Neurological examination for cervical radiculopathy: a scoping review

BACKGROUND

To diagnose cervical radiculopathy according to the International Association for the Study of Pain definition, signs of neurological deficits must be examined with the neurological examination. However, the diagnostic accuracy of the standard neurological examination remains unclear, and no clear recommendations exist about standard components. Therefore, the objectives of this review are to map the research about the diagnostic accuracy, components, and performance of the neurological examination for cervical radiculopathy.

METHOD

PubMed, Embase, Scopus, Cinhal, DiTA databases were searched up to February 23rd, 2024. Additional studies were identified through screening reference lists of the included studies. Studies on neurological examination procedures and their diagnostic accuracy for cervical radiculopathy were included.

RESULTS

From an initial 12,365 records, 6 articles met the inclusion criteria. All articles were cross-sectional studies and compared the neurological examination with electrodiagnostic tests or magnetic resonance imaging. Reduced tendon reflexes were found to be most specific (81% (95% CI 69-89%) to 99% (95% CI not reported)), while somatosensation testing was least sensitive (25% (95% CI 12-38%; -LR 0.84) to 52% (95% CI 30-74%)). Taking all components into account resulted in higher specificity (98% (95% CI not reported) to 99% (95% CI 95-100%)) but lower sensitivity (7% (95% CI not reported) to 14% (95% CI 5-16%)) compared to electrodiagnostic tests.

CONCLUSIONS

We found varying operational definitions of radiculopathy, suboptimal reference standards, and great heterogeneity in the neurological examination procedure and its diagnostic accuracy. Future research should address these issues to establish the clinical utility of the neurological examination for cervical radiculopathy.

PROTOCOL

https://doi.org/10.1101/2023.05.22.23290194 .

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.

Accuracy of the Standard and Distal-to-Proximal Sequence of the Upper Limb Neurodynamic Test 1 for the Diagnosis of Carpal Tunnel Syndrome: The Role of Side-to-Side Comparisons

Background/Objective: This study aimed to evaluate the diagnostic accuracy of two upper limb neurodynamic test 1 (ULNT1) sequences for detecting carpal tunnel syndrome (CTS) in patients with unilateral symptoms. The standard sequence (ULNT1-STD) and a distal-to-proximal sequence (ULNT1-DIST) were investigated. A local-initiated sequence may facilitate symptoms reproduction in CTS, and comparing the affected side with the unaffected side could improve the detection of altered median nerve mechanosensitivity when symptoms are not directly reproduced. Methods: A total of 134 consecutive patients with clinically suspected unilateral CTS were recruited. Nerve conduction studies were used as a reference test. Results: When considering only symptom reproduction as the criterion for a positive test, ULNT1-STD showed a sensitivity of 0.398 and a specificity of 0.780 (positive likelihood ratio [+LR]: 1.81; negative likelihood ratio [-LR]: 0.77); whereas ULNT1-DIST demonstrated a sensitivity of 0.548 with a specificity of 0.732 (+LR: 2.04; -LR: 0.62). When a positive test was defined by symptom reproduction or inter-limb asymmetry (in range of motion or sensory response), ULNT1-STD showed an improved sensitivity of 0.613 but a reduced specificity of 0.537 (+LR: 1.32; -LR: 0.72). In comparison, ULNT1-DIST increased its sensitivity to 0.871 with a specificity of 0.683 (+LR: 2.75; -LR: 0.19). Conclusions: ULNT1-DIST offers better diagnostic accuracy for CTS compared to the ULNT1-STD sequence, especially when interlimb asymmetries in range of motion or sensory response are considered. However, side-to-side comparisons have reduced utility in cases with bilateral symptoms, limiting their application in clinical practice.

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.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Somatosensory profiles in patients with non-specific neck-arm pain with and without positive neurodynamic tests

Despite normal neurological integrity tests, some patients with non-specific neck-arm pain (NSNAP) have heightened nerve mechanosensitivity upon neurodynamic testing. The aim of this study was to determine whether or not a nerve dysfunction is present in patients with positive neurodynamic tests compared to those with negative neurodynamic tests or healthy controls. Somatosensory profiling using quantitative sensory testing (QST) was established in 40 consecutive patients with unilateral NSNAP; 23 had positive upper limb neurodynamic tests (ULNT_POS) and 17 had negative neurodynamic tests (ULNT_NEG) and in 26 healthy controls. QST included measurement of thermal and mechanical detection and pain thresholds in the maximal pain area on the symptomatic side as well as the corresponding contralateral area. Fifty-seven percent of patients with NSNAP had positive neurodynamic tests. Somatosensory profiling revealed a loss of function phenotype in NSNAP patients compared to healthy controls both in the maximal pain area and asymptomatic side. Hyperalgesia (cold, heat and pressure) was present bilaterally in both NSNAP groups. Direct comparison between the patient groups revealed no significant differences in somatosensory profiles. However, the ULNT_POS group demonstrated sensory loss compared to healthy controls in more parameters than the ULNT_NEG group. The ULNT_NEG subgroup represented an intermediate phenotype between ULNT_POS patients and healthy controls in most detection thresholds as well as thermal and pressure pain thresholds. Even though patients with NSNAP present as a spectrum, it remains unclear whether the sensory changes are indicative of a nerve dysfunction/lesion or rather a marker of altered central pain processing.

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Fascial entrapment neuropathy

Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.

