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Warren JR, Link RC, Cheng AL, Sinclair MK, Sorensen AA. Carpal tunnel syndrome and sleep, a systematic review and meta-analysis. HAND SURGERY & REHABILITATION 2024; 43:101698. [PMID: 38641062 DOI: 10.1016/j.hansur.2024.101698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The most common symptom and reason patients seek treatment for carpal tunnel syndrome is lack of sleep. Our purpose was to determine how much sleep-related symptoms of carpal tunnel syndrome improve after carpal tunnel release using validated patient-reported outcome measures (PROMs) and objective sleep data as primary measures of interest. METHODS A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMed, Cochrane, and ClinicalTrials.gov. Only interventional clinical trials that examined primary outcome measures of interest were included. Patient-reported outcome measures underwent meta-analysis to determine how much scores improved following carpal tunnel release. RESULTS The Pittsburgh Sleep Quality Index improved significantly after carpal tunnel release, by 4.43 points and 6.02 points at 1-3 and 6-12 months postoperatively, respectively, and continued to improve up to 2 years. Improvement on the Insomnia Severity Index after carpal tunnel release was also significant, with improvement up to 1 year postoperatively, by 8.54 points and 9.05 points at 1-3 and 6-12 months, respectively. Insomnia Severity Index scores improved significantly after splinting as well. CONCLUSIONS The present meta-analysis determined to what extent patients can expect their sleep to improve after operative and non-operative intervention, as measured by various patient-reported outcome measures that assess sleep. The Pittsburgh Sleep Quality Index and Insomnia Severity Index correlated very well between studies and across hundreds of patients with carpal tunnel syndrome. Data are lacking to define the minimal clinically important difference and assess whether patients achieve a minimal clinically important difference for sleep questionnaires; more information on this topic is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jonathan R Warren
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA.
| | - R Clayton Link
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
| | - An-Lin Cheng
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
| | - Micah K Sinclair
- Department of Orthopaedic Surgery, University of California Davis, 4860 Y St #1700, Sacramento, CA 95817, USA
| | - Amelia A Sorensen
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
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Bueno-Gracia E, Fanlo-Mazas P, Malo-Urriés M, Rodriguez-Mena D, Montaner-Cuello A, Ciuffreda G, Shacklock M, Estébanez-de-Miguel E. Diagnostic accuracy of the upper limb neurodynamic test 1 using neurodynamic sequencing in diagnosis of carpal tunnel syndrome. Musculoskelet Sci Pract 2024; 69:102897. [PMID: 38118353 DOI: 10.1016/j.msksp.2023.102897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND The upper limb neurodynamic test 1 is used in the diagnosis of median nerve neuropathies such as carpal tunnel syndrome but its diagnostic validity remains limited. Neurodynamic sequencing has been suggested to increase the specificity of the neurodynamic tests, however, to date, information on the diagnostic accuracy of this variation in neurodynamic testing is required. OBJECTIVES The aim of this study was to analyze the diagnostic validity of the local sequence of ULNT1 (LS-ULNT1) (i.e. a sequence that begins at the joint where the problem is (wrist) and progressively moves joints further away from it), in the diagnosis of CTS. A secondary aim was to describe the location of sensory responses to this modified neurodynamic test sequence. DESIGN A prospective diagnostic accuracy study was designed. METHOD Nerve conduction studies were used as the gold standard. The LS-ULNT1 was performed in 58 consecutive patients (17 men, 44 women) with suspected CTS. RESULTS Sensitivity of the LS-ULNT1 was 65.7% (CI 48.0-80.9%) and the specificity was 95.7% (CI 78.1-99.9%). The positive and negative likelihood ratios were >5 and < 0.5, respectively, indicating the ability of the test to generate small but sometimes important changes in post-test probability. CONCLUSIONS The overall results of this study showed that the LS-ULNT1 could be useful in confirming the diagnosis of CTS. The test demonstrated high specificity and the +LR indicated the ability of the test to generate changes in posttest probability, especially with a positive LS-ULNT1 result.
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Affiliation(s)
- Elena Bueno-Gracia
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain.
| | - Pablo Fanlo-Mazas
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain.
| | - Miguel Malo-Urriés
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain.
| | - Diego Rodriguez-Mena
- Neurophysiology Service, Hospital Clínico Universitario Lozano Blesa, Zaragoza. C/ San Juan Bosco 15, 50009, Zaragoza, Spain
| | - Alberto Montaner-Cuello
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain
| | - Gianluca Ciuffreda
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain
| | | | - Elena Estébanez-de-Miguel
- Department of Physiatrist and Nursery, Faculty of Heath Sciences, University of Zaragoza. C/ Domingo Miral s/n 50009, Zaragoza, Spain.
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Verhagen AP, Brown H, Hancock M, Anderson D. Test procedures and positive diagnostic criteria of the upper limb tension tests differ: a systematic review of the DiTA database. Braz J Phys Ther 2023; 27:100558. [PMID: 37967500 PMCID: PMC10679807 DOI: 10.1016/j.bjpt.2023.100558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND The validity of the ULTT is unclear, due to heterogeneity of test procedures and variability in the definition of a positive test OBJECTIVE: To evaluate test procedures and positive diagnostic criteria for the upper limb tension test (ULTT) in diagnostic test accuracy studies. METHODS A systematic review of diagnostic accuracy studies was performed. We conducted a search of the DiTA (Diagnostic Test Accuracy) database and selected primary studies evaluating the diagnostic accuracy of the ULTT. We assessed risk of bias, performed data extraction on study characteristics, test procedures, and positive diagnostic criteria, and performed a descriptive analysis. RESULTS We included nine studies (681 participants), four diagnosing people with cervical radiculopathy (CR), four diagnosing people with carpal tunnel syndrome (CTS), and one included both CR and CTS. The risk of bias varied between 2 and 6 out of 6 positive items. Eight studies reported on the ULTT1 (median nerve). Overall, all studies clearly described their test procedures and positive diagnostic criteria although the order of movements and the diagnostic criteria between studies varied. We suggest a more standardised test procedure for the ULTT1 to consist of: 1) stabilising the shoulder in abduction, 2) extending the wrist/fingers, 3) supinating the forearm, 4) externally rotating the shoulder, 5) extending the elbow, and finally 6) performed structural differentiation by side bending (lateral flexion) of the neck. This proposed test procedure should reproduce the symptoms and enables the clinician to evaluate whether symptoms increase/decrease when stressing or relaxing the nerves. CONCLUSION Based on our findings we proposed a more standardised test procedure for the ULTT1 with accompanying positive diagnostic criteria to facilitate homogeneity in future diagnostic accuracy studies of the ULTT.
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Affiliation(s)
- Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, Australia.
| | - Hayley Brown
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Mark Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - David Anderson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Sydney Spine Institute Research Group, Sydney Spine Institute, Burwood, Sydney, Australia
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Pinto da Silva FH, Dos Santos Silva J, Pereira de Barros LF, Souza RDF, Landeiro JA, Rueda Lopes FC, da Silva MB, Fonseca GVDS, Acioly MA. Use of diffusion tensor imaging as a prognostic biomarker after decompression surgery for carpal tunnel syndrome. Acta Radiol 2023; 64:1109-1115. [PMID: 35876308 DOI: 10.1177/02841851221113518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Magnetic resonance diffusion tensor imaging (MR-DTI) has been increasingly applied for carpal tunnel syndrome (CTS) diagnosis, but relatively little is known about the effect of CTS treatment on median nerve (MN) integrity and functional outcome prediction. PURPOSE To assess how structural changes in MR-DTI of the MN correlates with symptom severity, functional status, and electrophysiological parameters in patients suffering from CTS before and after decompression surgery. MATERIAL AND METHODS Nine wrists were prospectively enrolled to perform MR-DTI pre- and postoperatively. The apparent diffusion coefficients (ADC) and fractional anisotropy (FA) of the MN were examined in three different regions-distal radioulnar joint, pisiform bone, and hamate bone-and correlated with clinical and electrophysiological parameters. RESULTS Postoperatively, mean Boston Carpal Tunnel Questionnaire scores decreased 1.55 points (range = 0.08-3; P = 0.0172) and 1.01 points (-0.13 to 1.88; P = 0.0381) in the symptomatic and functional domains, respectively. Postoperative clinical improvement was reflected in proximal FA elevation (P = 0.0078), but not in diffusivity in comparison to baseline examination. Preoperative electrophysiological parameters were correlated with a reduction in the pre- (sensory latencies [rho = -0.6826; P = 0.0312]) and postoperative (motor latencies [rho = -0.7488; P = 0.0325]) distal FA values. Higher sensory amplitudes indicated higher postoperative proximal FA values (rho = 0.7618; P = 0.0280) and lower postoperative proximal ADC values (rho = -0.9047; P = 0.0020). CONCLUSION Our study demonstrated that pre- and postoperative proximal FA values are useful biomarkers for the structural evaluation of the MN in patients with CTS. Symptomatic improvement can be better predicted by analyzing FA changes.
