Ulnar nerve neurodynamic test: study of the normal sensory response in asymptomatic individuals

Reliability and validity of modified upper limb neurodynamic tests in patients with cervical radiculopathy

Background

Neurodynamic Tests (NDTs) are used to assess neural mechanosensitivity in various conditions such as neural sliding, tension or inflammatory dysfunction. But in some upper quadrant dysfunctions, standard testing procedure of NDT cannot be assessed or tolerated by patient.

Objective

The purpose of the study was to determine the validity, intra-rater and inter-rater reliability of modified NDTs via median and ulnar nerve in patients with cervical radiculopathy.

Methods

Thirty-three patients (18 men and 15 women, mean age ± SD - 40 . 18 ± 9 . 01 ) with cervical radiculopathy having positive response to standard NDTs were included in the study. Modified neurodynamic tests for median & ulnar nerve were performed with modification in the sequencing of standard neurodynamic test at lower degrees of glenohumeral abduction and external rotation. Outcome measures used were angle of elbow extension for median nerve and angle elbow flexion for ulnar nerve at the point of pain onset indicated by "OP" (Onset of Pain).

Results

Reliability of OP was evaluated using measurement of Intra-class Correlation Coefficient (ICC), Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) values. Results indicated high ICC values and low SEM values for OP during modified median and modified ulnar NDTs (M-MNT1 and M-UNT) on symptomatic side of patients with cervical radiculopathy. Spearman correlation analysis for validity of test score showed strong correlation (r = 0 . 767 ) with standard NDT.

Conclusion

There was strong correlation between Modified NDTs and standard tests depicting good validity and substantial reliability of OP during M-MNT1 and M-UNT for positive NDT response in patients with cervical radiculopathy.

Exploring Symptom Responses to Upper Limb Neural Test Variations of the Radial Nerve in Patients With Lateral Epicondylalgia: An Observational Study

OBJECTIVE

Clinical practice guidelines recommend the radial nerve mechanosensitivity evaluation in patients with lateral epicondylalgia. Despite different positions and sequences having been described, no research analyzed how each variation triggers symptoms associated with lateral epicondylalgia. The aim of this study was to explore the effects of different positions and sequences in the upper limb neural tension test 2b (ULNT2b) in symptom responses in patients with lateral epicondylalgia.

METHODS

In this observational study, 66 patients underwent 4 test conditions: standard ULNT2b, ULNT2b proximal to distal, ULNT2B with resisted supination, and resisted supination isolated. Paresthesia sensations, symptom reproduction, pain intensity (measured using a visual analog scale), and distribution of painful symptoms data were collected.

RESULTS

Significant differences in paresthesia sensations were observed between groups, with significant differences between the standard ULNT2B and other ULNT variations or resisted supination maneuvers. Symptom reproduction also differed significantly across groups, with significant differences between the standard ULNT2B and other ULNT or resisted supination tests. The positive/negative test and percentage of distribution of painful symptoms scores varied significantly across 4 conditions in both lateral and frontal views. Although pain intensity scores during tests were comparable among the tests, distribution of painful symptoms differed significantly.

CONCLUSION

Variations in the ULNT2b test can affect symptom responses in patients with lateral epicondylalgia. The standard ULNT2b test appears more effective at reproducing symptoms, intensity of paresthesia, and distribution of painful symptoms compared to other ULNT variations and the resisted supination test.

IMPACT

ULNT2b sequences have been shown to elicit varying responses concerning paresthesia, replication of familiar symptoms, positive/negative test results, and distribution of painful symptoms. Clinicians should consider specific test variations during the patients' radial nerve mechanosensitivity assessment to identify aggravating factors reproducing recognizable symptoms. A control group of asymptomatic participants and the role of presence of other comorbidities, psychological factors, or the duration of symptoms were not considered in this study and might play an important role influencing the results of the tests.

