time Point Mean (SD) Mean (SD) Mean Difference Effect Size
Cervical lateral and PA glides and STM vs surgery 1 mo 1.6 (0.6) 2.3 (0.7) 0.7 −1.07
Cervical lateral and PA glides and STM vs surgery 3 mo 1.6 (0.7) 1.7 (0.7) 0.1 −0.14

Cervical lateral and PA glides and STM vs surgery 6 mo 1.6 (0.5) 1.6 (0.6) 0 0.00

Cervical lateral and PA glides and STM vs surgery 12 mo 1.6 (0.6) 1.5 (0.6) 0.1 0.17

BCTQ (severity) Cervical lateral and PA glides and STM vs surgery Baseline 2.5 (0.7) 2.6 (0.6) 0.1 −0.15

Cervical lateral and PA glides and STM vs surgery 1 mo 1.7 (0.6) 1.7 (0.5) 0 0.00

Cervical lateral and PA glides and STM vs surgery 3 mo 1.7 (0.7) 1.5 (0.5) 0.2 0.33

Cervical lateral and PA glides and STM vs surgery 6 mo 1.6 (0.6) 1.4 (0.5) 0.2 0.36

Cervical lateral and PA glides and STM vs surgery 12 mo 1.6 (0.6) 1.4 (0.5) 0.2 0.36

Tal-Akabi51 Functional box scale Carpal joint mobilization vs control Baseline 2 (1.41) 2.42 (1.27) 0.42 −0.31

Carpal joint mobilization vs control After intervention 0.71 (0.76) 2.42 (1.27) 1.71 −1.63

52
Talebi BCTQ (function) Wrist mobilization, STM and neurodynamic techniques vs electro- Baseline 18.33 (8.31) 16.5 (6.20) 1.83 0.25
physical modalities

Wrist mobilization, STM and neurodynamic techniques vs electro- After intervention 14.33 (6.25) 15.75 (5.31) 1.42 0.24
physical modalities

BTCQ (severity) Wrist mobilization, STM and neurodynamic techniques vs electro- Baseline 29.91 (9.65) 29.91 (7.24) 0 0.00
physical modalities

Wrist mobilization, STM and neurodynamic techniques vs electro- After intervention 19.25 (6.25) 25.41 (6.25) 6.16 −0.99
physical modalities

Wolny48 BCTQ (function) Wrist mobilization, STM and neurodynamic techniques vs electro- Baseline 2.80 (0.94) 2.77 (0.94) 0.03 0.03
physical modalities

Wrist mobilization, STM and neurodynamic techniques vs electro- After intervention 1.90 (0.62) 2.55 (0.94) 0.65 −0.81
physical modalities

BCTQ (severity) Wrist mobilization, STM and neurodynamic techniques vs electro- Baseline 2.97 (0.63) 2.94 (0.74) 0.03 0.04
physical modalities

Joint Mobilization for CTS

Wrist mobilization, STM and neurodynamic techniques vs electro- After intervention 1.78 (0.47) 2.57 (0.77) 0.77 −1.24
physical modalities

BCTQ, Boston carpal tunnel questionnaire; CTOA, carpal tunnel outcome assessment; PA, posterior-anterior; SD, standard deviation; STM, soft tissue mobilization.