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Affiliation(s)
- Fábio Henrique Pinto da Silva
- Division of Neurosurgery, 282806Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil
- Postgraduation Program in Neurology, Federal University of the State of Rio de Janeiro (UNIRIO)
| | | | | | - Renan de Freitas Souza
- Division of Neurosurgery, 219791Fluminense Federal University, Niterói - Rio de Janeiro, Brazil
| | - José Alberto Landeiro
- Division of Neurosurgery, 219791Fluminense Federal University, Niterói - Rio de Janeiro, Brazil
| | - Fernanda Cristina Rueda Lopes
- Division of Radiology, 455295DASA, Rio de Janeiro, Brazil
- Division of Radiology, Fluminense Federal University, Niterói - Rio de Janeiro, Brazil
| | | | | | - Marcus André Acioly
- Postgraduation Program in Neurology, Federal University of the State of Rio de Janeiro (UNIRIO)
- Division of Neurosurgery, 219791Fluminense Federal University, Niterói - Rio de Janeiro, Brazil
- Division of Neurosurgery, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Accuracy of the Most Common Provocation Tests for Diagnosing Carpal Tunnel Syndrome: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2022; 52:522-531. [PMID: 35722757 DOI: 10.2519/jospt.2022.10828] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the screening performances of the most important provocation tests for diagnosing carpal tunnel syndrome (CTS). DESIGN Diagnostic test accuracy systematic review with meta-analysis. LITERATURE SEARCH We systematically searched the MEDLINE, Scopus, Web of Science, and Cochrane databases from inception to November 2020. STUDY SELECTION CRITERIA Observational studies comparing the accuracies of the Durkan test (DT), the hand elevation test (HET), the Phalen test (PT), the Tinel test (TT), and the upper-limb neurodynamic test specific to the median nerve (ULNT1) with electrodiagnosis for screening for CTS. DATA SYNTHESIS Random-effects models for the diagnostic odds ratio (dOR) values computed by Moses' constant for a linear model and 95% confidence intervals (CIs) were used to calculate the accuracy of these tests. Hierarchical summary receiver operating characteristic curve analyses were used to summarize the overall test performance. RESULTS Thirty-seven studies were included in the meta-analysis, with a total sample of 2662 wrists for DT, 864 wrists for HET, 6361 wrists for PT, 6094 wrists for TT, and 571 wrists for ULNT1. The pooled dORs for screening for CTS were 15.84 (95% CI: 3.78, 66.38) for DT, 128.63 (95% CI: 40.64, 407.12) for HET, 7.23 (95% CI: 4.06, 12.86) for PT, 5.31 (95% CI: 3.49, 8.09) for TT, and 1.78 (95% CI: 0.61, 5.19) for ULNT1. CONCLUSION HET has the best clinical performance for detecting CTS and should be considered the first screening test of choice during the physical examination. The most common tests (DT, PT, and TT) have good accuracies for screening for CTS. J Orthop Sports Phys Ther 2022;52(8):522-531. Epub: 19 June 2022. doi:10.2519/jospt.2022.10828.
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Chu MM, Chan J, Chan CC. Predicting outcomes of conservative treatment for patients with carpal tunnel syndrome: Group- and individual-based rehabilitation. Hong Kong J Occup Ther 2021; 34:39-49. [PMID: 34408558 PMCID: PMC8366207 DOI: 10.1177/1569186121997937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To identify predicting factors of treatment outcomes of a two stage group-based and then individual-based intervention programme for patients with carpal tunnel syndrome (CTS). Methods A prospective cohort study where patients diagnosed with CTS were recruited from an out-patient occupational therapy clinic to join the two-stage CTS programme. The Stage-One programme consisted of splinting and educational talks in a group format, while the Stage-Two programme consisted of four weekly individual sessions providing psychosocial support, reinforcing correct ergonomics and mobilization. Baseline assessment on six potential predicting factors and four outcome measures was done for all patients. Patients were re-assessed at the end of the Stage-One and the Stage-Two programme. Analysis was done by binary logistic regression adjusted for baseline covariates. Results One hundred and sixty-six patients completed the Stage-One programme and 46 patients also completed the Stage-Two programme. Results showed that the Chinese Symptom Severity Scale (SSS) baseline score was the only significant predictor for the Stage-One programme outcomes (AUC for ROC was 0.708) with an optimum cut-off score of 23.5. On the other hand, the Chinese QuickDASH baseline score was the only significant predictor for the Stage-Two programme outcomes (AUC for ROC was 0.801) with an optimum cut-off score of 27.4. Conclusions The significant predictor for the Stage One Programme was the Chinese SSS baseline score and that for the Stage Two Programme was the Chinese QuickDASH baseline score. The optimum cut-off scores identified may be applied clinically to guide client-centered treatment planning.
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Dos Santos Silva J, de Barros LFP, de Freitas Souza R, Mendonça SM, Costa FM, Landeiro JA, Lopes FCR, Acioly MA. "Million dollar nerve" magnetic resonance neurography: first normal and pathological findings. Eur Radiol 2021; 32:1154-1162. [PMID: 34363135 DOI: 10.1007/s00330-021-08213-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate prospectively the feasibility of magnetic resonance neurography (MRN) in identifying the anatomical characteristics of thenar muscular branch (TMB) of the median nerve, also known as the "million dollar nerve," in patients and controls. METHODS Thirteen patients affected by carpal tunnel syndrome (CTS) and four healthy controls had their hands scanned on a 3-T MR imaging scanner for TMB visualization. Median nerve anatomical variations were classified into four groups according to Poisel's classification system modified by Lanz. TMB signal intensity and diameter were assessed for the diagnosis of neuropathy. RESULTS TMB was successfully identified in all patients and subjects by using MRN. The most suitable pulse sequences to identify and measure nerve diameter were 3D DW-PSIF and T2-FS-TSE. The axial oblique and sagittal oblique planes are complementary in demonstrating its entire course. TMB had mostly an extraligamentous course with radial side origin (93.8%, each). All patients experienced increased T2 signal intensity (p < 0.001) and thickened nerves. Mean TMB diameters were 1.27 ± 0.21 mm (range, 1.02-1.74 mm) and 0.87 ± 0.16 mm (0.73-1.08 mm) (p = 0.008) in the patient and control groups, respectively. CONCLUSION MRN is a reliable imaging technique for identification and anatomical characterization of TMB in patients affected by CTS. This innovative imaging workup may therefore be included in the preoperative evaluation of patients scheduled for carpal tunnel release, especially in CTS with TMB involvement or even in isolated TMB neuropathy. KEY POINTS • Magnetic resonance neurography allows precise visualization of the thenar muscular branch of the median nerve. • Thenar muscular branch anatomical variations can be correctly identified. • Preoperative scanning can contribute to reducing the risk of iatrogenic injuries during carpal tunnel release, especially in carpal tunnel syndrome with thenar muscular branch involvement or even in isolated thenar muscular branch neuropathy.
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Affiliation(s)
| | | | - Renan de Freitas Souza
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | | | | | - José Alberto Landeiro
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Fernanda Cristina Rueda Lopes
- Division of Radiology, DASA, Rio de Janeiro, Brazil.,Division of Radiology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Marcus André Acioly
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil. .,Division of Neurosurgery, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
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Ozer Kaya D, Toprak Celenay S, Sas S. The characteristics, disabilities, and spinal alignment of women with double crush syndrome: a case-control study. Somatosens Mot Res 2021; 38:157-163. [PMID: 33818284 DOI: 10.1080/08990220.2021.1908250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS Double crush syndrome is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The aims were to investigate the characteristics and disabilities of women with double crush syndrome, to compare the spinal alignment to healthy women, and to determine the cut-offs for the spinal alignment characteristics. METHODS Twenty women with double crush syndrome (age: 49.50 ± 8.64 years) and 21 asymptomatic healthy controls (age: 44.76 ± 7.82 years) were included in the study. The physical characteristics, pain intensity, and symptoms were questioned. Disability with Disability of Arm and Shoulder Questionnaire and Neck Disability Index and spinal alignment with Spinal Mouse® (Idiag, Fehraltorf, Switzerland) were assessed. RESULTS The pain intensity at rest, night, and during activity was 3.70 ± 3.25, 6.01 ± 2.77, and 7.15 ± 2.68 cm, respectively. The most bothersome symptom was numbness (65%). The symptoms were seen in hands and/or fingers (55%), arms (15%), shoulder blade (15%), and neck (15%). The Disability of Arm and Shoulder Questionnaire and Neck Disability Index scores were 58.64 ± 15.41 and 19.55 ± 6.37, respectively. The sagittal thoracic curvature (p: .011) and lumbar curvature (p: .049) increased, and the overall spine mobility (p<.001) decreased in the double crush syndrome patients. The cut-off points were detected as 54.5° (area under the curve: 0.680, p: .049, 40% sensitivity, 99.9% specificity) for the thoracic spinal curvature, and 113.5° (area under the curve: 0.667, p<.000, 65% sensitivity, 99.9% specificity) for the overall spine mobility. CONCLUSIONS The double crush syndrome patients had moderate to severe pain and disability, increased thoracic and lumbar curvature, and decreased spine mobility. The cut-off values were found as 54.5° for thoracic curvature and 113.5° for spine mobility.
