Journal of Hand Therapy 27 (2014) 192e200

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CREDIT ARTICLE #311.

Scientic/Clinical Article

Outcomes following the conservative management of patients with

non-radicular peripheral neuropathic pain
Joseph M. Day MSPT, PhD, OCS, CIMT a, *, Jason Willoughby MHS, OTR/L, CHT b,
Donald Greg Pitts MS, OTR/L, CHT b, Michelle McCallum MS, DPT, OCS b, Ryan Foister OTR/L, CHT b,
Tim L. Uhl PT, ATC, PhD, FNATA c
a

Pat Capps Covey College of Allied Health Professions, Department of Physical Therapy, University of South Alabama, HAHN 2011, 5721 USA Drive N, Mobile, AL 36688-0002, USA
Kentucky Hand & Physical Therapy, Lexington, KY, USA
c
Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY, USA
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 8 October 2013
Received in revised form
4 February 2014
Accepted 17 February 2014
Available online 27 February 2014

Study design: Prospective cohort.

Introduction: There is limited evidence for conservative management of patients with non-radicular
peripheral neuropathic pain (PNP).
Purpose: To investigate the effectiveness of a comprehensive treatment approach on pain and disability in
patients with noneradicular PNP and to determine if improvements are maintained following the
discontinuation of therapy.
Methods: Patients received a multi-modal therapeutic intervention. Outcome measures were the
shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QDASH), Numeric
Pain Rating Scale (NPRS), and grip strength. Follow-up data were collected 5
2 months post-discharge.
Results: There was a signicant improvement in the QDASH and mean pain (p < .001). There was no
signicant change in grip strength (p > .13). Follow-up data suggest that pain and disability scores are
maintained (p < .001).
Conclusion: A comprehensive, conservative treatment program has a positive and lasting effect on pain
and disability scores in patients with non-radicular PNP.
Level of evidence: IIIa
2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Keywords:
Multiple nerve compression
Carpal tunnel syndrome
Cubital tunnel syndrome
Proximal
Distal

Introduction
Non-radicular peripheral neuropathic pain (PNP) can be
described as nociceptive symptoms that are a result of a lesion or
disease affecting the somatosensory nervous system distal to the
cervical nerve roots.1 Non-radicular PNP can be caused from a variety of systemic conditions, trauma, or nerve entrapments.2 The
symptoms associated with nerve entrapments, burning, numbness,
pain, and tingling, are specic nociceptive symptoms that originate
from repetitive motion, microtrauma, and poor posture.3e6
Neurogenic thoracic outlet syndrome (TOS), carpal tunnel syndrome (CTS), or cubital tunnel syndrome (CuTS) are examples of
nerve entrapments commonly treated in physical rehabilitation
settings. However, it is sometimes difcult for clinicians to give a
denitive diagnosis for patients with nerve entrapment symptoms
Adapted from APTA Combined Sections Meeting 2013.
* Corresponding author. Tel.: 1 251 445 9330; fax: 1 251 445 9238.
E-mail address: josephday@southalabama.edu (J.M. Day).

due to the poor diagnostic accuracy of some of the available

physical tests7 and the clinical observation that nerve entrapment
syndromes often involve multiple nerves. Therefore, investigators
have used the term non-radicular PNP as a more inclusive way to
describe patients with nerve entrapment symptoms.1,8
Conservative treatment strategies for patients with nonradicular PNP often include a multi-modal program that focuses
on the specic region of the pathologic tissue. For CuTS, treatment
techniques such as neural gliding, splinting, rest, ultrasound, activity modication, and ergonomic education at the cubital are
recommended.9e12 In a recent systematic review on the conservative management of patients with CTS, the authors concluded
that strong to moderate evidence was found for interventions that
focus on the specic region of the carpal tunnel. Interventions such
as ultrasound, nocturnal splinting, and ergonomic keyboards were
found to be effective only in the short term, up to 6 months post
treatment.13
Despite the literatures focus on interventions solely at the site
of the symptoms, evidence suggests that the proximal region of the

0894-1130/$ e see front matter 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jht.2014.02.003