Entrapment Neuropathies: Challenging Common Beliefs With Novel Evidence

Entrapment neuropathies are the most prevalent type of peripheral neuropathy and often a challenge to diagnose and treat. To a large extent, our current knowledge is based on empirical concepts and early (often biomechanical) studies. This Viewpoint will challenge some of the current beliefs with recent advances in both basic and clinical neurosciences. J Orthop Sports Phys Ther 2018;48(2):58-62. doi:10.2519/jospt.2018.0603.

Addressing neurodynamic irritability in a patient with adhesive capsulitis: a case report

BACKGROUND

Patients with adhesive capsulitis are commonly seen by physical therapists. Pain and limited shoulder motion from adhesive capsulitis have at times been linked to neural irritation. The purpose of this case is to describe the examination and intervention of a patient with adhesive capsulitis who appeared to have a coexisting, underlying neural irritation. This paper emphasizes how the neurological component must initially be identified and addressed for a successful outcome.

CASE DESCRIPTION

A 47-year-old female presented with reduced shoulder motion and function, upper extremity neural irritation, diffuse weakness, altered sensation in the involved extremity, and symptoms reproduced with upper limb neurodynamic testing. Her reduced shoulder range of motion was accompanied by limited glenohumeral glides and a report of local neck stiffness. Symptoms began several months earlier after an apparent electrical shock injury to the arm that caused symptoms and guarding of the shoulder. Intervention initially addressed the underlying neural component with spinal mobilizations while avoiding further irritation. Interventions were progressed to include mobilization and exercise to address shoulder mobility.

OUTCOMES

The patient's neurodynamic irritability, distal symptoms, and neck stiffness were normalized within the first weeks of care. Subsequently, interventions were directed at the shoulder. Outcomes over an 12-week time frame included reduced pain from 10/10 to 2/10. Passive range of motion increases included flexion from 121 to 160°, abduction from 71 to 121°, and external rotation from 18 to 60°. Disability scores on Disabilities of the Arm, Shoulder, and Hand (DASH) dropped from initially 68·3 to 18·3% at discharge. She ultimately regained full upper extremity function.

DISCUSSION

Therapists should be cognizant of possible neural irritation in shoulder disorders, which may contribute to conditions such as adhesive capsulitis. Identifying neural irritation is critical when determining which interventions will achieve optimal outcomes without aggravating the condition.

Quantitative sensory testing somatosensory profiles in patients with cervical radiculopathy are distinct from those in patients with nonspecific neck-arm pain

The aim of this study was to establish the somatosensory profiles of patients with cervical radiculopathy and patients with nonspecific neck-arm pain associated with heightened nerve mechanosensitivity (NSNAP). Sensory profiles were compared to healthy control (HC) subjects and a positive control group comprising patients with fibromyalgia (FM). Quantitative sensory testing (QST) of thermal and mechanical detection and pain thresholds, pain sensitivity and responsiveness to repetitive noxious mechanical stimulation was performed in the maximal pain area, the corresponding dermatome and foot of 23 patients with painful C6 or C7 cervical radiculopathy, 8 patients with NSNAP in a C6/7 dermatomal pain distribution, 31 HC and 22 patients with FM. For both neck-arm pain groups, all QST parameters were within the 95% confidence interval of HC data. Patients with cervical radiculopathy were characterised by localised loss of function (thermal, mechanical, vibration detection P<.009) in the maximal pain area and dermatome (thermal detection, vibration detection, pressure pain sensitivity P<.04), consistent with peripheral neuronal damage. Both neck-arm pain groups demonstrated increased cold sensitivity in their maximal pain area (P<.03) and the foot (P<.009), and this was also the dominant sensory characteristic in patients with NSNAP. Both neck-arm pain groups differed from patients with FM, the latter characterised by a widespread gain of function in most nociceptive parameters (thermal, pressure, mechanical pain sensitivity P<.027). Despite commonalities in pain characteristics between the 2 neck-arm pain groups, distinct sensory profiles were demonstrated for each group.

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

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

Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system

Background

Clinical tests to assess peripheral nerve disorders can be classified into two categories: tests for afferent/efferent nerve function such as nerve conduction (bedside neurological examination) and tests for increased mechanosensitivity (e.g. upper limb neurodynamic tests (ULNTs) and nerve palpation). Reliability reports of nerve palpation and the interpretation of neurodynamic tests are scarce. This study therefore investigated the intertester reliability of nerve palpation and ULNTs. ULNTs were interpreted based on symptom reproduction and structural differentiation. To put the reliability of these tests in perspective, a comparison with the reliability of clinical tests for nerve function was made.

Methods

Two experienced clinicians examined 31 patients with unilateral arm and/or neck pain. The examination included clinical tests for nerve function (sensory testing, reflexes and manual muscle testing (MMT)) and mechanosensitivity (ULNTs and palpation of the median, radial and ulnar nerve). Kappa statistics were calculated to evaluate intertester reliability. A meta-analysis determined an overall kappa for the domains with multiple kappa values (MMT, ULNT, palpation). We then compared the difference in reliability between the tests of mechanosensitivity and nerve function using a one-sample t-test.

Results

We observed moderate to substantial reliability for the tests for afferent/efferent nerve function (sensory testing: kappa = 0.53; MMT: kappa = 0.68; no kappa was calculated for reflexes due to a lack of variation). Tests to investigate mechanosensitivity demonstrated moderate reliability (ULNT: kappa = 0.45; palpation: kappa = 0.59). When compared statistically, there was no difference in reliability for tests for nerve function and mechanosensitivity (p = 0.06).

Conclusion

This study demonstrates that clinical tests which evaluate increased nerve mechanosensitivity and afferent/efferent nerve function have comparable moderate to substantial reliability. To further investigate the clinometric properties of these tests, more studies are needed to evaluate their validity.