Neural management plus advice to stay active on clinical measures and sciatic neurodynamic for patients with chronic sciatica: Study protocol for a controlled randomised clinical trial

Advice to stay active is the primary management strategy for sciatica. Other conservative treatments such as neural management techniques may also contribute to sciatica recovery, but currently, the effects have not been robustly assessed. Thus, the aim of this study is to compare the effects of adding neural management to advice to stay active versus advice to stay active alone in improving pain intensity and functional limitation. Secondarily, to compare the effects of the experimental intervention in the sciatic neurodynamic, pain modulation, and psychosocial factors. A parallel-group, controlled, examiner-blinded superiority clinical trial randomised at a 1:1 allocation will be conducted in 210 participants with chronic sciatica. Patients will be recruited from outpatient physiotherapy clinics and community advertisements. The experimental group will receive neural mobilisation techniques and soft tissue mobilisation techniques for 30 minutes per session, 10 weekly sessions, plus advice to stay active on their activities of daily living, information on physical activity, imaging tests, and sciatica for 5 biweekly sessions lasting 25-30 minutes. The control group will receive advice to stay active only. The re-evaluation will be performed out after 5 weeks, 10 weeks, and 26 weeks after randomisation and primary endpoints will be pain intensity and functional limitation at 10 weeks. Secondary outcomes will include neuropathic symptoms, sciatic neurodynamic, pain modulation, and psychosocial factors. Adverse events and patient satisfaction will be assessed. Ethical approval has been granted from an Institutional Human Research Ethics Committee. Trial registration: Trial was prospectively registered in the Brazilian Registry of Clinical Trials (number: RBR-3db643c).

Normal response to tibial neurodynamic test in asymptomatic subjects

BACKGROUND

The straight leg raise test (SLR) is one of the most performed physical tests for mechanosensitivity and impairment of the nervous system. According to the anatomy of the tibial nerve, ankle dorsiflexion and eversion movements could be used to perform the tibial neurodynamic test (TNT). To date, no study has documented the normal responses of the TNT.

OBJECTIVE

To document normal responses of the TNT in asymptomatic individuals and to investigate influences from sex and leg dominance.

METHODS

A cross-sectional study with 44 asymptomatic volunteer subjects, a total of 88 lower limbs, was carried out. The range of motion (ROM), quality, and distribution of sensory responses were recorded. The hip flexion ROM was measured when subjects reported an intensity of their symptoms of 2/10 (P1) and 8/10 (P2).

RESULTS

The mean ROM for hip flexion at P1 was 44.22 ± 13.13∘ and 66.73 ± 14.30∘ at P2. Hip flexion was significantly greater at P2 than P1 (p< 0.001). However, it was not different between sex or limbs (p> 0.05). The descriptor of the quality of sensory responses most often used by participants was stretching (88.6% and 87.5% for P1 and P2, respectively) in the popliteal fossa and posterior calf.

CONCLUSIONS

This study describes the sensory responses of asymptomatic subjects resulting from the TNT. Our findings indicate that TNT responses are independent of the influence of sex or leg dominance.

Agreement and Reliability of Median Neurodynamic Test 1 and Resting Scapular Position

Objective

The purposes of this study were to determine whether there are differences between the dominant and nondominant arms for the Median Neurodynamic Test 1 (MNT 1); whether there are differences between men and women on the MNT 1; the reliability of an assessment of resting scapular position; the reliability of the MNT 1; and the frequency and percentage of sensory responses that are present during the MNT 1 in the asymptomatic population.

Methods

This was a reliability and agreement study. It included asymptomatic students enrolled in the college of health professions and the college of nursing at a university. The Mann-Whitney U was used to determine whether there were any differences between the dominant and nondominant sides and between sexes for elbow extension range of motion and for sensory responses on the numeric pain rating scale when performing the MNT 1. A χ² analysis was used to determine whether there were any differences between sexes and between dominant and nondominant upper extremities for sensory-response location, sensory-response type, and structural differentiation for raters 1 and 2. The intraclass correlation coefficient (ICC_2,3) was used to determine the intertester and intratester reliability for the degrees of elbow extension attained during testing.