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Affiliation(s)
- Derya Ozer Kaya
- Department of Physiotherapy and Rehabilitation, Health Sciences Faculty, Izmir Katip Celebi University, Izmir, Turkey
| | - Seyda Toprak Celenay
- Department of Physiotherapy and Rehabilitation, Health Sciences Faculty, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Senem Sas
- Rheumatology Department, Erciyes University, Kayseri, Turkey
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Riley SP, Grimes JK, Calandra K, Foster K, Peet M, Walsh MT. Agreement and Reliability of Median Neurodynamic Test 1 and Resting Scapular Position. J Chiropr Med 2021; 19:203-212. [PMID: 33536857 DOI: 10.1016/j.jcm.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/28/2020] [Accepted: 09/17/2020] [Indexed: 11/19/2022] Open
Abstract
Objective The purposes of this study were to determine whether there are differences between the dominant and nondominant arms for the Median Neurodynamic Test 1 (MNT 1); whether there are differences between men and women on the MNT 1; the reliability of an assessment of resting scapular position; the reliability of the MNT 1; and the frequency and percentage of sensory responses that are present during the MNT 1 in the asymptomatic population. Methods This was a reliability and agreement study. It included asymptomatic students enrolled in the college of health professions and the college of nursing at a university. The Mann-Whitney U was used to determine whether there were any differences between the dominant and nondominant sides and between sexes for elbow extension range of motion and for sensory responses on the numeric pain rating scale when performing the MNT 1. A χ2 analysis was used to determine whether there were any differences between sexes and between dominant and nondominant upper extremities for sensory-response location, sensory-response type, and structural differentiation for raters 1 and 2. The intraclass correlation coefficient (ICC2,3) was used to determine the intertester and intratester reliability for the degrees of elbow extension attained during testing. Results Reliability for degrees of elbow extension and strength of the sensory response was excellent (ICC2,3 ˃ 0.75) and substantial (κ ≥ 0.68), respectively. Resting scapular position and all other components of the MNT 1 demonstrated statistically significant side-to-side differences and κ values ranging from 0.23 to 0.88. Conclusion Elbow extension and magnitude of sensory response are reliable components of the MNT 1 that are not different between the dominant and nondominant sides in the asymptomatic population.
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Affiliation(s)
- Sean P Riley
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
| | - Jason K Grimes
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
| | - Kylie Calandra
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
| | - Kelsey Foster
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
| | - Melissa Peet
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
| | - Matthew T Walsh
- Physical Therapy Program, Sacred Heart University, Fairfield, Connecticut
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Bueno-Gracia E, Pérez-Bellmunt A, Estébanez-de-Miguel E, López-de-Celis C, Caudevilla-Polo S, Shacklock M, González-Rueda V. Effect of cervical contralateral lateral flexion on displacement and strain in the median nerve and flexor digitorum superficialis at the wrist during the ULNT1 - Cadaveric study. Musculoskelet Sci Pract 2020; 50:102244. [PMID: 32906084 DOI: 10.1016/j.msksp.2020.102244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A key issue in neurodynamic testing is whether a manoeuvre designed to produce differential biomechanical behaviour (structural differentiation) of nerve compared to adjacent muscle is mechanically accurate. The aim of this study was to investigate the capacity of cervical contralateral lateral flexion to produce differential biomechanical behaviour of the median nerve at the wrist (mechanical specificity) in relation to the adjacent muscle (flexor digitorum superficialis) at different ranges of upper limb neurodynamic test 1 in cadavers. MATERIAL AND METHODS A cross-sectional study was carried out. In fresh frozen cadavers, with microstrain devices and Vernier calipers, strain and excursion in the median nerve and flexor digitorum superficialis muscle were measured during cervical contralateral lateral flexion at 0°, 30°, 60° and 90° of elbow flexion of the upper limb neurodynamic test 1. RESULTS The cervical movement resulted in proximal excursion and significant changes in strain in the median nerve at 0°, 30° and 60° of elbow flexion during the upper limb neurodynamic test 1 (p < 0.05). In contrast, the structural differentiation manoeuvre did not affect the strain nor the excursion in the muscle at any position of the elbow (p > 0.05). CONCLUSION Adding CCLF to each ULNT1 median elbow angle increased strain and created proximal excursion of the median nerve at the wrist. Neck movement produced no changes in strain nor excursion of the flexor digitorum superficialis. This study adds to evidence that, in certain circumstances, neck movement may be used in differentiation of nerve and muscle disorders in the wrist.
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Affiliation(s)
| | - Albert Pérez-Bellmunt
- Faculty of Medicine and Health Sciences, International University of Catalonia, Barcelona, Spain
| | | | - Carlos López-de-Celis
- Faculty of Medicine and Health Sciences, International University of Catalonia, Barcelona, Spain
| | | | | | - Vanesa González-Rueda
- Faculty of Medicine and Health Sciences, International University of Catalonia, Barcelona, Spain
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Diagnosing Carpal Tunnel Syndrome: Diagnostic Test Accuracy of Scales, Questionnaires, and Hand Symptom Diagrams-A Systematic Review. J Orthop Sports Phys Ther 2020; 50:622-631. [PMID: 32938312 DOI: 10.2519/jospt.2020.9599] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To summarize and evaluate research on the accuracy of clinical diagnostic scales, questionnaires, and hand symptom diagrams/maps used for diagnosis of carpal tunnel syndrome (CTS). DESIGN Systematic review of diagnostic test accuracy. LITERATURE SEARCH A comprehensive literature search of the MEDLINE, CINAHL, and Embase databases was conducted on January 20, 2020. STUDY SELECTION CRITERIA Studies that assessed at least 1 diagnostic accuracy property of the scales, questionnaires, and hand symptom diagrams used for the diagnosis of CTS. DATA SYNTHESIS The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Diagnostic accuracy properties were summarized. RESULTS Out of 4052 citations after removing duplicates, 21 articles met the inclusion criteria. Twelve articles reported on the diagnostic accuracy of scales and questionnaires, including the Bland questionnaire, Kamath and Stothard questionnaire, 6-item carpal tunnel syndrome symptoms scale (CTS-6), Boston Carpal Tunnel Questionnaire, Wainner clinical prediction rule, and Lo clinical prediction rule. Positive likelihood ratios ranged from 0.94 for the Boston Carpal Tunnel Questionnaire to 10.5 for the CTS-6, and negative likelihood ratios ranged from 1.04 to 0.05 for the same diagnostic tools, respectively. Nine studies reported the diagnostic accuracy of the Katz and Stirrat hand symptom diagram. Positive and negative likelihood ratios ranged from 1.42 to 8 and from 0.78 to 0.05, respectively. Only 4 studies had high methodologic quality. CONCLUSION Limited evidence supports high accuracy of the CTS-6, Kamath and Stothard questionnaire, and Katz and Stirrat hand symptom diagram. Other scales have lesser and more conflicting evidence. Further high-quality studies are necessary to examine the diagnostic accuracy of these tests to assist ruling in or ruling out CTS. J Orthop Sports Phys Ther 2020;50(11):622-631. Epub 16 Sep 2020. doi:10.2519/jospt.2020.9599.
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Kuroiwa T, Nimura A, Takahashi Y, Sasaki T, Koyama T, Okawa A, Fujita K. Device Development for Detecting Thumb Opposition Impairment Using Carbon Nanotube-Based Strain Sensors. SENSORS 2020; 20:s20143998. [PMID: 32708416 PMCID: PMC7412202 DOI: 10.3390/s20143998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 12/03/2022]
Abstract
Research into hand-sensing is the focus of various fields, such as medical engineering and ergonomics. The thumb is essential in these studies, as there is great value in assessing its opposition function. However, evaluation methods in the medical field, such as physical examination and computed tomography, and existing sensing methods in the ergonomics field have various shortcomings. Therefore, we conducted a comparative study using a carbon nanotube-based strain sensor to assess whether opposition movement and opposition impairment can be detected in 20 hands of volunteers and 14 hands of patients with carpal tunnel syndrome while avoiding existing shortcomings. We assembled a measurement device with two sensors and attached it to the dorsal skin of the first carpometacarpal joint. We measured sensor expansion and calculated the correlation coefficient during thumb motion. The average correlation coefficient significantly increased in the patient group, and intrarater and interrater reliability were good. Thus, the device accurately detected thumb opposition impairment due to carpal tunnel syndrome, with superior sensitivity and specificity relative to conventional manual inspection, and may also detect opposition impairment due to various diseases. Additionally, in the future, it could be used as an easy, affordable, and accurate sensor in sensor gloves.
