1
|
Kimura H, Furuhata R, Matsuo T, Suzuki T, Matsumura N, Sato K, Iwamoto T. Point of care ultrasound combined with CTS-6 to diagnose idiopathic carpal tunnel syndrome. J Orthop Sci 2024:S0949-2658(24)00008-3. [PMID: 38302310 DOI: 10.1016/j.jos.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND This study aimed to demonstrate the effectiveness of our new diagnostic chart using point of care ultrasound combined with CTS-6 for diagnosing idiopathic carpal tunnel syndrome. METHODS We conducted a retrospective analysis of the data of patients who visited our department and received point of care ultrasound combined with CTS-6 from 2020 to 2023. Data regarding age, sex, initial and final diagnosis, cross-sectional area of the median nerve, CTS-6 score, and electrodiagnostic severity were obtained and statistically analyzed. RESULTS Of the 177 wrists included in our study, 138 (78 %) were diagnosed with carpal tunnel syndrome, while 39 (22 %) were not (non-carpal tunnel syndrome). With our diagnostic method, 127 wrists (72 %) were diagnosed initially with carpal tunnel syndrome, 23 wrists (13 %) with non-carpal tunnel syndrome, and the rest 27 wrists (15 %) as borderline. Our initial diagnoses of carpal tunnel syndrome and non-carpal tunnel syndrome were maintained in all cases except for two. Cross-sectional area, CTS-6 score, and electrodiagnostic severity showed a positive correlation. A post hoc analysis showed that the new scoring system (CTS-6 score + 2 × cross-sectional area) with a cutoff value of 31.25 points showed a sensitivity as high as 95 % and a specificity of 100 %. CONCLUSIONS Our findings suggest that most suspected idiopathic carpal tunnel syndrome cases can be diagnosed correctly using the diagnostic chart. Although additional tools, including electrodiagnostic studies, may be needed for borderline cases, the use of point of care ultrasound combined with CTS-6 may be a recommendable first-line confirmatory test because point of care ultrasound and CTS-6 could be complementary tools, and this chart may be especially beneficial for atypical or outlier cases. LEVEL OF EVIDENCE Diagnostic III.
Collapse
Affiliation(s)
- Hiroo Kimura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan; Department of Orthopaedic Surgery, Kitasato Institute Hospital, Tokyo, Japan.
| | - Ryogo Furuhata
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Tomoki Matsuo
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Taku Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Noboru Matsumura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Takuji Iwamoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
| |
Collapse
|
2
|
Tada K, Murai A, Nakamura Y, Nakade Y, Tsuchiya H. In Carpal Tunnel Syndrome, Sensory Nerve Conduction Velocities Are Worst in the Middle Finger Than in the Index Finger. Front Neurol 2022; 13:851108. [PMID: 35359636 PMCID: PMC8961683 DOI: 10.3389/fneur.2022.851108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 02/15/2022] [Indexed: 11/15/2022] Open
Abstract
Although the index finger is generally used for sensory nerve conduction study in cases of carpal tunnel syndrome, there are reports that the middle finger should be used. The purpose of this study was to compare the results of sensory nerve conduction studies of the index finger and middle finger in patients with carpal tunnel syndrome. Among the 120 hands of 93 patients who were diagnosed with carpal tunnel syndrome and underwent carpal tunnel release surgery at our hospital, 54 hands of 48 patients who showed waveforms in sensory nerve conduction studies both index and middle fingers were included. 6 hands of 6 patients who showed no waveform in the index or middle finger, and 60 hands of 39 patients who showed no waveform in both index and middle finger were excluded. The subjects were 14 males and 34 females, and their ages were 66.2 years. The preoperative sensory nerve action potential (μV) and sensory nerve conduction velocity (m/s) of the index and middle fingers were tested using Wilcoxon's signed rank test. Spearman's rank correlation coefficient was also calculated for the results of the index and middle fingers. Sensory nerve action potentials were 2.0 in the index finger and 1.8 in the middle finger, with significantly lower in the middle finger. Sensory nerve conduction velocity was 30.1 in the index finger and 27.2 in the middle finger, with significantly lower in the middle finger. The correlation coefficients of sensory nerve action potentials and conduction velocities between the index finger and middle finger were 0.82 and 0.96, respectively, both of which showed a significant correlation. The results of the sensory nerve conduction studies of the middle finger were significantly worse than those of the index finger in cases of carpal tunnel syndrome. In addition, there was a strong correlation between the results of the index finger and the middle finger. The results of this study suggest that the nerve bundle to the middle finger may be more strongly affected than the nerve bundle to the index finger in cases of carpal tunnel syndrome.