Results

Reliability for degrees of elbow extension and strength of the sensory response was excellent (ICC_2,3 ˃ 0.75) and substantial (κ ≥ 0.68), respectively. Resting scapular position and all other components of the MNT 1 demonstrated statistically significant side-to-side differences and κ values ranging from 0.23 to 0.88.

Conclusion

Elbow extension and magnitude of sensory response are reliable components of the MNT 1 that are not different between the dominant and nondominant sides in the asymptomatic population.

Effects of Diacutaneous Fibrolysis on Mechanosensitivity, Disability, and Nerve Conduction Studies in Mild to Moderate Carpal Tunnel Syndrome: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

People diagnosed with carpal tunnel syndrome (CTS) have fibrosis between the soft, connective, and neural tissues that could worsen the compression of the median nerve. The diacutaneous fibrolysis (DF) technique may release tissue adhesions and increase the mobility of connective tissues. The purpose of this study was to compare the outcomes of DF in people with mild to moderate CTS on mechanosensitivity, disability, and nerve conduction studies.

METHODS

This was a secondary analysis of a double-blinded, randomized, placebo-controlled trial. Patients were recruited between April and September 2016 from the Department of Neurophysiology at the Hospital Miguel Servet, Zaragoza, Spain. Thirty-nine people (52 wrists) diagnosed with mild to moderate CTS were included. Participants were randomly assigned to either the DF group (n = 26) or the sham group (n = 26). Both groups received 5 therapy sessions, 2 sessions per week. Mechanosensitivity with the Upper Limb Neurodynamic Test 1, symptom severity and functional status with the Boston Carpal Tunnel Questionnaire, and median nerve sensory conduction velocity with nerve conduction studies were the outcomes measured. Assessments were recorded at baseline and after the intervention.

RESULTS

The DF group showed significant improvements in the following: mechanosensitivity, with 28.46 degrees of elbow extension range of motion (95% CI = 19.2-37.7); an increase of 1.0 point (95% CI = 0.7-1.4) for the Boston Carpal Tunnel Questionnaire symptom severity and functional status score; and sensory conduction velocity of median nerve, which improved to 5.8 m/s (95% CI = 2.5-9.2).

CONCLUSION

Participants with mild to moderate CTS experienced improvements in symptom severity, functional status, mechanosensitivity, and nerve conduction studies after 5 sessions of DF.

IMPACT

This study provides evidence of an approach based on soft and connective tissues around the median nerve in patients with CTS.

Normal response to sural neurodynamic test in asymptomatic participants. A cross-sectional study

BACKGROUND

Neurodynamic tests (NDTs) consist of a combination of movements aimed to stress different parts of the nervous system and are considered to be able to detect increased nerve mechanosensitivity. Currently, there are no studies in healthy subjects that define the normal response to sural neurodynamic test (NDT_SUR).

OBJECTIVES

The main aim of this study was to document normal responses of the NDT_SUR in asymptomatic participants. The secondary aim was to investigate potential gender and leg dominance influences.

DESIGN

A cross-sectional study was designed.

METHODS

NDT_SUR was performed on 44 asymptomatic participants with a total of 88 lower limbs. The range of motion at the point of first appearance of symptoms (S1) and the point of pain tolerance (S2), quality and distribution of sensory responses were recorded.

RESULTS

Hip flexion was significantly greater (p < 0.001) at S2 (63.6 ± 13.1°) than S1 (42.5 ± 12°) and the mean difference was 21.8° (95% CI: 21.8; 22.8) (p < 0.001). However, hip flexion was not different between gender nor dominance (p > 0.05). The descriptor of the quality of the sensory responses more often used by participants was stretching (87% and 76% for S1 and S2, respectively) in the posterior knee and lateral leg.

CONCLUSIONS

This study describes the sensory responses of asymptomatic participants resulting from the NDT_SUR. The findings indicate that NDT_SUR responses are independent of the influence of gender or leg dominance.

