Reliability of the straight leg raise test for suspected lumbar radicular pain: A systematic review with meta-analysis.

BACKGROUND: The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability. OBJECTIVES: To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain. DESIGN: Systematic review with meta-analysis. METHOD: MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD95) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles. RESULTS/FINDINGS: Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD95 values for different raters measuring SLR range of motion ranged from 13 to 20°. CONCLUSIONS: Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.

Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks.

OBJECTIVES: Neck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern's validity has not been tested against the 'gold standard' of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain. DESIGN: Prospective concurrent validity study that employed a diagnostic model building approach to analysis. SETTING: Hospital-based multidisciplinary outpatient clinic in Joliet, Illinois. PARTICIPANTS: A convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis. OUTCOME MEASURES: Participants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3-C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants' responses to diagnostic blocks. RESULTS: Ten of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants' responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses. CONCLUSIONS: This study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.

Protective myoelectric activity at performing upper limb neurodynamic test 1 in breast cancer survivors. A cross-sectional observational study.

Myoelectric activity and range of motion during ULNT1 were recorded in 62 breast cancer (BC) survivors who had axillary lymph node dissection (n = 30) or sentinel lymph node biopsy (n = 32) within the previous 18 months, and 63 age-matched healthy women. BC survivors' symptoms were reproduced by ULNT1 and exhibited greater myoelectric activity in the biceps brachii than healthy women (MD (95% CI): 21,26 (10,83-31,70)). No differences between the axillary lymph node dissection and sentinel lymph node biopsy groups (MD (95% CI): 8,47 (-7,84-24,79)) were found. Myoelectric activity in the triceps brachii was greater in the sentinel lymph node biopsy group (MD (95% CI): 2,70 (-2,06-7,60)). BC survivors exhibited less shoulder and elbow range of motion during ULNT1 than healthy women. Increased upper limb nerve mechanosensitivity in BC survivors was associated with a greater protective muscle response during ULNT1.

Safety of lower extremity neurodynamic exercises in adults with diabetes mellitus: a feasibility study.

OBJECTIVES: Neurodynamic exercises aim to improve neural mechanosensitivity in order to promote pain-free movement and function. People with diabetes mellitus (DM) may be candidates for neurodynamic exercises to address common DM-related impairments such as reduced lower extremity range of motion (ROM) and altered neural mechanosensitivity. However, no studies have examined the safety and immediate effects of neurodynamic exercise in people with DM. This study aims to determine the feasibility of applying neurodynamic exercises in adults with DM by evaluating the rate of adverse events and quantifying immediate changes in straight leg raise (SLR) ROM. METHODS: This quasi-experimental study included 20 people with DM who performed a series of neurodynamic exercises on their right leg. Their left leg was used as an internal control. SLR testing was performed before and immediately after these exercises. Adverse events were monitored, including provocation of their neuropathy symptoms or discomfort or pain. RESULTS: All participants completed the neurodynamic exercises without provocation of their neuropathy symptoms. No pain was reported and only one participant had minor discomfort with one exercise; a <30-s calf cramp. The right SLR ROM increased by an average of 5.2°-5.3° (p < 0.01) with no change on the left. DISCUSSION: This study demonstrated that lower extremity neurodynamic exercises are safe in adults with DM and may create small immediate improvements in SLR testing. Further research is indicated to investigate the safety and efficacy of neurodynamic exercises performed over multiple sessions. LEVEL OF EVIDENCE: 3b.

Excursion of the Sciatic Nerve During Nerve Mobilization Exercises: An In Vivo Cross-sectional Study Using Dynamic Ultrasound Imaging.