Sault et al
365
366 Sault et al
Joint Mobilization for CTS
at final follow-up, with moderate to large effect sizes
noted.48,49,51,52
Nine of the 10 articles used an outcome measure related
to function.35,48-55 Functional assessments included the car-
pal tunnel outcome assessment of pain or mental distress,
the Boston carpal tunnel questionnaire, global rating of
change, and functional box scale. Of the articles evaluating
functional outcomes, joint mobilization was associated with
a statistical improvement in 8 of the 9 articles. Five of
the 9 articles reported statistically significant between-
group improvements favoring the group receiving joint
mobilization, with large effect sizes noted.35,48-50,52
Interestingly, when conservative care including joint
mobilization was compared with surgery, one article
reported no significant difference in functional out-
comes,55 whereas another reported that functional
improvements were greater in the short term (1 month)
for the physical therapy group while long-term follow-up
demonstrated no difference.35
Besides pain and function, the following outcomes were
assessed in some articles: overall health status, electrophysio-
logic variables, pinch-grip and hand-grip force, cervical
ROM, wrist ROM, 2-point discrimination, and upper limb
tension testing. Groups receiving joint mobilization demon-
strated significant improvements in nerve conduction velocity
studies,48-50,54 although only half of these studies reported
greater improvements than in the comparison group.48,50 One
study reported improvements in self-reported overall health
status, as measured with the short-form 36, in a group receiv-
ing wrist joint mobilization, cervical STM, and neurodynamic
mobilization, when compared with a control group.53 Two
studies investigated the effects of joint mobilization in con-
junction with other interventions on grip strength, with both
reporting significant improvements, greater than in the com-
parison group.50,55 In regard to motion, cervical ROM did not
change after intervention,55 whereas wrist ROM improved in
a group receiving joint mobilization and remained unchanged
in a control group.50 Two-point sensory discrimination
improved in both groups receiving treatment, with statisti-
cally greater improvement in the group receiving joint
mobilization.47 Finally, one study investigated the effects
of neurodynamic intervention, carpal mobilization, or no
treatment on the upper limb tension testing. Both treatment
groups demonstrated improvement in sensitivity of the test,
whereas the control group demonstrated no change.51
TAGEDH1DISCUSSIONTAGEDEN
This systematic review reported the effects of joint
mobilization in the management of individuals with CTS.
After filtering 2068 titles, a total of 10 full-text RCTs were
included in this review. In each study, joint mobilization
was used in conjunction with other interventions, which
provides the reader a practical and clinically relevant
Journal of Manipulative and Physiological Therapeutics
May 2020
assessment of utility, as joint mobilization is rarely used
clinically in isolation and has not been studied indepen-
dently of other interventions. Considering this review, it
appears that performing joint mobilization can be beneficial
in improving pain and self-reported functional limitations,
in addition to overall health status, sensory and electro-
physiologic function, pinch and grip strength, and wrist
ROM for persons with CTS.
Although the exact mechanism of CTS is unknown and
likely multifactorial in nature, CTS is commonly reported
to arise from median nerve compression from increased
pressure within the carpal tunnel resulting in local ischemia
of the nerve.1,51 Anatomic sites of median nerve compres-
sion include the flexor retinaculum during wrist flexion and
at the narrowest portion of the carpal tunnel near the hook
of the hamate.56 Compression of the median nerve at these
reported locations leads to variations of the intraneural
blood microcirculation and changes of the myelin sheath
and supporting connective tissue of the wrist.56 Proposed
mechanisms of joint-based manual therapy at the wrist
include decreased tissue adhesion at the carpal tunnel,
improved mobility at the wrist, decreased pressure inside
the carpal tunnel, improved positioning of the carpal bones,
overall decreased nerve compression, and improved blood
perfusion to the median nerve.49,57 Carpal mobilization as
part of intervention was frequently associated with
improvement in reported outcomes, indicating that the
effects might be biomechanical in nature.
In addition to local mobilization, there could be a benefit
to mobilizing the cervical spine in the management of CTS.
Previous studies have examined the local segmental mobil-
ity of the lumbar spine.58,59 However, few studies have
looked at the segmental mobility of the cervical spine dur-
ing application of joint mobilizations. Lee et al60 assessed
segmental mobility with the use of a grade 3 mobilization
at the C5 level as described by Maitland36 and found atten-
uation of forces throughout the entire cervical spine.
Despite the possible lack of specificity of joint mobiliza-
tions at the cervical spine, manual therapy techniques con-
tinue to be used clinically with reported improvement of
symptoms distally in the upper extremities.35,55,61 It could
be hypothesized that application of cervical spine mobiliza-
tion improves intervertebral mobility and glided cervical
nerve roots within the intervertebral foramina, thereby
reducing mechanical sensitivity of the nerve root.62 In the
articles reviewed, a multimodal manual therapy treatment
program including cervical spine mobilization was effec-
tive in improving pain and function. However, available
evidence does not identify whether local joint mobiliza-
tions are more or less effective than cervical spine mobili-
zations.
CTS has been described as pain or sensory disturbances
in a median nerve distribution secondary to localized com-
pression and irritation of the median nerve at the carpal tun-
nel and considered to be a peripheral neuropathy.13,35,63
Journal of Manipulative and Physiological Therapeutics Sault et al 367
Volume 43, Number 4 Joint Mobilization for CTS