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Affiliation(s)
- Tomoyuki Kuroiwa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (T.K.); (T.S.); (T.K.); (A.O.)
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan;
| | - Yu Takahashi
- AI Group, Department of 1st Research and Development, Yamaha Corporation, Shizuoka 430-0904, Japan;
| | - Toru Sasaki
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (T.K.); (T.S.); (T.K.); (A.O.)
| | - Takafumi Koyama
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (T.K.); (T.S.); (T.K.); (A.O.)
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan; (T.K.); (T.S.); (T.K.); (A.O.)
| | - Koji Fujita
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan;
- Correspondence: ; Tel.: +81-3-5803-5279
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Abstract
PURPOSE OF REVIEW To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.
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Affiliation(s)
- Peter J. Ostergaard
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Maximilian A. Meyer
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Brandon E. Earp
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
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Butler MW, Karagiannopoulos C, Galantino ML, Mastrangelo MA. Reliability and accuracy of the brachial plexus neurodynamic test. J Hand Ther 2020; 32:483-488. [PMID: 30017417 DOI: 10.1016/j.jht.2018.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 02/20/2018] [Accepted: 02/24/2018] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Observational study. INTRODUCTION The brachial plexus neurodynamic test (BPNT), based on previous neurodynamic tests, is considered a clinically meaningful tool to objectively assess brachial plexus extensibility. This novel test's psychometric properties have yet to be determined. PURPOSE OF THE STUDY The primary study aim was to assess the inter- and intrarater reliability and accuracy of the BPNT, which biases the median nerve and brachial plexus, among clinicians of various professional experience levels and geographic US regions. The secondary study aim was to determine if professional experience or geographic region affects the accuracy levels of this test. METHODS In phase 1, inter-rater reliability and accuracy was determined. About 307 participants attending neural mobilization conferences and courses were instructed in the BPNT and asked to score 7 different videos of 14 possible test levels. In phase 2, intrarater reliability was determined via scoring the same test videos twice. RESULTS High inter-rater intraclass correlation coefficient (range, 0.98-0.99) and accuracy (range, 0.88-0.94) levels were determined for all clinical experience levels and geographic regions. Intrarater intraclass correlation coefficient values were high (range, 0.96-1.0) among all participants. One-way analysis of variance indicated no significant differences on test accuracy based on professional clinical experience (F = 0.104; P = .958) and geographic region (F = 0.416; P = .416) among all 307 participants. DISCUSSION Excellent inter- and intrarater reliability and accuracy levels may allow clinicians to correctly identify BPNT positions regardless of their professional experience or geographic location. CONCLUSION The BPNT can reliably and accurately quantify outcomes in neural mobility scoring.
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Affiliation(s)
- Mark W Butler
- Medford, NJ NovaCare, Medford, NJ, USA; Rutgers School of Health Professions, Blackwood, NJ, USA.
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Mathews H, Middleton A, Boan L, Jacks M, Riddick L, Shepherd J, Patel J, McNeal A, Fritz S. Intrarater and interrater reliability of a hand-held dynamometric technique to quantify palmar thumb abduction strength in individuals with and without carpal tunnel syndrome. J Hand Ther 2019; 31:554-561. [PMID: 28943237 DOI: 10.1016/j.jht.2017.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Clinical measurement. INTRODUCTION Individuals with carpal tunnel syndrome (CTS) sometimes exhibit weakness of palmar abduction strength (TAS). Reliable assessment of this strength in both subjects with and without CTS with the commonly available Microfet 2 is not known. PURPOSE OF THE STUDY The purpose of this study was to determine the intrarater and interrater reliabilities of a handheld dynamometric (HHD) method to assess TAS in individuals with and without CTS using the commercially available MicroFET2 and to examine the association between TAS in individuals with CTS and the Carpal Tunnel Symptom Questionnaire (CTSQ) scores. METHODS In 2 different study phases, individuals with and without CTS were assessed for TAS by 2 different examiners. The CTSQ was administered to the individuals with CTS. RESULTS Intrarater and interrater reliability coefficients (0.89-0.93 and 0.82-0.90, respectively) were excellent in individuals with and without CTS. Weak negative correlations were found between TAS and overall CTSQ and symptom severity subscale scores, and a moderate negative correlation was found between TAS and functional Status Subscale score. DISCUSSION This HHD method of reliably assessing TAS better quantifies deficits and progress than traditional manual muscle testing for muscle grades greater than 3/5. CONCLUSION This method of HHD reliably quantifies TAS but is more reliable with the same than different raters.
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Affiliation(s)
- Harvey Mathews
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC.
| | - Addie Middleton
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Lindsey Boan
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Madison Jacks
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Lindsey Riddick
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Jessica Shepherd
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Jay Patel
- Palmetto Health USC Medical Center, Palmetto Health USC Orthopedic Rehabilitation, Columbia, SC
| | - Antonia McNeal
- Palmetto Health USC Medical Center, Palmetto Health USC Orthopedic Rehabilitation, Columbia, SC
| | - Stacy Fritz
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
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Trillos MC, Soto F, Briceno-Ayala L. Upper limb neurodynamic test 1 in patients with clinical diagnosis of carpal tunnel syndrome: A diagnostic accuracy study. J Hand Ther 2019. [PMID: 28623065 DOI: 10.1016/j.jht.2017.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Diagnostic accuracy. INTRODUCTION Upper limb neurodynamic test 1 (ULNT1) is used to evaluate the mechanical sensitivity especially in the peripheral nerves of the upper limbs. The reproduction of typical symptoms in the affected hand improves the estimation of the probability of carpal tunnel syndrome (CTS). However the test has not been evaluated sufficiently to determine its real usefulness. In the present study the diagnostic accuracy of ULNT1 as a clinical test for CTS was determined. METHODS We used the ULNT1 as the index test and nerve conduction as the reference standard. 120 subjects, (240 hands), with a medical diagnosis of CTS were evaluated. The study population was a consecutive series of participants. Sensitivity, specificity, positive and negative predictive values, accuracy, and positive likelihood ratio were calculated. RESULTS ULNT1 was found to have a sensitivity of 93 % and a specificity of 6.67 %. The positive likelihood ratio was 1.04 and the negative likelihood ratio was 1.00. The positive predictive value was 86.9 % and the negative predictive value was 12.5%. DISCUSSION Acute or relatively mild CTS cases may not be accurately identified through nerve conduction tests. The findings of this study coincide with other studies in the finding that ULNT1 has a significant diagnostic and clinical screening value for CTS in people at-risk, or with upper limb symptoms. CONCLUSION(S) This research suggests the use of ULNT1 as a screening test for CTS, followed by tests that are more specific. LEVEL OF EVIDENCE III-2.
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Affiliation(s)
| | - Felipe Soto
- Instituto de Diagnostico Medico, Idime, Bogota, Colombia
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Tuttle N, Hazle C. An empirical, pragmatic approach applying reflection in interaction approach to manual therapy treatments. Physiother Theory Pract 2019; 37:775-786. [PMID: 31385748 DOI: 10.1080/09593985.2019.1650405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Most literature on decision processes within physiotherapy relates to "reasoning that results in action" - decisions based on information including assessments that are gathered prior to treatment decisions. A process of "reasoning in interaction" that is often used, particularly by expert clinicians, has received less attention. Objective: To provide a theoretical and practical approach to applying reasoning in interaction in a musculoskeletal setting. Methods: The theory is: If an impairment that can be directly targeted by treatment (i.e. pain or limitation of passive movement) is related to patient's active impairments and functional limitations, then moment-to-moment changes in the targeted impairment can be used as feedback to guide real-time treatment modification before formal reassessment of functional limitations and other impairments. Results: Applying the theory to manual therapy results in parameters of techniques such as force, speed, direction and duration no longer being pre-determined, but rather being continually adjusted in real-time according to feedback from the patient through both therapist perception (changes in movement quantity or quality) and patient verbal responses. Conclusion: A process of continuous decision-making is described that the authors believe is used by many experienced clinicians but has not previously been adequately described in the literature. .
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Affiliation(s)
- Neil Tuttle
- School of Allied Health Sciences, Griffith University, Gold Coast, Australia
| | - Charles Hazle
- Division of Physical Therapy, Center for Rural Health, University of Kentucky, Hazard, Kentucky, USA
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Abstract
The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.
