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Starting position of Upper-Limb Neurodynamic Test (ULNT) #1. Ending position of ULNT #1. Combining median nerve elongation with the Phalen's test position of the wrist. C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 101 PERFORMING THE TEST Have your client lie in a supine position. Stand facing the client's head on the testing side. The client's elbow is flexed to 90 degrees at the beginning of the test. Image 2 shows the starting position of the shoulder in ULNT #1. Image 3 shows the ending position. This test is contraindicated if shoulder instability is present (previous dislocations or subluxations) because the final test position puts the shoulder in its most vulnerable positions of abduction and external rotation. A video of the ULNT can be viewed at http://bit.ly/1s4NTnh. • Shoulder is brought into depression. • Arm is abducted to about 110 degrees. • Forearm is supinated. • Wrist and fingers are hyperextended. • Shoulder is laterally rotated. • Elbow is extended. • Neck is laterally flexed to the opposite side. Since this test was first described, there have been a few variations and improvements to increase its accuracy. Almost anyone is likely to have some neurological symptoms by the time they get to the fully stretched position in this test. This result has led to a higher degree of false positive results for the test. In one study, the authors suggested a specific range-of-motion cutoff point in order to decrease the number of false positive results. 4 However, despite this proposed range-of-motion cutoff or limitation, this concept has not proven to greatly increase the accuracy of the median nerve ULNT. 5 Keep in mind that some symptoms may arise with anyone at the very end of the test, so it is clinically important to note when symptoms arise prior to the ending position. The ULNT is valuable on its own, but once you understand the basic principles of the test, it can also be applied in other situations. For example, some of the upper- extremity maneuvers that further tension the median nerve could be combined with the wrist flexion position used in the Phalen's test. Combining some of the upper- extremity neural tension maneuvers with the Phalen's test makes the Phalen's test even more sensitive and, therefore, more accurate at picking up potential nerve compression problems (Image 4). 6 THE ROLE IN TREATMENT While the ULNTs are used extensively for evaluation, they are also valuable in treatment. For example, they may be used in cases where neural tension develops because fibrous tissue may be binding or restricting the nerve and preventing it from gliding freely. The positions used for the ULNTs enhance mobility of upper-extremity nerves through techniques called nerve mobilization, nerve gliding, or sometimes nerve flossing. In future installments of this column, we'll explore neural mobilization techniques and how ULNT positions can be a part of a comprehensive treatment approach. Modern pain science is helping us understand that the nervous system plays an exceptionally important role in pain complaints. Learning more about biomechanics and physiology of the nervous system is an essential skill that will enhance your treatment effectiveness and help you bring relief to clients who may not have found successful treatment strategies through other approaches. Notes 1. D. Butler, Mobilisation of the Nervous System (London: Churchill Livingstone, 1991). 2. M. Shacklock, Clinical Neurodynamics (Edinburgh: Elsevier, 2005). 3. C. Vanti et al., "Relationship Between Interpretation and Accuracy of the Upper Limb Neurodynamic Test 1 in Carpal Tunnel Syndrome," Journal of Manipulative Physiological Therapy 35, no. 1 (2012): 54–63. doi:10.1016/j.jmpt.2011.09.008.; R. J. Nee et al., "The Validity of Upper-Limb Neurodynamic Tests for Detecting Peripheral Neuropathic Pain," Journal of Orthopaedic Sports & Physical Therapy 42, no. 5 (2012): 413–24. doi:10.2519/jospt.2012.3988. 4. D. S. Davis et al., "Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate Among Healthy Young Adults without Cervical or Lumbar Symptoms," Journal of Manual & Manipulative Therapy 16, no. 3 (2008): 136–41. doi:10.1179/jmt.2008.16.3.136. 5. R. J. Nee et al., "The Validity of Upper- Limb Neurodynamic Tests for Detecting Peripheral Neuropathic Pain." 6. W. Lowe, "Suggested Variations on Standard Carpal Tunnel Syndrome Assessment Tests," Journal of Bodywork and Movement Therapies 12, no. 2 (2008): 151–57. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. 2 3 4