Diagnoses involving lesions to the somatosensory system, TAGEDH1LIMITATIONSTAGEDEN

such as CTS, are often described as neuropathic pain condi-
A number of limitations exist within this systematic
tions.64 Others have reported involvement and alterations
review. This review sought to determine the effects of joint
in nociceptive afferents, particularly nociceptive thermore-
mobilization in the management of CTS. The discrete
ceptive fibers, in patients with carpal tunnel syndrome.63
effect could not be determined, as joint mobilization was
Recent evidence has demonstrated the presence of central not performed in isolation in any study retrieved. Although
sensitization involvement with CTS.8,11,13,65 Central sensi-
this could be considered a limitation to the original ques-
tization or “nociplastic” pain is defined as increased
tion, practical conclusions can be made. Because only full-
response of nociceptive neurons in the central nervous
texts in English were included, it is possible that additional
system (CNS) to noxious stimuli. This phenomenon is
relevant work was excluded. Although effect sizes of vari-
facilitated by heightened signals to the CNS at the spinal
ous interventions was calculated and presented as possible,
and supraspinal levels.66,67 Nociplastic pain conditions
meta-analysis was not appropriate given the study and clin-
occur because of to two proposed mechanisms: altered
ical heterogeneity noted. Finally, the review protocol was
pain processing within the CNS secondary to increased not pre-registered. Pre-registration of a systematic review
CNS excitability and decreased pain inhibition leading to
may be useful to avoid project duplication and to determine
pain hypersensitivity.67,68 The mechanisms for manual
changes from planned to performed methods. No remark-
therapy at distal joints and the spine are likely complex
able changes were made to the initially planned methods of
and multifaceted, with effects at the peripheral, spinal, and
this study, aside from a rerun of the search with a more
supraspinal levels.69 Recent research has demonstrated the
inclusive search string. Further research is indicated to
effects of manual therapy to address both mechanisms of
identify the most effective interventions for the common
nociplastic pain. Courtney et al42 reported both hypoalge-
condition of CTS.
sic effect and improved descending pain inhibition (condi-
tioned pain modulation) after application of joint
mobilization at the knee.42 Conversely, joint mobilization
has also been reported to decrease hyperexcitability of TAGEDH1CONCLUSIONTAGEDEN
nociceptive pathways in both animal and human sub- In this review, we found that when combined with
jects.70,40 Given the beneficial effects of joint mobilization other interventions, joint mobilization may be beneficial
in modulating pain, and the correlation between CTS and in managing pain and improving function, along with
central sensitization, it seems a natural fit to add joint enhancing electrophysiologic variables, ROM, sensory
mobilization into intervention strategies to optimize treat- function, and motor function. Although the results of
ment outcomes. this review can assist the reader in guiding clinical rea-
Management of CTS symptoms includes both conser- soning, the authors suggest interpreting the results with
vative or surgical interventions71,72; however, the debate caution given the limited number of studies, heterogene-
as to which is more beneficial remains ongoing.35,55 ity in studies, and lack of consistent control or compari-
Clinical decision making on treatment and plan of care son groups.
for patients with CTS often depends on the severity of