Collapse
Affiliation(s)
- Kaoru Tada
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
- *Correspondence: Kaoru Tada
| | - Atsuro Murai
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yuta Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yusuke Nakade
- Department of Clinical Laboratory, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| |
Collapse
|
3
|
Wallace ES, Carberry JC, Toson B, Eckert DJ. A Systematic Review and Meta-Analysis of Upper Airway Sensation in Obstructive Sleep Apnea – Implications for Pathogenesis, Treatment and Future Research Directions. Sleep Med Rev 2022; 62:101589. [DOI: 10.1016/j.smrv.2022.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
|
4
|
Pain mechanisms in carpal tunnel syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. Pain 2021; 163:e1054-e1094. [PMID: 35050958 DOI: 10.1097/j.pain.0000000000002566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 12/08/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Carpal tunnel syndrome (CTS) is the most common nerve compression in the arm. A mix of peripheral and central contributions on quantitative sensory testing (QST) has been reported in the literature. Thus, this systematic review or meta-analysis aimed to identify the dominant sensory phenotype and draw conclusive evidence about the presence of central sensitization (CS) in CTS. Based on an a priori published protocol and using PRISMA guidelines, 7 databases were searched (Embase, Web of Science, Scopus, PubMed, SAGE, EBSCOhost, and ProQuest). Eligible studies compared the QST findings of individuals with subacute and chronic CTS with those of healthy controls through thermal, mechanical, and vibration detection thresholds; thermal, pressure, and mechanical pain thresholds; mechanical pain sensitivity; presence of allodynia; wind-up ratio; and conditioned pain modulation. Thirty-seven studies were included in the qualitative analysis. Results showed a significant loss of all detection thresholds of hand median nerve territories and hand extramedian areas (little finger and hand dorsum) in CTS (P < 0.05) but no significant difference (P > 0.05) in wind-up ratio, cold, heat, or mechanical pain thresholds of the median nerve territories. Furthermore, there was a significant increase in mechanical pain sensitivity in median nerve territories and remotely in the forearm (P < 0.05) and a significant gain in pressure and heat pain thresholds in the carpal area (P < 0.05). Conditioned pain modulation was impaired in CTS. Hypoesthesia and increased thermal and mechanical pain ratings are the dominant sensory phenotype with inconclusive evidence about CS in CTS due to the heterogenous results of thermal and mechanical pain thresholds.
Collapse
|
5
|
Kennedy DL, Vollert J, Ridout D, Alexander CM, Rice ASC. Responsiveness of quantitative sensory testing-derived sensory phenotype to disease-modifying intervention in patients with entrapment neuropathy: a longitudinal study. Pain 2021; 162:2881-2893. [PMID: 33769367 DOI: 10.1097/j.pain.0000000000002277] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/19/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The German Research Network on Neuropathic Pain (DFNS) quantitative sensory testing (QST) method for sensory phenotyping is used to stratify patients by mechanism-associated sensory phenotype, theorised to be predictive of intervention efficacy. We hypothesised that change in pain and sensory dysfunction would relate to change in sensory phenotype. We investigated the responsiveness of sensory phenotype to surgery in patients with an entrapment neuropathy. With ethical approval and consent, this observational study recruited patients with neurophysiologically confirmed carpal tunnel syndrome. Symptom and pain severity parameters and DFNS QST were evaluated before and after carpal tunnel surgery. Surgical outcome was evaluated by patient-rated change. Symptom severity score of the Boston Carpal Tunnel Questionnaire and associated pain and paraesthesia subgroups were comparators for clinically relevant change. Quantitative sensory testing results (n = 76) were compared with healthy controls (n = 54). At 6 months postsurgery, 92% participants reported a good surgical outcome and large decrease in pain and symptom severity (P < 0.001). Change in QST parameters occurred for thermal detection, thermal pain, and mechanical detection thresholds with a moderate to large effect size. Change in mechanical pain measures was not statistically significant. Change occurred in sensory phenotype postsurgery (P < 0.001); sensory phenotype was associated with symptom subgroup (P = 0.03) and patient-rated surgical outcome (P = 0.02). Quantitative sensory testing-derived sensory phenotype is sensitive to clinically important change. In an entrapment neuropathy model, sensory phenotype was associated with patient-reported symptoms and demonstrated statistically significant, clinically relevant change after disease-modifying intervention. Sensory phenotype was independent of disease severity and may reflect underlying neuropathophysiology.