STUDY DESIGN: Controlled laboratory cross-sectional study using single-group, within-subject comparisons. OBJECTIVES: To determine whether different types of neurodynamic techniques result in differences in longitudinal sciatic nerve excursion. BACKGROUND: Large differences in nerve biomechanics have been demonstrated for different neurodynamic techniques for the upper limb (median nerve), but recent findings for the sciatic nerve have only revealed small differences in nerve excursion that may not be clinically meaningful. METHODS: High-resolution ultrasound imaging was used to quantify longitudinal sciatic nerve movement in the thigh of 15 asymptomatic participants during 6 different mobilization techniques for the sciatic nerve involving the hip and knee. Healthy volunteers were selected to demonstrate normal nerve biomechanics and to eliminate potentially confounding variables associated with dysfunction. Repeated-measures analyses of variance were used to analyze the data. RESULTS: The techniques resulted in markedly different amounts of nerve movement (P<.001). The tensioning technique was associated with the smallest excursion (mean ± SD, 3.2 ± 2.1 mm; P < or = .004). The sliding technique resulted in the largest excursion (mean ± SD, 17.0 ± 5.2 mm; P<.001), which was approximately 5 times larger than that resulting from the tensioning technique and, on average, twice as large as that resulting from individual hip or knee movements. CONCLUSION: Consistent with current theories and findings for the median nerve, different neurodynamic exercises for the lower limb resulted in markedly different sciatic nerve excursions. Considering the continuity of the nervous system, the movement and position of adjacent joints have a large impact on nerve biomechanics.

Reappraising entrapment neuropathies--mechanisms, diagnosis and management.

The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.

Baseline characteristics of patients with nerve-related neck and arm pain predict the likely response to neural tissue management.

STUDY DESIGN: Planned secondary analysis of a randomized controlled trial comparing neural tissue management (NTM) to advice to remain active. OBJECTIVE: To develop a model that predicts the likelihood of patient-reported improvement following NTM. BACKGROUND: Matching patients to an intervention they are likely to benefit from potentially improves outcomes. However, baseline characteristics that predict patients' responses to NTM are unknown. METHODS: Data came from 60 consecutive adults who had nontraumatic, nerve-related neck and unilateral arm pain for at least 4 weeks. Participants were assigned to a group that received NTM (n = 40), which involved brief education, manual therapy, and nerve gliding exercises for 4 treatments over 2 weeks, or to a group that was given advice to remain active (n = 20), which involved instruction to continue their usual activities. The participants' global rating of change at a 3- to 4-week follow-up defined improvement. Penalized regression of NTM data identified the best prediction model. A medical nomogram was created for prediction model scoring. Post hoc analysis determined whether the model predicted a specific response to NTM. RESULTS: Absence of neuropathic pain qualities, older age, and smaller deficits in median nerve neurodynamic test range of motion predicted improvement. Prediction model cutoffs increased the likelihood of improvement from 53% to 90% (95% confidence interval: 56%, 98%) or decreased the likelihood of improvement to 9% (95% confidence interval: 1%, 42%). The model did not predict the outcomes of the advice to remain active group. CONCLUSION: Baseline characteristics of patients with nerve-related neck and arm pain predicted the likelihood of improvement with NTM. Model performance needs to be validated in a new sample using different comparison interventions and longer follow-up. Australian New Zealand Clinical Trials Registry (ACTRN 12610000446066). LEVEL OF EVIDENCE: Prognosis, level 2b-.

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

SYNOPSIS: 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.

Neural tissue management provides immediate clinically relevant benefits without harmful effects for patients with nerve-related neck and arm pain: a randomised trial.

QUESTION: What are the benefits and harms of neural tissue management in the short term for treating nerve-related neck and arm pain? DESIGN: Randomised controlled trial. PARTICIPANTS: Sixty participants with non-traumatic nerve-related neck and unilateral arm pain were randomised to experimental (n=40) or control (n=20) groups. INTERVENTION: Both groups were advised to continue usual activities. The experimental group also received education, manual therapy, and nerve gliding exercises in 4 treatments over 2 weeks. OUTCOME MEASURES: Primary outcomes were participant-reported improvement and worsening on a Global Rating of Change scale. Secondary outcomes were neck pain, arm pain, the Neck Disability Index, the Patient-Specific Functional Scale, and adverse events related to treatment. Follow-up occurred 3-4 weeks after baseline. RESULTS: Numbers needed to treat favoured the experimental intervention for participant-reported improvement (2.7, 95% CI 1.7 to 6.5), neck pain (3.6, 95% CI 2.1 to 10), arm pain (3.6, 95% CI 2.1 to 10), Neck Disability Index (4.3, 95% CI 2.4 to 18.2), and Patient-Specific Functional Scale (3.0, 95% CI 1.9 to 6.7). The prevalence of worsening in the experimental (13%) and control (20%) groups were not different (RD -7%, 95% CI -28 to 13). Adverse events had minimal impact on daily activities and did not reduce the chance of improving with the experimental intervention (RR = 1.03, 95% CI 0.58 to 1.84). CONCLUSION: These results enable physiotherapists to inform patients that neural tissue management provides immediate clinically relevant benefits beyond advice to remain active with no evidence of harmful effects. TRIAL REGISTRATION: ACTRN 12610000446066.

