This is Brent of the Brookbush Institute, and in this video we're going to go
over the upper-limb tension test. I'm going to have my friend a Yvette come out, she's
going to help me demonstrate. Now these tests are to help us determine whether
the median ulna or radial nerve are involved in our patients complaint. We
could see these as trying to find the concordance sign as part of some nerve
dysfunction, usually we're using these tests as part of a cervical
radiculopathy cluster and we'll be going over that in a later video. Now the first
thing we want to do with these tests is notice that the patient's in supine,
laying flat, we don't want to add any tension to the nervous system, for
example by bringing ourselves up into hip flexion and hook lying. We want to
make sure that the head is nice and neutral, that we have a stable position
we continue to come back to, and then we're going to ask hey how is your neck
feeling right now? If somebody has a cervical radiculopathy and it is
irritable you'll be surprised, sometimes people
will get a little nerve symptoms just being flat back with their cervical
spine a little bit in extension. So it's important that you rate your
starting symptoms so you know if the tests actually change them. Now what
we're going to be doing with these tests is essentially stretching nerves.
Unfortunately nerves are a little bit more complicated than muscles as far as
trying to stretch them because they go around so many other joints, and have so
many ways of relieving tension and gaining tension depending on what
movements are added. So it gets a little complicated, these are going to take a
little bit of practice, but all of the tests start with this little bit of
scapular depression, and as you can imagine if you think of how those nerves
run, off of the brachial plexus, this would stretch the brachial plexus.
So we just want to start out with hey did that increase your symptoms at all?
Okay so if we know this didn't increase the symptoms now we need to start
loading the nerve further along. We'll start with the median nerve, and what
you're going to do with the median nerve, and what I do is I usually use my
fist here to brace and then I'll use my thigh
to help me support the arm, and then we'll go ahead and with the median nerve
bring up to 110-degrees, so right about there and go
hey how does that feel? If that feels fine we're going to now do this funny hand
position thing, all right you have seen these on some of those nerves
tension tests I'm sure before. But notice how I'm using my pinky to get across all
of her fingers, I have good purchase of her entire hand. I'm going to bring her
fingers back into extension, her wrist back into extension and into a little
ulna deviation, and I can ask again how does that feel? Okay and I'm going to bring
down to about 90-degrees of external rotation here, that's okay? Good and for
most people, even if they have median nerve involvement,
they're probably still okay here. Where you usually get things starting to show
some signs of symptoms is when you go into elbow extension; and right about
there you can see Yvette is starting to feel it. Now this actually is not
abnormal, and that's that is something you have to keep in mind is feeling
nervy symptoms at let's say within 135-degrees of elbow extension
is not necessarily an abnormal thing. We need to ask them does this
bring on the symptoms you were talking about, and if it doesn't then it's not
what you're looking for. You might also want to compare sides. If we're
talking about a right cervical radiculopathy and she's the same on her
right in her left, well then we can kind of determine that this is not as
involved. The other thing you can do for all of these tests is try to sensitize
the cervical spine involvement, or sensitize the test to cervical spine
involvement by going okay let's go lateral flexion, increasing tension right
and see if that changes this. If all the sudden she's like oh right and that
brings out a lot like it magnifies her symptoms,
then there's a good chance that we have median nerve involvement from a cervical
radiculopathy. You could also go the other way, we could go okay let's take a
bunch of tension off and see if you get better. So now the hard
part is you got to make sure you get your hand in there before they get their
head down to their shoulder, but if she takes a bunch of tension off and all of
a sudden like all of her symptoms go away, that's probably a good sign that
the cervical spine is involved. So before we go into the other test
let's just take a quick tally of things that are going to apply to all your
tests. All of the tests are going to involve this depression of the shoulder
girdle, so that we lengthen out the brachial plexus. All of the tests, you
can sensitize the tests to cervical spine involvement by either increasing
tension with lateral flexion away, or decreasing tension with lateral flexion
towards right. Now the median nerve you saw was this funky little movement,
we're kind of doing this thing. So it's supination and extension of the fingers,
extension of the wrist and then once we get to a 110-degrees of
abduction, 90-degrees of elbow extension. We got all of that extended in
the hand and wrist, then it's the elbow extension at the end which is usually
where we start to see funny stuff happen. Now the ulnar nerve test is just
in the opposite direction, so rather than supinate we're going to
pronate, rather than extend the elbow we're going to flex the elbow, are you
with me. So here's what that's going to look like, you're going to again depress the
shoulder. Hey how you doing, everything's okay? Cool back to 110-degrees, you okay?