Collapse
Affiliation(s)
- Donna L Kennedy
- Pain Research Group, Imperial College London, London, United Kingdom
| | - Jan Vollert
- Pain Research Group, Imperial College London, London, United Kingdom
- MSK Labs, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Germany
| | - Deborah Ridout
- Population, Policy and Practice Programme, University College London Great Ormond St Institute of Child Health, London, United Kingdom
| | - Caroline M Alexander
- Therapies Department, Imperial College Healthcare NHS Trust, London, United Kingdom
- MSK Labs, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Andrew S C Rice
- Pain Research Group, Imperial College London, London, United Kingdom
| |
Collapse
|
6
|
Effective assessments to identify overuse injuries in unaffected limbs of persons with unilateral upper limb amputations. J Hand Ther 2021; 34:298-308. [PMID: 34148738 DOI: 10.1016/j.jht.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Cross-sectional study. INTRODUCTION Overuse injuries (OI) present major health problems and oftentimes, permanent disability. Persons with unilateral upper limb diagnoses, such as amputation, are at-risk for developing OI in their unaffected limbs. Measures to identify high-risk populations are needed. PURPOSE OF THE STUDY Scores on 6 OI-assessments were compared for persons with unilateral upper limb amputations (UULA) and healthy participants. Cutoff values were proposed. METHODS Sixty-two persons with UULA and 62 healthy controls completed this study. Scores for hand volume (HV), visual analogue scale (VAS), multi-site Semmes Weinstein Monofilament for median and ulnar nerves (SWM-M/SWM-U), torque range of motion for wrist/finger extension and flexion (TROM-E/TROM-F), intrinsic tightness (IT), and differential flexor tendon gliding (DFTG) were collected before and after 15 minutes of repetitive and resistive exercise. When analyzing collected data, descriptive statistics, and ANOVA were used to identify differences between groups. Receiver operating characteristic curves (ROC), area under the curve (AUC), sensitivity, and specificity were calculated to determine acceptable cutoff scores. Cutoff values with significant AUC ≥ 0.60 and sensitivity ≥ 0.80 were accepted. RESULTS Statistically significant differences were found between HV by gender in both pre-exercise and post-exercise conditions. Gain scores for whole sample HV, female HV, and TROM-E were statistically different although differences were small and not meaningful. Significant AUC and acceptable pre-exercise cutoff values included 375 ml. for female HV (sensitivity 89%, specificity 87%), 505 ml. for male HV (sensitivity 81%, specificity 70%), 82 degrees for TROM-E (sensitivity 92%, specificity 71%), and 73 degrees of TROM-F (sensitivity 90%, specificity 89%). CONCLUSIONS Potential at-risk OI-related populations, especially unaffected limbs of UULA persons, are best identified by pre-exercise cutoff values using HV by gender, TROM, and single-site SWM 2.83.
Collapse
|
7
|
Wessel LE, Ekstein CM, Marshall DC, Chen AZ, Osei DA, Fufa DT. Pre-operative Two-Point Discrimination Predicts Response to Carpal Tunnel Release. HSS J 2020; 16:206-211. [PMID: 33088234 PMCID: PMC7534881 DOI: 10.1007/s11420-019-09694-y] [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: 02/15/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Limited evidence informs whether pre-operative values of two-point discrimination (2PD) in patients with carpal tunnel syndrome predict response to surgery. QUESTIONS/PURPOSES The primary aim of this study was to determine the predictive value of pre-operative 2PD scores on outcomes following carpal tunnel release (CTR). In particular, we sought to evaluate whether a clinically relevant 2PD threshold exists that can predict symptomatic response after surgery. METHODS Patients who underwent CTR between 2014 and 2018 were retrospectively reviewed. Static 2PD scores in each digit, as well as Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Levine-Katz scores, were collected from pre- and post-operative records. Pearson correlation coefficients assessed the relationship between pre-operative 2PD, early post-operative 2PD, and patient-reported outcome scores. Poor 2PD was defined as 2PD greater than 10 mm. RESULTS Eighty-nine hands in 73 patients with a mean follow-up of 1.8 years were analyzed. Mean pre- and post-operative 2PD was 7.2 mm and 6.4 mm, respectively, in the most affected digit when measurable. Twenty patients had poor 2PD scores pre-operatively and 14 post-operatively. There was a positive correlation between pre- and early post-operative 2PD scores but no correlation between pre-operative 2PD score and final post-operative functional scores. Only 30% of patients with poor pre-operative 2PD scores demonstrated improvement, compared with 69% of patients with measurable 2PD. CONCLUSION We found that greater pre-operative 2PD scores predicted greater early post-operative 2PD scores but did not lead to worse functional outcome scores post-operatively. Patients with poor pre-operative 2PD scores were likely to demonstrate improvement in functional outcomes scores, while having less reliable improvement in 2PD after CTR. Patients with poor 2PD should be counseled that improvement of tactile perception is less predictable.
