Jospt 2012 3988

[ clinical commentary ]
ROBERT J. NEE, PT, MAppSc1 • GWENDOLEN A. JULL, PT, PhD2 • BILL VICENZINO, PT, PhD2 • MICHEL W. COPPIETERS, PT, PhD3
The Validity of Upper-Limb

Neurodynamic Tests for Detecting
Peripheral Neuropathic Pain
U
Downloaded from www.jospt.org at on August 29, 2023. For personal use only. No other uses without permission.
pper-limb neurodynamic tests (ULNTs) (FIGURE 1, tralateral neck sidebending in-

ONLINE VIDEOS) use a series of movements to apply creases a sensory response in the
SUPPLEMENTAL forearm).12,38 Moving a distant
mechanical forces to a portion of the nervous system.12,38 VIDEO ONLINE
body part to evaluate a ULNT re-
ULNTs also load nonneural tissues.12,38 Therefore, when sponse is referred to as structural
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
central pain mechanisms are not the primary reason for a patient’s differentiation.12,38,45
pain experience, a ULNT response could be related to neural or Peripheral neuropathic pain (PNP)
is pain that arises as a direct result of a
nonneural tissue sensitivity. In these ity when it changes with movement of lesion or disease affecting the somato-
situations, a ULNT response is thought a distant body part that further loads sensory component of the peripheral
to be related to neural tissue sensitiv- or unloads the nervous system (eg, con- nervous system.99 Clinicians use ULNTs
to help determine whether patients have
PNP conditions such as cervical radicu-
TTSYNOPSIS: The validity of upper-limb neurody- These findings should be interpreted cautiously,
namic tests (ULNTs) for detecting peripheral neu- lopathy,110 carpal tunnel syndrome,104,111
because diagnostic accuracy might have been
Journal of Orthopaedic & Sports Physical Therapy®
ropathic pain (PNP) was assessed by reviewing the distorted by the investigators’ definitions of a and cubital tunnel syndrome.20,85 The ra-
evidence on plausibility, the definition of a positive positive ULNT. Furthermore, patients with PNP tionale for the use of ULNTs is that they
test, reliability, and concurrent validity. Evidence who presented with increased nerve mechano- are considered capable of detecting the
was identified by a structured search for peer- increased nerve mechanosensitivity as-
sensitivity rather than conduction loss might have
reviewed articles published in English before May
been incorrectly classified by electrophysiological sociated with these conditions.12,38,42,45,112
2011. The quality of concurrent validity studies was
reference standards as not having PNP. The only Other clinical tests proposed for detect-
assessed with the Quality Assessment of Diagnos-
tic Accuracy Studies tool, where appropriate. Bio- evidence for concurrent validity of the ulnar nerve ing these conditions, such as the Spurl-
mechanical and experimental pain data support test was a case study on cubital tunnel syndrome. ing test,92 Phalen’s test,75 and the elbow
the plausibility of ULNTs. Evidence suggests that a We recommend that researchers develop more
flexion-pressure test,68 use the same
positive ULNT should at least partially reproduce comprehensive reference standards for PNP to
rationale.
the patient’s symptoms and that structural dif- accurately assess the concurrent validity of ULNTs
ferentiation should change these symptoms. Data While ULNTs can also be used to
and continue investigating the predictive validity of
indicate that this definition of a positive ULNT is ULNTs for prognosis or treatment response. J Or- guide treatment selection,12,38,45 a specific
reliable when used clinically. Limited evidence sug- thop Sports Phys Ther 2012;42(5):413-424, Epub 8 assessment of their diagnostic validity is
gests that the median nerve test, but not the radial important. Guidelines recommend that
March 2012. doi:10.2519/jospt.2012.3988
nerve test, helps determine whether a patient
TTKEY WORDS: carpal tunnel syndrome, cervical
clinicians use these tests when examin-
has cervical radiculopathy. The median nerve test
does not help diagnose carpal tunnel syndrome. radiculopathy, cubital tunnel syndrome, reliability ing patients with symptoms affecting the
neck or upper limb,1,16 and expert physical
1
PhD candidate, Division of Physiotherapy and NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences,
The University of Queensland, Brisbane, Australia. 2Professor, Division of Physiotherapy and NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury and Health,
School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. 3Associate Professor, Division of Physiotherapy and NHMRC Centre of Clinical
Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. Robert J. Nee was funded
by an Endeavour International Postgraduate Research Scholarship from the Australian Government and a Research Scholarship from The University of Queensland. Address
correspondence to Dr Michel W. Coppieters, Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland 4072,
Australia. E-mail: m.coppieters@uq.edu.au
journal of orthopaedic & sports physical therapy | volume 42 | number 5 | may 2012 | 413
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therapists and pain consultants rely heav-
ily on neurodynamic tests for making a ULNT1MEDIAN
clinical diagnosis of PNP.90 The validity of • Shoulder girdle stabilization
• Shoulder abduction
ULNTs to detect PNP can be assessed by • Wrist/finger extension
answering 4 questions.41,58,80,87 First, are • Forearm supination
ULNTs plausible tests for detecting PNP? • Shoulder external rotation
Second, what criteria should be used to • Elbow extension
• Structural differentiation
define a positive ULNT? Third, can cli- - Cervical sidebending
nicians make reliable decisions about a - Release wrist extension
positive ULNT? Fourth, are ULNTs accu-
rate for detecting PNP clinically (concur- ULNT2MEDIAN
rent validity)? This clinical commentary • Shoulder girdle depression
• Elbow extension
reviews the available evidence to help • Shoulder external rotation and forearm
answer these questions. supination
• Wrist/finger extension
SEARCH STRATEGY • Shoulder abduction
• Structural differentiation
- Cervical sidebending
S
earch terms were entered into - Release shoulder girdle depression
PubMed, CINAHL, EMBASE, Sco- - Release wrist extension
pus, and Web of Science to find peer-