the nerve dysfunction.50 Conservative care is often
selected first with mild to moderate symptoms or when TAGEDH1SUPPLEMENTARY MATERIALSTAGEDEN
surgical intervention is contraindicated.50,55 Common
conservative care options include orthotic intervention, Supplementary material associated with this article can
exercise therapy, steroid injections, ergonomic adjust- be found in the online version at https://doi.org/10.1016/j.
ments, laser therapy, and medication.1,49,57 Recent stud- jmpt.2020.02.001.
ies also indicate that neurodynamic techniques could
provide meaningful benefits in pain, function, and nerve
conduction.73,74 Surgical intervention is often reserved TAGEDH1FUNDING SOURCES AND CONFLICTS OF INTERESTTAGEDEN
for patients with chronic symptoms, higher level nerve No funding sources or conflicts of interest were reported
dysfunction, symptom severity, and motor disturbances. for this study.
A recent Cochrane review reported limited high-level
evidence for the use of joint mobilization in the treat-
ment of CTS.57 Given the purported heterogeneity of
the origin of CTS symptoms and the multifactor mecha-
TAGEDH1CONTRIBUTORSHIP INFORMATIONTAGEDEN
nism of manual therapy interventions, the consideration Concept development (provided idea for the research): J.S.,
of joint-based manual therapy directed locally at the D.J., J.M., A.P.
wrist and at the spinal level may be beneficial for clini- Design (planned the methods to generate the results): J.S.,
cians when addressing CTS symptoms and complaints. D.J., J.M., A.P.
368 Sault et al
Joint Mobilization for CTS
Supervision (provided oversight, responsible for organiza-
tion and implementation, writing of the manuscript): J.S.,
D.J., J.M., A.P.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): J.S.,
D.J., J.M., A.P.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): J.S., D.J., J.M.,
A.P.
Literature search (performed the literature search): J.S., D.
J., J.M., A.P.
Writing (responsible for writing a substantive part of the
manuscript): J.S., D.J., J.M., A.P.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking): J.
S., D.J., J.M., A.P.
Practical Applications
 No previous studies have investigated the
clinical efficacy of joint mobilization for car-
pal tunnel as part of a systematic review.
 Joint mobilization, when combined with addi-
tional interventions can be helpful for persons
with carpal tunnel syndromes.
 When joint mobilization was integrated, sub-
jects frequently reported and demonstrated
greater improvement than when joint mobili-
zation was not performed.
TAGEDH1REFERENCESTAGEDEN
1. Huisstede BM, Friden J, Coert JH, Hoogvliet P, European
HANDGUIDE Group. Carpal tunnel syndrome: Hand sur-
geons, hand therapists, and physical medicine and rehabilita-
tion physicians agree on a multidisciplinary treatment
guideline-results from the european HANDGUIDE study.
Arch Phys Med Rehabil. 2014;95(12):2253-2263.
2. Bland JD. Carpal tunnel syndrome. BMJ. 2007;335(7615):
343-346.
3. Shiri R. Arthritis as a risk factor for carpal tunnel syndrome: a
meta-analysis. Scand J Rheumatol. 2016;45(5):339-346.
4. Pierre-Jerome C, Bekkelund SI. Magnetic resonance assess-
ment of the double-crush phenomenon in patients with carpal
tunnel syndrome: a bilateral quantitative study. Scand J Plast
Reconstr Surg Hand Surg. 2003;37(1):46-53.
5. De-la-Llave-Rincon AI, Fernandez-de-las-Penas C, Palacios-
Cena D, Cleland JA. Increased forward head posture and
restricted cervical range of motion in patients with carpal tunnel
syndrome. J Orthop Sports Phys Ther. 2009;39(9):658-664.
6. De-la-Llave-Rincon AI, Fernandez-de-Las-Penas C, Laguarta-