Collapse
Affiliation(s)
- Lauren E. Wessel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Charles M. Ekstein
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Danielle C. Marshall
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Aaron Z. Chen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Daniel A. Osei
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Duretti T. Fufa
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| |
Collapse
|
8
|
Ikpeze TC, Childs S, Buckley T, Elfar JC. Validity of QuickDASH at day of surgery versus day of initial consultation: Does informed consent make a difference? J Orthop Surg (Hong Kong) 2019; 26:2309499018777897. [PMID: 29848213 DOI: 10.1177/2309499018777897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The trend toward requiring explicit consent from patients participating in observational research increases time and resources required to perform such research. Informed consent introduces the potential for "consent bias"-either through selection bias or through the "Hawthorne effect," where patients may alter responses based upon the awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that administering Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) to patients on the day of surgery with informed consent would alter responses in a statistically and clinically meaningful way compared to patients who complete QuickDASH as a quality control measure. METHODS We previously instituted the QuickDASH questionnaire as the standard new patient intake and postoperative questionnaire for quality assurance purposes. We retrospectively reviewed data on a cohort of patients who underwent isolated carpal tunnel release (CTR) who had completed preoperative and postoperative QuickDASH forms without providing consent for study participation. Next, a cohort of patients scheduled to undergo isolated CTR who completed the intake questionnaire was approached on the day of surgery for consent to participate in the study. After obtaining consent but prior to surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire on follow-up at a mean of 8 weeks postoperatively. RESULTS Thirty-nine patients and 35 patients were included in the retrospective and prospective cohorts, respectively. No significant differences were observed in age, gender, symptom duration, nerve conduction study/electromyography results, or disease severity between the two groups. We identified no statistically significant difference in preoperative or postoperative QuickDASH score between the retrospective and prospective cohorts (39.8 ± 22.7 vs. 39.7 ± 19.1 preoperatively; 27.3 ± 24.7 vs. 18.7 ± 13.3 postoperatively) or within the prospective cohort before and after obtaining informed consent. CONCLUSION Informed consent did not significantly alter patient responses to the QuickDASH questionnaire. These results suggest that both "opt-in" and "opt-out" approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice. CLINICAL RELEVANCE This study provides evidence that will inform the interpretation of observational research findings in hand surgery.
Collapse
Affiliation(s)
- Tochukwu C Ikpeze
- 1 Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester NY, USA
| | - Sean Childs
- 1 Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester NY, USA
| | | | - John C Elfar
- 3 Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Nelson JT, Gauger MR, Whaley JD, Zinberg EM. Patient-reported symptom-mapping in carpal tunnel syndrome. Muscle Nerve 2018; 59:321-325. [PMID: 30549061 DOI: 10.1002/mus.26398] [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: 01/30/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION To date, no method has been described or utilized to study the distribution of symptoms in carpal tunnel syndrome. We describe a technique of symptom-mapping that yields a population-based "anatomic profile" of carpal tunnel syndrome. METHODS Symptoms were mapped on visual questionnaires depicting the volar hand, wrist, and forearm. Thirty-four hands in 26 patients with isolated carpal tunnel syndrome were included in the study. RESULTS Painful symptoms were clearly centered over the carpal tunnel and were reported much less frequently in the digits. Nonpainful sensory disturbances (e.g., numbness, paresthesias) were found to have a much more peripheral and lateral distribution. DISCUSSION Our technique serves to establish a population-based "anatomic profile" of carpal tunnel syndrome, assisting with clinical diagnosis and serving as a reference point for the comparison of pretreatment and posttreatment clinical data. Muscle Nerve 59:321-325, 2019.