J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

upper quarter may be an important component of the rehabilitation of patients with non-radicular PNP. In a review of conservative
thoracic outlet syndrome (TOS) management, the authors
concluded that proximal posture corrections and peri-scapular
strengthening were effective at reducing pain, improving function, and facilitating return to work.6 In further support of postural
interventions, distal neural mobility has been shown to decrease
when the scapula is placed in a protracted position.14 As it relates to
patients with distal non-radicular PNP, it has been observed that
patients with mild to moderate CTS exhibit an increase in forward
head posture15 and disturbances in the thoracic outlet16 compared
to controls. Therefore, it has been proposed conceptually and
demonstrated with a case study that proximal impairments should
be addressed in the treatment of patients with non-radicular PNP
as a part of a multi-modal therapeutic intervention.17e20
A therapeutic program that focuses on both the proximal and
distal impairments has never been empirically investigated in a
cohort of patients with non-radicular PNP. A comprehensive
treatment program, intervention that addresses both proximal and
distal impairments, has the potential to improve outcomes in patients with non-radicular PNP. Therefore, the purpose of this study
is to investigate the effectiveness of a comprehensive treatment
approach in patients with non-radicular PNP. The investigators

193

primary hypothesis is that this cohort of patients will demonstrate

a signicant improvement in measures of pain, disability, and grip
strength after therapeutic intervention. Secondarily, improvements
in pain and disability will be maintained following the discontinuation of therapy.
Methods
Selection of subjects
Consecutive patients presenting to 1 of 4 outpatient clinics between January 2011 and May 2012 with non-surgical neurological
complaints in their upper extremity were considered for participation in this prospective single cohort study. Of the 36 enrolled
patients, 2 dropped out and 2 were excluded from the study (Fig. 1).
Demographic data of the 32 included patients are presented in
Table 1. Mean age was 44
11 years (range 21e71 years). Mean
duration of symptoms was 5
6 months (range 2 weeks to 2 years).
Patients with bilateral involvement (15/32) represented 47% of our
patients.
Inclusion criteria were: patient primary complaint of unilateral
or bilateral neurological symptoms in the arm, elbow, wrist, or
hand; between the ages of 18 and 75; presented with any positive

Fig. 1. Flowchart of subjects.

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J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

Table 1
Baseline data of study population
Item

Subgroup

Percentage (%)

Diagnosis

MNC
CTS
CUTS
Hand Pares
RTS
Male
Female
<1
1e3
4e12
24
Missing data
Yes
No
Missing data
Sedentary
Light
Medium
Heavy
Missing data

14
9
6
3
1
10
22
3
15
9
2
3
15
3
14
9
9
4
1
9

40.6
28.1
18.8
9.4
3.1
31.2
68.8
9.4
47.0
28.1
6.3
9.4
46.9
9.4
43.8
28.1
28.1
12.5
3.1
28.1

Gender
Symptom duration (months)

Lost time from work

Physical demand level

MNC multiple nerve compression, CTS carpal tunnel syndrome, CuTS cubital
tunnel syndrome, Hand Pares hand paresthesia, RTS radial tunnel syndrome. In
all cases the diagnosis was made by the referring physician and was independent of
the patient being included in the study. Missing data e indicates that the treating
therapist did not record this information at the initial evaluation.

upper limb neurodynamic test (ULNT) that was exacerbated with a

proximal maneuver.8 A proximal maneuver was dened as cervical
side bending, rotation away from the involved upper extremity or
scapular depression. The ULNT with the proximal maneuver was
used as part of the inclusion criteria in an attempt to identify
compromised neural tissue proximal to the shoulder region. Three
separate ULNTs, median, ulnar, and radial, were performed actively
in a seated position (Fig. 2). Although the validity and reliability of
this procedure has never been addressed, an active ULNT in sitting
was chosen because patients often complain of an exacerbation of
symptoms during functional tasks. Neurodynamic testing was performed for up to 60 s and was considered positive if the patient
reported reproduction of the neurological symptoms for which they
were seeking treatment. Neurological symptoms included descriptions like numbness, tingling, burning, sharp, or electric pain.
The results of the neurodynamic testing are reported in Table 2.
Patients were excluded for: demonstrating at least 2 signs
consistent with cervical radiculopathy. The tests performed to
screen for cervical radiculopathy included Spurling A, cervical
distraction, and cervical active range of motion rotation in sitting.21
Other exclusion criteria included: patient reported history of diabetes, peripheral neuropathy, progressive neurological disorders,
cancer, any upper motor neurological disorder, surgery in the last 6