A novel protocol to develop a prediction model that identifies patients with nerve-related neck and arm pain who benefit from the early introduction of neural tissue management.

Researchers have been encouraged to identify characteristics that predict patients' responses to different musculoskeletal interventions. We describe a novel protocol to develop a prediction model that identifies patients with nerve-related neck and arm pain who are likely to benefit from the early introduction of neural tissue management (NTM). Prediction models for musculoskeletal treatments have usually been developed by analyzing single group study data with standard logistic regression. However, this approach has important limitations and our two step process for model development will address these limitations. Eligible patients will be aged 18 to 60 years with a minimum four week episode of non-traumatic neck and unilateral arm pain that is reproduced by a mechanical provocation test for the cervical nerve roots and median nerve. The outcome being predicted by the model is patient-reported improvement four weeks after baseline. Patients rating themselves at least 'moderately better' on a Global Rating of Change scale will be considered 'improved'. First, a randomized control trial (RCT) comparing standardized NTM to advice to remain active will determine whether this outcome represents a NTM treatment effect. The RCT has 80% power to detect a number needed to treat ≤ 3 favoring NTM (p ≤ 0.05). Second, a comprehensive set of examination items will be analyzed with penalized logistic regression to select the best items for the prediction model.

Impact of order of movement on nerve strain and longitudinal excursion: a biomechanical study with implications for neurodynamic test sequencing.

It is assumed that strain in a nerve segment at the end of a neurodynamic test will be greatest if the joint nearest that nerve segment is moved first in the neurodynamic test sequence. To test this assumption, the main movements of the median nerve biased neurodynamic test were applied in three different sequences to seven fresh-frozen human cadavers. Strain and longitudinal excursion were measured in the median nerve at the distal forearm. Strain and relative position of the nerve at the end of a test did not differ between sequences. The nerve was subjected to higher levels of strain for a longer duration during the sequence where wrist extension occurred first. The pattern of excursion was different for each sequence. The results highlight that order of movement does not affect strain or relative position of the nerve at the end of a test when joints are moved through comparable ranges of motion. When used clinically, different neurodynamic sequences may still change the mechanical load applied to a nerve segment. Changes in load may occur because certain sequences apply increased levels of strain to the nerve for a longer time period, or because sequences differ in ranges of joint motions.

Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To investigate whether females seeking physical therapy treatment for unilateral patellofemoral pain syndrome (PFPS) exhibit deficiencies in hip strength compared to a control group. BACKGROUND: Decreased hip strength may be associated with poor control of lower extremity motion during weight-bearing activities, leading to abnormal patellofemoral motions and pain. Previous studies exploring the presence of hip strength impairments in subjects with PFPS have reported conflicting results. METHODS AND MEASURES: Twenty females, aged 12 to 35 years, participated in the study. Ten subjects with unilateral PFPS were compared to 10 control subjects with no known knee pathologies. Hip abduction, extension, and external rotation strength were tested using a handheld dynamometer. A limb symmetry index (LSI) was used to quantify physical performance for all tests. RESULTS: The symptomatic limbs of subjects with PFPS exhibited impairments in hip strength for all variables tested. LSI values in subjects with PFPS (range, 71%-79%) were significantly lower than those in control subjects (range, 93%-101%) (P< or =.007). A secondary analysis of data normalized to body mass demonstrated that the symptomatic limbs of subjects with PFPS had 52% less hip extension strength (P<.001), 27% less hip abduction strength (P = .007), and 30% less hip external rotation strength (P= .004) when compared to the weaker limbs of control subjects. CONCLUSION: Females aged 12 to 35 presenting with unilateral PFPS demonstrate significant impairments in hip strength compared to control subjects when LSI values or body mass normalized values are used to quantify physical performance of the symptomatic limb.