Collapse
Affiliation(s)
- Johnny T Nelson
- Hand & Upper Extremity Surgery, University of Pittsburgh Medical Center, 9104 Babcock Boulevard, 5th floor, Pittsburgh, Pennsylvania, 15237, USA
| | | | - James D Whaley
- Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ephraim M Zinberg
- Orthopaedic Surgery, Wayne State University School of Medicine, Southfield, Michigan, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Wolny T, Linek P. Reliability of two-point discrimination test in carpal tunnel syndrome patients. Physiother Theory Pract 2018; 35:348-354. [DOI: 10.1080/09593985.2018.1443358] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Tomasz Wolny
- Department of Kinesiotherapy and Special Physiotherapy Methods, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Paweł Linek
- Department of Kinesiotherapy and Special Physiotherapy Methods, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| |
Collapse
|
13
|
Wolny T, Saulicz E, Linek P, Myśliwiec A, Saulicz M. Effect of manual therapy and neurodynamic techniques vs ultrasound and laser on 2PD in patients with CTS: A randomized controlled trial. J Hand Ther 2017; 29:235-45. [PMID: 27094495 DOI: 10.1016/j.jht.2016.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 03/13/2016] [Accepted: 03/17/2016] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Randomized controlled trial. INTRODUCTION Two-point discrimination (2PD) test can be used to assess both clinical condition and the effects of therapy in carpal tunnel syndrome (CTS) patients. PURPOSE OF THE STUDY To determine whether there are specific differences in 2PD between symptomatic and asymptomatic hands in CTS patients and to evaluate the impact of 2 therapy regimes on 2PD in patients with CTS. METHODS Therapy for the neurodynamic mobilization group was based on manual therapy and neurodynamic techniques. Therapy for the electrophysical modalities group was based on red and infrared laser and ultrasound therapy using a contact method applied in the transverse ligament area. Therapeutic cycle consisted of 20 therapy sessions delivered at twice-weekly intervals. RESULTS After therapy, 2PD in the symptomatic limbs in the neurodynamic mobilization and electrophysical modalities groups significantly improved (p < .001). However, there was no statistically significant difference between the treatment groups. CONCLUSIONS Both therapy programs used in this study were beneficial for improving 2PD. LEVEL OF EVIDENCE 2.
Collapse
Affiliation(s)
- Tomasz Wolny
- Department of Kinesiotherapy and Special Physiotherapy Methods, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland; Department of Physiotherapy, The Academy of Business, Dąbrowa Górnicza, Poland
| | - Edward Saulicz
- Department of Kinesiotherapy and Special Physiotherapy Methods, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland; Department of Physiotherapy, The Academy of Business, Dąbrowa Górnicza, Poland
| | - Paweł Linek
- Department of Kinesiotherapy and Special Physiotherapy Methods, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland.
| | - Andrzej Myśliwiec
- Department of Kinesiotherapy and Special Physiotherapy Methods, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Mariola Saulicz
- Department of Physiotherapy, The Academy of Business, Dąbrowa Górnicza, Poland; Department of Physiotherapy in Diseases of Internal Organs, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| |
Collapse
|
14
|
Chimenti PC, McIntyre AW, Childs SM, Hammert WC, Elfar JC. Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions. Open Orthop J 2016; 10:111-9. [PMID: 27347239 PMCID: PMC4897207 DOI: 10.2174/1874325001610010111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 09/20/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. METHODS 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. RESULTS Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. CONCLUSION This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.