months, or signicant hand deformation due to nerve damage such

as wrist drop or ulnar clawing.
After the initial examination, all eligible patients were informed
of the potential risks and benets of the study and written
informed consent was obtained. The Institutional Review Board at
the University of Kentucky approved this study.

Outcome measures
Demographic information, the Numeric Pain Rating Scale
(NPRS), quick version of the Disabilities of the Arm, Shoulder, and
Hand questionnaire (QDASH), and grip strength were collected
with the initial evaluation. The NPRS was scored from 0 to 10 with
0 representing no pain and 10 representing worst imaginable pain.
The context of the NPRS was based on 3 questions pain at worst,
best and current. The mean of these 3 measures were used to
represent pain level and for statistical analysis.22 The QDASH was
scored from 0 to 100 with 0 representing the least possible
disability. Previous research has demonstrated good reliability and
responsiveness of this score.23,24 The QDASH and NPRS were the
primary outcomes used to evaluate effectiveness of the
intervention.
Grip strength was used as a secondary outcome measure to
quantify patients distal motor performance. A Jamar (Lafayette
Instruments, Lafayette, IN) hand held dynamometer was utilized
following the American Society of Hand Therapists guidelines.25
Data collection was obtained with the elbow exed to 90 . Measurements were collected bilaterally and for 3 repetitions with the
mean value used for statistical analysis.
Four physical therapists and 4 occupational therapists, spread
between 4 clinics, were involved with treatment and collecting
outcomes in the study. All therapists had at least three years of
clinical experience; while four had specialty certications (3
certied hand therapists and 1 orthopedic certied specialist). The
treating therapist performed a standardized history and evaluation
of the upper quarter on all potential participants. During the initial
evaluation, the treating therapist performed the inclusion/exclusion tests and recorded grip strength measures. To improve consistency between therapists, the therapists were trained for
administering and reading grip strength testing using the Jamar
hand held dynamometer prior to commencing the study. Additionally, all therapists were trained on the delivery of the rehabilitation program and performance of the examination.
All outcome measures were collected at the initial evaluation,
the 4th visit, and at discharge. Frequency of visits and discharge
was determined by the treating therapist after considering the
patients goals. For patients completing the treatment program, an
attempt was made to contact them by phone or mail at 3 and 6

Fig. 2. Upper limb neurodynamic test with median nerve bias. Right: Contralateral cervical side bending. Left: Manual scapular depression.

J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

Table 2
Physical ndings in the initial evaluation
Test

Bilateral

Right

Left

Negative

Not tested

Median NTS
Ulnar NTS
Radial NTS

10 (31%)
6 (19%)
1 (3%)

12 (38%)
9 (28%)
3 (9%)

6 (19%)
4 (13%)
2 (6%)

4 (13%)
8 (25%)
19 (59%)

0 (0%)
5 (16%)
7 (22%)

Results are based on 32 included patients that presented with 15 bilateral complaints, 10 right involved sides, and 7 left involved sides. ULNT upper limb neurodynamic test. All ULNT tests were held for 60 s and were considered positive if
reproduction of the patients primary symptoms was reproduced.

