Persistent mechanical allodynia following injury of the hand. Treatment through mobilization of the nervous system

How should we treat painful sensitivity in the hand? An international e-Delphi study

BACKGROUND

Evidence synthesis suggests allodynia resulting from neuropathic pain has few interventions with clear effectiveness. As research continues to build this needed evidence base, expert consensus recommendations can address the conflicting approaches within current hand therapy practice.

PURPOSE

This study aimed to develop consensus recommendations for the clinical management of allodynia from an international panel of hand therapists.

STUDY DESIGN

This was an international e-Delphi survey study.

METHODS

We recruited international hand rehabilitation experts to participate in an e-Delphi survey. Consensus was defined as 75% or more of participants agreeing with a recommendation, and at least 3 rounds of consensus building were anticipated. Experts were identified from 21 countries, and clinical vignettes describing a spectrum of patients with painful sensitivity in the hand were provided to elicit treatment recommendations. Initial recommendations were summarized, and consensus sought for clinical practice recommendations.

RESULTS

Sixty-eight participants were invited, with 44 more added through peer nominations. Fifty-four participants from 19 countries completed the initial survey and were invited to participate in all subsequent rounds. Over 900 treatment suggestions were provided from the initial vignettes across domains, including sensory, physical, and functional interventions, education, and cortical representation techniques: 46 ultimately reached consensus. However, important discrepancies in justification (eg, why allodynia should be covered) and implementation of techniques (eg, desensitization, sensory reeducation) were identified as the consensus exercise progressed.

CONCLUSIONS

Experts recommend individually tailored programs to treat allodynia using a variety of physical/movement, sensory-based, and "top-down" approaches; this is highly aligned with contemporary theories, such as the Neuromatrix Model of Pain. However, consensus was not reached on the justification and implementation of some of these approaches, reflecting the lack of a taxonomy and supporting evidence for tactile stimulation approaches in the current literature. Trials directly comparing the effectiveness of these approaches are needed.

How should we define and assess painful sensitivity in the hand? An international e-Delphi study

BACKGROUND

Painful sensitivity in the hand is commonly seen with neuropathic pain, interfering with daily activities including rehabilitation. However, there are currently several terms used to describe the problem and a lack of guidance on what assessments should be used.

PURPOSE

To gather expert opinion a) identifying current and common terminology used in hand therapy, b) developing a consensus definition of hypersensitivity, and c) developing consensus guidance on how to best assess allodynia.

STUDY DESIGN

International e-Delphi survey study.

METHODS

We conducted an e-Delphi consensus study drawing on international experts in hand rehabilitation. We planned up to four rounds of consensus-seeking, defining consensus as 75% or more of participants agreeing with a definition or recommendation. Experts were identified from 21 countries, with the nomination of other experts encouraged for 'snowball sampling'. The first round included clinical vignettes describing 'painful sensitivity of the hand' and asked participants to describe how they would assess each case. Definitions for hypersensitivity, tactile hyperesthesia, and allodynia were also requested.

RESULTS

We invited 68 participants: 44 more were added through nominations. Sixty-three agreed to participate and were sent the round one survey; 54 participants from 19 countries completed this survey and were invited to participate in all subsequent rounds. No two definitions of hypersensitivity were the same, while 87% of the definitions for allodynia and 78% for tactile hyperesthesia were concordant with a published taxonomy. Over 700 assessment items were proposed in round one: ultimately 38 items representing eight distinct constructs reached a consensus for assessing allodynia.

CONCLUSIONS

Therapists definitions were consistent with an existing taxonomy for allodynia. Although hypersensitivity conceptualizations varied regarding the qualities of stimulus and response, a working definition was reached. Recommended assessments were relatively consistent internationally, holistic, and reflected a potential link between allodynia and central sensitization.

Cervicobrachial pain - How Often is it Neurogenic?

INTRODUCTION

Neck pain associated with pain in the arm (cervicobrachial pain) is a common complaint in patients seeking physiotherapy management. The source of symptoms for this complaint is commonly presumed to be neural. However, this pain pattern could also result from various other innervated tissue structures of the upper quarter. Knowledge about frequency of neural structures being a predominant source of symptoms would help in implementing appropriate therapeutic strategies such as neural tissue mobilization along with other complimentary therapies for optimal outcomes.

AIM

To determine the frequency of cervicobrachial pain being neurogenic.

MATERIALS AND METHODS

Participants (n=361) aged between 20-65 years, reporting cervicobrachial pain were screened for neurogenic nature of symptoms. These physical signs included: active and passive movement dysfunction, adverse responses to neural tissue provocation tests, tenderness on palpating nerve trunks and related cutaneous tissues and evidence of a related local area of pathology (Clinical/radiological). The consistency of all these signs was checked to identify a significant neural involvement.

