Neurological Examination of the Upper Limb: A Study of Construct Validity

Abstract

Objective:We have previously demonstrated that neurological individual findings and patterns can be reliably assessed in the examination of the upper limb and also that they are related to pain, weakness, and/or numbness/tingling. This study aimed to study further aspects of the construct validity of the neurological examination.Methods:Blinded to patient-characteristics, two examiners assessed the function of 16 muscles, the sensibility in 7 territories, and the nerve-mechanosensitivity at 20 locations in 82 upper limbs. Based on anatomical patterns and pre-designed algorithms, one or both examiners rated neuropathy as “possible” or “definite” in 40 limbs and also determined the location( s). We developed and tested hypotheses on anatomically and regionally related locations of nerve afflictions (a selective vulnerability of neurons, double and multiple crush, and a tendency to regional spread) and examined the stability of the internal structure of the constructs in different situations. The interrelations of findings were analyzed by hypothesis testing and factor analyses, and the homogeneity of location profiles was analyzed by a conditional likelihood test.Results:Out of 30 limbs with related locations of neuropathy, the findings of each examiner correlated positively (gamma > 0.35) in 22/25, respectively. The patterns of the interrelations identified by the two examiners were similar, with no evidence of any heterogeneity of location profiles for either examiner.Conclusions:This study supports the validity of the physical examination. However, feasibility of its application requires the demonstration of further aspects of construct validity and a favorable influence on patient-management and/or prevention.

Clinical Diagnosis and Wide-Awake Surgical Treatment of Proximal Median Nerve Entrapment at the Elbow: A Prospective Study

“…Similarly, the earliest publications on PMNE describe the need of thorough physical examination to diagnose the patient [18], in particular the presence of weakness in muscles innervated by the median nerve both in the hand and the forearm. The efficacy (sensitivity and specificity) of manual muscle testing of antagonist muscles to determine levels of focal neuropathies in the upper extremities have been established in randomized, blinded validity studies to 88–93 %, respectively [11,12].…”

Brachial plexopathy: a case–control study of the relation to physical exposures at work

“…The application in people with upper limb pain in the primary health sector [ 16 ] and in clinical occupational medicine [ 17 - 19 ] of a physical examination consisting of semi-quantitative ratings of selective muscle weakness, sensory deviations from normal in homonymous innervation territories and disturbed mechano-sensitivity of nerve trunks has revealed high frequencies of neurological patterns in accordance with neuropathies with various locations. The clinical applicability and feasibility of this approach, which is based on the classical neurological examination, is indicated by good inter-examiner reliability [ 17 , 20 - 22 ], construct validity in terms of correlation of physical findings to symptoms [ 19 ], and significant interrelations of locations of defined focal neuropathy [ 23 ]. The majority of the patients that were subjected to this examination displayed neurological physical patterns in accordance with brachial plexopathy with a prevailing infraclavicular location [ 16 , 20 ].…”

“…Brachial plexopathy can be defined as a combination of symptoms (pain or subjective weakness or sensory abnormalities) and physical findings (weakness in defined muscles, mechanical allodynia at the brachial plexus, and sensory deviations from normal with specific locations). This physical approach permits the examiner to diagnose brachial plexopathy and to define its location precisely [ 17 , 20 ] and accurately [ 19 , 23 ] in a significant number of symptomatic patients, including patients that are diagnostically unclassifiable according to standard diagnostic criteria [ 17 , 20 , 34 ]. With the application of this diagnostic approach, brachial plexopathy with an infraclavicular location was found to be the most frequent diagnosis in a sample of people with upper limb pain in the primary health sector [ 16 ] as well as among patients referred to a department of occupational medicine [ 19 , 20 ].…”