Reliability of the beighton score and impact of generalized joint mobility and resting scapular position on Median Neurodynamic Test 1

INTRODUCTION

There is a lack of understanding of the impact of generalized joint mobility, joint hypermobility, and resting scapular position on neurodynamic testing of the median nerve. The objectives of the study were to determine: 1) the reliability of the Beighton score (BS) with and without the cutoff score for general joint hypermobility (GJH); 2) if there are differences in the Median Neurodynamic Test 1 (MNT 1) based on the Beighton cutoff score for GJH; 3) if there are differences in the MNT 1 based on an assessment of resting scapular position; 4) if there are relationships between the BS with and without the cutoff score for GJH, resting scapular position, and MNT 1.

METHODS

Testing was performed by two testers at two-time intervals at least 1 week apart. The population of interest was healthy asymptomatic adults. The outcome measures included the BS, resting scapular position, and MNT 1.

RESULTS

Intraclass correlation coefficients (ICC_2,1) were 0.52 for intertester reliability at visit 1 and 0.86 at visit 2, with intratester reliability of 0.88 for Tester 1 and 0.71 for Tester 2 for the BS. Intertester prevalence-adjusted bias-adjusted kappa (PABAK) values for the Beighton GJH cutoff scores were 0.80-0.84 and 0.80 to 0.92 for intratester reliability. There were no statistically significant differences or relationships for any of the other variables of interest.

CONCLUSION

Joint mobility and resting scapular position are not confounding variables when performing MNT 1 in an asymptomatic population.

Side-to-side elbow range of movement variability in an ulnar neurodynamic test sequence variant in asymptomatic people

Background:

Range of motion (ROM) asymmetry between sides is one indicator of a positive neurodynamic test, but this has been less well studied for the ulnar nerve.

Objective:

The purpose of this study was to investigate side-to-side variation in elbow ROM during an ulnar neurodynamic test sequence, including contralateral cervical side flexion, in 40 asymptomatic subjects.

Methods:

A traditional goniometer was used to measure elbow flexion ROM at two end points, onset of resistance (R1) and symptom onset (P1). Two repeated measures of R1 and P1 were taken on each side.

Results:

Reliability for R1 and P1 was found to be good (ICC ≥0.83, SEM ≤5.37) with no significant difference in mean ROM between sides. A significant relationship between sides was seen (r values ≥0.48) and R2 values >0.23; this indicates at least 23% of the variance observed in one limb was accounted for by range in the opposite limb. This relationship was slightly stronger for R1 than P1. Lower bound scores indicate that intra-individual ROM difference >23° for R1 and 22^° for P1 would exceed normal ROM asymmetry.

Conclusion:

These findings provide clinicians with background information of ROM asymmetry during the ulnar neurodynamic test.

Impact of shoulder internal rotation on normal sensory response during ulnar nerve-biased neurodynamic testing of asymptomatic individuals

OBJECTIVE

To determine if substitution of shoulder internal rotation for external rotation during the upper limb neurodynamic test (ULNT₃) evokes comparable ulnar nerve sensory responses in asymptomatic individuals.

METHODS

Range of motion, quality, quantity, and distribution of sensory responses in 50 asymptomatic individuals during the traditional ULNT₃ were compared to identical measures during an experimental maneuver using shoulder internal rotation. Quality and quantity of sensory responses were recorded using a 10-cm visual analog scale.

RESULTS

Means of sensory responses for traditional and experimental maneuvers, respectively, were as follows: stretching, 3.84 ± 8.85 and 5.38 ± 2.85 cm; burning, 1.82 ± 2.82 and 2.50 ± 3.10 cm; tingling, 2.13 ± 3.12 and 2.18 ± 2.97 cm; and numbness, 1.04 ± 2.17 and 1.01 ± 2.03 cm. A moderate to strong correlation (ICC = 0.51-0.86) was shown to exist between maneuvers; this relationship was significant (p = .001).

