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1412

ORIGINAL ARTICLE

An Experimental Pain Model to Investigate the Specificity of


the Neurodynamic Test for the Median Nerve in the
Differential Diagnosis of Hand Symptoms
Michel W. Coppieters, PT, PhD, Ali M. Alshami, MPhty, Paul W. Hodges, PhD, PT, MedDr
ABSTRACT. Coppieters MW, Alshami AM, Hodges PW. ARPAL TUNNEL SYNDROME (CTS), an entrapment of
An experimental pain model to investigate the specificity of the
neurodynamic test for the median nerve in the differential
C the median nerve at the wrist, is a condition characterized
by pain, neurologic symptoms, and functional limitation of the
diagnosis of hand symptoms. Arch Phys Med Rehabil 2006;87: hand.1 Despite the high prevalence of CTS,2 and its major
1412-7. socioeconomic impact,3,4 there is no criterion standard avail-
Objective: To indirectly assess the specificity of the neuro- able to diagnose CTS.5-8 The relevance of numerous clinical tests
dynamic test for the median nerve using an experimental pain is questionable considering their poor diagnostic accuracy,9,10 and
model. there are no universally accepted criteria7 for the various electro-
Design: Repeated-measures design. diagnostic parameters that have been suggested.11 Because
Setting: Laboratory setting. symptoms originating from nerve compression often occur
Participants: Twenty asymptomatic participants in whom before conduction is impaired,12 the clinical utility of electro-
hand symptoms were induced by infusion of hypertonic saline diagnosis for CTS remains controversial.13
into the thenar muscles. Unlike clinical tests for CTS, many provocation tests for
Interventions: Not applicable. other common neuropathies not only challenge the nerve by
Main Outcome Measures: Pain intensity of the induced application of direct pressure over the affected area or move-
hand symptoms and size of the painful area were evaluated in ment of the nearest joint, but further provocation of the in-
8 different arm positions, which correspond with different volved nerve is often produced indirectly by stressing the nerve
stages of the neurodynamic test for the median nerve. These via movements in adjacent joints. For example, ankle dorsi-
positions have a variable degree of median nerve provocation flexion is frequently added to the straight-leg raising test to
at the wrist. diagnose lumbar nerve root irritation.14 Similarly, wrist exten-
Results: Because the induced symptoms had a non-neural sion can be included in the elbow flexion test for cubital tunnel
origin, changes in symptom provocation with the neurody- syndrome.15 Inclusion of neighboring joints to elicit symptoms
namic test would have indicated poor specificity. However, of neural origin is supported by numerous anatomical studies
there were no statistically significant differences in pain per- that demonstrate that tension can be transmitted over a rela-
ception (Pⱖ.22) and the recorded differences were negligible tively long section of a peripheral nerve, for example, along the
from a clinical perspective. median nerve between the shoulder and wrist.16-19 From this
Conclusions: Taking into consideration the limitations of an perspective, a clinical test that considers various joints along
experimental pain model, this study indirectly confirms the the median nerve bed (the tract formed by the structures that
specificity of the neurodynamic test for the median nerve. The surround the nerve) may be more sensitive than traditional
results of this study, together with previous studies that dem- diagnostic tests for CTS, which focus on the wrist only.
onstrated a high sensitivity, support the use of the neurody- The neurodynamic test for the median nerve (fig 1),20,21 also
namic test for the median nerve to differentially diagnose termed upper limb tension test and neural provocation test for
neurogenic disorders, such as carpal tunnel syndrome, from the median nerve,22 is a relatively novel test in the diagnosis of
other wrist and hand pathologies. CTS and challenges the median nerve at the carpal tunnel by
Key Words: Carpal tunnel syndrome; Diagnosis; Entrap- combined movements of the wrist, elbow, and shoulder girdle.
ment neuropathies; Median nerve; Rehabilitation; Reliability While preventing elevation of the shoulder girdle, the shoulder
and validity. is abducted and the wrist extended; supination of the forearm is
© 2006 by the American Congress of Rehabilitation Medi- followed by lateral rotation of the shoulder and elbow exten-
cine and the American Academy of Physical Medicine and sion.20,22 Frequently, not all test maneuvers are needed to
Rehabilitation reproduce symptoms and the standard test can be varied to
adapt to individual patients. Alternatively, the final test position
can be sustained or additional pressure can be applied over the
carpal tunnel when it is difficult to reproduce mild symptoms.20
From the Division of Physiotherapy, School of Health and Rehabilitation Sciences, Diagnosis of CTS using the neurodynamic test for the me-
The University of Queensland, Brisbane, Australia (Coppieters, Alshami, Hodges); dian nerve is dependent on reproduction or increase of CTS
and Neuro Orthopaedic Institute, Adelaide, Australia (Coppieters). symptoms, such as pain and paresthesia in the hand. A second
Supported by The University of Queensland, Brisbane, Australia (early career
research grant). condition for a positive test is that symptoms in the hand can be
No commercial party having a direct financial interest in the results of the research influenced by changing the amount of nerve provocation at the
supporting this article has or will confer a benefit upon the authors or upon any wrist by alteration of the position in more proximal joints, such
organization with which the authors are associated. as the elbow or shoulder girdle, while maintaining the wrist in
Reprint requests to Michel W. Coppieters, PT, PhD, School of Health and Reha-
bilitation Sciences, Bldg 84A, The University of Queensland, QLD 4072 St. Lucia, extension. Alteration of symptoms via changes in median nerve
Australia, e-mail: m.coppieters@uq.edu.au. strain, without influencing local musculoskeletal tissues around
0003-9993/06/8710-10856$32.00/0 the wrist, is a valuable tool to differentiate symptoms of neural
doi:10.1016/j.apmr.2006.06.012 origin from local wrist pathology, such as arthritis, tendinoses,