reviewed articles published in English ULNTRADIAL
• Shoulder girdle depression
before May 2011. Titles and abstracts were • Elbow extension
screened, and full-text articles of all poten- • Shoulder internal rotation and forearm
tially relevant publications were retrieved pronation
for further assessment. Reference lists of • Wrist/finger flexion
retrieved articles were hand searched for • Structural differentiation
additional publications. Cadaveric stud- - Cervical sidebending
ies measuring nerve strain (percent elon- - Release shoulder girdle depression
gation) and nerve sliding (longitudinal - Release wrist flexion

displacement) during ULNT movements
had to use whole-body or transthoracic ULNTULNAR
• Wrist/finger extension
specimens that maintained the nerve root • Forearm pronation
attachments to the spinal cord.124 Biome- • Elbow flexion
chanical studies focusing only on moving • Shoulder external rotation
individual digits were excluded, because • Shoulder girdle depression
the hand and wrist are normally moved • Structural differentiation
together during ULNTs.12,38 FIGURE 2 sum- - Cervical sidebending
marizes the search. - Release shoulder girdle depression
- Release wrist extension
DIAGNOSING PERIPHERAL FIGURE 1. Standard sequence of joint movements and suggested structural differentiation maneuvers for each
NEUROPATHIC PAIN ULNT.12 Joint movements for each ULNT can be applied in different sequences (ONLINE VIDEOS).12,38 Abbreviation:
ULNT, upper-limb neurodynamic test.
A
reference standard for diag-
nosing PNP is needed to interpret consistent with a nerve-related problem,
results from clinical studies on and either (3a) a clinical neurological PLAUSIBILITY OF ULNTs
ULNT validity. Treede et al99 proposed examination shows positive or negative
B
that their criteria for “probable” neuro- sensory signs that match the innervation iomechanical studies on nerve
pathic pain would be sufficient for mak- territory of the suspected nerve problem, strain, sliding, and compres-
ing a neuropathic pain diagnosis. For or (3b) diagnostic tests, such as imaging sion help answer wheth-
PNP, probable means that (1) the pa- or electrophysiological studies, confirm er ULNTs are plausible tests for
tient’s symptoms fit a nerve-related dis- an injury or disease that explains the dis- detecting PNP. Cadaveric studies show
tribution, (2) the history of symptoms is tribution of PNP.99 that joint movements used in the me-
414 | may 2012 | volume 42 | number 5 | journal of orthopaedic & sports physical therapy
42-05 Nee.indd 414 4/18/2012 7:10:32 PM

Median nerve “AND” biomechanics (English, humans)* Brachial plexus tension test
Radial nerve Brachial plexus provocation test
Ulnar nerve Neural tissue provocation test
Brachial plexus “AND” excursion (English, humans)* Upper-limb tension test
Spinal nerve roots Upper-limb neural tension test
Spinal nerves Upper-limb neurodynamic test
Nerve roots “AND” sliding (English, humans)* Neurodynamic(s) “AND” test (English)*
PubMed, 932 records

CINAHL, 237 records†
EMBASE, 622 records
Scopus, 1388 records

Web of Science, 293 records
Excluded, 3360 including duplicates
Full-text articles retrieved, 112

Excluded, 46
Relevant articles from hand • Cadaver limbs only, 13
search of reference lists, 12 • Finger motion only, 8
• Validity questions not addressed, 25
Articles included in review, 78