DISCUSSION

Results of this study provide evidence that there was no appreciable difference in sensory responses with regard to burning and tingling when substituting shoulder internal rotation for external rotation during the ULNT₃. The results also suggest that there were only marginal differences in the sensory responses of stretching and numbness during the same substitution.

CONCLUSION

Patients who have limited glenohumeral external rotation due to pain, instability, and/or articular limitation may benefit from this substitution when presenting with signs of ulnar nerve pathodynamics. Further research will be needed to validate this maneuver in a symptomatic population.

LEVEL OF EVIDENCE

Level 2b.

The influence of a depressed scapular alignment on upper limb neural tissue mechanosensitivity and local pressure pain sensitivity

BACKGROUND

A depressed scapular alignment could lead to prolonged and repetitive stress or compression of the brachial plexus, resulting in sensitization of neural tissue. However, no study has investigated the influence of alignment of the scapulae on sensitization of upper limb neural tissue in otherwise asymptomatic people. In this case-control study, we investigate the influence of a depressed scapular alignment on mechanosensitivity of the upper limb peripheral nervous system as well as pressure pain thresholds (PPT).

METHODS

Asymptomatic individuals with neutral vertical scapular alignment (n = 25) or depressed scapular alignment (n = 25) participated. We measured the upper limb neurodynamic test (ULNT1), including assessment of symptom response and elbow range of motion (ROM), and PPT measured over upper limb peripheral nerve trunks, the upper trapezius muscle and overlying cervical zygapophyseal joints.

RESULTS

Subjects with a depressed scapular reported significantly greater pain intensity (t = 5.7, p < 0.0001) and reduced elbow extension ROM (t = -2.7, p < 0.01) during the ULNT1 compared to those with a normal scapular orientation. Regardless of the location tested, the group presenting with a depressed scapular had significantly lower PPT compared to those with a normal scapular orientation (PPT averaged across all sites: normal orientation: 3.3 ± 0.6 kg/cm², depressed scapular: 2.1 ± 0.5 kg/cm², p < 0.00001).

CONCLUSIONS

Despite being asymptomatic, people with a depressed scapular have greater neck and upper limb neural tissue mechanosensitivity when compared to people with a normal scapular orientation. This study offers insight into the potential development of neck-arm pain due to a depressed scapular position.

Effect of leg dominance, gender and age on sensory responses to structural differentiation of straight leg raise test in asymptomatic subjects: a cross-sectional study

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To assess the effect of structural differentiation on sensory responses of asymptomatic individuals to standard neurodynamic tests of straight leg raise (SLR) and to evaluate the relevance of leg dominance, gender, and age.

BACKGROUND

SLR test is a well-known neurodynamic test among physical therapists; no studies to date have investigated the influence of gender, age, and leg dominance to the sensory responses of this neurodynamic test and its structured differentiating maneuver.

METHODS

Thirty (16 women) asymptomatic individuals enrolled in this study. Dominancy test was performed for each participant. Pain intensity using visual analogue scale (VAS), symptoms location in a body chart, nature of symptoms evoked, and hip range of motion (ROM) were recorded and compared at ankle neutral position (N-SLR) and dorsiflexion (DF-SLR) in both legs at the point of pain tolerance during SLR (P2). In addition, hip ROM was recorded at the onset of pain (P1).

RESULTS

There was a statistically significant sex main effect for P1 and P2 between N-SLR and DF-SLR (p < 0.05). Mean hip ROM during the SLR was more than 10° greater in women than men. There was no statistically significant interaction between leg dominance and age group in N-SLR, DF-SLR, and VAS. Pain intensity was moderate for each SLR test. Symptoms most often described were stretch (96.7%), followed by tightness (70%) in the posterior thigh and leg.

CONCLUSIONS

SLR hip ROM is influenced by sex in asymptomatic individuals, leading to a greater hip ROM in SLR in women. Age and limb dominance are not relevant to SLR hip ROM or pain intensity.

