1412
ORIGINAL ARTICLE
An Experimental Pain Model to Investigate the Specificity of
the Neurodynamic Test for the Median Nerve in the
Differential Diagnosis of Hand Symptoms
Michel W. Coppieters, PT, PhD, Ali M. Alshami, MPhty, Paul W. Hodges, PhD, PT, MedDr
ABSTRACT. Coppieters MW, Alshami AM, Hodges PW.
An experimental pain model to investigate the specificity of the
neurodynamic test for the median nerve in the differential
diagnosis of hand symptoms. Arch Phys Med Rehabil 2006;87:
1412-7.
Objective: To indirectly assess the specificity of the neuro-
dynamic test for the median nerve using an experimental pain
model.
Design: Repeated-measures design.
Setting: Laboratory setting.
Participants: Twenty asymptomatic participants in whom
hand symptoms were induced by infusion of hypertonic saline
into the thenar muscles.
Interventions: Not applicable.
Main Outcome Measures: Pain intensity of the induced
hand symptoms and size of the painful area were evaluated in
8 different arm positions, which correspond with different
stages of the neurodynamic test for the median nerve. These
positions have a variable degree of median nerve provocation
at the wrist.
Results: Because the induced symptoms had a non-neural
origin, changes in symptom provocation with the neurody-
namic test would have indicated poor specificity. However,
there were no statistically significant differences in pain per-
ception (Pⱖ.22) and the recorded differences were negligible
from a clinical perspective.
Conclusions: Taking into consideration the limitations of an
experimental pain model, this study indirectly confirms the
specificity of the neurodynamic test for the median nerve. The
results of this study, together with previous studies that dem-
onstrated a high sensitivity, support the use of the neurody-
namic test for the median nerve to differentially diagnose
neurogenic disorders, such as carpal tunnel syndrome, from
other wrist and hand pathologies.
Key Words: Carpal tunnel syndrome; Diagnosis; Entrap-
ment neuropathies; Median nerve; Rehabilitation; Reliability
and validity.
© 2006 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Division of Physiotherapy, School of Health and Rehabilitation Sciences,
The University of Queensland, Brisbane, Australia (Coppieters, Alshami, Hodges);
and Neuro Orthopaedic Institute, Adelaide, Australia (Coppieters).
Supported by The University of Queensland, Brisbane, Australia (early career
research grant).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Michel W. Coppieters, PT, PhD, School of Health and Reha-
bilitation Sciences, Bldg 84A, The University of Queensland, QLD 4072 St. Lucia,
Australia, e-mail: m.coppieters@uq.edu.au.
0003-9993/06/8710-10856$32.00/0
doi:10.1016/j.apmr.2006.06.012
Arch Phys Med Rehabil Vol 87, October 2006
ARPAL TUNNEL SYNDROME (CTS), an entrapment of
C the median nerve at the wrist, is a condition characterized
by pain, neurologic symptoms, and functional limitation of the
hand.1 Despite the high prevalence of CTS,2 and its major
socioeconomic impact,3,4 there is no criterion standard avail-
able to diagnose CTS.5-8 The relevance of numerous clinical tests
is questionable considering their poor diagnostic accuracy,9,10 and
there are no universally accepted criteria7 for the various electro-
diagnostic parameters that have been suggested.11 Because
symptoms originating from nerve compression often occur
before conduction is impaired,12 the clinical utility of electro-
diagnosis for CTS remains controversial.13
Unlike clinical tests for CTS, many provocation tests for
other common neuropathies not only challenge the nerve by
application of direct pressure over the affected area or move-
ment of the nearest joint, but further provocation of the in-
volved nerve is often produced indirectly by stressing the nerve
via movements in adjacent joints. For example, ankle dorsi-
flexion is frequently added to the straight-leg raising test to
diagnose lumbar nerve root irritation.14 Similarly, wrist exten-
sion can be included in the elbow flexion test for cubital tunnel
syndrome.15 Inclusion of neighboring joints to elicit symptoms
of neural origin is supported by numerous anatomical studies
that demonstrate that tension can be transmitted over a rela-
tively long section of a peripheral nerve, for example, along the
median nerve between the shoulder and wrist.16-19 From this
perspective, a clinical test that considers various joints along
the median nerve bed (the tract formed by the structures that
surround the nerve) may be more sensitive than traditional
diagnostic tests for CTS, which focus on the wrist only.
The neurodynamic test for the median nerve (fig 1),20,21 also
termed upper limb tension test and neural provocation test for
the median nerve,22 is a relatively novel test in the diagnosis of
CTS and challenges the median nerve at the carpal tunnel by
combined movements of the wrist, elbow, and shoulder girdle.
While preventing elevation of the shoulder girdle, the shoulder
is abducted and the wrist extended; supination of the forearm is
followed by lateral rotation of the shoulder and elbow exten-
sion.20,22 Frequently, not all test maneuvers are needed to
reproduce symptoms and the standard test can be varied to
adapt to individual patients. Alternatively, the final test position
can be sustained or additional pressure can be applied over the
carpal tunnel when it is difficult to reproduce mild symptoms.20
Diagnosis of CTS using the neurodynamic test for the me-
dian nerve is dependent on reproduction or increase of CTS
symptoms, such as pain and paresthesia in the hand. A second
condition for a positive test is that symptoms in the hand can be
influenced by changing the amount of nerve provocation at the
wrist by alteration of the position in more proximal joints, such
as the elbow or shoulder girdle, while maintaining the wrist in
extension. Alteration of symptoms via changes in median nerve
strain, without influencing local musculoskeletal tissues around
the wrist, is a valuable tool to differentiate symptoms of neural
origin from local wrist pathology, such as arthritis, tendinoses,
 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters
Fig 1. The neurodynamic test for the median nerve. The test is used
to evaluate the impact of compression and tension in the median
nerve at the carpal tunnel by combined movements of the wrist,