RESULTS

Descriptive statistics were used to analyse data. Of 361 participants, 206 were males (44.6 ±10.8 years) and 155 were females (41.8 ± 11.2 years). The frequency of neurogenic cervicobrachial pain was determined to be 19.9% (n=72) and the non-neurogenic sources for symptoms were attributed to 80.1% (n=289) of screened participants.

CONCLUSION

Lower frequency of cervicobrachial pain being neurogenic indicates thorough screening for appropriate therapeutic interventions to be successful.

The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain

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.

Upper limb neurodynamic test of the radial nerve: a study of responses in symptomatic and asymptomatic subjects

STUDY DESIGN

Clinical measurement.

INTRODUCTION

Nonspecific cervical pain is a common clinical presentation. The role of upper limb neurodynamic tests (ULNT), for evaluation and treatment intervention, is not well defined for this population.

PURPOSE OF THE STUDY

This study's purpose was to determine if the radial-biased (RB)-ULNT discriminates any response differences between symptomatic subjects with a positive (+) RB-ULNT (n=36), symptomatic subjects with a negative (-) RB-ULNT (n=24), and asymptomatic subjects (n=60).

METHODS

Sixty asymptomatic and 60 subjects presenting with nonspecific cervical and/or unilateral upper extremity pain were compared using the RB-ULNT. Symptomatic subjects were further divided in (+) and (-) RB-ULNT groups due to their response to the RB-ULNT. Within the symptomatic population, a positive response to the RB-ULNT was defined by the symptomatic subject reporting their sensations were increased with contralateral cervical lateral flexion and decreased with ipsilateral cervical lateral flexion. Sensation provocation and location were evaluated using the RB-ULNT in all the subjects during each stage of the testing.

RESULTS

Significant differences on stage of reproduction and type of sensations were identified between 1) the (+) RB-ULNT symptomatic subjects, 2) the (-) RB-ULNT symptomatic subjects, and 3) the asymptomatic subjects. The (+) RB-ULNT group showed significantly increased pain responses during the first stage of the RB-ULNT compared with the (-) RB-ULNT group and the asymptomatic subjects. The (+) RB-ULNT also showed significantly decreased glenohumeral abduction passive range of motion when compared with the asymptomatic group.

CONCLUSION

Clinically, the differences found between the groups in their response to the RB-ULNT suggest heightened mechanosensitivity in the (+) RB-ULNT group.

LEVEL OF EVIDENCE

3a.

The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital

The purpose of this study was to determine whether neural mobilization in addition to standard care is more effective than standard care alone in the treatment of Carpal Tunnel Syndrome (CTS). Sixty participants were randomly assigned to one of two groups. Group 1 received standard care, and Group 2 performed a neurodynamic mobilization exercise in addition to standard care. Outcomes were assessed at baseline and at one and six months using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Brigham and Woman's Hospital Carpal Tunnel Specific Questionnaire (CTSQ), and elbow extension range of motion during an upper limb median nerve tension test. There were no significant differences in the outcome measures between groups, except Group 1 had improved scores on the function status scale of the CTSQ compared to Group 2 at six months. The addition of neural mobilization to standard care did not result in improved outcomes in patients with CTS.

Upper limb neural tension testing and mobilization. Fact, fiction, and a practical approach

The use of upper limb neural tension testing (ULNTT) and neural mobilization by physical and occupational therapists has become common in clinical practice. The purpose of this article is to discuss the basic science and the research that supports or refutes the efficacy of these techniques. There is sufficient biomechanical evidence that the peripheral nerve under tension undergoes strain and glides within its interfacing tissue. Evidence supports that ULNTT causes strain within the peripheral nervous system however; it is also evident that ULNTT places strain on other multisegmental tissues. Clinical investigation has examined intrarater reliability and has begun to define the parameters of a positive test but there is lack of randomized controlled studies. There is limited evidence reporting favorable outcomes when using neural mobilization to treat specific patient populations, and the appropriate parameters of dosage (i.e., duration, frequency, and amplitude) remain to be confirmed. Clinical application of these techniques must be applied in a practical manner that relies on continual clinical reasoning. The clinician should integrate basic science and experimental evidence as we work to achieve a sufficient level of confidence in the development of evidence-based practice.

Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome

The purpose of this clinical commentary is to provide a comprehensive review of compressive neuropathies that may mimic carpal tunnel syndrome, provide the clinician with information to differentially diagnose these median nerve compression sites, and provide an evidence-based opinion regarding conservative intervention techniques for the various compression syndromes. While rare in comparison to carpal tunnel syndrome, pronator syndrome and anterior interosseous nerve syndrome are proximal median nerve compressions that may be suspected if a patient with carpal tunnel syndrome fails to respond to conservative or surgical intervention. Differential diagnosis is based largely on the symptoms, patterns of paresthesia, and specific patterns of muscle weakness. Due to the relative rarity of pronator syndrome and anterior interosseous nerve syndrome, few controlled studies exist to determine the most effective treatment techniques. Based on sound anatomical and biomechanical considerations, anecdotal experience, and available research, however, treatment strategies for pronator syndrome and anterior interosseous nerve syndrome compression neuropathies can be divided into 4 major categories: (1) rest/immobilization, (2) modalities, (3) nerve gliding, and (4) nonconservative treatment.