Arch Phys Med Rehabil Vol 87, October 2006


VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters 1413

study was to indirectly assess the specificity of the test by


analyzing whether the test is negative in the absence of CTS.
Because inclusion of asymptomatic volunteers may overesti-
mate the validity of a test,28 an experimental pain model was
used to induce hand symptoms in healthy volunteers. The
specificity of the neurodynamic test for the median nerve
would be compromised if the symptoms were altered with the
test because the experimentally induced symptoms had a non-
neural origin.

METHODS

Participants
Twenty asymptomatic volunteers (17 men, 3 women; mean
age ⫾ standard deviation [SD], 23⫾7y; height, 175⫾9cm;
weight, 72⫾11kg) participated in the study. Subjects with a
history of neck, arm, or hand pain during the last year or
Fig 1. The neurodynamic test for the median nerve. The test is used subjects with any known neurologic condition were excluded
to evaluate the impact of compression and tension in the median from the study. Participants were naive to the concept of
nerve at the carpal tunnel by combined movements of the wrist, neurodynamic testing and were given a full explanation of the
elbow, and shoulder girdle. While elevation of the shoulder girdle is procedure, without disclosure of the hypothesis of the study.
prevented, the nerve bed of the median nerve is elongated by
shoulder abduction, wrist extension, forearm supination, lateral Written consent was obtained prior to the commencement of
rotation of the shoulder, and elbow extension. Cervical contralat- the study. The study was approved by the institutional ethics
eral side bending can be added to further increase the length of the committee. All investigations conformed to the protocol and
nerve bed. From Butler DS. The sensitive nervous system. Unley: the ethical and humane principles of research.
Noigroup Publications; 2000. p 317.20 © 2000. Reprinted with per-
mission of Noigroup Publications.
Experimental Muscle Pain
We used an experimental pain model to ensure that pain was
isolated in muscle tissue. Intramuscular injection of hypertonic
or tenosynovitis, and painful sequelae following a Colles’ saline has been used extensively because the quality of the
fracture. induced pain is considered comparable to clinical pain and it
Analysis of the validity of several clinical tests for CTS shows localized as well as referred pain characteristics.29,30
(including provocation tests such as the Phalen test, Tinel test, In the absence of a validated infusion protocol to induce
and the application of pressure over the carpal tunnel) demon- experimental hand pain with a constant intensity, we developed
strated that the tests were not very sensitive (.23–.69), but were and tested a protocol prior to the conduction of the main study.
fairly specific (.66 –.87).9 By inclusion of joints proximal to the The infusion protocol was based on the procedure described by
wrist to increase stress to the median nerve in the carpal tunnel, Svensson et al31,32 for the jaw muscles. A single bolus of
the clinical assumption is that the neurodynamic test for the 0.2mL of saline (5% NaCl) was infused over 20 seconds into
median nerve is a more sensitive test for CTS than tests that the thenar muscles of the right hand, followed by a steady
focus on the wrist only. However, the high sensitivity may be infusion rate of 6mL/h for 440 seconds and 9mL/h for the next
at the expense of the test’s specificity because the test not only 440 seconds. Saline was infused with an infusion pumpa with
challenges the median nerve at the wrist, but also challenges a 10-mL plastic syringe. A low sorbing extension tube was
other sections of the median nerve and many non-neural struc- connected from the syringe to a 22-gauge disposable cannula,
tures. Recent studies confirmed the high sensitivity for the which was placed obliquely into the thenar eminence with the
neurodynamic test for the median nerve in patients with CTS tip of the cannula at a depth of approximately 0.5cm. This
(.7523 and .8224), but discrepancies have been reported for the infusion paradigm was evaluated on 8 asymptomatic volunteers
specificity of the test, with values ranging from .1323 to .75.24 (3 men, 5 women; mean age ⫾ SD, 32⫾7y; height, 170⫾9cm;
Although a consensus statement was issued that diagnosis based weight, 66⫾13kg) prior to the commencement of the main
on electrophysiologic findings alone is not recommended,6 both experiment. Pain perception was evaluated every 30 seconds
studies used electrodiagnostic tests as the criterion standard. using a 10-cm electronic visual analog scale (VAS) and a chart
Because symptoms of nerve compression can be present with- to determine the size of the painful area. This chart depicted a
out deficits in nerve conduction,12,13,25-27 using electrophysi- series of 15 circles increasing in size from 0.5 to 7.5cm in
ologic tests as a criterion standard may result in the inclusion diameter. In addition, each subject marked the location of the
of patients with nerve entrapment in a category of subjects that pain distribution on a body chart. Results demonstrated that
should consist of subjects without CTS. For these incorrectly after a rapid increase in the first 60 seconds, the infusion
categorized patients, a positive clinical test will be wrongly paradigm produced a relatively constant pain perception of
regarded as a false-positive test. As a consequence, the speci- moderate intensity (fig 2). The pain was predominantly local-
ficity will be underestimated, because a higher number of ized over the thenar eminence and radiated further into the
false-positive tests lowers the specificity. palm of the hand and occasionally into the thumb and fingers.
Because a high sensitivity coefficient has already been dem- Based on these findings, we concluded that the proposed infu-
onstrated for the neurodynamic test for the median nerve,23,24 sion protocol was appropriate to induce experimental muscle
priority was given to reassess the test’s specificity by using an pain in the hand. However, because some of the participants
alternative method that is not negatively affected by the lack of experienced swelling of the thenar eminence towards the end of
a sound criterion standard. Because direct validation in the the experiment, probably due to the infused volume, the max-
absence of a criterion standard is impossible, the aim of this imal infusion time was limited to 10 minutes.

Arch Phys Med Rehabil Vol 87, October 2006


1414 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters

10 10 progressively increased or decreased the loading of the median


nerve (appendix 1). The sequences were performed in random
6 6
order. The order of the positions within each sequence was
Pain intensity (VAS)