Collapse
Affiliation(s)
- Peter C Chimenti
- University of Rochester Medical Center, Rochester, New York, United States
| | - Allison W McIntyre
- University of Rochester Medical Center, Rochester, New York, United States
| | - Sean M Childs
- University of Rochester Medical Center, Rochester, New York, United States
| | - Warren C Hammert
- University of Rochester Medical Center, Rochester, New York, United States
| | - John C Elfar
- University of Rochester Medical Center, Rochester, New York, United States
| |
Collapse
|
15
|
Intraoperative dynamic pressure measurements in carpal tunnel syndrome: Correlations with clinical signs. Clin Neurol Neurosurg 2016; 140:33-7. [DOI: 10.1016/j.clineuro.2015.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/09/2015] [Indexed: 11/23/2022]
|
16
|
Yucel H. Factors affecting symptoms and functionality of patients with carpal tunnel syndrome: a retrospective study. J Phys Ther Sci 2015; 27:1097-101. [PMID: 25995565 PMCID: PMC4433986 DOI: 10.1589/jpts.27.1097] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/04/2014] [Indexed: 12/02/2022] Open
Abstract
[Purpose] The aim of this retrospective study was to determine the associations between
clinical, physical, and neurophysiological outcomes and self-reported symptoms and
functions of patients after surgical carpal tunnel release. [Subjects and Methods] Among
261 patients who had undergone open surgical carpal tunnel release within the last three
years, 83 (mean age 50.27 ± 11.13 years) participated in this study. Their
socio-demographics and comorbidities were recorded. The intensity of pain, paresthesia,
and fatigue symptoms in the hand were assessed by means of a Visual Analogue Scale, the
Semmes-Weinstein Monofilaments test of light touch pressure sensation, and Jamar
dynamometry for measurement of grip and pinch strengths. The Boston Carpal Tunnel
Questionnaire evaluated the severity of symptoms and hand functional status, and the
variables were analyzed by multivariate linear regression. [Results] The severity of the
symptoms and functional status of release surgery patients was associated with diabetes
mellitus, migraine, night pain, paresthesia and fatigue symptoms, impaired light touch
pressure, and lack of medical treatment. [Conclusion] Appropriate post-surgery treatment
programs for these factors should be taken into consideration to help patients obtain
optimal functionality and health in their daily lives.
Collapse
Affiliation(s)
- Hulya Yucel
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Bezmialem Vakif University, Turkey
| |
Collapse
|
17
|
Abstract
Context: Sideline management of sports-related joint dislocations often places the treating medical professional in a challenging position. These injuries frequently require prompt evaluation, diagnosis, reduction, and postreduction management before they can be evaluated at a medical facility. Our objective is to review the mechanism, evaluation, reduction, and postreduction management of sports-related dislocations to the shoulder, elbow, finger, knee, patella, and ankle joints. Evidence Acquisition: A literature review was performed using the PubMed database to evaluate previous and current publications focused on joint dislocations. This review focused on articles published between 1980 and 2013. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinician should weigh the benefits and risks of on-field reduction based on their knowledge of the injury and the presence of associated injuries. Conclusion: When properly evaluated and diagnosed, most sports-related dislocations can be reduced and initially managed at the game.
Collapse
|
18
|
Kim SW, Park HW, Won SJ, Jeon SY, Jin HR, Lee SJ, Chang DY, Kim DW. Palatal sensory threshold reflects nocturnal hypoxemia and airway occlusion in snorers and obstructive sleep apnea patients. J Clin Sleep Med 2013; 9:1179-86. [PMID: 24235900 DOI: 10.5664/jcsm.3164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Upper airway sensory deficit has been reported to be associated with snoring or obstructive sleep apnea. There are limited data on the correlation between disease severity and upper airway sensation. In this study, we investigated the relationship between clinical parameters and standardized palatal sensory threshold (SPST) using Semmes Weinstein monofilaments. METHODS We recruited 40 snorers and 19 control subjects. Palatal sensory threshold was measured in all study subjects, using Semmes Weinstein monofilaments. Standardized palatal sensory threshold was determined by subtraction of hard palate sensation from uvular sensation. All subjects with snoring underwent a modified Muller maneuver during wakefulness before polysomnography. RESULTS SPST was higher in snorers than in control subjects, but did not differ according to the severity of obstructive sleep apnea. Patients with higher SPST (≥ 0.45 g/mm(2)) were older and had more severe hypoxemia indices: lower nadir oxyhemoglobin saturation (SpO2) and higher percentage of sleep time at < 90% SpO2. Adjusted for age, sex, neck circumference, and body mass index, SPST was correlated with the apnea-hypopnea index and hypoxemia indices. With a cutoff value ≥ 0.45 g/mm(2), the sensitivity of SPST for nocturnal hypoxemia (nadir SpO2, < 80%) was 81.3%. Patients with higher SPST (≥ 0.45 g/mm(2)) showed more airway occlusion in modified Muller maneuver, than those with lower values. CONCLUSIONS The SPST measured using Semmes Weinstein monofilaments reflects nocturnal hypoxemia and airway occlusion. This test provides a potential tissue marker of the severity of hypoxemia in patients who snore.