months following discharge from therapy to collect QDASH and

NPRS scores. No attempt was made to collect grip strength measures at follow-up as this was a secondary outcome measure.
Intervention
Previous studies that addressed proximal impairments in patients with CTS20,26 served in part in the design of our comprehensive treatment approach with the other component coming
from the concept of the Kinetic Chain Theory (KCT). The KCT
highlights the potential importance of proximal treatment for a
distal pathology.27,28 In summary, our approach addressed 5 components; postural education, scapular stabilization, neural gliding,
proximal manual therapy, and distal stretching.
Table 3 and Appendices AeD provide a detailed description of
the comprehensive program. The rst component, patient education, given to all patients was verbal and written instruction on
sleeping posture and sitting posture for activities such as working
at a desk or on a computer at initial visit.14,16,17,29 Patients were also
given verbal instructions for positions to avoid during daily activities. For example, for patients with ulnar nerve symptoms, patients
were instructed to avoid extreme elbow exion to reduce neural
tensioning. Finally, patients demonstrating signs and symptoms
consistent with CTS were issued a custom wrist orthosis n 9/32
(28%) tted in a neutral wrist position.13 Those patients demonstrating signs and symptoms consistent with CuTS were issued a
Helbo Elbow Protector (North Coast Medical, Morgan Hill, CA),
n 6/32 (19%). The prescription of this equipment was in part
dependent on request from referring physician and determination
by the treating therapists. The frequency and duration of wearing
the medical equipment issued was determined by the treating
therapist.
Second, all patients received treatment for proximal musculature addressing strengthening of shoulder and scapular musculature.6,20,30 Patients were given at least one clinic and one home
exercise to address the anterior musculature (serratus anterior) and
posterior musculature (rhomboids and trapezius). Proximal
strengthening interventions were based on a treatment algorithm
suggested previously.31 The three phased progression was created
based on electromyographical studies progressing from low to high
electromyographical activity and biomechanical principle of short
to long lever arm to further challenge patients.32e36 Phase 1
(neuromuscular education) was instructed to facilitate scapular
motor control for all patients. To progress to Phase 2 (short lever
arm resistance), the patient had to demonstrate the ability to
isolate scapular retraction and sternal lift with correct head posture
from a resting neutral posture 20 times while standing in an upright posture without substitution, support, and without aggravating symptoms. Each repetition was held for a full 5 s. To progress
to Phase 3 (long lever arm resistance), the patient demonstrated
that they could perform 20 repetitions with a set load of 10 lbs.
without pain, substitution, or increasing symptoms while performing a single arm row. The goal was to have the patient perform

195

each exercise for 3 sets of 10. In all cases, the patient began without
weight. When the patient no longer experienced 24 h post onset
muscle soreness or their pain did not go up more than 1 level on the
NPRS, then resistance was added.
Third, all patients were issued neurodynamic exercises to
address decits identied in the initial evaluation.37 The purpose of
a neurodynamic exercises is to mobilize the peripheral nervous
system in an attempt to reduce symptoms and improve function.38
Based on the exam ndings, the patient was assigned at least 1
glide. At least 1 glide was given for the home exercise program. In
the clinic, the glide was performed as an exercise or manually by
the therapist. Based on clinical experience, there were three phases
to the gliding program, starting in supine and progressing to sitting
and nally performing in standing. A patient was progressed to
sitting or standing when he/she was able to demonstrate 30 full
nerve glides in the supine/sitting position without symptom
reproduction. Although the goal was to perform 3 sets of 10
through a full range, the amount of repetitions and range of motion
was modied based on the patients response.
The nal two components of the intervention consisted of
proximal and distal stretching. For the purposes of this paper,
stretching included patient exibility exercises and manual
therapy. All patients received proximal stretching, and 23/32
(72%) of the patients also received distal stretching. Proximal
and distal exibility exercises were held for 30 s and performed
for 3e5 repetitions. Manual therapy techniques included
proximal and distal soft tissue mobilization, cervical mobilizations (grades 1e4), and thrust and nonthrust thoracic
mobilizations.19
Patients missing an appointment were contacted within 1, 24,
and 48 h of that missed appointment by phone per standard
operating procedures at the clinics where the study took place.
Patients who did not reschedule after three reschedule attempts
were discharged from therapy and were identied in the study as
self-discharged.
Statistical analysis
Before the data were analyzed, a power analysis was performed
using G Power version 3.1.5.39 A sample size of 32 subjects provided
89% power to detect a minimal detectable change (MDC) of 11
points on the QDASH assuming a common standard deviation of
18.9 points with an alpha value of .05. The minimal difference and
standard deviation values were chosen from a previous study
reporting QDASH values in a variety of upper extremity
pathologies.23
Frequency counts were calculated to describe patient demographics and to report our patients symptoms at baseline. Our
primary dependent variables included the QDASH percent score
and NPRS, while the secondary dependent variable was grip
strength. The mean pain score was determined by taking the mean
of the patients reported NPRS regarding current pain, best pain, and
worst pain in the last 24 h. The minimal detectible change for the
NPRS is 2.40 The independent variable time included four levels:
baseline, visit 4, discharge, and at follow-up.
For all dependent variables, separate repeated measures linear
mixed models were run across 3 time points (baseline, visit 4, and
discharge). A mixed model approach was chosen secondary to the
models exibility to analyze data that is missing at random.41 For
those subjects with follow-up data, separate repeated measure
mixed models were run across 4 time points (baseline, visit 4,
discharge, and follow-up) for both average pain and the QDASH.
Grip strength values were analyzed separately for patients with
unilateral and bilateral symptoms. Patients with bilateral symptoms baseline values were analyzed with a mixed linear model to

