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88 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 7 to 90 degrees (Image 2). If the sensory symptoms of pain, paresthesia, or numbness in the median nerve distribution are reproduced within about 60 seconds, the test is considered positive for median nerve compression in the carpal tunnel. Neurological symptoms are increased with the Phalen's test because holding the wrist in flexion increases compression in the carpal tunnel region. However, the standard Phalen's test position of using both hands at the same time with the elbows flexed decreases tensile forces on the remainder of the median nerve. If the nerve is pulled taut, less pressure on the nerve is required in the carpal tunnel region for symptoms to appear. Greater sensitivity for this test can be achieved by holding the wrist in the Phalen's test position while the upper extremity is held in a position that increases neural tension on the remainder of the median nerve. This position includes lateral flexion of the neck to the opposite side, shoulder abduction, elbow extension, and wrist flexion (Image 3). This test would be performed unilaterally, unlike the standard Phalen's test, which is performed bilaterally. Carpal Compression and Pressure Provocative Tests Applying a moderate amount of direct pressure to the median nerve at the carpal tunnel with both thumbs is called the carpal compression test (Image 4). If symptoms arise within about 20–30 seconds, the test is considered positive for median nerve compression. This test is considered pretty accurate. A suggested modification of this procedure is called the pressure provocative test. It includes elbow extension, forearm supination, and about 60 degrees of wrist flexion along with pressure over the carpal tunnel. The pressure provocative test could be enhanced with increased tension on the median nerve by using the upper extremity median nerve stretch position described with the Phalen's test. The position would include lateral neck flexion to the opposite side, shoulder abduction, elbow extension, forearm supination, and partial wrist flexion. Pressure would then be applied to the carpal tunnel while the arm is in this position (Image 5). Hand Elevation Test Another relatively new evaluation procedure that has demonstrated greater accuracy than the Phalen's test is the hand elevation test. In this procedure, the client holds the hand as high as comfortably possible overhead (Image 6). If neurological symptoms in the median nerve distribution of the hand are reproduced within one minute, the test is considered positive. This test could be made more sensitive by adding additional neural tension to the median nerve with the hand and arm elevated. With the arm held overhead, the neck would then be laterally flexed to the opposite side. Additional tension on the median nerve is added by putting the wrist in extension (Image 7). Another variation would be keeping the wrist in flexion (as in the Phalen's test wrist position). Phalen's test. 2 Carpal compression test. 4 Modified Phalen's test position. 3