Val S, Ortega-Santiago R, Palacios-Cena D, Martinez-Perez
A. Women with carpal tunnel syndrome show restricted cervi-
cal range of motion. J Orthop Sports Phys Ther. 2011;41
(5):305-310.
Journal of Manipulative and Physiological Therapeutics
May 2020
7. Fernandez-de-Las-Penas C, Cleland JA, Plaza-Manzano G,
et al. Clinical, physical, and neurophysiological impairments
associated with decreased function in women with carpal tunnel
syndrome. J Orthop Sports Phys Ther. 2013;43(9):641-649.
8. Zanette G, Marani S, Tamburin S. Extra-median spread of
sensory symptoms in carpal tunnel syndrome suggests the
presence of pain-related mechanisms. Pain. 2006;122
(3):264-270.
9. Mansiz-Kaplan B, Akdeniz-Leblecicier M, Yagci I. Are
extramedian symptoms associated with peripheral causes in
patient with carpal tunnel syndrome? electrodiagnostic and
ultrasonographic study. J Electromyogr Kinesiol. 2018;38:
203-207.
10. Zanette G, Marani S, Tamburin S. Proximal pain in patients
with carpal tunnel syndrome: A clinical-neurophysiological
study. J Peripher Nerv Syst. 2007;12(2):91-97.
11. de la Llave-Rincon AI, Fernandez-de-las-Penas C, Laguarta-
Val S, et al. Increased pain sensitivity is not associated with
electrodiagnostic findings in women with carpal tunnel syn-
drome. Clin J Pain. 2011;27(9):747-754.
12. Bialosky JE, Bishop MD, Robinson ME, Price DD, George
SZ. Heightened pain sensitivity in individuals with signs and
symptoms of carpal tunnel syndrome and the relationship to
clinical outcomes following a manual therapy intervention.
Man Ther. 2011;16(6):602-608.
13. Zanette G, Cacciatori C, Tamburin S. Central sensitization in
carpal tunnel syndrome with extraterritorial spread of sensory
symptoms. Pain. 2010;148(2):227-236.
14. Fernandez-de-Las-Penas C, Ortega-Santiago R, Ambite-
Quesada S, Jimenez-Garci AR, Arroyo-Morales M, Cleland
JA. Specific mechanical pain hypersensitivity over peripheral
nerve trunks in women with either unilateral epicondylalgia
or carpal tunnel syndrome. J Orthop Sports Phys Ther.
2010;40(11):751-760.
15. Schmid AB, Coppieters MW. Left/right judgment of body
parts is selectively impaired in patients with unilateral carpal
tunnel syndrome. Clin J Pain. 2012;28(7):615-622.
16. Maeda Y, Kettner N, Holden J, et al. Functional deficits in
carpal tunnel syndrome reflect reorganization of primary
somatosensory cortex. Brain. 2014;137(Pt 6):1741-1752.
17. Maeda Y, Kettner N, Kim J, et al. Primary somatosensory/
motor cortical thickness distinguishes paresthesia-dominant
from pain-dominant carpal tunnel syndrome. Pain. 2016;157
(5):1085-1093.
18. Spahn G, Wollny J, Hartmann B, Schiele R, Hofmann GO.
Metaanalysis for the evaluation of risk factors for carpal tun-
nel syndrome (CTS) part I. general factors. Z Orthop Unfall.
2012;150(5):503-515.
19. Foley M, Silverstein B, Polissar N. The economic burden
of carpal tunnel syndrome: Long-term earnings of CTS
claimants in washington state. Am J Ind Med. 2007;50
(3):155-172.
20. Milone M.T., Karim A., Klifto C.S., Capo J.T.Analysis of
expected costs of carpal tunnel syndrome treatment strategies.
Hand (N Y). 2017:1558944717743597.
21. Pomerance J, Zurakowski D, Fine I. The cost-effectiveness of
nonsurgical versus surgical treatment for carpal tunnel syn-
drome. J Hand Surg. 2009;34(7):1193-1200.
22. Vasiliadis HS, Georgoulas P, Shrier I, Salanti G, Scholten RJ.
Endoscopic release for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2014(1) CD008265.
23. Basson A, Olivier B, Ellis R, Coppieters M, Stewart A,
Mudzi W. The effectiveness of neural mobilization for neuro-
musculoskeletal conditions: a systematic review and meta-
analysis. J Orthop Sports Phys Ther. 2017;47(9):593-615.