The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain

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 < or = .0306). For the mobilization group, the increase in elbow extension from 137.3 degrees to 156.7 degrees, the 43.4% decrease in area of symptom distribution, and the decreased pain intensity from 7.3 to 5.8 were significant (P < or = .0003). For the ultrasound group, there were no significant improvements (P > or = .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.

Reliability of detecting 'onset of pain' and 'submaximal pain' during neural provocation testing of the upper quadrant

BACKGROUND AND PURPOSE

Conflicting results have been reported with regard to the reliability of neural tissue provocation tests and it is unclear whether repeated testing affects the test results. In the present study, the stability and reliability of the occurrence of 'onset of pain' and 'submaximal pain' throughout the range of motion during neurodynamic testing was analysed, in both a laboratory and a clinical setting.

METHOD

A repeated-measures study design within and between sessions was used. In the laboratory and clinical settings, the base neurodynamic test for the median nerve was performed during a single session on a total of 27 patients with neurogenic cervico-brachial pain. In addition, the base test and three common variations were performed on two occasions by two examiners on 10 asymptomatic subjects in laboratory conditions only. Patients indicated the moment of 'submaximal pain' occurrence, whereas asymptomatic subjects indicated 'onset of pain' and 'submaximal pain'. Corresponding angles at the elbow were recorded by use of an electrogoniometer.

RESULTS

In the asymptomatic group, the intra- and inter-tester reliability within the same session was excellent (intraclass correlation coefficient (ICC2.1 > or = 0.95; standard error of measurement (SEM) < or = 4.9 degrees). Reliability after a 48-hour interval was moderate (ICC2.1 > or = 0.69; SEM < or = 9.9 degrees). The reliability coefficients for the symptomatic group within the same session were comparable with the excellent results of the asymptomatic group, for both the laboratory (ICC2.1 = 0.98; SEM = 2.8 degrees) and clinical settings (ICC2.1 > or = 0.98; SEM < or = 3.4 degrees). Consequently, from a statistical perspective, improvements in range of motion as small as approximately 7.5 degrees may be interpreted meaningfully. No significant trend due to repeated testing could be observed when three consecutive repetitions were analysed.

CONCLUSIONS

Pain provocation during neurodynamic testing is a stable phenomenon and the range of elbow extension corresponding with the moment of 'pain onset' and 'submaximal pain' may be measured reliably, both in laboratory and clinical conditions.

A randomized clinical trial of manual therapy for cervico-brachial pain syndrome -- a pilot study

Cervico-brachial pain syndrome is an upper quarter pain condition in which mechanosensitive neural tissue is considered a primary feature. A single-blind randomized controlled trial was conducted to determine the clinical effect of two manual therapy interventions. Thirty subjects (20 females and 10 males) were randomly allocated to one of three groups - one of two manual therapy intervention groups or a control group. One manual therapy intervention group consisted of passive techniques aimed at mobilizing neural tissue structures and the cervical spine. The other involved indirect manual therapy techniques with a focus on articular components of the gleno-humeral joint and thoracic spine. The treatment period lasted 8 weeks in total and was combined with a home exercise programme. Following the 8-week baseline period the control group were crossed over into the specific neural tissue manual therapy group. Pain visual analogue scale (VAS), the short-form McGill pain and Northwick Park neck pain questionnaires were completed before, midway and after the treatment period. The findings suggest that both manual physiotherapy interventions combined with home exercises are effective in improving pain intensity, pain quality scores and functional disability levels. A group difference was observed for the VAS scores at 8 weeks with the neural manual therapy technique having a significantly lower score.

Shoulder girdle elevation during neurodynamic testing: an assessable sign?

One of the signs advocated for monitoring during neurodynamic testing in the assessment of patients with upper quadrant disorders, is the response of the shoulder girdle. It is stated that a protective rising of the shoulder girdle is present when patients with neurogenic disorders are assessed and that the elevation is absent in asymptomatic subjects. As sensory responses are elicited in the majority of asymptomatic subjects and as the range of motion (ROM) is often limited during neurodynamic testing, it is questionable whether the elevation of the shoulder girdle would be absent in asymptomatic subjects. The aim of this study was to measure the shoulder girdle elevation force during five variants of the neural tissue provocation test for the median nerve. Thirty-five asymptomatic male subjects were assessed. A load cell was used to measure the amount of shoulder girdle elevation force and two electrogoniometers were used to measure the ROM at the elbow and wrist. When the ROM at the end of the test was restricted, a gradual increase in shoulder girdle elevation force could be observed throughout the test. Compared to the initial force at the start of the test, all variants resulted in a significant increase in force. It is concluded that a gradual increase in shoulder girdle elevation force should not be regarded as an abnormal sign in the interpretation of neurodynamic tests.