Collapse
Affiliation(s)
- Sang-Wook Kim
- Institute of Health Sciences, Gyeongsang National University, Jinju, South Korea ; Department of Otorhinolaryngology, Gyeongsang National University Hospital, Jinju, South Korea
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Buckley T, Mitten D, Elfar J. The effect of informed consent on results of a standard upper extremity intake questionnaire. J Hand Surg Am 2013; 38:366-71. [PMID: 23291079 PMCID: PMC5822429 DOI: 10.1016/j.jhsa.2012.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 10/14/2012] [Accepted: 10/16/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The trend toward requiring explicit consent from patients participating in observational research introduces the potential for consent bias, either through selection bias or through the Hawthorne effect. In the Hawthorne effect, patients may alter responses based on awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that study subjects' awareness of participation in an observational study by informed consent would alter responses to a standard upper extremity questionnaire in a statistically and clinically meaningful way compared with patients who filled out the questionnaire as a quality control measure. METHODS We retrospectively reviewed data on 39 patients who underwent isolated carpal tunnel release, who had completed preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) forms without providing consent for study participation. Next, we approached 35 patients scheduled to undergo isolated carpal tunnel release who completed the intake questionnaire on the day of surgery, for consent to participate in the study. After obtaining consent but before surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire at a mean of 8 weeks postoperatively. RESULTS There were no significant differences in age, sex, insurance status, symptom duration, nerve conduction study and electromyography results, or disease severity between groups. We identified no statistically significant difference in preoperative or postoperative Quick DASH score between the retrospective and prospective cohorts (40 ± 23 vs 40 ± 19 preoperatively; 27 ± 25 vs 19 ± 13 postoperatively) or within the prospective cohort before and after obtaining informed consent. CONCLUSIONS Informed consent did not significantly alter patients' responses to the Quick DASH questionnaire. These results suggest that both opt-in and opt-out approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice. CLINICAL RELEVANCE This study provides evidence that will inform the interpretation of observational research findings in hand surgery.
Collapse
|
20
|
Calfee RP, Dale AM, Ryan D, Descatha A, Franzblau A, Evanoff B. Performance of simplified scoring systems for hand diagrams in carpal tunnel syndrome screening. J Hand Surg Am 2012; 37:10-7. [PMID: 21975100 PMCID: PMC3438892 DOI: 10.1016/j.jhsa.2011.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 08/16/2011] [Accepted: 08/17/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Katz et al have published a standardized scoring system of hand diagrams for carpal tunnel syndrome. The purpose of this study was to quantitatively evaluate an alternative scoring of the hand diagram for detection of carpal tunnel syndrome. METHODS In a prospective study of 1,107 workers, 221 workers with hand symptoms completed hand diagrams and electrodiagnostic testing for carpal tunnel syndrome. Scoring algorithms for the hand diagrams included the Katz rating; a median nerve digit score (0-2) with a maximum of 2 symptomatic digits of thumb, index, and long fingers; and isolated digit scores (0-1) of thumb, index, or long finger. Intraclass correlation coefficients quantified inter-rater reliability. Sensitivity, specificity, and logistic regression analyses evaluated the scoring systems' ability to predict abnormal median nerve conduction. RESULTS One hundred ten subjects illustrated symptoms within the median nerve distribution. All scoring systems demonstrated substantial inter-rater reliability. "Classic" or "probable" Katz scores, median nerve digit score of 2, and positive long finger scores were significantly associated with abnormal median nerve distal sensory latency and median-ulnar difference. Abnormal distal motor latency was significantly associated with the median nerve digit score of 2 and positive long finger scores. Increasing Katz scores from "possible" to "probable" and "classic" were not associated with greater odds of electrodiagnostic abnormality. Positive long finger scores performed at least as well as the most rigorous scoring by Katz. CONCLUSIONS Symptoms diagrammed within the median nerve distribution are associated with abnormal nerve conduction among workers. The median nerve digit score and the long finger score offer increased ease of use compared to the Katz method, while maintaining similar performance characteristics. The long finger appears best suited for isolated digit scoring to predict abnormal median nerve conduction in a working population. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
Collapse
Affiliation(s)