Biomechanical studies, 40 Clinical studies, 38
Cadaver studies, 23 In vivo studies, 17
FIGURE 2. Search strategy and results. *Limits used for each search. †Nerve structure terms were searched in isolation because combining each term with biomechanics,
excursion, or sliding revealed no records.
dian (ULNTMEDIAN),13,18,21,56,57,61,66,67,119,124,127 throughout the brachial plexus.55 Cadav- neck sidebending spread along the entire
radial (ULNTRADIAL),122 and ulnar (ULN- eric13,18,21,67,118,122-124 and in vivo22,29,30,32,33,35, nerve.18,21,22,30,52,56,57,61,65,119,122,124 These data
TULNAR)2,3,13,21,47,66,72,83,98,123 nerve tests in- 49,52,65,100,101
studies also show that ULNT support the concept of structural differ-
crease strain in the corresponding nerve. movements produce sliding between the entiation. The spread of biomechanical
Each test preferentially loads its corre- nerve and surrounding tissues. A nerve effects along the nerve is a plausible ex-
sponding nerve at the elbow and wrist,13,56 segment slides toward the moving joint planation for why movement of a distant
suggesting that mechanosensitivity of a as each ULNT movement lengthens the body part can change sensory responses
particular nerve near these joints may be nerve bed. at the end of a ULNT.
most readily assessed by the correspond- Strain and sliding produced by Transfer of strain through the fascial
ing ULNT. ULNTs cannot selectively a joint movement are greatest in network in the neck and upper limb91,93
test mechanosensitivity of individual nerve segments closest to the moving may also explain why moving a distant
nerve roots.55 Shoulder girdle stabiliza- joint.18,30,32,52,56,57,122-124 However, when the body part changes sensory responses at
tion/depression and shoulder abduction limb is in the end ULNT position, biome- the end of a neurodynamic test.5 How-
involved in all ULNTs increase strain chanical effects from wrist movement or ever, a separate literature search did
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Sensory Responses
ULNT1MEDIAN and ULNT2MEDIAN ULNTRADIAL Anterior view ULNTRADIAL Posterior view
FIGURE 3 shows the most common areas in
which asymptomatic individuals reported
sensory responses at the end of ULNT1ME-
DIAN
,23,54,63 ULNT2MEDIAN,63,77 and ULNTRA-
x
DIAL
.73,126 There were no equivalent studies
for ULNTULNAR. Sensory responses were
predominantly described as stretch, ache,
x
pain, burning, and tingling.23,54,63,73,77,102,126
Structural differentiation with contra-
lateral neck sidebending increased limb
responses in more than 85% of partici-
pants.54,73,77,126 This suggests that asymp-
tomatic individuals have a certain level of
nerve mechanosensitivity. The variety of

FIGURE 3. The most common areas where asymptomatic individuals reported sensory responses at the end of responses reported by asymptomatic in-
ULNT1MEDIAN,23,54,63 ULNT2MEDIAN,63,77 and ULNTRADIAL.73,126 Abbreviation: ULNT, upper-limb neurodynamic test. dividuals signifies the need to be specific
about the type of sensory response that
not identify any studies that specifically intensity of muscle-related pain. This qualifies as a positive ULNT in symptom-
measured whether strain produced by a suggests that ULNT1MEDIAN can poten- atic populations. To be confident that a
structural differentiation maneuver, such tially distinguish pain related to muscle sensory response distinguishes a patient
as contralateral neck sidebending, might irritation from pain related to increased with PNP from asymptomatic individu-
be transferred to distant parts of this fas- nerve mechanosensitivity. Although bio- als and, therefore, potentially discrimi-
cial network. mechanical and experimental pain data nates patients with PNP from those with
ULNT movements also compress support using ULNTs to detect PNP, it competing diagnoses, the ULNT needs
nerves. For example, wrist extension must be remembered that plausibility is to reproduce at least part of the patient’s
compresses the median nerve in the car- the lowest level of test validity.87 symptoms. For example, if a patient re-
pal tunnel114,115; the combination of elbow ports pain in the neck that spreads down
extension, forearm pronation, and wrist DEFINING A POSITIVE ULNT 1 limb past the elbow, the ULNT should
flexion compresses the deep branch of reproduce this pain at least somewhere in
S
the radial nerve in the radial tunnel39,62; ensory responses, resistance to the neck, upper arm, or forearm.
and the combination of elbow flexion movement, and range of motion
and wrist extension compresses the ulnar during a ULNT are assessed to de- Resistance to Movement
nerve in the cubital tunnel.69 termine whether a patient shows signs Resistance to movement during ULNT-
Based on these biomechanical data, of increased nerve mechanosensitiv- 1MEDIAN has been quantified by relating
ULNTs appear to be plausible tests for ity.12,38 To be useful criteria for defining shoulder girdle elevation force24,25 and
detecting PNP. Strain and compression a positive test, ULNT responses should torque resisting passive elbow extension50
from ULNT movements will likely pro- exhibit 2 properties.80 First, the ULNT to elbow extension range of motion. Only
voke mechanically sensitive neural tis- responses must discriminate patients shoulder girdle elevation force has been
sues in patients with PNP. Furthermore, with PNP from asymptomatic individu- assessed in a symptomatic population.25
the ability for wrist or neck movement in als. Second, concurrent validity studies Patients with nerve-related neck and uni-
the end ULNT position to produce bio- must show that these ULNT responses lateral arm pain showed increased shoul-
mechanical effects throughout the nerve also discriminate patients with PNP der girdle elevation force at earlier stages
supports using structural differentiation from patients who present with compet- of elbow extension in the symptomatic
to determine whether an ULNT response ing diagnoses. This section addresses limb. These findings cannot be general-
is related to nerve mechanosensitivity. the potential ability of ULNT responses ized to everyday clinical practice, because
An experimental pain model further to discriminate patients with PNP from a load cell was used to measure shoulder
supports the plausibility of ULNTs. Cop- asymptomatic individuals and proposes girdle elevation force.
pieters et al19 induced experimental pain criteria for defining a positive ULNT. Two studies used clinically feasible
in the thenar muscles of asymptomatic Evidence on the concurrent validity of methods for quantifying resistance to
volunteers and showed that ULNT1ME- ULNTs is presented later in this clinical movement during ULNT1MEDIAN.48,105 Ex-
DIAN
did not change the distribution or commentary. aminers identified the onset of resistance
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during elbow extension in asymptomatic
participants and measured this angle (n = 38)
with a standard goniometer48 or an elec-
trogoniometer.105 Intraclass correlation Chien et al15 (n = 38)
coefficients (ICC2,1)86 for interexaminer
reliability were 0.42 (calculated from re- (n = 31)
ported data)48 and 0.48.105 The standard