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Tong MMY, Liu VCH, Hall T. Side-to-side elbow range of movement variability in an ulnar neurodynamic test sequence variant in asymptomatic people. Hong Kong Physiother J 2019; 38:133-139. [PMID: 30930585 PMCID: PMC6405357 DOI: 10.1142/s1013702518500117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/28/2017] [Indexed: 11/30/2022] Open
Abstract
Background: Range of motion (ROM) asymmetry between sides is one indicator of a positive neurodynamic test, but this has been less well studied for the ulnar nerve. Objective: The purpose of this study was to investigate side-to-side variation in elbow ROM during an ulnar neurodynamic test sequence, including contralateral cervical side flexion, in 40 asymptomatic subjects. Methods: A traditional goniometer was used to measure elbow flexion ROM at two end points, onset of resistance (R1) and symptom onset (P1). Two repeated measures of R1 and P1 were taken on each side. Results: Reliability for R1 and P1 was found to be good (ICC ≥0.83, SEM ≤5.37) with no significant difference in mean ROM between sides. A significant relationship between sides was seen (r values ≥0.48) and R2 values >0.23; this indicates at least 23% of the variance observed in one limb was accounted for by range in the opposite limb. This relationship was slightly stronger for R1 than P1. Lower bound scores indicate that intra-individual ROM difference >23° for R1 and 22° for P1 would exceed normal ROM asymmetry. Conclusion: These findings provide clinicians with background information of ROM asymmetry during the ulnar neurodynamic test.
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Affiliation(s)
- Michelle Meng Yim Tong
- School of Physiotherapy and Exercise Science, Curtin University of Technology, Perth, Western Australia 6102, Australia
| | - Vincent Cheng-Hsin Liu
- School of Physiotherapy and Exercise Science, Curtin University of Technology, Perth, Western Australia 6102, Australia
| | - Toby Hall
- School of Physiotherapy and Exercise Science, Curtin University of Technology, Perth, Western Australia 6102, Australia
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Diagnostic accuracy of upper limb neurodynamic tests for the assessment of peripheral neuropathic pain: A systematic review. Musculoskelet Sci Pract 2019; 40:21-33. [PMID: 30665045 DOI: 10.1016/j.msksp.2019.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Upper limb neurodynamic tests (ULNTs) are used to identify a neuropathic pain component in patients' presenting with arm and/or neck pain. Clinical tests with established diagnostic accuracy are required to not only to inform clinical management but also minimise costs associated with expensive medical investigations. OBJECTIVE To evaluate the role of ULNTs in assessment of peripheral neuropathic pain and to inform their value in clinical practice when assessing patients with arm and/or neck symptoms. DESIGN Systematic review was undertaken according to published guidelines, and reported in line with PRISMA-DTA. METHOD Key databases were searched up to 21/11/2017. INCLUSION CRITERIA Patient population experiencing arm and/or neck symptoms with suspected peripheral neuropathic involvement, studies that compared ULNT to a reference standard, any study design using primary diagnostic accuracy data. Two reviewers independently assessed risk of bias (ROB) using QUADAS-2. The overall quality of evidence was evaluated using GRADE. RESULTS Of eight included studies (n = 579), four were assessed as low ROB, although all had concerns regarding applicability. For carpal tunnel syndrome, ULNT1 sensitivity values ranged 0.4-0.93, specificity 0.13-0.93, positive likelihood ratio 0.86-3.67 and negative likelihood ratio 0.5-1.9. For cervical radiculopathy ULNT1 and the combined use of four ULNTs had sensitivity of 0.97 (95%CI 0.85-1.00) whereas the ULNT3 was the most specific (0.87, 95%CI 0.62-0.98). Positive likelihood ratio ranged 0.58-5.68 and negative likelihood ratio 0.12-1.62. CONCLUSION Based on the available evidence ULNTs cannot be utilised as a stand-alone test for the diagnosis of CTS. Limited evidence suggests that ULNTs may be clinically relevant for the diagnosis of CR, but only as a "ruling out" strategy. However, the overall quality of the body of evidence after applying the GRADE approach was low to very low across studies. Further higher quality research is needed to establish firm conclusions.
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Panagopoulos GN, Wu T, Fowler JR. Correlation of ultrasound cross-sectional area of the median nerve, nerve conduction studies and 2-point discrimination. Muscle Nerve 2018; 59:236-239. [PMID: 30390396 DOI: 10.1002/mus.26374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 09/16/2018] [Accepted: 10/30/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The purpose of this study was to determine the correlation between a measure of physical performance, a measure of physiology and a measure of anatomy in the setting of carpal tunnel syndrome (CTS). METHODS A retrospective review of 215 consecutive patients with suspected CTS was conducted. All patients were evaluated with static 2-point discrimination (2PD), ultrasound (US) measurement of the median nerve cross-sectional area (CSA), and nerve conduction studies (NCS). Correlations between 2PD and US and NCS parameters were calculated. The ability of US/NCS to predict 2PD was evaluated. RESULTS Analysis failed to prove a statistically significant correlation between 2PD and median nerve CSA. A weak correlation was detected between 2PD and NCS parameters. When 2PD was used as a reference standard, NCS parameters combined had the greatest sensitivity, followed by US. CONCLUSIONS Currently used diagnostic tests (NCS and US) correlate poorly with 2PD. Muscle Nerve 000: 000-000, 2018 Muscle Nerve 59:236-239, 2019.
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Affiliation(s)
- Georgios N Panagopoulos
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, Pennsylvania, 15213, USA
| | - Tiffany Wu
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, Pennsylvania, 15213, USA
| | - John R Fowler
- Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, Pennsylvania, 15213, USA
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Wang WL, Buterbaugh K, Kadow TR, Goitz RJ, Fowler JR. A Prospective Comparison of Diagnostic Tools for the Diagnosis of Carpal Tunnel Syndrome. J Hand Surg Am 2018; 43:833-836.e2. [PMID: 29935774 DOI: 10.1016/j.jhsa.2018.05.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 04/17/2018] [Accepted: 05/16/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Nerve conduction studies (NCS), CTS-6, Wainner, Kamath, and Lo are diagnostic tests that are used to diagnose carpal tunnel syndrome (CTS). To our knowledge, no study has compared the sensitivity and specificity of these 5 tests with one another. The purpose of this study is to compare NCS, CTS-6, Wainner, Kamath, and Lo using clinical diagnosis by a hand fellowship-trained orthopedic surgeon as reference standard. METHODS A hand fellowship-trained surgeon completed the CTS-6, Wainner, Kamath, and Lo diagnostic tools. Cutoff values for a positive test were based on values in the literature, if available. The NCS were performed by a certified electrodiagnostic physician according the standards of the American Association of Neuromuscular and Electrodiagnostic Medicine and were interpreted using absolute latencies, relative latencies, and combined sensory index. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated for the tests using clinical diagnosis as the reference standard. RESULTS A total of 408 wrists from 250 patients were analyzed in the study. The NCS had the highest sensitivity (94%) but also the lowest specificity (50%) of any of the diagnostic tests. Using a cutoff of 18, CTS-6 had the highest specificity (99%). The NCS had the highest area under the curve at 74%, followed closely by the Kamath at 69%. CONCLUSIONS The NCS were traditionally felt to be a strong confirmatory test given their high specificity. However, this prospective series demonstrated that NCS had the lowest specificity of any diagnostic test. CLINICAL RELEVANCE Consideration should be given to using alternative diagnostic tests/tools based on the results of this study.
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Affiliation(s)
- William L Wang
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kristin Buterbaugh
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tiffany R Kadow
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert J Goitz
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John R Fowler
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Szikszay T, Hall T, von Piekartz H. In vivo effects of limb movement on nerve stretch, strain, and tension: A systematic review. J Back Musculoskelet Rehabil 2017; 30:1171-1186. [PMID: 28869435 DOI: 10.3233/bmr-169720] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKROUND The mechanical behavior of the peripheral nervous system under elongation and tension has not been adequately established in vivo. OBJECTIVE The purpose of this review is to investigate the mechanical behavior of the peripheral nervous system in vivo. METHODS In vivo studies which evaluated the effects of limb movement and neurodynamic tests on peripheral nerve biomechanics were systematically searched in PubMed (Medline), the Cochrane Database, CINAHL, PEDro, Embase and Web of Science. Studies fulfilling the search criteria were assessed for methodological quality with a modified version of the Down & Blacks scale by two reviewers. RESULTS This review includes the results of 22 studies, of which 15 examined limb movement influencing the median nerve, four the sciatic nerve, two the tibial nerve; and one each the ulnar and peroneal nerves respectively. Substantial nerve longitudinal and transverse excursion and changes in diameter were reported. Despite this, increased nerve strain was not a major finding. CONCLUSION The heterogeneity of included studies, including wide variety of nerves tested, measurement location and joint position prevented comparisons between studies and also amalgamation of data. Limb movement induces complex biomechanical effects of which nerve elongation plays only a minor role.