Size of painful area


5 5 constant. All movements were performed by the investigator
while the participant remained relaxed. Participants were made
4 4 aware that the pain in the hand could increase, decrease, or
3 3 remain unchanged in one position relative to another.
The 8 test positions consisted of combinations of wrist, elbow,
2 2 shoulder girdle, and neck positions. The positions of the elbow
1
Pain intensity (VAS)
1
were 90° of flexion and submaximal extension. The submaxi-
Size of painful area mal range of elbow extension was determined with the arm in
0 0 the neurodynamic test position and before experimental hand
0 60 120 180 240 300 360 420 480 540 600 pain was induced, and was defined as the maximal range of
elbow extension without causing discomfort in the arm. The
Fig 2. Pain perception during continuous infusion of hypertonic range of elbow extension was measured during the experiment
saline in the thenar muscles. Following a rapid increase during the
first minute, a relatively constant pain intensity could be induced.
with a twin-axis electrogoniometerb attached with double-sided
adhesive tape to the medial side of the elbow.
The shoulder girdle was positioned in neutral, depression,
and elevation. With the arm in 90° of abduction, a neutral
Test Positions shoulder girdle position is obtained by application of a caudally
In the main experiment, we evaluated the perception of pain directed force of 30N over the shoulder girdle to neutralize the
in 8 positions, which had a variable amount of elongation of the elevation of the shoulder girdle caused by abduction of the
nerve bed (fig 3A). These positions correspond with different arm.33 A larger depression force (60N) results in shoulder
stages of the neurodynamic test for the median nerve. The 8 girdle depression, whereas no depression force (0N) results in
positions were divided in 2 sequences of 4 maneuvers, which shoulder girdle elevation. Throughout the experiment, the force

B 10

5 + 0. 2 - 0.2
+ 0. 1 - 0.3 + 0. 1 - 0.2
+ 0. 3
4

+ 0. 2 + 0. 1 - 0.2 + 0. 1
3 + 0. 2 + 0. 1 - 0.4

1 S S

0 Increasing length of nerve bedding Decreasing length of nerve bedding

Fig 3. (A) The different test positions that correspond with different stages of the neurodynamic test for the median nerve. The positions
are described in detail in appendix 1. (B) The intensity of the induced hand pain ( ) and the size of the painful area ( ) did not differ
significantly for the 8 different positions with a variable amount of nerve bed elongation. The y axis represents both pain intensity (VAS) and
size of the painful area (diameter of the presented circles ranging from 0.5 to 7.5cm). The error bars denote 95% confidence intervals. The
right panel shows the most frequently reported locations of hand pain during the experiment. A darker gray tint represents a larger number
of subjects reporting pain in the involved area.

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VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters 1415