- Ryan P. Calfee
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ann Marie Dale
- Department of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Ryan
- Department of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Alexis Descatha
- Department of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA,University of Versailles-Saint Quentin (UVSQ), Poincaré Teaching Hospital AP-HP, Occupational health department, INSERM U1018, Garches, France
| | - Alfred Franzblau
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Bradley Evanoff
- Department of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
21
|
Clark D, Amirfeyz R, Leslie I, Bannister G. Often atypical? The distribution of sensory disturbance in carpal tunnel syndrome. Ann R Coll Surg Engl 2011; 93:470-3. [PMID: 21929918 DOI: 10.1308/003588411x586191] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study aimed to examine the disturbance of hand sensation in patients with carpal tunnel syndrome (CTS) and assess the usefulness of objective and subjective measures. The study included 64 patients with CTS confirmed by electrophysiological testing. Sensory assessment was made by objective (pressure aesthesiometry) and subjective (hand symptom diagram) measures in different anatomical areas. The results of the subjective and objective testing were correlated with nerve conduction studies by a kappa analysis. Sensory disturbance occurred more frequently in areas innervated by the median nerve (index finger, 94%) but also with great frequency in other areas (little finger, 39%). Pain occurred frequently in anticipated areas (wrist crease, 33%) but also in other areas (little finger, 11%). There was very poor correlation between objective measures and electrophysiological testing or subjective measures. This study does therefore not support the use of objective sensory assessment for the initial diagnosis of CTS. An atypical distribution of symptoms is a common occurrence and should not discourage diagnosis of CTS. The patient's description of symptoms remains the most important tool in diagnosis.
Collapse
Affiliation(s)
- D Clark
- Orthopaedic Department, Bristol Royal Infirmary, Bristol, UK.
| | | | | | | |
Collapse
|
22
|
Trachter R, Brouwer B, Faris M, McLean L. Performance on a manual tracking task differentiates individuals at risk of developing carpal tunnel syndrome from those not at risk. J Electromyogr Kinesiol 2011; 21:998-1003. [DOI: 10.1016/j.jelekin.2011.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 10/16/2022] Open
|
23
|
Elfar JC, Calfee RP, Stern PJ. Topographical assessment of symptom resolution following open carpal tunnel release. J Hand Surg Am 2009; 34:1188-92. [PMID: 19643551 PMCID: PMC4422642 DOI: 10.1016/j.jhsa.2009.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 04/15/2009] [Accepted: 04/15/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE Patients with carpal tunnel syndrome commonly present with paresthesias and pain extending into the small finger and proximal to the hand. This study was conducted to assess the ability of carpal tunnel release to relieve symptoms outside of the median nerve distribution. METHODS We enrolled 34 consecutive surgical patients (40 wrists) diagnosed exclusively with carpal tunnel syndrome based on the history, physical examination, and electrodiagnostic studies. Preoperative symptoms were categorized as pain, numbness, tingling, or "burning and electrical shocks." The presence or absence of each symptom type was recorded in 5 topographical areas (zone I, palmar thumb/index/long; zone II, small finger; zone III, volar forearm; zone IV, volar arm; and zone V, dorsal hand/forearm/arm). Patients were contacted at 4 to 6 weeks postoperatively to assess resolution of each symptom type by topographic zone. RESULTS Preoperatively, the cohort reported symptoms in all zones: zone I, 120 reports; zone II, 47 reports; zone III, 33 reports; zone IV, 7 reports; and zone V, 23 reports. Numbness (n = 40) and tingling (n = 38) were the most common symptoms, followed by pain (n = 29) and "burning/shocks" (n = 16). Postoperatively, the total number of reports within the 5 zones decreased from 230 to 20. The probability that surgery would eliminate patient symptoms was 88% (104 of 120) in zone I, 96% (45 of 47) in zone II, 97% (32 of 33) in zone III, 86% (6 of 7) in zone 4, and 100% (23 of 23) in zone V. Across zones, the overall probability of symptom resolution was as follows: pain > 80%, numbness/tingling > 85%, and "burning/shocks" > 90%. CONCLUSIONS Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after carpal tunnel release. Over 85% of symptoms in each of the anatomic zones studied resolved. Feelings of burning or shock-like sensations were most reliably relieved at early follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
Affiliation(s)
| | - Ryan P. Calfee
- Washington University School of Medicine, Department of Orthopedic Surgery, Division of Hand Surgery
| | - Peter J. Stern
- Hand Surgery Specialists, Inc., University of Cincinnati, Department of Orthopedic Surgery, Division of Hand Surgery
| |
Collapse
|