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Affiliation(s)
- Tibor Szikszay
- Department of Physiotherapy and Rehabilitation, University of Applied Science, Osnabrück, Germany
| | - Toby Hall
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Harry von Piekartz
- Department of Physiotherapy and Rehabilitation, University of Applied Science, Osnabrück, Germany
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Knox GM, Snodgrass SJ, Stanton TR, Kelly DH, Vicenzino B, Wand BM, Rivett DA. Physiotherapy students’ perceptions and experiences of clinical prediction rules. Physiotherapy 2017; 103:296-303. [DOI: 10.1016/j.physio.2016.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/06/2016] [Indexed: 12/15/2022]
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Hutchison RL, Hutchison AL, Hirthler MA. An Experimental Survey on the Effect of Using the CTS-6 Tool on the Diagnosis of Carpal Tunnel Syndrome by Hand Surgeons. J Hand Surg Asian Pac Vol 2017; 22:88-92. [PMID: 28205476 DOI: 10.1142/s0218810417500150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This controlled randomized experiment tested the research hypothesis that providing the CTS-6 quantitative diagnostic information to hand surgeons affects the diagnosis of carpal tunnel syndrome. METHODS Surgeon members of American Association for Hand Surgery participated in an online survey. Demographic and practice pattern information was collected. Few surgeons routinely use diagnostic questionnaires or algorithms. Each member was given four clinical scenarios. The respondents were randomized, The experimental group was given the same scenarios as the control group plus the quantitative results of the CTS-6 diagnostic tool. RESULTS There were statistically significant differences between the groups in the diagnostic decisions. Using the CTS-6 quantitative diagnostic tool affected the diagnosis of carpal tunnel syndrome, especially for patients with the lowest number of findings associated with carpal tunnel syndrome. CONCLUSIONS While accurate diagnostic decisions are dependent on the incorporation of all of the pertinent information gathered during the history and physical exams, the results of the CTS-6 may help the clinician focus their thinking and revise their diagnostic probabilities.
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Affiliation(s)
- Richard L Hutchison
- * Section of Hand Surgery, Division of Orthopaedic Surgery, Children's Mercy Hospitals and Clinics, University of Missouri, Kansas City, MO, USA
| | - Alan L Hutchison
- † Medical Scientist Training Program, Graduate Program in the Biophysical Sciences, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
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Four hundred or more participants needed for stable contingency table estimates of clinical prediction rule performance. J Clin Epidemiol 2017; 82:137-148. [DOI: 10.1016/j.jclinepi.2016.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/05/2016] [Accepted: 10/11/2016] [Indexed: 12/18/2022]
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Mondelli M, Farioli A, Mattioli S, Aretini A, Ginanneschi F, Greco G, Curti S. Severity of Carpal Tunnel Syndrome and Diagnostic Accuracy of Hand and Body Anthropometric Measures. PLoS One 2016; 11:e0164715. [PMID: 27768728 PMCID: PMC5074522 DOI: 10.1371/journal.pone.0164715] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 09/29/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To study the diagnostic properties of hand/wrist and body measures according to validated clinical and electrophysiological carpal tunnel syndrome (CTS) severity scales. Methods We performed a prospective case-control study. For each case, two controls were enrolled. Two five-stage clinical and electrophysiological scales were used to evaluate CTS severity. Anthropometric measurements were collected and obesity indicators and hand/wrist ratios were calculated. Area under the receiver operating characteristic curves (AUC), sensitivity, specificity, and likelihood ratios were calculated separately by gender. Results We consecutively enrolled 370 cases and 747 controls. The wrist-palm ratio, waist-hip-height ratio and waist-stature ratio showed the highest proportion of cases with abnormal values in the severe stages of CTS for clinical and electrophysiological severity scales in both genders. Accuracy tended to increase with CTS severity for females and males. In severe stage, most of the indexes presented moderate accuracy in both genders. Among subjects with severe CTS, the wrist-palm ratio presented the highest AUC for hand measures in the clinical and electrophysiological severity scales both in females (AUC 0.83 and 0.76, respectively) and males (AUC 0.91 and 0.82, respectively). Among subjects with severe CTS, the waist-stature ratio showed the highest AUC for body measures in the clinical and electrophysiological severity scales both in females (AUC 0.78 and 0.77, respectively) and males (AUC 0.84 and 0.76, respectively). The results of waist-hip-height ratio AUC were similar. Conclusions Wrist-palm ratio, waist-hip-height ratio and waist-stature ratio could contribute to support the diagnostic hypothesis of severe CTS that however has to be confirmed by nerve conduction study.
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Affiliation(s)
- Mauro Mondelli
- EMG Service, Local Health Unit no.7, Siena, Italy
- * E-mail:
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Stefano Mattioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Federica Ginanneschi
- Department of Medical, Surgical and Neurosciences, University of Siena, Siena, Italy
| | - Giuseppe Greco
- EMG Service, Local Health Unit no.7, “Nottola” Hospital, Montepulciano, Siena, Italy
| | - Stefania Curti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Baselgia LT, Bennett DL, Silbiger RM, Schmid AB. Negative Neurodynamic Tests Do Not Exclude Neural Dysfunction in Patients With Entrapment Neuropathies. Arch Phys Med Rehabil 2016; 98:480-486. [PMID: 27449322 PMCID: PMC5324720 DOI: 10.1016/j.apmr.2016.06.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 06/22/2016] [Accepted: 06/26/2016] [Indexed: 12/13/2022]
Abstract
Objective To examine differences in somatosensory phenotypes of patients with positive and negative neurodynamic tests and compare these with healthy participants. Design Case-control study. Setting University department. Participants Patients with electrodiagnostically confirmed carpal tunnel syndrome (CTS) (n=53) and people without CTS (n=26) participated in this study (N=79). Patients with CTS were subgrouped according to the results of the upper limb neurodynamic tests biasing the median nerve into patients with positive or negative neurodynamic tests. Interventions Not applicable. Main Outcome Measure All participants underwent quantitative sensory testing in the median innervated territory of their hand. Results Only 46% of patients with CTS had positive neurodynamic tests. No differences were identified between groups for pain thresholds (P>.247). However, patients with CTS had increased mechanical (P<.0001) and thermal detection thresholds (P<.0001) compared with people without CTS. Patients with negative neurodynamic tests had a more pronounced vibration detection deficit (mean, 7.43±0.59) than people without CTS (mean, 7.89±0.22; P=.001). Interestingly, warm detection was the only domain differentiating positive (mean, 4.03°C±2.18°C) and negative neurodynamic test groups (6.09°C±3.70°C, P=.032), with patients with negative neurodynamic tests demonstrating increased loss of function. Conclusions Patients with negative neurodynamic tests seem to have a more severe dysfunction of the unmyelinated fiber population. Our findings suggest that neurodynamic tests should not be used in isolation to judge neural involvement. Rather, they should be interpreted in the context of loss of function tests of the small fiber domain.
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Affiliation(s)
- Larissa T Baselgia
- Institute of Physiotherapy, Zurich University of Applied Sciences ZHAW, Winterthur, Switzerland
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, UK
| | | | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, UK; School of Health and Rehabilitation Sciences, The University of Queensland, St Lucia, QLD, Australia.
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Bueno-Gracia E, Tricás-Moreno JM, Fanlo-Mazas P, Malo-Urriés M, Haddad-Garay M, Estébanez-de-Miguel E, Hidalgo-García C, Krauss JR. Validity of the Upper Limb Neurodynamic Test 1 for the diagnosis of Carpal Tunnel Syndrome. The role of structural differentiation. ACTA ACUST UNITED AC 2016; 22:190-5. [DOI: 10.1016/j.math.2015.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 12/12/2015] [Accepted: 12/15/2015] [Indexed: 01/23/2023]
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Tanik N, Sarp U, Ucar M, Celikbilek A, Balbaloglu O, Ak H, Atalay T, Arik HO, Okyay MY, Inan LE. Pain, depression and sleep disorders in patients with diabetic and nondiabetic carpal tunnel syndrome: a vicious cycle. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:207-11. [DOI: 10.1590/0004-282x20160020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/10/2015] [Indexed: 12/18/2022]
Abstract
ABSTRACT Carpal tunnel syndrome (CTS) is a condition involving nerve entrapment that often leads to chronic neuropathic pain. We aimed to evaluate sleep quality and related parameters in diabetic and non-diabetic CTS patients. Method This study included a total of 366 patients with chronic CTS. These patients’ sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) and depression using the Beck Depression Inventory (BDI). The severity of neuropathic pain was evaluated using the Douleur Neuropathique-4 (DN4) questionnaire and a visual analogue scale (VAS). Results In the non-diabetic patient group, the total PSQI score was found to affect BDI and VAS, while in the diabetic patient group, the duration of symptoms affected VAS, BDI and fasting glucose levels. Conclusion For diabetic patients, hyperglycemia depression and chronification of neuropathic pain may lead to deterioration of sleep quality. Therefore, consideration of these parameters in the treatment may break a vicious cycle.