Journal of Manipulative and Physiological Therapeutics
Volume 43, Number 4
24. Ballestero-Perez R, Plaza-Manzano G, Urraca-Gesto A, et al.
Effectiveness of nerve gliding exercises on carpal tunnel syn-
drome: a systematic review. J Manip Physiol Ther. 2017;40
(1):50-59.
25. Lim YH, Chee DY, Girdler S, Lee HC. Median nerve mobili-
zation techniques in the treatment of carpal tunnel syndrome:
a systematic review. J Hand Ther. 2017;30(4):397-406.
26. Huisstede BM, Hoogvliet P, Franke TP, Randsdorp MS,
Koes BW. Carpal tunnel syndrome: effectiveness of physical
therapy and electrophysical modalities. an updated systematic
review of randomized controlled trials. Arch Phys Med Reha-
bil. 2018;99(8):1623-1634. .e23.
27. Choi GH, Wieland LS, Lee H, Sim H, Lee MS, Shin BC.
Acupuncture and related interventions for the treatment of
symptoms associated with carpal tunnel syndrome. Cochrane
Database Syst Rev. 2018;12: CD011215.
28. Franke TP, Koes BW, Geelen SJ, Huisstede BM. Do patients
with carpal tunnel syndrome benefit from low-level laser ther-
apy? A systematic review of randomized controlled trials.
Arch Phys Med Rehabil. 2018;99(8):1650-1659. .e15.
29. Sutton D, Gross DP, Cote P, et al. Multimodal care for the
management of musculoskeletal disorders of the elbow, fore-
arm, wrist and hand: a systematic review by the ontario proto-
col for traffic injury management (OPTIMa) collaboration.
Chiropr Man Therap. 2016;24:8.
30. D’Angelo K, Sutton D, Cote P, et al. The effectiveness of
passive physical modalities for the management of soft tissue
injuries and neuropathies of the wrist and hand: A systematic
review by the ontario protocol for traffic injury management
(OPTIMa) collaboration. J Manipulative Physiol Ther.
2015;38(7):493-506.
31. Graham B, Peljovich AE, Afra R, et al. The American Acad-
emy of Orthopaedic Surgeons evidence-based clinical prac-
tice guideline on management of carpal tunnel syndrome.
J Bone Joint Surg Am. 2016;98(20):1750-1754.
32. Huisstede BM, Randsdorp MS, van den Brink J, Franke TPC,
Koes BW, Hoogvliet P. Effectiveness of oral pain medication
and corticosteroid injections for carpal tunnel syndrome: a
systematic review. Arch Phys Med Rehabil. 2018;99
(8):1609-1622.
33. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting
for carpal tunnel syndrome. Cochrane Database Syst Rev.
2012(7) CD010003.
34. Klokkari D, Mamais I. Effectiveness of surgical versus con-
servative treatment for carpal tunnel syndrome: a systematic
review, meta-analysis and qualitative analysis. Hong Kong
Physiother J. 2018;38(2):91-114.
35. Fernandez-de-Las Penas C, Ortega-Santiago R, de la Llave-
Rincon AI, et al. Manual physical therapy versus surgery for
carpal tunnel syndrome: a randomized parallel-group trial. J
Pain. 2015;16(11):1087-1094.
36. Hengeveld E, Banks K. Maitland’s Peripheral Manipulation.
4th ed. Edinburgh: Elsevier; 2005.
37. Cruz-Diaz D, Lomas Vega R, Osuna-Perez MC, Hita-Contre-
ras F, Martinez-Amat A. Effects of joint mobilization on
chronic ankle instability: a randomized controlled trial. Disa-
bil Rehabil. 2015;37(7):601-610.
38. Estebanez-de-Miguel E, Fortun-Agud M, Jimenez-Del-Barrio
S, Caudevilla-Polo S, Bueno-Gracia E, Tricas-Moreno JM.
Comparison of high, medium and low mobilization forces for
increasing range of motion in patients with hip osteoarthritis:
a randomized controlled trial. Musculoskelet Sci Pract.
2018;36:81-86.
39. Villafane JH, Silva GB, Fernandez-Carnero J. Effect of
thumb joint mobilization on pressure pain threshold in elderly
Sault et al 369
Joint Mobilization for CTS
patients with thumb carpometacarpal osteoarthritis. J Manip-
ulative Physiol Ther. 2012;35(2):110-120.