elbow, and shoulder girdle. While elevation of the shoulder girdle is
prevented, the nerve bed of the median nerve is elongated by
shoulder abduction, wrist extension, forearm supination, lateral
rotation of the shoulder, and elbow extension. Cervical contralat-
eral side bending can be added to further increase the length of the
nerve bed. From Butler DS. The sensitive nervous system. Unley:
Noigroup Publications; 2000. p 317.20 © 2000. Reprinted with per-
mission of Noigroup Publications.
or tenosynovitis, and painful sequelae following a Colles’
fracture.
Analysis of the validity of several clinical tests for CTS
(including provocation tests such as the Phalen test, Tinel test,
and the application of pressure over the carpal tunnel) demon-
strated that the tests were not very sensitive (.23–.69), but were
fairly specific (.66 –.87).9 By inclusion of joints proximal to the
wrist to increase stress to the median nerve in the carpal tunnel,
the clinical assumption is that the neurodynamic test for the
median nerve is a more sensitive test for CTS than tests that
focus on the wrist only. However, the high sensitivity may be
at the expense of the test’s specificity because the test not only
challenges the median nerve at the wrist, but also challenges
other sections of the median nerve and many non-neural struc-
tures. Recent studies confirmed the high sensitivity for the
neurodynamic test for the median nerve in patients with CTS
(.7523 and .8224), but discrepancies have been reported for the
specificity of the test, with values ranging from .1323 to .75.24
Although a consensus statement was issued that diagnosis based
on electrophysiologic findings alone is not recommended,6 both
studies used electrodiagnostic tests as the criterion standard.
Because symptoms of nerve compression can be present with-
out deficits in nerve conduction,12,13,25-27 using electrophysi-
ologic tests as a criterion standard may result in the inclusion
of patients with nerve entrapment in a category of subjects that
should consist of subjects without CTS. For these incorrectly
categorized patients, a positive clinical test will be wrongly
regarded as a false-positive test. As a consequence, the speci-
ficity will be underestimated, because a higher number of
false-positive tests lowers the specificity.
Because a high sensitivity coefficient has already been dem-
onstrated for the neurodynamic test for the median nerve,23,24
priority was given to reassess the test’s specificity by using an
alternative method that is not negatively affected by the lack of
a sound criterion standard. Because direct validation in the
absence of a criterion standard is impossible, the aim of this
1413
study was to indirectly assess the specificity of the test by
analyzing whether the test is negative in the absence of CTS.
Because inclusion of asymptomatic volunteers may overesti-
mate the validity of a test,28 an experimental pain model was
used to induce hand symptoms in healthy volunteers. The
specificity of the neurodynamic test for the median nerve
would be compromised if the symptoms were altered with the
test because the experimentally induced symptoms had a non-
neural origin.
METHODS
Participants
Twenty asymptomatic volunteers (17 men, 3 women; mean
age ⫾ standard deviation [SD], 23⫾7y; height, 175⫾9cm;
weight, 72⫾11kg) participated in the study. Subjects with a
history of neck, arm, or hand pain during the last year or
subjects with any known neurologic condition were excluded
from the study. Participants were naive to the concept of
neurodynamic testing and were given a full explanation of the
procedure, without disclosure of the hypothesis of the study.
Written consent was obtained prior to the commencement of
the study. The study was approved by the institutional ethics
committee. All investigations conformed to the protocol and
the ethical and humane principles of research.
Experimental Muscle Pain
We used an experimental pain model to ensure that pain was
isolated in muscle tissue. Intramuscular injection of hypertonic
saline has been used extensively because the quality of the
induced pain is considered comparable to clinical pain and it
shows localized as well as referred pain characteristics.29,30
In the absence of a validated infusion protocol to induce
experimental hand pain with a constant intensity, we developed
and tested a protocol prior to the conduction of the main study.
The infusion protocol was based on the procedure described by
Svensson et al31,32 for the jaw muscles. A single bolus of
0.2mL of saline (5% NaCl) was infused over 20 seconds into
the thenar muscles of the right hand, followed by a steady
infusion rate of 6mL/h for 440 seconds and 9mL/h for the next
440 seconds. Saline was infused with an infusion pumpa with
a 10-mL plastic syringe. A low sorbing extension tube was
connected from the syringe to a 22-gauge disposable cannula,
which was placed obliquely into the thenar eminence with the
tip of the cannula at a depth of approximately 0.5cm. This
infusion paradigm was evaluated on 8 asymptomatic volunteers
(3 men, 5 women; mean age ⫾ SD, 32⫾7y; height, 170⫾9cm;
weight, 66⫾13kg) prior to the commencement of the main
experiment. Pain perception was evaluated every 30 seconds
using a 10-cm electronic visual analog scale (VAS) and a chart
to determine the size of the painful area. This chart depicted a
series of 15 circles increasing in size from 0.5 to 7.5cm in
diameter. In addition, each subject marked the location of the
pain distribution on a body chart. Results demonstrated that
after a rapid increase in the first 60 seconds, the infusion
paradigm produced a relatively constant pain perception of
moderate intensity (fig 2). The pain was predominantly local-
ized over the thenar eminence and radiated further into the
palm of the hand and occasionally into the thumb and fingers.
Based on these findings, we concluded that the proposed infu-
sion protocol was appropriate to induce experimental muscle
pain in the hand. However, because some of the participants
experienced swelling of the thenar eminence towards the end of
the experiment, probably due to the infused volume, the max-
imal infusion time was limited to 10 minutes.
Arch Phys Med Rehabil Vol 87, October 2006
1414 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters