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J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

Table 3
Treatment matrix
Treatment program
2. Posterior
Patient education
- Standing row with Theraband
All subjects were given instruction on the following:
- External rotation and scapular retraction with T-band
1. Ergonomic posture e www.seating-ergonomics.com
- Lawnmower with external rotation
2. Sleeping posture e http://blog.gaiam.com/blog/insomniac-sleep-like-youre- Robbery
doing-yoga/
Phase 3: Resistive with moderate to heavy loads/long lever arms
3. Extremity positioning precautions for median/ulnar nerve protection
1. Anterior
- Adduction with straight arm
Scapular stabilization
- Standing horizontal adduction
At least one exercise was assigned for the anterior group (serratus anterior) and
- Knee push up plus
posterior group (rhomboids and trapezius) for clinical intervention and HEP
- Full push up plus
Phase 1: Neuromuscular education
- Upper cut
1. Anterior
2. Posterior
- Scapular depression
- Prone extension
- Inferior glides
- Standing arm with elbow extended
- Wall washes
- Prone horizontal abduction
- Towel slides side-lying
- Horizontal abduction with resistance
- Ball roll standing
- Prone elevation at 135
- Supine scapular punches with a plus (no weight)
- Standing exion with Theraband
2. Posterior
- Isometric scapular retraction
- Low row
- Sternal lift with trunk extension
- Lawnmower w/out weight
Phase 2: Resistive with light to moderate loads/short lever arm
1. Anterior
- Supine punch with a plus (with weight)
- Supine punch with a plus on wedge (with or w/out weight)
- Wall push up plus
- Incline push up plus
- Theraband punch with plus

Neural gliding matrix

The targeted nerve (median, ulnar, or radial) was based on the initial evaluation. One
exercise was assigned for clinical intervention and HEP
Phase 1: Supine
Phase 2: Sitting
Phase 3: Standing

Distal stretching matrix

Proximal stretching matrix
The therapist was given the option of assigning 1 home exercise and 1 or more clinical The therapist was given the option of assigning 1 home exercise and 1 or more clinical
interventions for each of the three proximal stretching categories:
interventions for each of the three proximal stretching categories.
Pectoralis major/minor:
Dorsal compartment:
1. Home:
1. Home:
- Supine with towel roll
- Dorsal compartment stretch
- 1 arm doorway stretch
2. Clinic:
- 2 arm doorway stretch
- Soft tissue mobilization
2. Clinic:
- Manual stretching
- Soft tissue mobilization
- Dorsal compartment stretching
- Manual stretching
Volar compartment:
- 1 of the above home exercises
1. Home:
Cervical spine:
- Volar compartment stretch
1. Home:
- Individual tendon glides
- Cervical AROM in supine
- Distal median nerve glides
- Cervical AROM in sitting
2. Clinic:
- Cervical stretching
- Soft tissue mobilization
2. Clinic:
- Manual stretching
- Soft tissue mobilization
- 1 of the above home exercises
- Mobilizations (grades 1e4)
Intrinsics:
- 1 of the above home exercise programs
1. Home:
Thoracic spine:
- Passive intrinsic stretching
1. Home:
- Joint blocks
- Sitting thoracic extension
- Hook exercises
- Supine thoracic extension
2. Clinic
- Standing ball roll extension
- Manual intrinsic stretching
2. Clinic
- Manual joint blocks
- Soft tissue mobilization
- 1 of the above home exercises
- Thoracic and rib mobilizations
- 1 of the above home exercise programs