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Affiliation(s)
| | | | | | | | | | - Hakan Ak
- Bozok University Medical School, Turkey
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31
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Physiotherapy clinical educators’ perceptions and experiences of clinical prediction rules. Physiotherapy 2015; 101:364-72. [DOI: 10.1016/j.physio.2015.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 03/05/2015] [Indexed: 12/19/2022]
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Caro-Morán E, Díaz-Rodríguez L, Cantarero-Villanueva I, Galiano-Castillo N, Arroyo-Morales M, Fernández-Lao C. Nerve Pressure Pain Hypersensitivity and Upper Limb Mechanosensitivity in Breast Cancer Survivors: A Case–Control Study. PAIN MEDICINE 2014; 15:1715-23. [DOI: 10.1111/pme.12567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Side-to-side range of movement variability in variants of the median and radial neurodynamic test sequences in asymptomatic people. ACTA ACUST UNITED AC 2014; 19:338-42. [DOI: 10.1016/j.math.2014.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 03/03/2014] [Accepted: 03/05/2014] [Indexed: 11/19/2022]
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Duckworth AD, Jenkins PJ, McEachan JE. Diagnosing carpal tunnel syndrome. J Hand Surg Am 2014; 39:1403-7. [PMID: 24818965 DOI: 10.1016/j.jhsa.2014.03.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 03/30/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew D Duckworth
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom.
| | - Paul J Jenkins
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jane E McEachan
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
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Schmid AB, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies--mechanisms, diagnosis and management. ACTA ACUST UNITED AC 2013; 18:449-57. [PMID: 24008054 DOI: 10.1016/j.math.2013.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 12/13/2022]
Abstract
The diagnosis of entrapment neuropathies can be difficult because symptoms and signs often do not follow textbook descriptions and vary significantly between patients with the same diagnosis. Signs and symptoms which spread outside of the innervation territory of the affected nerve or nerve root are common. This Masterclass provides insight into relevant mechanisms that may account for this extraterritorial spread in patients with entrapment neuropathies, with an emphasis on neuroinflammation at the level of the dorsal root ganglia and spinal cord, as well as changes in subcortical and cortical regions. Furthermore, we describe how clinical tests and technical investigations may identify these mechanisms if interpreted in the context of gain or loss of function. The management of neuropathies also remains challenging. Common treatment strategies such as joint mobilisation, neurodynamic exercises, education, and medications are discussed in terms of their potential to influence certain mechanisms at the site of nerve injury or in the central nervous system. The mechanism-oriented approach for this Masterclass seems warranted given the limitations in the current evidence for the diagnosis and management of entrapment neuropathies.
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Affiliation(s)
- Annina B Schmid
- The University of Queensland, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane (St Lucia), Australia; University of Oxford, Nuffield Department of Clinical Neurosciences, Oxford, United Kingdom.
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Ntani G, Palmer KT, Linaker C, Harris EC, Van der Star R, Cooper C, Coggon D. Symptoms, signs and nerve conduction velocities in patients with suspected carpal tunnel syndrome. BMC Musculoskelet Disord 2013; 14:242. [PMID: 23947775 PMCID: PMC3765787 DOI: 10.1186/1471-2474-14-242] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 08/09/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To inform the clinical management of patients with suspected carpal tunnel syndrome (CTS) and case definition for CTS in epidemiological research, we explored the relation of symptoms and signs to sensory nerve conduction (SNC) measurements. METHODS Patients aged 20-64 years who were referred to a neurophysiology service for investigation of suspected CTS, completed a symptom questionnaire (including hand diagrams) and physical examination (including Tinel's and Phalen's tests). Differences in SNC velocity between the little and index finger were compared according to the anatomical distribution of symptoms in the hand and findings on physical examination. RESULTS Analysis was based on 1806 hands in 908 patients (response rate 73%). In hands with numbness or tingling but negative on both Tinel's and Phalen's tests, the mean difference in SNC velocities was no higher than in hands with no numbness or tingling. The largest differences in SNC velocities occurred in hands with extensive numbness or tingling in the median nerve sensory distribution and both Tinel's and Phalen's tests positive (mean 13.8, 95% confidence interval (CI) 12.6-15.0 m/s). Hand pain and thumb weakness were unrelated to SNC velocity. CONCLUSIONS Our findings suggest that in the absence of other objective evidence of median nerve dysfunction, there is little value in referring patients of working age with suspected CTS for nerve conduction studies if they are negative on both Tinel's and Phalen's tests. Alternative case definitions for CTS in epidemiological research are proposed according to the extent of diagnostic information available and the relative importance of sensitivity and specificity.
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Affiliation(s)
- Georgia Ntani
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
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Glynn PE, Cleland JA. Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report. J Man Manip Ther 2013. [DOI: 10.1179/jmt.2006.14.3.30e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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The value of provocative tests for the wrist and elbow: a literature review. J Hand Ther 2013; 26:32-42; quiz 43. [PMID: 23062797 DOI: 10.1016/j.jht.2012.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 08/25/2012] [Accepted: 08/29/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED To describe and determine the usefulness of provocative tests for the wrist and elbow a literature search was performed. A total of 31 diagnostic studies were identified, assessed, and ranked. The highest ranking tests had a mean positive likelihood ratio of ≥2.0, or a mean negative likelihood ratio of ≤0.5, from more than one study. The highly recommended tests were found to be the Phalen's, Tinel's test for carpal tunnel and cubital tunnel, and modified compression test, scaphoid shift test, and elbow flexion test. A total of 14 tests met our requirements to be considered a recommended test. A greater number of provocative tests either do not have adequate data to support their usefulness or their clinical utility has not been assessed. This information may assist hand therapists in choosing which provocative tests are considered clinically useful in improving the probability of the presence or absence of pathology in the hand, wrist, and elbow. LEVEL OF EVIDENCE NA.
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Van Hoof T, Vangestel C, Shacklock M, Kerckaert I, D’Herde K. Asymmetry of the ULNT1 elbow extension range-of-motion in a healthy population: Consequences for clinical practice and research. Phys Ther Sport 2012; 13:141-9. [DOI: 10.1016/j.ptsp.2011.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 09/20/2011] [Accepted: 09/22/2011] [Indexed: 11/30/2022]
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Abstract
The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.
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Abstract
BACKGROUND Sleep disturbance is common in carpal tunnel syndrome (CTS), and we hypothesize that it has an important impact on the quality of life of CTS patients. The characteristic of sleep problems associated with CTS has not been evaluated. METHODS We performed a case-control study to measure the association between a variety of sleep disturbances and CTS. Sixty-two cases with clinically diagnosed CTS and a probable or classic hand diagram were compared to 138 primary care patients without CTS. In addition to demographic features, we collected the nature of sleep disturbance experienced by the patients from a categorical list and the nature, impact, and severity of sleep disturbance using the Insomnia Severity Index. RESULTS Patients with CTS complained of significantly more severe problems with sleep than the control population and had multiple sleep complaints compared to the control group. Sixty-three of the 138 control patients indicated that they had one cause of sleeping disturbance with no control patient choosing more than one. In contrast, in CTS patients, 44 of 63 patients indicated they had two or more causes of sleep disturbance. The Insomnia Severity Index was significantly higher in CTS patients and the impact of sleep disturbance on quality of life was higher in the cases. CONCLUSION Sleep disturbance in CTS patients is characterized by a broad array of physical symptoms that have a significant impact on quality of life.
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Vanti C, Bonfiglioli R, Calabrese M, Marinelli F, Violante FS, Pillastrini P. Relationship Between Interpretation and Accuracy of the Upper Limb Neurodynamic Test 1 in Carpal Tunnel Syndrome. J Manipulative Physiol Ther 2012; 35:54-63. [DOI: 10.1016/j.jmpt.2011.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 07/21/2011] [Accepted: 08/17/2011] [Indexed: 10/15/2022]
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Covill LG, Petersen SM. Upper extremity neurodynamic tests: Range of motion asymmetry may not indicate impairment. Physiother Theory Pract 2011; 28:535-41. [DOI: 10.3109/09593985.2011.641198] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Davis DS, Anderson IB, Carson MG, Elkins CL, Stuckey LB. Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms. J Man Manip Ther 2011; 16:136-41. [PMID: 19119402 DOI: 10.1179/jmt.2008.16.3.136] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
This study examined the false positive rate of the upper limb neural tension test (ULNTT) and seated slump test (SST) among healthy young adults with no history of cervical, lumbar, or peripheral symptoms. Eighty-four subjects (27 men and 57 women) with a mean age of 22.9 years participated in the investigation. All participants completed a screening questionnaire designed to exclude subjects with a history of cervical or lumbar spine pain or injury, or upper or lower extremity neurological symptoms. The ULNTT and the SST were performed on the left upper and lower extremity of each participant. Of the 84 participants tested, 73 (86.9%) were found to have a positive ULNTT at some point in the available range of elbow extension. Twenty-eight (33.3%) of the 84 subjects had a positive SST at some point in the available range of knee extension. The mean knee extension angle for those subjects with a positive SST was 15.1 degrees with a 95% confidence interval (CI) of 12.3 and 19.7 degrees . The mean elbow extension angle for those with a positive ULNTT was 49.4 degrees with a 95% CI of 44.8 and 54.0 degrees . The number of positive tests for both the ULNTT and the SST was found to be high in this sample of asymptomatic healthy young adults. Based on the results of this investigation, the authors suggest that the current criteria for determining a positive test for both the ULNTT and the SST should be examined using the proposed range of motion cut-off scores.