40. Courtney CA, Witte PO, Chmell SJ, Hornby TG. Heightened
flexor withdrawal response in individuals with knee osteoar-
thritis is modulated by joint compression and joint mobiliza-
tion. J Pain. 2010;11(2):179-185.
41. Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vice-
nzino B. Cervical lateral glide increases nociceptive flexion
reflex threshold but not pressure or thermal pain thresholds in
chronic whiplash associated disorders: a pilot randomised
controlled trial. Man Ther. 2010;15(2):149-153.
42. Courtney C.A., Steffen A.D., Fernandez-de-Las-Penas C.,
Kim J., Chmell S.J.Joint mobilization enhances mechanisms
of conditioned pain modulation in individuals with osteoar-
thritis of the knee. J Orthop Sports Phys Ther. 2016:1-30.
43. Salamh P, Cook C, Reiman MP, Sheets C. Treatment effec-
tiveness and fidelity of manual therapy to the knee: a system-
atic review and meta-analysis. Musculoskeletal Care.
2017;15(3):238-248.
44. Xu Q, Chen B, Wang Y, et al. The effectiveness of manual
therapy for relieving pain, stiffness, and dysfunction in knee
osteoarthritis: a systematic review and meta-analysis. Pain
Physician. 2017;20(4):229-243.
45. Voogt L, de Vries J, Meeus M, Struyf F, Meuffels D, Nijs J.
Analgesic effects of manual therapy in patients with musculo-
skeletal pain: a systematic review. Man Ther. 2015;20
(2):250-256.
46. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA state-
ment for reporting systematic reviews and meta-analyses of
studies that evaluate health care interventions: explanation
and elaboration. Ann Intern Med. 2009;151(4):W65-W94.
47. Wolny T, Saulicz E, Linek P, Mysliwiec A, Saulicz M. Effect
of manual therapy and neurodynamic techniques vs ultra-
sound and laser on 2PD in patients with CTS: a randomized
controlled trial. J Hand Ther. 2016;29(3):235-245.
48. Wolny T, Saulicz E, Linek P, Shacklock M, Mysliwiec A.
Efficacy of manual therapy including neurodynamic techni-
ques for the treatment of carpal tunnel syndrome: a random-
ized controlled trial. J Manipulative Physiol Ther. 2017;40
(4):263-272.
49. Dinarvand V, Abdollahi I, Raeissadat SA, Mohseni Bandpei
MA, Babaee M, Talimkhani A. The effect of scaphoid and
hamate mobilization on treatment of patients with carpal tun-
nel syndrome. Anesth Pain Med. 2017;7(5):e14621.
50. Gunay B, Alp A. The effectiveness of carpal bone mobiliza-
tion accompanied by night splinting in idiopathic carpal tun-
nel syndrome. Turkish J Phys Med and Rehab. 2015;61
(1):45-50.
51. Tal-Akabi A, Rushton A. An investigation to compare the
effectiveness of carpal bone mobilisation and neurodynamic
mobilisation as methods of treatment for carpal tunnel syn-
drome. Man Ther. 2000;5(4):214-222.
52. Talebi GA, Saadat P, Javadian Y, Taghipour M. Manual ther-
apy in the treatment of carpal tunnel syndrome in diabetic
patients: a randomized clinical trial. Caspian J Int Med.
2018;9(3):283-289.
53. Wolny T, Linek P. The effect of manual therapy includ-
ing neurodynamic techniques on the overall health status
of people with carpal tunnel syndrome: a randomized
controlled trial. J Manip Physiol Ther. 2018;41(8):641-
649.
54. Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative
efficacy of conservative medical and chiropractic treatments
for carpal tunnel syndrome: a randomized clinical trail.
J Manipulative Physiol Ther. 1998;21(5):317-326.
370 Sault et al
Joint Mobilization for CTS
55. Fernandez-de-Las-Penas C, Cleland J, Palacios-Cena M,
Fuensalida-Novo S, Pareja JA, Alonso-Blanco C. The effec-
tiveness 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. J Orthop
Sports Phys Ther. 2017;47(3):151-161.