Coppieters et al17 (n = 10)
error of measurement36 for both studies
was 10° (calculated from reported data). Sterling et al94 (n = 20)
This translates to a smallest detectable
difference at a 95% confidence level Sterling et al95 (n = 20)
(SDD95)36 of 28°. This amount of mea-

Vanti et al105 (n = 36)
surement error suggests that onset of
resistance probably cannot be sensitive
0 10 20 30 40 50 60
enough to discriminate patients with
PNP from asymptomatic individuals and Deficit in Elbow Extension at Onset of Pain, deg
is, therefore, unlikely to be a useful crite-
rion for a positive ULNT1MEDIAN. Symptomatic limb of patients with cervical radiculopathy
Asymptomatic limb of patients with cervical radiculopathy
Range of Motion Asymptomatic individuals
ULNT range of motion is usually quan-

FIGURE 4. Average deficit in elbow extension range of motion at the onset of pain during ULNT1MEDIAN (cervical
tified by the joint angle at pain onset
spine in neutral). Error bars represent 1 standard deviation and provide an indication of the variability in range-of-
or pain tolerance (eg, ULNT1MEDIAN el- motion deficit among participants. Abbreviation: ULNT, upper-limb neurodynamic test.
bow extension or ULNTRADIAL shoulder
abduction). Patients with PNP are ex- bending before applying ULNT1MEDIAN, range of motion at pain onset during
pected to exhibit less range of motion elbow extension deficits greater than ULNT1MEDIAN in asymptomatic17,105 and
in their symptomatic limb compared to 60° at pain onset could be classified as symptomatic103 individuals range from
their asymptomatic limb or asymptom- abnormal. Because this proposed cut-off 14° to 20° (calculated from reported
atic individuals. is based on asymptomatic data only, its data). In light of the variability and over-
Several studies have compared ULNT- ability to discriminate patients with PNP lap in range of motion for these popula-
1MEDIAN14,15,17,26,84,94-97,103,121 or ULNTRADI- from asymptomatic individuals needs to tions, this amount of measurement error
AL
71,73,106,107,121,125
range of motion between be tested. Despite this proposed cut-off, makes it unlikely that an absolute cut-off
patients’ symptomatic and asymptom- data suggest that it is very difficult to find can accurately discriminate patients with
atic limbs or between patients and a- an absolute range-of-motion cut-off that PNP from asymptomatic individuals. It
symptomatic individuals. Only Chien et successfully identifies patients with PNP. is, therefore, questionable whether an
al15 included patients with PNP who met ULNT1MEDIAN range of motion at pain absolute range-of-motion cut-off could
the diagnostic criteria of Treede et al.99 onset is highly variable in asymptomatic be a meaningful criterion for a positive
Patients with cervical radiculopathy had individuals17,94,95,105 and patients with cer- ULNT1MEDIAN.
less ULNT1MEDIAN range of motion at pain vical radiculopathy (FIGURE 4).15 There is Another strategy for detecting abnor-
onset in the symptomatic limb compared also considerable overlap in ULNT1MEDIAN mal deficits in ULNT range of motion is
to the asymptomatic limb or asymptom- range of motion between these 2 groups. to identify a relative cut-off that requires
atic individuals (FIGURE 4). However, sig- Comparing asymptomatic and cervical a certain difference in range of motion
nificant differences in range of motion for radiculopathy data is appropriate, be- between the symptomatic and asymp-
group data do not help determine wheth- cause these studies15,17,94,95,105 used simi- tomatic limbs in an individual patient.
er an individual patient has an abnormal lar methods for applying ULNT1MEDIAN. PNP conditions in which bilateral in-
deficit in ULNT range of motion. Range-of-motion variability and overlap volvement is common are the exception
One strategy for determining whether highlight the difficulty in distinguishing (eg, more than 50% of individuals with
an individual patient has an abnormal normal from abnormal range of motion carpal tunnel syndrome have the condi-
deficit in ULNT range of motion is to in an individual patient. Measurement tion bilaterally10). Despite this exception,
identify an absolute cut-off for the symp- error adds to the difficulty in finding an no data currently exist on the differ-
tomatic limb. Davis et al28 proposed that, effective absolute range-of-motion cut- ence in range of motion between limbs
when the neck is in contralateral side- off. SDD95 estimates for elbow extension that would normally be expected in as-
42-05 Nee.indd 417 4/18/2012 7:10:35 PM

