SYNOPSIS: The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.

J Orthop Sports Phys Ther 2012;42(5):413-424, Epub 8 March 2012. doi:10.2519/jospt.2012.3988

KEY WORDS: carpal tunnel syndrome, cervical radiculopathy, cubital tunnel syndrome, reliability

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STUDY DESIGN: Controlled laboratory study using single-group, within-subject comparisons. OBJECTIVES: To determine in an in vivo study whether different types of nerve-gliding exercises are associated with different amounts of longitudinal nerve excursion. BACKGROUND: Different types of nerve-gliding exercises have been proposed. It is assumed that different exercises produce different amounts of excursion and strain in the peripheral nervous system. Although this has been confirmed in cadaveric experiments, in vivo studies are lacking. METHODS: High-resolution ultrasound was used to measure longitudinal excursion of the median nerve in the upper arm during 6 different nerve-gliding exercises. Nerve mobilization techniques that involved the elbow and neck were evaluated in 15 asymptomatic volunteers (mean ± SD age, 30 ± 8 years). Nerve longitudinal excursion was calculated using a frame-by-frame cross-correlation analysis. A repeated-measures analysis of variance was used to analyze the data. RESULTS: Different exercises induced different amounts of longitudinal nerve excursion (P<.0001). The "sliding technique" was associated with the largest excursion (mean ± SD, 10.2 ± 2.8 mm; P = .0001). The amount of nerve movement associated with the "tensioning technique" (mean ± SD, 1.8 ± 4.0 mm) was smaller than the nerve excursion induced with individual movements of the neck or elbow (mean ± SD range, –3.4 ± 0.9 to 5.6 ± 2.1 mm; P = .0001). CONCLUSION: These findings confirm that different types of neurodynamic techniques have different mechanical effects on the nervous system. Recognition of these differences may assist in the selection of treatment techniques. Having demonstrated differences in mechanical effects, future research will have to evaluate whether these different techniques are also associated with different physiological and therapeutic effects.

J Orthop Sports Phys Ther 2009;39(3):164-171, Epub 15 December 2008. doi:10.2519/jospt.2009.2913

KEY WORDS: diagnostic ultrasound, nerve biomechanics, neurodynamic test, ultrasonography

Study Design: Randomized clinical trial. Objectives: To analyze the immediate treatment effects of cervical mobilization and therapeutic ultrasound in patients with neurogenic cervicobrachial pain. Background: Different treatment modalities have been described for patients with neurogenic cervicobrachial pain. Although it has been suggested that a more specific approach, like cervical mobilization, would be more effective, effect studies are scarce. Methods and Measures: Twenty patients with subacute peripheral neurogenic cervicobrachial pain were assessed. Besides other criteria, patients were included if a cervical segmental motion restriction was present which could be regarded as a possible cause of the neurogenic disorder. Patients were randomly assigned to a mobilization or ultrasound group. Mobilization consisted of a contralateral lateral glide technique. The range of elbow extension, symptom distribution, and pain intensity during the neural tissue provocation test for the median nerve were used as outcome measures. Results were analyzed using a 2-way mixed-design ANOVA. Results: Significant differences in treatment effects between the 2 groups could be observed for all outcome measures (P=.0306). For the mobilization group, the increase in elbow extension from 137.3° to 156.7°, the 43.4% decrease in area of symptom distribution, and the decreased pain intensity from 7.3 to 5.8 were significant (P=.0003). For the ultrasound group, there were no significant improvements (P=.0521). Conclusions: When a cervical dysfunction can be regarded as a cause of the neurogenic disorder or as a contributing factor that impedes natural recovery, a cervical lateral glide mobilization has positive immediate effects in patients with subacute peripheral neurogenic cervicobrachial pain. This movement-based approach seems preferable to ultrasound.

J Orthop Sports Phys Ther. 2003;33(7):369-378.

Key Words: Brachial plexus, cervical spine, manipulative therapy, manual therapy, neurodynamic test

Study Design: Single session, repeated-measures design. Objectives: To analyze the impact of different components of the neural tissue provocation test for the median nerve (NTPT1) on the range of motion (ROM) of the elbow and wrist and the sensory responses elicited by the test. Background: The assessment of minor peripheral nerve injuries by neurodynamic tests is becoming more integrated in physical therapy practice. The influence of different test components on the nervous system has been analyzed in numerous in vitro studies, but in vivo studies are still lacking. Methods and Measures: Five test variations were performed on 35 asymptomatic men (23.5 ± 2.3 years). Elbow extension was performed (1) without additional components (NTPT1NEUTRAL), (2) with wrist extension (NTPT1WE), (3) with cervical contralateral lateral flexion (NTPT1CLLF), and (4) with both wrist extension and cervical contralateral lateral flexion (NTPT1WE+CLLF). In the fifth variant, the wrist was extended from a preloaded position (WENTPT1). The range of elbow and wrist extension when a submaximal discomfort was elicited was measured with 2 electrogoniometers. Results: The addition of each test component resulted in a significantly reduced ROM (NTPT1NEUTRAL: 179.5 ± 8.8°, NTPT1WE: 169.0 ± 13.9°, NTPT1CLLF: 154.7 ± 13.2°, NTPT1WE+CLLF: 143.9 ± 16.1°; WENTPT1: 67.1 ± 11.0°). Sensory responses were predominantly evoked at the region of the added component. Conclusions: The different test components, whose mechanical influence on the nervous system has been demonstrated in anatomical studies, also have an effect on joint ROM and sensory responses during neurodynamic testing, when individually or simultaneously added. If the nerve bedding is elongated throughout its whole length, the available ROM is markedly reduced and sensory responses can be elicited throughout the entire arm.

J Orthop Sports Phys Ther. 2001;31(5):226-237.

Key Words: brachial plexus, mechanosensitivity, median nerve, neurodynamics, upper limb tension test