56. Chammas M, Boretto J, Burmann LM, Ramos RM, Dos San-
tos Neto FC, Silva JB. Carpal tunnel syndrome - part I (anat-
omy, physiology, etiology and diagnosis). Rev Bras Ortop.
2014;49(5):429-436.
57. Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Exercise
and mobilisation interventions for carpal tunnel syndrome.
Cochrane Database Syst Rev. 2012(6) CD009899.
58. Kulig K, Powers CM, Landel RF, et al. Segmental lumbar
mobility in individuals with low back pain: In vivo assess-
ment during manual and self-imposed motion using dynamic
MRI. BMC Musculoskelet Disord. 2007;8:8.
59. Powers CM, Kulig K, Harrison J, Bergman G. Segmental
mobility of the lumbar spine during a posterior to anterior
mobilization: assessment using dynamic MRI. Clin Biomech
(Bristol, Avon). 2003;18(1):80-83.
60. Lee RY, McGregor AH, Bull AM, Wragg P. Dynamic
response of the cervical spine to posteroanterior mobilisation.
Clin Biomech (Bristol, Avon). 2005;20(2):228-231.
61. Fernandez-Carnero J, Cleland JA, Arbizu RL. Examination
of motor and hypoalgesic effects of cervical vs thoracic spine
manipulation in patients with lateral epicondylalgia: a clinical
trial. J Manipulative Physiol Ther. 2011;34(7):432-440.
62. Nee RJ, Vicenzino B, Jull GA, Cleland JA, Coppieters MW.
A novel protocol to develop a prediction model that identifies
patients with nerve-related neck and arm pain who benefit
from the early introduction of neural tissue management.
Contemp Clin Trials. 2011;32(5):760-770.
63. de la Llave-Rincon AI, Fernandez-de-las-Penas C, Fernan-
dez-Carnero J, Padua L, Arendt-Nielsen L, Pareja JA. Bilat-
eral hand/wrist heat and cold hyperalgesia, but not
hypoesthesia, in unilateral carpal tunnel syndrome. Exp Brain
Res. 2009;198(4):455-463.
Journal of Manipulative and Physiological Therapeutics
May 2020
64. Chimenti RL, Frey-Law LA, Sluka KA. A mechanism-based
approach to physical therapist management of pain. Phys
Ther. 2018;98(5):302-314.
65. Fernandez-de-las-Penas C, de la Llave-Rincon AI, Fernan-
dez-Carnero J, Cuadrado ML, Arendt-Nielsen L, Pareja JA.
Bilateral widespread mechanical pain sensitivity in carpal
tunnel syndrome: evidence of central processing in unilateral
neuropathy. Brain. 2009;132(Pt 6):1472-1479.
66. International Association for the Study of Pain. IASP taxon-
omy. Available at: https://www.iasp-pain.org/Taxonomy.
Accessed June 20, 2017.
67. Courtney CA, Fernandez-de-Las-Penas C, Bond S. Mecha-
nisms of chronic pain - key considerations for appropriate
physical therapy management. J Man Manip Ther. 2017;25
(3):118-127.
68. Woolf CJ. Central sensitization: implications for the diagno-
sis and treatment of pain. Pain. 2011;152(3 suppl):S2-15.
69. Bialosky JE, Bishop MD, Price DD, Robinson ME, George
SZ. The mechanisms of manual therapy in the treatment of
musculoskeletal pain: a comprehensive model. Man Ther.
2009;14(5):531-538.
70. Sluka KA, Wright A. Knee joint mobilization reduces sec-
ondary mechanical hyperalgesia induced by capsaicin
injection into the ankle joint. Eur J Pain. 2001;5(1):
81-87.
71. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tun-
nel syndrome. J Am Acad Orthop Surg. 2007;15(9):537-548.
72. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome:
clinical features, diagnosis, and management. Lancet Neurol.
2016;15(12):1273-1284.
73. Wolny T, Linek P. Is manual therapy based on neurodynamic
techniques effective in the treatment of carpal tunnel syn-
drome? A randomized controlled trial. Clin Rehabil. 2019;33
(3):408-417.
74. Wolny T, Linek P. Neurodynamic techniques versus “sham”
therapy in the treatment of carpal tunnel syndrome: a random-
ized placebo-controlled trial. Arch Phys Med Rehabil.
2018;99(5):843-854.