ymptomatic individuals. It is unknown
Interexaminer Reliability
whether a certain difference in range of TABLE 1
for a Positive ULNT 82*
motion between limbs may discriminate
patients with PNP from asymptomatic
Test Kappa Value (95% CI) Prevalence Index† Bias Index†
individuals.
ULNT1MEDIAN 0.54 (0.19, 0.89) ‡
0.19 0.10
In summary, due to the measurement
ULNT2MEDIAN 0.46 (0.11, 0.81)‡ 0.23 0.06
error for resistance to movement and the
ULNTRADIAL 0.44 (0.09, 0.79)‡ 0.29 0.06
lack of discriminatory cut-offs for range
ULNTULNAR 0.36 (0.01, 0.71)‡ 0.32 0.10
of motion, current evidence does not
All ULNTs combined 0.45 (0.27, 0.63) ... ...
support these components of the test
Abbreviations: CI, confidence interval; ULNT, upper-limb neurodynamic test.
response to decide whether a patient’s *A positive ULNT required at least partial reproduction of a patient’s symptoms and a change in these
ULNT is positive. At this time, the sug- symptoms with structural differentiation.
gested criteria for a positive ULNT are †
Calculated from original data obtained from Schmid et al,82 according to formulas proposed by Sim
and Wright.88
(1) at least partial reproduction of the
‡
Confidence interval calculated as 1.96 times reported standard error. The standard error of the kappa
patient’s symptoms and (2) a change value for each ULNT was 0.18.82
in these symptoms with structural dif-
ferentiation. Reproducing the patient’s
symptoms is necessary because asymp- be reduced by a high or low proportion clinical prediction rule to diagnose cer-
tomatic individuals report a wide vari- of positive tests (prevalence) or inflated vical radiculopathy from 81 patients re-
ety of sensations in response to ULNTs. by a high level of disagreement between ferred for electrophysiological testing
Changing the patient’s symptoms with examiners on the proportion of posi- for suspected cervical radiculopathy or
structural differentiation is necessary tive tests (bias).88 Prevalence and bias carpal tunnel syndrome. ULNT1MEDIAN
to show that these symptoms are at indices88 (calculated from original data and ULNTRADIAL were 2 of several clini-
least partly related to increased nerve obtained from the authors) were low cal tests considered as potential predic-
mechanosensitivity. (TABLE 1), indicating that these issues did tors for the diagnostic prediction rule.
not affect the kappa values reported by Needle electromyography was the ref-
RELIABILITY OF A Schmid et al.82 Additional studies are erence standard for diagnosing cervical
POSITIVE ULNT needed to improve the precision of these radiculopathy. Only 1 of the following 3
reliability estimates, because 95% con- criteria was required for a ULNT to be
T
he next question is whether fidence intervals for each ULNT’s kap- positive: (1) the ULNT reproduced the
this definition of a positive ULNT pa value ranged from less than 0.20 to patient’s symptoms, (2) the difference be-
is reliable when used clinically. greater than 0.70 (TABLE 1). Nevertheless, tween limbs in elbow extension (ULNT-
Most reports of ULNT reliability in as- clinical tests with fair to moderate reli- 1MEDIAN) or wrist flexion (ULNTRADIAL)
ymptomatic 14,17,27,43,48,63,70,74,77,105,126 and ability can still have sufficient concurrent was greater than 10°, or (3) contralateral
symptomatic 17,84,103 populations have validity to help make a diagnosis.41,109 neck sidebending increased symptoms or
focused on measuring range of mo- ipsilateral neck sidebending decreased
tion, not whether examiners agreed on CONCURRENT VALIDITY symptoms. The methodological quality
a positive test. Four studies assessed OF ULNTs of this study was high (11/14 QUADAS
reliability for identifying a positive items).116,117
E
ULNT.9,82,108,110 Only Schmid et al82 re- vidence on the concurrent va- The data from Wainner and col-
quired that a positive test reproduce the lidity of ULNTs came from diag- leagues110 suggest that ULNT1MEDIAN, but
patient’s symptoms and that structural nostic accuracy studies on cervical not ULNTRADIAL, may help determine
differentiation change these symptoms. radiculopathy110 and carpal tunnel syn- whether a patient has cervical radiculop-
Each ULNT was applied to 31 patients drome,104,111 and a case study on cubital athy. The negative likelihood ratio (LR)
with unilateral arm and/or neck pain tunnel syndrome.85 The methodological of 0.12 indicated that a negative ULNT-
that had been present for at least 4 quality of the diagnostic accuracy stud- 1MEDIAN would essentially rule out cervical
weeks. According to cut-offs proposed ies was assessed with the Quality Assess- radiculopathy.51,110 A positive ULNT1ME-
by Landis and Koch,59 interexaminer ment of Diagnostic Accuracy Studies DIAN
combined with positive findings on
reliability was moderate (κ = 0.41-0.60) (QUADAS) tool.116,117 the 3 other clinical tests in the diagnostic
for ULNT1MEDIAN, ULNT2MEDIAN, and prediction rule (ipsilateral cervical rota-
ULNTRADIAL, and fair (κ = 0.21-0.40) for Cervical Radiculopathy tion less than 60°, reduction of symp-
ULNTULNAR (TABLE 1).82 Kappa values can Wainner and colleagues110 developed a toms with the supine distraction test,
42-05 Nee.indd 418 4/18/2012 7:10:36 PM