by which the shoulder girdle was depressed was measured with of the painful area for the sequence which elongates the nerve
a hand held load cellc and shown on a digital display to enable bed, and a slight decrease when the length of the nerve bed
the investigator to accurately position the shoulder girdle prior decreases. However, variations were statistically not significant
to performing the test component. (pain intensity: F7,133⫽1.37, P⫽.22; size of painful area:
The cervical spine was positioned in neutral and ipsilateral F7,133⫽.98, P⫽.45) and, from a clinical perspective, the dif-
and contralateral side bending. Cervical side bending was tar- ferences were small. The mean difference between 2 consec-
geted to the middle and lower part of the cervical spine because utive positions for the sequence that increased the length of the
the brachial plexus originates from C5 to T1. Cervical side nerve bed was 0.2⫾0.6 for both pain intensity (VAS) and size
bending was performed submaximally, that is, to the maximal of the painful area. Differences for the sequence that decreased
amplitude that did not induce any symptoms in the neck. the length of the nerve bed were ⫺0.1⫾0.7 for pain intensity
We used a custom made hand-wrist splint to position the hand and ⫺0.1⫾0.5 for size of the painful area.
in a neutral position and to maintain the wrist in 70° of exten- The mean infusion time was 4.5 minutes ⫾ 46 seconds. All
sion.34 The splint had a separate strap to stabilize the thumb. trials were finished within the maximum set infusion time of 10
This prevented changes in muscle length of the thenar muscles minutes (range, 3.3– 6.3min). The total infusion time varied
that could influence pain perception. When the hand splint between subjects because the time required to obtain a stable
could not be applied comfortably because of the position of the pain intensity before the first test position was adopted fluctu-
catheter (6 subjects), an electrogoniometerb was attached to the ated between subjects and the time required by the subject to
dorsum of the wrist to monitor the position of the wrist. rate the pain in each position also varied between subjects.
Previous studies have demonstrated that the neurodynamic test
for the median nerve has a high reliability when performed DISCUSSION
with either the hand-wrist splint or wrist electrogoniometer.35 The main finding of this study was that the perception of
Electromyographic activity of the thenar muscles was moni- experimentally induced hand pain of muscular origin did not
tored to ensure that the muscles remained relaxed during the vary between different positions of the arm and neck that are
experiment. Surface electrodes (Ag-AgCl; diameter, 11mm) were associated with different levels of mechanical nerve provoca-
placed with about 20-mm interelectrode distance over the bulk of tion. Anatomic and biomechanic studies have demonstrated that
the thenar muscles, parallel to the muscle fibers. elbow, shoulder, and shoulder girdle positions that increase the
length of the nerve bed increase tension in the median nerve.16-19
Pain Measurements This increase in nerve strain occurs not only at the joint where
Because pain is subjective, self-reports are regarded as pro- the nerve bed is elongated, but the strain is transmitted over a
viding the most valid measure of the experience.36 In each relatively long section of the peripheral nerve, for example,
position, participants were asked to indicate the pain intensity along the median nerve between the shoulder and wrist.17-19 The
on a 10-cm electronic VAS, anchored with “no pain” and fact that neither the intensity of muscular hand pain nor the