Good. Now watch, boom I just went in the other
direction. How's that feel? All right sometimes you get a little funny
stuff, make sure you get the pinky on this one. So make sure you get
the pinky extended too, and then what am I going to do flex towards her head.
All right this test is almost like if you thought about doing this, I don't
know if you have ever tried to make that face, I can't do it evidently
my ulnar nerve is not as
extensible as some other people's, but if you think about this test for ulnar nerves
and you think about this for median nerve, you're getting close. Then it's
just a matter of practising enough to get your hand position comfortable.
You can notice here that again I'm using my thigh to help. Now the
last one we're going to do which is a little different is the radial nerve. Now
again start with depression. Okay how does that feel? That's okay. Now in this
one I'm going to ask her to hold her thumb. All right so she's going to do this because
we want thumb flexion. I'm going to totally internally rotate and pronate
the forearm, internally rotate the shoulder, pronate the forearm. Hey how
does that feel? Then the last step, and again I use my thigh to help me
maintain some elbow extension here, is we're going to abduct her
locked out arm. How does that feel? Now once again feeling nervy
stuff like the little tingly or a little shock once you get out like
here is actually pretty normal. So let's not make a positive out
of something that's just normal uncomfortability. Keep going back to does
that bring on the symptoms you were talking about, that concordant sign thing.
That was actually a fairly normal extensibility that she felt. We saw she
had fairly normal extensibility on the median nerve test, the ulnar nerve test
she actually had almost like she had great mobility throughout that position
and had no symptoms at all. So so far with Yvette we're seeing negative
involvement of her median, radial and ulnar nerve.
So let's go over that last one one more time. Neutral position her hand was down
by her side, I had her tuck her thumb, I'm going to internally rotate, you can kind of
look at internally rotating everything. So pronation, internal rotation of
the shoulder, flexion of the wrist and then I pull out and abduction, check it
all along the way. How do you feel, how do you feel, how do you feel, how do you feel?
Good better to be annoying than did not ask, because if she was brought on
symptoms here but you didn't ask until here and then thought she was normal,
that's going to give you a false negative. Now could I sensitize this
test? Absolutely, can you laterally flex your head away? Good, did that make things
worse? No. Can you go the other way? Did that
make things better? Yeah it's still fine, it's still
fine. It didn't actually make her symptoms better she's just saying she's
still fine. So these are going to take some practice
and these are some of those tests where let's be real with each other as
professionals. If you haven't done them in a while chances are you're going to have
to look them back up, so this might be a video that you want to highlight. I
definitely have to look them back up every once in a while, because you know
if I go a little bit of time without seeing a cervical radiculopathy there's
no reason to necessarily do these exams, your not going to do them with
everybody who walks in the door. Now we said that all of the tests start in the
supine position, all of them start with a neutral head position, all of them start
with depression; and then the only thing you have to remember is what movements
you're trying to create. So are you trying to do this, are you trying to do
this, or are you trying to do this. If you can remember that you're in
really good shape. If the next thing you can remember is that elbow extension and
elbow flexion are probably the keys for the median and ulnar nerve tests, and
abduction is the key for the radial nerve test, as in
those are the movements that generally give you an indication that this is a
positive test, you've now taken it one step further and of course when you have
complicated things like this as we've said in manual therapy videos over and
over again, do me a favor practice these on your colleagues first. Colleagues who
can give you some feedback on how it feels so that before you do this on a
patient and look like you know Muppet hands, and just have no coordination, like
I know it's supposed to be something like that. You want to be
confident in the way you look with these. You want to be able to go right
into the position and know whether or not you've loaded this nerve, and that
takes just a little bit of practice. If you have any questions leave it in
the comments box below, I look forward to hearing from you.