agnostic prediction rule for carpal tunnel
Diagnostic Accuracy of ULNT1 MEDIAN and
TABLE 2 syndrome.111
ULNT RADIAL for Cervical Radiculopathy 110
The diagnostic accuracy of ULNT1ME-
DIAN
for detecting carpal tunnel syndrome
Test Sensitivity (95% CI) Specificity (95% CI) Positive LR (95% CI) Negative LR (95% CI)
was also assessed by Vanti et al.104 They
ULNT1MEDIAN* 0.97 (0.90, 1.00) 0.22 (0.12, 0.33) 1.30 (1.10, 1.50) 0.12 (0.01, 1.90)
studied 44 consecutive patients referred
ULNTRADIAL* 0.72 (0.52, 0.93) 0.33 (0.21, 0.45) 1.10 (0.77, 1.50) 0.85 (0.37, 1.90)
for nerve conduction tests for possible
Diagnostic CPR†‡ 0.24 (0.05, 0.43) 0.99 (0.97, 1.00) 30.30 (1.70, 538.20) ...
carpal tunnel syndrome. The method-
Abbreviations: CI, confidence interval; CPR, clinical prediction rule; LR, likelihood ratio; ULNT,
upper-limb neurodynamic test.
ological quality of this study was also
*ULNT positive if 1 or more of the following criteria are present: ULNT reproduces the patient’s high (12/14 QUADAS items).116,117 Two
symptoms, greater than 10° difference between limbs in elbow extension (ULNT1MEDIAN) or wrist flexion separate analyses were performed that
(ULNTRADIAL) at the end of the test, contralateral neck sidebending increased symptoms or ipsilateral
neck sidebending decreased symptoms when performed at the end position of the ULNT on the symp-
involved slightly different definitions of
tomatic limb. a positive ULNT1MEDIAN. First, a posi-
†
All 4 of the following variables are present: positive ULNT1MEDIAN, ipsilateral cervical rotation less tive test required the presence of only 1
than 60°, supine cervical distraction test alleviates symptoms, and ipsilateral Spurling test provokes
symptoms.
of the 3 criteria used by Wainner and
‡
Negative LR not reported because the focus of the CPR was to identify patients who were most likely to colleagues.110,111 Second, the “symptom
have cervical radiculopathy confirmed by electrophysiological testing. reproduction” criterion was modified so
that symptoms had to be reproduced in
the first 3 digits of the hand (typical me-
Diagnostic Accuracy of ULNT1 MEDIAN and dian nerve distribution), but still only 1 of
TABLE 3
ULNT RADIAL for Carpal Tunnel Syndrome 104,111 the 3 criteria was required for a positive
test. ULNT1MEDIAN was not considered
Test Sensitivity (95% CI) Specificity (95% CI) Positive LR (95% CI) Negative LR (95% CI) helpful for either making or ruling out
ULNT1MEDIAN111* 0.75 (0.58, 0.92) 0.13 (0.04, 0.22) 0.86 (0.67, 1.10) 1.90 (0.72, 5.10) a diagnosis of carpal tunnel syndrome
ULNT1MEDIAN104* 0.92 (0.74, 0.98) 0.15 (0.05, 0.36) 1.08 (0.38, 3.08) 0.56 (0.19, 1.59) with either definition of a positive test,
ULNT1MEDIAN104† 0.54 (0.35, 0.72) 0.70 (0.48, 0.85) 1.81 (1.13, 2.88) 0.65 (0.41, 1.04) because LRs were between 0.5 and 2.0
ULNTRADIAL111* 0.64 (0.45, 0.83) 0.30 (0.17, 0.42) 0.91 (0.65, 1.30) 1.20 (0.62, 2.40) (TABLE 3).51,104
Abbreviations: CI, confidence interval; LR, likelihood ratio; ULNT, upper-limb neurodynamic test.
*ULNT positive if 1 or more of the following criteria are present: ULNT reproduces the patient’s Cubital Tunnel Syndrome
symptoms, greater than 10° difference between limbs in elbow extension (ULNT1MEDIAN) or wrist flexion
The only evidence on concurrent validity
(ULNTRADIAL) at the end of the test, contralateral neck sidebending increased symptoms or ipsilateral
neck sidebending decreased symptoms when performed at the end position of the ULNT on the symp- for ULNTULNAR came from a case study of
tomatic limb. a patient with suspected cubital tunnel
†
Same criteria for a positive ULNT, but symptoms had to be reproduced in the first 3 digits (median
syndrome.85 ULNTULNAR was considered
nerve distribution).
positive because it reproduced the pa-
tient’s symptoms and structural differen-
and provocation of symptoms with the Carpal Tunnel Syndrome tiation changed these symptoms. Surgical
Spurling test) would confirm the pres- Wainner and colleagues111 used the same confirmation of ulnar nerve entrapment
ence of cervical radiculopathy (positive sample of patients to develop a diag- at the elbow and alleviation of the pa-
LR, 30.30).51,110 These findings should nostic prediction rule for carpal tunnel tient’s forearm and hand symptoms after
be interpreted cautiously because of the syndrome. Nerve conduction tests were surgical release confirmed a diagnosis of
wide 95% confidence intervals (TABLE the reference standard for diagnos- PNP. A corresponding improvement in
2). Additionally, prediction rule perfor- ing carpal tunnel syndrome, and the the ULNTULNAR response after surgery
mance should be confirmed in a second aforementioned criteria were used for a supported the concurrent validity of this
patient sample before it is considered positive ULNT. ULNT1MEDIAN and ULN- test.85 However, conclusions about the di-
ready for widespread clinical applica- TRADIAL were not considered helpful for agnostic accuracy of ULNTULNAR cannot
tion.64 ULNTRADIAL does not help detect either making or ruling out a diagnosis be made from a case study.41
cervical radiculopathy, because LRs were of carpal tunnel syndrome, because LRs
between 0.5 and 2.0 (TABLE 2).51,110 LRs in for each test were between 0.5 and 2.0 Potential for Bias in Diagnostic Accuracy
this range mean that clinical test results (TABLE 3).51,111 Combining ULNT1MEDIAN Studies
do not lead to important shifts in pretest- or ULNTRADIAL with other clinical tests Despite the high QUADAS scores for the
to-posttest probability of the target con- did not improve diagnostic accuracy, be- diagnostic accuracy studies on cervical
dition being present.51 cause neither test was included in the di- radiculopathy110 and carpal tunnel syn-
42-05 Nee.indd 419 4/18/2012 7:10:37 PM