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Affiliation(s)
- D Scott Davis
- Associate Professor and Director of Professional Education, Division of Physical Therapy, West Virginia University, Morgantown, WV
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May S, Rosedale R. Prescriptive clinical prediction rules in back pain research: a systematic review. J Man Manip Ther 2011; 17:36-45. [PMID: 20046564 DOI: 10.1179/106698109790818214] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Prescriptive clinical prediction rules (CPRs) are a way of using a small selection of clinical findings to match patients to optimal interventions. A number of CPRs have been developed for use with back pain patients, but these have not been systematically reviewed. The purpose of this review was to evaluate existing CPRs against established criteria to determine the quality of the studies and the overall development of the CPR against a set number of stages. Medline was searched up until June 2008, and 16 studies were reviewed that related to 9 different CPRs. These studies investigated and attempted to find clinical characteristics for responders to manipulation, stabilization exercise, physical therapy, chiropractic, traction, rehabilitation, usual care, and zygapophyseal joint injections. Eleven of these studies related to the derivation stage and five to the validation stage. The manipulation and stabilization CPRs had been the most studied. The derivation studies were mostly high quality, whereas none of the validation studies were. Some of the validation studies did not provide evidence that validated the CPR. Most of these CPRs need further evaluation before they can be applied clinically; most did not pass the lowest level of evidence hierarchy. As regards the manipulation CPR, evidence to date for its clinical utility is limited and contradictory. For the stabilization CPR, there was limited evidence that it may be considered but only with caution and in similar patients. Overall, there is limited evidence to support the general application of spinal CPRs.
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McCabe SJ, Gupta A, Tate DE, Myers J. Preferred sleep position on the side is associated with carpal tunnel syndrome. Hand (N Y) 2011; 6:132-7. [PMID: 22654695 PMCID: PMC3092881 DOI: 10.1007/s11552-010-9308-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although carpal tunnel syndrome is the most common compressive neuropathy, there is no comprehensive theory of its etiology. Because of the prevalence of night symptoms, we are interested in the role of sleep position in the causation of carpal tunnel syndrome. METHODS We performed a case-control study comparing the prevalence of preferred sleep position in 68 cases and 138 controls. Analysis was stratified by age and gender and controlled for body mass index. RESULTS We found a strong and significant association between a preference for sleeping on the side and the presence of carpal tunnel syndrome in men and in women less than 60 years of age. Body mass index was associated with carpal tunnel syndrome in women but not men. CONCLUSIONS Our findings of a strong association between the presence of carpal tunnel syndrome and preferred sleeping on the side suggest a comprehensive unifying theory of causation.
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Affiliation(s)
- Steven J. McCabe
- Department of Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Sciences, 485 Gray Street, Rm 130, Louisville, KY 40202 USA
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY 40202 USA
| | - Amit Gupta
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY 40202 USA
| | - David E. Tate
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY 40202 USA
| | - John Myers
- Department of Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Sciences, 485 Gray Street, Rm 130, Louisville, KY 40202 USA
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Abstract
STUDY DESIGN A case control, blinded study. OBJECTIVES To compare the amount of cervical range of motion in women with minimal, mild/moderate, and severe carpal tunnel syndrome (CTS) to that of healthy control participants. We also assessed the relationships between cervical range of motion and clinical variables related to the intensity and temporal profile of pain within each CTS group. BACKGROUND It is plausible that the cervical spine may be involved in individuals with CTS. No study has investigated the relationship between cervical range of motion and symptoms associated with CTS severity. METHODS Cervical range of motion was assessed in 71 women with CTS (18 with minimal, 18 with mild/moderate, and 35 with severe signs and symptoms) and in 20 similar, healthy women. Those with CTS were aged 35 to 59 years (mean ± SD, 45 ± 8 years) and those in the healthy group were aged 31 to 60 years (45 ± 8 years). An experienced therapist, blinded to the participants' conditions, used a cervical range-of-motion (CROM) device to assess cervical range of motion. Mixed-model analyses of variance (ANOVAs) were conducted to evaluate the differences in cervical range of motion among the 3 groups of patients with CTS and healthy controls. A corrected P value of less than .025 was used as threshold for significance (Bonferroni correction). RESULTS The mixed-model ANOVAs revealed that the individuals with CTS exhibited restricted cervical range of motion compared to healthy controls (P<.001), with no significant differences among the groups with minimal, mild/moderate, or severe CTS (P>.356). A significant negative correlation between pain intensity and cervical spine lateral flexion away from the affected side was identified: the greater the mean pain intensity, the lesser the cervical lateral flexion away from the affected side. CONCLUSIONS Women with minimal, mild/moderate, or severe CTS exhibited less cervical range of motion compared to women of a similar age, suggesting that restricted cervical range of motion may be a common feature in individuals with CTS, independent of severity subgroups, as defined by electrodiagnosis. Future research should investigate cervical range of motion as a possible consequence or causative factor of CTS and related symptoms.
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Vaught MS, Brismée JM, Dedrick GS, Sizer PS, Sawyer SF. Association of disturbances in the thoracic outlet in subjects with carpal tunnel syndrome: a case-control study. J Hand Ther 2011; 24:44-51; quiz 52. [PMID: 21272763 DOI: 10.1016/j.jht.2010.09.070] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 09/27/2010] [Accepted: 09/28/2010] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A limited amount of research has investigated the potential relationship between carpal tunnel syndrome (CTS) and thoracic outlet dysfunction. PURPOSE OF THE STUDY To compare the prevalence of positive clinical tests suggestive of disputed neurogenic thoracic outlet syndrome (TOS) in subjects with CTS (CTS+) with that of subjects without CTS (control). STUDY DESIGN Case-control study. METHODS Subjects with electrodiagnostically confirmed CTS (CTS+) were recruited consecutively and matched by age (±2 years) and gender with asymptomatic (control) subjects. Subjects underwent clinical testing for neurogenic TOS using two provocative tests: modified Cyriax release test and elevated arm stress test (EAST). Subjects were tested for the presence of an elevated first rib using cervical rotation lateral flexion (CRLF) test. RESULTS A total of 32 investigational subjects and 32 matched control subjects was included in each group (mean age: 43.5+5.9 years). A significantly greater number of CTS+ subjects presented with positive provocative testing for TOS (modified Cyriax release test p=0.005; EAST approached significance p=0.027) and for the presence of an elevated first rib (CRLF test p=0.003) as compared with controls. The likelihood of neck pain, shoulder pain, or an elevated first rib was 16 times greater in the CTS+ group as compared with that in the control group. CONCLUSIONS A greater number of subjects with CTS presented with proximal dysfunctions suggestive of TOS and history of neck and shoulder pain. Evaluation of proximal structures involved with thoracic outlet dysfunction in persons with CTS has clinical merit. LEVEL OF EVIDENCE Level III-b.
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Affiliation(s)
- Megan S Vaught
- Sister Kenny Rehabilitation Institute, Minneapolis, Minnesota, USA
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Foti C, Romita P, Vestita M. Unusual presentation of carpal tunnel syndrome with cutaneous signs: a case report and review of the literature. Immunopharmacol Immunotoxicol 2011; 33:751-3. [PMID: 21320000 DOI: 10.3109/08923973.2010.551214] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Carpal tunnel syndrome (CTS) is a neurological impairment caused by compression of the median nerve throughout the carpal tunnel, which consequently induces ischemia and mechanical disruption, dysfunctional axonal transport, and epidural blood flow. Most common symptoms include numbness, rather than pain, with a typical night exacerbation, weakness, paresthesia, and loss of sensitive discrimination. In rare cases, such syndrome may present with cutaneous manifestations localized on the distal phalanges of the hands, even without the above mentioned neurological symptoms. We describe a case of a woman who came to our attention complaining of the appearance of recurrent bullous eruptions involving the distal phalanges innervated by the median nerve. She did not report any neurological signs whatsoever. After excluding a bullous disease, we further investigated through additional analysis that revealed a CTS. Hence, physicians should consider CTS as a differential diagnosis when assessing cutaneous lesions of the first three fingers of the hands.
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Affiliation(s)
- C Foti
- Department of Internal Medicine, Immunology and Infectious Diseases, Unit of Dermatology, University of Bari, Bari, Italy.
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