determine if dominance needed to be considered at baseline, visit

4, and at discharge. In this sample there was no difference between sides (p  .12). Therefore, only one side, right side, was
reported for patients with bilateral symptoms. In addition, gender
was used as a covariate in the grip strength analysis secondary to
previous studies that indicate mean grip strength for males is
greater than females.42e44 Alpha adjustments were made using
Bonferroni corrections for multiple comparisons in all mixed
model analyses.

Results
Patients enrolled in this study presented primarily from their
referring physician with the diagnosis from the physician of multiple nerve compression 14/32 (41%) or carpal tunnel syndrome 9/
32 (28%) along with a few other diagnoses presented in Table 1. The
mean number of visits until discharge was 9.5
5 visits and the
mean follow-up period was 5
2 months. There was a signicant
improvement for both the QDASH (Fig. 3) and mean pain (Fig. 4)

J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

Fig. 3. Quick DASH means and 95% condence intervals for all subjects. The Quick
DASH is a measure of disability ranging from 0 (no disability) to 100 (complete
disability). The minimal detectible change for the QDASH is 11. *Signicant difference
from baseline (p .041). ySignicant difference from baseline (p < .001). zSignicant
difference from visit 4 (p .009). All subjects were included (N 32).

197

Fig. 5. Quick DASH Means and 95% condence intervals for subjects with follow up.
The Quick DASH is a measure of disability ranging from 0 (no disability) to 100
(complete disability). The minimal detectible change for the QDASH is 11. *Signicant
difference from baseline (p < .001). ySignicant difference from visit 4 (p .024).
z
Signicant difference from visit 4 (p .009). Only subjects with follow up were
included (N 20).

(p < .001). Post-hoc analysis revealed that QDASH scores improved

from baseline at visit 4 by a mean change of 11 points (p .041) and
continued to improve from visit 4 to discharge by a mean change of
11 additional points (p .009) (Fig. 3). Post-hoc analysis revealed
that mean pain decreased by visit 4 and remained decreased at
discharge compared to baseline measures (p < .001) (Fig. 4).
Analysis of the subgroup of 20 people that had follow-up revealed a
similar signicant improvement in QDASH (Fig. 5) and pain (Fig. 6)
over the course of treatment (p < .001). QDASH post hoc analysis
revealed that at both discharge and at follow-up disability had
improved signicantly from baseline (p < .001). There was a
decrease in disability from baseline to visit 4 but did not reach a
statistical signicance (p .74). The level of improved disability
obtained at discharge was maintained at follow-up (p 1) (Fig. 5).
Post hoc analysis of mean pain scores revealed a signicant pain
reduction from baseline to visit 4 (p .005). This reduced pain level
did not change signicantly at discharge (p 1) or at follow-up
(p 1) from visit 4. Grip strength did not change during the
intervention when including gender as a covariate for patients with
unilateral symptoms (p .128) or bilateral symptoms (p .441)
(Table 4).