drome,104,111 2 significant methodological creased nerve mechanosensitivity rather ultrasound imaging on its own is posi-
concerns make it necessary to carefully than conduction loss may often be incor- tive in an individual patient can be dif-
interpret diagnostic accuracy findings. rectly classified by needle electromyog- ficult.40,44 Therefore, more work is needed
The first is the definition of a positive raphy and nerve conduction tests as not to develop composite reference standards
ULNT. Only 1 of 3 criteria—symptom having PNP. This potential misclassifica- for different PNP conditions.
reproduction, a greater-than-10° differ- tion of patients with PNP might have bi- When an ideal reference standard for
ence in range of motion between limbs, ased estimates of the diagnostic accuracy a diagnostic label is unavailable, research
or a change in symptoms with neck side- of ULNT1MEDIAN and ULNTRADIAL.78 on predictive validity for prognosis or
bending—was required for a positive treatment response provides alternative
ULNT.104,110,111 This is a liberal definition Alternate Strategies for a Reference information on how ULNT results can be
of a positive test. No data support a dif- Standard used clinically.41,78 Raney et al76 provided
ference greater than 10° in ULNT range The potential incorrect classification of this type of information on ULNT1MEDI-
of motion between limbs as able to distin- patients with PNP who present with in- AN
. They developed a clinical prediction
guish symptomatic patients from asymp- creased nerve mechanosensitivity rather rule to identify patients with neck pain
tomatic individuals. More importantly, than conduction loss suggests that an who will improve after cervical traction
changing symptoms with structural dif- electrophysiological reference standard and exercise. The reference standard was
ferentiation (neck sidebending) was not of conduction loss may not be compre- whether a patient reported being at least
required for a positive ULNT. QUADAS hensive enough to judge the diagnostic “a great deal better” after 6 treatments.
scoring does not address this method- accuracy of clinical tests of nerve mecha- A positive ULNT1MEDIAN was retained as
ological issue.116,117 It is unclear whether nosensitivity.113 One way to address this 1 of 5 variables in the rule. A positive test
this liberal definition of a positive ULNT problem is to create a composite refer- reproduced the patient’s symptoms, and
influenced diagnostic accuracy because ence standard by combining needle elec- neck sidebending changed these symp-
the number of patients with a positive tromyography and nerve conduction tests toms. Further studies are needed to de-
test whose symptoms did not change with other tests.78 Quantitative sensory termine whether this rule may predict a
with structural differentiation was not testing can assess the function of small- preferential response to cervical traction
reported. diameter afferents and provide evidence and exercise, or whether patients who are
The second concern is the potential of sensory hypersensitivity.44,79 Magnetic positive on the rule may respond equally
limitation of an electrophysiological ref- resonance neurography34 and ultrasound well to other interventions.46 Researchers
erence standard of conduction loss. This imaging7,40 can identify signs of nerve ir- should continue investigating the predic-
reference standard assumes that conduc- ritation and nerve thickening. Therefore, tive validity of ULNTs.
tion loss is consistently present in PNP. quantitative sensory testing, magnetic
However, clinical studies of cervical radic- resonance neurography, or ultrasound CONCLUSION
ular pain89 and carpal tunnel syndrome120 imaging might be options for a compos-
T
have demonstrated that increased nerve ite reference standard for various PNP he available evidence was re-
mechanosensitivity may contribute to conditions. viewed to assess the validity of
PNP even when impulse conduction is The composite reference standard using ULNTs to detect PNP condi-
normal. The pathophysiology of PNP approach has its own methodological tions such as cervical radiculopathy, car-
helps explain the potential discrepancy challenges. The combination(s) of test pal tunnel syndrome, and cubital tunnel
between increased nerve mechanosensi- results necessary to conclude that the syndrome. Aspects of validity that were
tivity and electrophysiological evidence target condition is present must be de- assessed included plausibility, the defi-
of conduction loss. Increased mechano- termined in advance.78 For example, nition of a positive test, reliability, and
sensitivity is related to increased excit- Beekman et al8 assessed the diagnostic concurrent validity (diagnostic accuracy).
ability of small-diameter afferents,6,11,31,37 accuracy of provocation tests for ulnar ULNTs are plausible tests for detect-
central nervous system pathways,6 and neuropathy at the elbow with a reference ing PNP. A positive ULNT should at
nociceptors in the nervi nervorum and standard of positive electrophysiological least partially reproduce the patient’s
sinu-vertebral nerves that innervate the findings or evidence of nerve thickening symptoms, and structural differentiation
nervous system’s connective tissues.4,53,81 on ultrasound imaging. Identifying these should change these symptoms. This
These pathophysiological changes cannot combinations also requires that each test definition of a positive ULNT is reliable
be detected by electrophysiological tests within the composite reference standard when used clinically. However, concur-
that focus on damage or conduction loss be labeled as positive or negative in an rent validity studies need to determine
in large-diameter fibers.60 Consequently, individual patient. However, deciding whether this specific definition of a posi-
patients with PNP who present with in- whether quantitative sensory testing or tive test may improve the diagnostic ac-
42-05 Nee.indd 420 4/18/2012 7:10:38 PM