“worst possible pain.” A chart depicting a series of 15 circles size of the painful area was significantly different between
increasing in size from 0.5 to 7.5cm in diameter was used to positions contributes to the further validation of neurodynamic
determine the size of the painful area. At the conclusion of the tests. The neurodynamic test for the median nerve is considered
study, the quality of pain was assessed by the McGill Pain positive in the diagnosis of CTS if neurogenic symptoms can
Questionnaire (MPQ). Words from the questionnaire chosen by be reproduced and if the intensity of the symptoms can be
at least 30% of the subjects were used to describe the quality of influenced by moving joints proximal to the wrist, while keep-
the induced pain. The distribution of the symptoms was deter- ing the wrist position constant. Changing positions in joints
mined from a hand diagram. proximal to the wrist that increase or decrease median nerve
strain at the carpal tunnel without changing local musculoskel-
Statistical Analysis etal structures around the wrist can contribute to the differential
diagnosis of disorders of the hand and wrist.
We used a 1-way, repeated-measures analysis of variance to No differences in pain perception were observed despite
analyze the pain intensity and size of the painful area in the largely different levels of nerve provocation in the different test
different positions of the neurodynamic test. The level of positions. Even though submaximal joint positions were used
significance was set at P less than .05. Statisticad was used for to limit discomfort from stressing articular structures, we be-
the analysis. lieve the mechanical provocation of the median nerve in some
of the positions was considerable. This judgment is based on
RESULTS anatomic and biomechanic16-19 and clinical34,38 data. Coppiet-
Pain was predominantly located around the infusion area in ers et al38 demonstrated that with the arm and cervical spine in
the thenar eminence and occasionally radiated toward the submaximal positions of nerve bed elongation, the elbow could
thumb, index finger, and middle finger (fig 3B, right panel). only be extended from 90° to 143.9°⫾16.1° before a maximal
The average pain intensity (VAS) throughout the experiment was pain level was reached. The positioning of the arm and cervical
4.0⫾2.2. According to the criteria proposed by Jensen et al,37 spine in the final test position of the sequence that increased the
35% of the participants experienced mild pain (VAS scores loading of the median nerve (see appendix 1) was similar to the
between 0.5 and 4.4) and 65% experienced moderate pain positions adopted by Coppieters.38 Although we limited exten-
(VAS scores between 4.5 and 7.4). The words most frequently sion of the elbow to 129.0°⫾7.9° (⬇15° less extension), we
chosen from the MPQ to describe the induced symptoms were believe that this range of motion, in combination with nerve
“tight” (45%), “cramping” (45%), “sharp” (35%), “stinging” bed elongation at the neck, shoulder, shoulder girdle, and wrist,
(35%), and “throbbing” (30%). The volunteers rated the pain challenged the median nerve substantially.
intensity throughout the experiment as “discomforting” (65%), Because there is no criterion standard available to assess the
“mild” (25%), or “distressing” (10%). concurrent validity of the neurodynamic test for the median
Figure 3B (left panel) demonstrates the pain intensity and nerve, we chose an experimental model as an alternative way to
size of the painful area for the 8 different positions. The figure indirectly investigate the specificity of the neurodynamic test
shows a tendency for a slight increase in pain intensity and size for the median nerve to differentially diagnose hand symptoms.