Management of a patient with non-radicular PNP has been

successfully treated with a comprehensive therapeutic intervention
incorporating both proximal and distal interventions. Our rst
hypothesis was partially conrmed in that we found statistical
improvement in our primary outcome measures of disability and
pain from baseline to discharge. Although grip strength improved,
the changes were not signicantly different. Our second hypothesis
was conrmed as we found no signicant differences in pain and
disability scores from discharge to follow-up which was on average
5 months later. This suggests that this comprehensive treatment
approach has apparent lasting benets on patients with nonradicular PNP.
The results of this cohort study also suggest that clinically
meaningful improvement in patients disability and pain was obtained. There was a signicant decrease in QDASH disability scores
between each time point (baseline, visit 4, and discharge) that met
or exceeded previously reported minimal detectable change (MDC)
values of 11 points for the QDASH.24 Changes in average pain scores
were also at or above the MDC, exceeding 2 points,45 between

Fig. 4. Mean Numeric Pain Rating Scale and 95% condence intervals for all subjects.
*Signicant difference from baseline (p < .001). All subjects were included (N 32).

Fig. 6. Mean Numeric Pain Rating Scale and 95% condence intervals for subjects with
follow up. The Numeric Pain Rating Scale (NPRS) is a measure of self-reported pain
ranging from 0 (no pain) to 10 (worst imaginable). The minimal detectible change for
the NPRS is 2. *Signicant difference from baseline (p  .005). Only subjects with
follow up were included (N 20).

Discussion

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J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

Table 4
Marginal mean grip values and 95% condence intervals
Group

Visit N

Unilateral symptoms 1
4
DC
Bilateral symptoms
1
4
DC

17
12
14
15
14
14

Upper
Lower
Mean Percent
boundary
(lbs) change from boundary
95% CI (lbs) 95% CI (lbs)
visit 1 (%)
59.65
70.83
79.14
61.33
68.29
77.36

e
18.74
32.67
e
11.35
26.14

47.53
51.67
63.48
45.95
54.09
61.59

71.77
90.00
94.80
76.72
82.48
93.13

Mean values reect adjustments for gender. lbs pounds, CI condence interval,
DC discharge.

baseline and discharge as well as baseline and visit 4. These ndings indicate that the changes observed in pain and disability scores
are greater than the measurement error associated with the
instruments.
The meaningful observed changes provide clinicians with information in communicating with patients, referral sources, and
secondary providers as limited information exist on the course of
this patient population. According to the results of our study, a
patient with a similar physical presentation may expect an average
of 10 physical therapy visits at 2 times a week for about a month. In
addition, a patient may expect to see a meaningful improvement in
disability and pain after the 4th visit using a similar intervention
approach. Overall, the QDASH and NPRS appear to provide a
responsive measure to report outcomes to referral sources and
secondary providers throughout the course of treatment in patients
with non-radicular PNP.
The ndings of the current study are similar to previous literature reporting treatment strategies in patients with TOS and CTS. In
a literature review of patients with thoracic outlet symptoms, the
authors concluded that conservative treatment such as postural
correction, proximal soft tissue mobilization, and TENS units were
effective at reducing symptoms and return to work.6 Wong et al
reported reduced pain levels in female ofce workers with CTS
symptoms while addressing only posture and cervical impairments
during a period of 10 treatment sessions.26 Brizinski and Prence
reported a 95% improvement of hand symptoms in a single case
report of a patient diagnosed with bilateral CTS who was treated
with cervical and thoracic mobilizations, nerve glides, and periscapular strengthening.20
Although meaningful improvements were observed with both
the QDASH and pain scores, grip strength minimally changed over
the course of the intervention. One reason for the lack of signicant
change in grip strength measurements may be that grip strength did
not appear to be severely impaired at baseline. The median grip
strength for normal females and males between the ages of 40e49
has been reported to be approximately 63 lbs and 107 lbs respectively.43 In comparison the mean values for females and males at
baseline in our study were 51 lbs and 81 lbs. respectively. Furthermore, our sample size was reduced in the grip strength analysis in
order to separate the bilaterally and unilaterally involved patients;
therefore the study was not adequately powered for grip strength
analysis. Independent from the reason for the lack of statistical
change, at discharge, both males (113 lbs) and females (64.35 lbs)
exceeded their reported mean normal grip strength values.
Despite improvements in disability and pain as a cohort, there
were individual patients who did not respond to this conservative
treatment approach. One patient reported worsening of her disability
score from visit 1 to visit 4 and subsequently underwent surgery for
carpal tunnel syndrome. Two patients reported no change in their
disability scores or pain scores at discharge from physical therapy.
Both patients continued to work in high demand jobs at an automobile manufacturing plant during the course of treatment. Known risk