Test-retest Reliability in Reporting the Pain Induced by a Pain Provocation Test: Further Validation of a Novel Approach for Pain Drawing Acquisition and Analysis

BACKGROUND

Pain drawings (PD) are frequently used in research to illustrate the pain response to pain provocation tests. However, there is a lack of data on the reliability in defining the extent and location of pain. We investigated the test-retest reliability in reporting an acute painful sensation induced by a pain provocation test using a novel approach for PD acquisition and analysis in healthy volunteers.

METHODS

Forty healthy volunteers participated. Each participant underwent 2 upper limb neurodynamic tests 1 (ULNT1), once to the point of pain onset (PO) and once until the point of submaximal pain (SP). After each ULNT1, participants completed 2 consecutive PD with an interval of 1 minute. Custom software was used to quantify the pain extent and analyze the pain overlap. The test-retest reliability of pain extent was examined using Intraclass Correlation Coefficient (ICC _2,1 ) and Bland-Altman plots. Pain location reliability was examined using the Jaccard similarity coefficient (JSC).

RESULTS

The ICC values for PO and SP were 0.98 (95% CI: 0.96-0.99) and 0.97 (95% CI: 0.95-0.98), respectively. The mean difference and 95% limits of agreement (± 1.96 SD) in the Bland-Altman plots were 14 pixels (-1080;1110) for PO, and 145 (-1610;1900) for SP. The median JSCs (Q1;Q3) were 0.73 (0.64;0.80) for PO and 0.76 (0.65;0.79) for SP.

CONCLUSIONS

Pain drawings is a reliable instrument to investigate pain extent and pain location in healthy individuals experiencing an acute painful sensation induced by a pain provocation test.

Tension of the ulnar, median, and radial nerves during ulnar nerve neurodynamic testing: observational cadaveric study

BACKGROUND

The ulnar nerve upper limb neurodynamic test (ULNT3) uses upper limb positioning to investigate symptoms arising from the ulnar nerve. It is proposed to selectively increase tension of the nerve; however, this property of the test is not well established.

OBJECTIVE

The aim of this study was to determine the upper limb position that results in: (1) the greatest tension of the ulnar nerve and (2) the greatest difference in tension between the ulnar nerve and the other 2 major nerves of the upper limb: median and radial.

DESIGN

This was an observational cadaver study.

METHODS

Tension (in newtons) of the ulnar, median, and radial nerves was measured simultaneously using 3 buckle force transducers in 5 upper limb positions in 10 embalmed human cadavers (N=20 limbs). Repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc tests determined differences in tension among nerves and among limb positions.

RESULTS

The addition of shoulder horizontal abduction (H.Abd; 12.62 N; 95% confidence interval [95% CI]=10.76, 14.47) and combined shoulder abduction and internal rotation (H.Abd+IR; 11.86 N; 95% CI=9.96, 13.77) to ULNT3 (scapular depression, shoulder abduction and external rotation, elbow flexion, forearm pronation, and wrist and finger extension) produced significantly greater ulnar nerve tension compared with the ULNT3 alone (8.71 N; 95% CI=7.25, 10.17). The ULNT3+H.Abd test demonstrated the greatest difference in tension among nerves (mean difference between ulnar and median nerves=11.87 N; 95% CI=9.80, 13.92; mean difference between ulnar and radial nerves=8.47 N; 95% CI=6.41, 10.53).

LIMITATIONS

These results pertain only to the biomechanical plausibility of the ulnar nerve neurodynamic test and do not account for other factors that may affect the clinical application of this test.

CONCLUSIONS

The ULNT3+H.Abd is a biomechanically plausible test for detecting peripheral neuropathic pain related to the ulnar nerve. In situations where the shoulder complex will not tolerate the combination of shoulder external rotation in abduction, performing upper limb neurodynamic tests with internal rotation instead of external rotation is a biomechanically plausible alternative.