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1416 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters

The main advantage of using an experimental model was that principal symptom produced by infusion with hypertonic saline
the exact origin of the symptoms was known. Furthermore, the was hand pain, which is only one of the symptoms of CTS.
probability that patients with minor neuropathies were in- Despite these limitations, the findings of this study contrib-
cluded, which could have confounded the results, was low ute to the current knowledge regarding the applicability of
because the participants of this study only experienced hand neurodynamic tests to structurally differentiate between sources of
symptoms during the experiment. symptoms. It has been suggested that painful muscles and joints,41
In this study, we focused on one of the criteria for a positive and continuity of the fascial system42 may result in false-
neurodynamic test, namely, whether the intensity of hand positive neurodynamic tests and that a peripheral nerve cannot
symptoms increases or decreases when the length of the nerve be selectively loaded because the test challenges many differ-
bed is altered by changing positions in joints proximal to the ent structures.41 The findings of this study provide evidence
against the opinion that pain of non-neural origin will increase
wrist. Although no studies have investigated this criterion in
during neurodynamic testing. The results are in agreement with
patients with CTS, case studies of patients with cubital tunnel previous experiments in which experimentally induced muscle
syndrome have demonstrated that shoulder abduction and cer- pain was used to contribute to the validation of other neurody-
vical contralateral side bending, when added to elbow flexion, namic tests, such as the straight-leg raising test and slump test.43
and wrist extension are able to reproduce symptoms related to
ulnar nerve compression around the elbow.39,40 The fact that CONCLUSIONS
symptoms of neural origin can be altered by movements in It is obvious that by inclusion of joints proximal to the wrist
adjacent joints, in combination with the finding of this exper- to increase the mechanical provocation of the median nerve at
iment that hand symptoms of muscular origin could not be the carpal tunnel, neurogenic symptoms may also be elicited
altered, suggest that nerve involvement can be differentiated from more proximal parts of the median nerve and brachial
from musculoskeletal wrist or hand pathologies using neuro- plexus. Proximal nerve entrapments that may mimic CTS
dynamic tests. symptoms include pronator teres syndrome, anterior interosse-
A disadvantage of using an experimental pain model was ous nerve syndrome, cervical radiculopathy, and peripheral
that a second criterion for a positive neurodynamic test, polyneuropathy.8,44 Although the findings of this and previous
namely, whether the test reproduces CTS symptoms, could not studies suggest that the neurodynamic test for the median nerve
be considered. As a result, we did not determine whether an may be a valuable test to differentiate neurogenic from non-
individual test was positive or negative, but rather compared neurogenic disorders, localization of the site of the nerve
results across all participants. Validity measures, such as sen- entrapment with a single test is unlikely to be possible. The
sitivity, specificity, and positive and negative predictive value, patient interview, specific symptoms, and additional tests
require individual test decisions and were therefore not calcu- should be used to obtain further information regarding the
lated. Another limitation of the chosen model was that the location of the neuropathy.
APPENDIX 1: POSITIONS USED TO INCREASE AND DECREASE THE LENGTH OF THE NERVE BED
OF THE MEDIAN NERVE

Sequence of positions that progressively increased the loading of the median nerve
Starting position: Shoulder abduction and lateral rotation (90°); neutral shoulder girdle position (30N depression force); elbow flexion
(90°); forearm supination; wrist extension (70°).
➊ Starting position plus elbow extension (submaximal).
➋ Starting position plus elbow extension and shoulder girdle depression (60N depression force).
➌ Starting position plus elbow extension, shoulder girdle depression, and cervical contralateral side bending.
Sequence of positions that progressively decreased the loading of the median nerve
Starting position: Shoulder abduction and lateral rotation (90°); neutral shoulder girdle position (30N depression force); elbow
extension (submaximal); forearm supination; wrist extension (70°).
➀ Starting position with shoulder girdle elevation (0N depression force).
➁ Starting position with shoulder girdle elevation and cervical ipsilateral side bending.
➂ Starting position with shoulder girdle elevation, cervical ipsilateral side bending, and elbow flexion (90°).

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Arch Phys Med Rehabil Vol 87, October 2006