10 10 progressively increased or decreased the loading of the median

nerve (appendix 1). The sequences were performed in random
6 6
order. The order of the positions within each sequence was
Pain intensity (VAS)

Size of painful area

5 5
4 4
3 3
2 2
1
Pain intensity (VAS)
1
Size of painful area
0 0
0 60 120 180 240 300 360 420 480 540 600
Fig 2. Pain perception during continuous infusion of hypertonic
saline in the thenar muscles. Following a rapid increase during the
first minute, a relatively constant pain intensity could be induced.
Test Positions
In the main experiment, we evaluated the perception of pain
in 8 positions, which had a variable amount of elongation of the
nerve bed (fig 3A). These positions correspond with different
stages of the neurodynamic test for the median nerve. The 8
positions were divided in 2 sequences of 4 maneuvers, which
constant. All movements were performed by the investigator
while the participant remained relaxed. Participants were made
aware that the pain in the hand could increase, decrease, or
remain unchanged in one position relative to another.
The 8 test positions consisted of combinations of wrist, elbow,
shoulder girdle, and neck positions. The positions of the elbow
were 90° of flexion and submaximal extension. The submaxi-
mal range of elbow extension was determined with the arm in
the neurodynamic test position and before experimental hand
pain was induced, and was defined as the maximal range of
elbow extension without causing discomfort in the arm. The
range of elbow extension was measured during the experiment
with a twin-axis electrogoniometerb attached with double-sided
adhesive tape to the medial side of the elbow.
The shoulder girdle was positioned in neutral, depression,
and elevation. With the arm in 90° of abduction, a neutral
shoulder girdle position is obtained by application of a caudally
directed force of 30N over the shoulder girdle to neutralize the
elevation of the shoulder girdle caused by abduction of the
arm.33 A larger depression force (60N) results in shoulder
girdle depression, whereas no depression force (0N) results in
shoulder girdle elevation. Throughout the experiment, the force