factors for developing upper extremity musculoskeletal pathologies

are repetitive, forceful motions and the use of vibration tools.46,47
Similarly, it has been reported that a poor prognosis is associated
with similar patients who continue to perform manual labor.48
Therefore, adding specic occupational modications may be an
important consideration for future research.
There are limitations to this study that should be considered in
interpreting the results. First there is a potential for bias as the
therapist that enrolled the patients also treated the patients. Second, follow-up data was only collected on 20/32 (63%) available
patients creating a potential in bias in patient selection. We do not
know if the other patients did well, required further intervention,
or may still have ongoing symptoms following the intervention.
Third, for patients where follow-up data were available, a small
portion 4/20 of the data was potentially confounded by follow-up
treatments. Two patients had a carpal tunnel release performed, 1
patient had a cortisone injection for carpal tunnel pain, and 1 patient received massage therapy to the proximal upper quarter
during the 5 month time frame. Fourth, the neurodynamic test for
the upper limb was administered in sitting for one of the inclusion
criterion in this study, while the reliability for this test has only
been reported in a supine position. Finally, the nature of a cohort
study is that no cause and effect can be determined as there is no
comparison made to a group with that received no intervention or
an alternative treatment.
Although preliminary evidence for a more comprehensive
treatment approach is encouraging, more research is needed to
support these ndings. Research should investigate whether a
comprehensive treatment approach is more effective than a traditional localized treatment approach and if the comprehensive
approach is more effective than no treatment in patients with nonradicular PNP. In addition, because it was observed that most of the
non-responders in this cohort demonstrated symptoms of CTS,
future research is needed to individually investigate a comprehensive treatment approach on patients with CTS, TOS, and CUTS.
Conclusion
In patients presenting with non-radicular PNP a comprehensive
treatment approach appears to be effective at reducing disability
and pain scores in an average of 10 visits. Furthermore the
improvement in both scores appears to be unchanged at 5 months
after discontinuation of therapy. Therefore, we believe this treatment approach can serve as a preliminary guide for the conservative management of patients with non-radicular peripheral
neuropathic pain. Future studies are needed to determine which
specic components of this treatment is more effective than other
components as no cause and effect can be determined from a
cohort study.
Acknowledgment
We would like to thank the staff at Kentucky Hand & Physical
Therapy for their assistance with this project. Additionally, we
would like to thank Dr. J. Martin Favetto for his consultation and
contributions to the treatment approach described in this paper.
Dr. Joseph Day carried out this research project while pursuing
his doctorate in Rehabilitation Sciences at the University of
Kentucky.
Appendix. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.jht.2014.02.003.

J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

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J.M. Day et al. / Journal of Hand Therapy 27 (2014) 192e200

JHT Read for Credit

Quiz: #311

Record your answers on the Return Answer Form found on the

tear-out coupon at the back of this issue or to complete online
and use a credit card, go to JHTReadforCredit.com. There is
only one best answer for each question.
#1. Patients with cervical radiculopathy
a. comprised 50% of the subject population
b. were not included in the subject population
c. were blended in with the carpal tunnel subjects
d. were blended in with the cubital tunnel subjects
#2. Outcome measures included
a. grip and the Purdue Peg Board
b. the DASH and the Sollerman functional scale
c. endurance and comfort levels
d. a modied DASH and pain
#3. The primary inclusionary criterion was a positive
a. Phalens
b. cubital tension test

c. ULNT
d. Tinels
#4. Five interventions were utilized. Of the ve
a. all were equally effective
b. no one intervention can be said to be the most effective
c. neural gliding was the most effective
d. neural gliding was the least effective
#5. One strength of the study was the inclusion of a control group
a. false
b. true
When submitting to the HTCC for re-certication, please batch your
JHT RFC certicates in groups of 3 or more to get full credit.

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