curacy of ULNTs. 2010;9:807-819. http://dx.doi.org/10.1016/ specificity of the neurodynamic test for the
S1474-4422(10)70143-5 median nerve in the differential diagnosis
The minimal evidence available pre-
7. Beekman R, Schoemaker MC, Van Der Plas JP, of hand symptoms. Arch Phys Med Rehabil.
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8. Beekman R, Schreuder AH, Rozeman CA, Koe- paerts KH. Incorporating nerve-gliding tech-
ing a liberal definition of a positive test, niques in the conservative treatment of cubital
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@ MORE INFORMATION
dinal excursion in peripheral nerves. Hand Clin. elbow and wrist associated with upper extrem-
1986;2:761-766. ity motion. J Hand Surg Am. 2001;26:655-662.

119. Wilson S, Selvaratnam P, Briggs C. Strain at the http://dx.doi.org/10.1053/jhsu.2001.26140 WWW.JOSPT.ORG
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[ clinical commentary ]

The Validity of Upper-Limb

pper-limb neurodynamic tests (ULNTs) (FIGURE 1, tralateral neck sidebending in-

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pus, and Web of Science to find peer-

gation) and nerve sliding (longitudinal - Release wrist flexion

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PubMed, 932 records

Scopus, 1388 records

Excluded, 3360 including duplicates

Full-text articles retrieved, 112

Articles included in review, 78

Biomechanical studies, 40 Clinical studies, 38

Cadaver studies, 23 In vivo studies, 17

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nerve mechanosensitivity. The variety of

42-05 Nee.indd 416 4/18/2012 7:10:34 PM

ported data)48 and 0.48.105 The standard

(SDD95)36 of 28°. This amount of mea-

Range of Motion Asymptomatic individuals

ULNT range of motion is usually quan-

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42-05 Nee.indd 419 4/18/2012 7:10:37 PM

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BRS.0000089685.55629.2E nerve-gliding exercises induce different magni-

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Neurosurg. 2010;112:362-371. http://dx.doi. org/10.1054/jhsb.2000.0453 Man Ther. 2011;16:125-130. http://dx.doi.

dx.doi.org/10.1197/j.jht.2007.11.001 51. Jaeschke R, Guyatt GH, Sackett DL. Users’ 2000;284:79-84.

42-05 Nee.indd 422 4/18/2012 7:10:40 PM

42-05 Nee.indd 423 4/18/2012 7:10:41 PM

1986;2:761-766. ity motion. J Hand Surg Am. 2001;26:655-662.

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dx.doi.org/10.1197/j.jht.2007.11.001 51. Jaeschke R, Guyatt GH, Sackett DL. Users’ 2000;284:79-84.