B 10

5 + 0. 2 - 0.2
+ 0. 1 - 0.3 + 0. 1 - 0.2
+ 0. 3
4

+ 0. 2 + 0. 1 - 0.2 + 0. 1
3 + 0. 2 + 0. 1 - 0.4

1 S S

0 Increasing length of nerve bedding Decreasing length of nerve bedding

Fig 3. (A) The different test positions that correspond with different stages of the neurodynamic test for the median nerve. The positions
are described in detail in appendix 1. (B) The intensity of the induced hand pain ( ) and the size of the painful area ( ) did not differ
significantly for the 8 different positions with a variable amount of nerve bed elongation. The y axis represents both pain intensity (VAS) and
size of the painful area (diameter of the presented circles ranging from 0.5 to 7.5cm). The error bars denote 95% confidence intervals. The
right panel shows the most frequently reported locations of hand pain during the experiment. A darker gray tint represents a larger number
of subjects reporting pain in the involved area.

Arch Phys Med Rehabil Vol 87, October 2006

 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters
by which the shoulder girdle was depressed was measured with
a hand held load cellc and shown on a digital display to enable
the investigator to accurately position the shoulder girdle prior
to performing the test component.
The cervical spine was positioned in neutral and ipsilateral
and contralateral side bending. Cervical side bending was tar-
geted to the middle and lower part of the cervical spine because
the brachial plexus originates from C5 to T1. Cervical side
bending was performed submaximally, that is, to the maximal
amplitude that did not induce any symptoms in the neck.
We used a custom made hand-wrist splint to position the hand
in a neutral position and to maintain the wrist in 70° of exten-
sion.34 The splint had a separate strap to stabilize the thumb.
This prevented changes in muscle length of the thenar muscles
that could influence pain perception. When the hand splint
could not be applied comfortably because of the position of the
catheter (6 subjects), an electrogoniometerb was attached to the
dorsum of the wrist to monitor the position of the wrist.
Previous studies have demonstrated that the neurodynamic test
for the median nerve has a high reliability when performed
with either the hand-wrist splint or wrist electrogoniometer.35
Electromyographic activity of the thenar muscles was moni-
tored to ensure that the muscles remained relaxed during the
experiment. Surface electrodes (Ag-AgCl; diameter, 11mm) were
placed with about 20-mm interelectrode distance over the bulk of
the thenar muscles, parallel to the muscle fibers.
Pain Measurements
Because pain is subjective, self-reports are regarded as pro-
viding the most valid measure of the experience.36 In each
position, participants were asked to indicate the pain intensity
on a 10-cm electronic VAS, anchored with “no pain” and
“worst possible pain.” A chart depicting a series of 15 circles
increasing in size from 0.5 to 7.5cm in diameter was used to
determine the size of the painful area. At the conclusion of the
study, the quality of pain was assessed by the McGill Pain
Questionnaire (MPQ). Words from the questionnaire chosen by
at least 30% of the subjects were used to describe the quality of
the induced pain. The distribution of the symptoms was deter-
mined from a hand diagram.
Statistical Analysis
We used a 1-way, repeated-measures analysis of variance to
analyze the pain intensity and size of the painful area in the
different positions of the neurodynamic test. The level of
significance was set at P less than .05. Statisticad was used for
the analysis.
RESULTS
Pain was predominantly located around the infusion area in
the thenar eminence and occasionally radiated toward the
thumb, index finger, and middle finger (fig 3B, right panel).
The average pain intensity (VAS) throughout the experiment was
4.0⫾2.2. According to the criteria proposed by Jensen et al,37
35% of the participants experienced mild pain (VAS scores
between 0.5 and 4.4) and 65% experienced moderate pain
(VAS scores between 4.5 and 7.4). The words most frequently
chosen from the MPQ to describe the induced symptoms were
“tight” (45%), “cramping” (45%), “sharp” (35%), “stinging”
(35%), and “throbbing” (30%). The volunteers rated the pain
intensity throughout the experiment as “discomforting” (65%),
“mild” (25%), or “distressing” (10%).
Figure 3B (left panel) demonstrates the pain intensity and
size of the painful area for the 8 different positions. The figure
shows a tendency for a slight increase in pain intensity and size
1415
of the painful area for the sequence which elongates the nerve
bed, and a slight decrease when the length of the nerve bed
decreases. However, variations were statistically not significant
(pain intensity: F7,133⫽1.37, P⫽.22; size of painful area:
F7,133⫽.98, P⫽.45) and, from a clinical perspective, the dif-
ferences were small. The mean difference between 2 consec-
utive positions for the sequence that increased the length of the
nerve bed was 0.2⫾0.6 for both pain intensity (VAS) and size
of the painful area. Differences for the sequence that decreased
the length of the nerve bed were ⫺0.1⫾0.7 for pain intensity
and ⫺0.1⫾0.5 for size of the painful area.
The mean infusion time was 4.5 minutes ⫾ 46 seconds. All
trials were finished within the maximum set infusion time of 10
minutes (range, 3.3– 6.3min). The total infusion time varied
between subjects because the time required to obtain a stable
pain intensity before the first test position was adopted fluctu-
ated between subjects and the time required by the subject to
rate the pain in each position also varied between subjects.
DISCUSSION
The main finding of this study was that the perception of
experimentally induced hand pain of muscular origin did not
vary between different positions of the arm and neck that are
associated with different levels of mechanical nerve provoca-
tion. Anatomic and biomechanic studies have demonstrated that
elbow, shoulder, and shoulder girdle positions that increase the
length of the nerve bed increase tension in the median nerve.16-19
This increase in nerve strain occurs not only at the joint where
the nerve bed is elongated, but the strain is transmitted over a
relatively long section of the peripheral nerve, for example,
along the median nerve between the shoulder and wrist.17-19 The
fact that neither the intensity of muscular hand pain nor the
size of the painful area was significantly different between
positions contributes to the further validation of neurodynamic
tests. The neurodynamic test for the median nerve is considered
positive in the diagnosis of CTS if neurogenic symptoms can
be reproduced and if the intensity of the symptoms can be
influenced by moving joints proximal to the wrist, while keep-
ing the wrist position constant. Changing positions in joints
proximal to the wrist that increase or decrease median nerve
strain at the carpal tunnel without changing local musculoskel-
etal structures around the wrist can contribute to the differential
diagnosis of disorders of the hand and wrist.
No differences in pain perception were observed despite
largely different levels of nerve provocation in the different test
positions. Even though submaximal joint positions were used
to limit discomfort from stressing articular structures, we be-
lieve the mechanical provocation of the median nerve in some
of the positions was considerable. This judgment is based on
anatomic and biomechanic16-19 and clinical34,38 data. Coppiet-
ers et al38 demonstrated that with the arm and cervical spine in
submaximal positions of nerve bed elongation, the elbow could
only be extended from 90° to 143.9°⫾16.1° before a maximal
pain level was reached. The positioning of the arm and cervical
spine in the final test position of the sequence that increased the
loading of the median nerve (see appendix 1) was similar to the
positions adopted by Coppieters.38 Although we limited exten-
sion of the elbow to 129.0°⫾7.9° (⬇15° less extension), we
believe that this range of motion, in combination with nerve
bed elongation at the neck, shoulder, shoulder girdle, and wrist,
challenged the median nerve substantially.
Because there is no criterion standard available to assess the
concurrent validity of the neurodynamic test for the median
nerve, we chose an experimental model as an alternative way to
indirectly investigate the specificity of the neurodynamic test
for the median nerve to differentially diagnose hand symptoms.
Arch Phys Med Rehabil Vol 87, October 2006
1416 VALIDATION OF THE MEDIAN NERVE NEURODYNAMIC TEST, Coppieters

The main advantage of using an experimental model was that
the exact origin of the symptoms was known. Furthermore, the
probability that patients with minor neuropathies were in-
cluded, which could have confounded the results, was low
because the participants of this study only experienced hand
symptoms during the experiment.
In this study, we focused on one of the criteria for a positive
neurodynamic test, namely, whether the intensity of hand
symptoms increases or decreases when the length of the nerve
bed is altered by changing positions in joints proximal to the
wrist. Although no studies have investigated this criterion in
patients with CTS, case studies of patients with cubital tunnel
syndrome have demonstrated that shoulder abduction and cer-
vical contralateral side bending, when added to elbow flexion,
and wrist extension are able to reproduce symptoms related to
ulnar nerve compression around the elbow.39,40 The fact that
symptoms of neural origin can be altered by movements in
adjacent joints, in combination with the finding of this exper-
iment that hand symptoms of muscular origin could not be
altered, suggest that nerve involvement can be differentiated
from musculoskeletal wrist or hand pathologies using neuro-
dynamic tests.
A disadvantage of using an experimental pain model was
that a second criterion for a positive neurodynamic test,
namely, whether the test reproduces CTS symptoms, could not
be considered. As a result, we did not determine whether an
individual test was positive or negative, but rather compared
results across all participants. Validity measures, such as sen-
sitivity, specificity, and positive and negative predictive value,
require individual test decisions and were therefore not calcu-
lated. Another limitation of the chosen model was that the
APPENDIX 1: POSITIONS USED TO INCREASE AND DECREASE THE LENGTH OF THE NERVE BED
OF THE MEDIAN NERVE
principal symptom produced by infusion with hypertonic saline
was hand pain, which is only one of the symptoms of CTS.
Despite these limitations, the findings of this study contrib-
ute to the current knowledge regarding the applicability of
neurodynamic tests to structurally differentiate between sources of
symptoms. It has been suggested that painful muscles and joints,41
and continuity of the fascial system42 may result in false-
positive neurodynamic tests and that a peripheral nerve cannot
be selectively loaded because the test challenges many differ-
ent structures.41 The findings of this study provide evidence
against the opinion that pain of non-neural origin will increase
during neurodynamic testing. The results are in agreement with
previous experiments in which experimentally induced muscle
pain was used to contribute to the validation of other neurody-
namic tests, such as the straight-leg raising test and slump test.43
CONCLUSIONS
It is obvious that by inclusion of joints proximal to the wrist
to increase the mechanical provocation of the median nerve at
the carpal tunnel, neurogenic symptoms may also be elicited
from more proximal parts of the median nerve and brachial
plexus. Proximal nerve entrapments that may mimic CTS
symptoms include pronator teres syndrome, anterior interosse-
ous nerve syndrome, cervical radiculopathy, and peripheral
polyneuropathy.8,44 Although the findings of this and previous
studies suggest that the neurodynamic test for the median nerve
may be a valuable test to differentiate neurogenic from non-
neurogenic disorders, localization of the site of the nerve
entrapment with a single test is unlikely to be possible. The
patient interview, specific symptoms, and additional tests
should be used to obtain further information regarding the
location of the neuropathy.

Sequence of positions that progressively increased the loading of the median nerve
Starting position: Shoulder abduction and lateral rotation (90°); neutral shoulder girdle position (30N depression force); elbow flexion
(90°); forearm supination; wrist extension (70°).
➊ Starting position plus elbow extension (submaximal).
➋ Starting position plus elbow extension and shoulder girdle depression (60N depression force).
➌ Starting position plus elbow extension, shoulder girdle depression, and cervical contralateral side bending.
Sequence of positions that progressively decreased the loading of the median nerve
Starting position: Shoulder abduction and lateral rotation (90°); neutral shoulder girdle position (30N depression force); elbow
extension (submaximal); forearm supination; wrist extension (70°).
➀ Starting position with shoulder girdle elevation (0N depression force).
➁ Starting position with shoulder girdle elevation and cervical ipsilateral side bending.
➂ Starting position with shoulder girdle elevation, cervical ipsilateral side bending, and elbow flexion (90°).

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Suppliers
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b. Models SG110 and SG65; Biometrics Ltd, Units 25-26, Nine Mile
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c. Model 535QD; DS Europe, Via Russoli 6, 20143 Milano, Italy.
d. Version 7.0; StatSoft Inc, 2300 E 14th St, Tulsa, OK 74104.
Arch Phys Med Rehabil Vol 87, October 2006