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Grandizio LC, Ozdag Y, Mettler AW, Garcia VC, Manzar S, Akoon A, Dwyer CL, Klena JC. Sensitivity, Specificity, and Reliability of the CTS-6 for Carpal Tunnel Syndrome Administered by Medical Assistants. J Hand Surg Am 2024; 49:656-662. [PMID: 38795104 DOI: 10.1016/j.jhsa.2024.04.001] [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: 10/31/2023] [Revised: 03/16/2024] [Accepted: 04/03/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE The CTS-6 can be used clinically to diagnose carpal tunnel syndrome (CTS) and has demonstrated high levels of interrater reliability when administered by nonexpert clinicians. Our purpose was to assess sensitivity (Sn), specificity (Sp), and interrater reliability of the CTS-6 when administered by medical assistants (MAs). METHODS A series of patients presenting to an academic, upper-extremity surgery clinic were screened using CTS-6 between May and June of 2023. The CTS-6 was first administered by one of seven MAs and then by one of four fellowship-trained upper-extremity surgeons. In addition to recording baseline demographics, the results of each of the six history and examination components of the CTS-6 were recorded, as was the cumulative CTS-6 score (0-26). Surgeons were blinded to the scores obtained by the MAs. Interrater reliability (Cohen's kappa) was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 items. Sensitivity/specificity was calculated for the MA-administered CTS-6, using the score obtained by the surgeon as the reference standard. A CTS-6 score >12 was considered diagnostic of CTS. RESULTS Two hundred eighteen patients were included, and 26% had a diagnosis of CTS. The MA group demonstrated a Sn/Sp of 84%/91% for the diagnosis of CTS. Interrater reliability was substantial (Cohen's kappa: 0.72, 95% confidence interval: 0.62-0.83) for MAs compared with hand surgeons for the diagnosis of CTS. For individual CTS-6 components, agreement was lowest for the assessment of two-point discrimination (fair) and highest for the assessment of subjective numbness (near perfect). CONCLUSIONS The CTS-6 demonstrates substantial reliability and high Sn/Sp when administrated by MAs in an upper-extremity clinic. These data may be used to inform the development of CTS screening programs and future investigations in the primary care setting. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
| | - Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Alexander W Mettler
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Victoria C Garcia
- Biostatistics Core, Henry Hood Center for Research, Geisinger Health System, Danville, PA
| | - Shahid Manzar
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - C Liam Dwyer
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Joel C Klena
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
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Hooper RC, Hider A, Thompson N, Fan Z, Freed GL, Waljee JF. Implications of Patient-Provider Concordance on Treatment Recommendations for Carpal Tunnel Syndrome. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:173-177. [PMID: 38903835 PMCID: PMC11185886 DOI: 10.1016/j.jhsg.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 06/22/2024] Open
Abstract
Purpose Differences in the utilization of carpal tunnel release (CTR) by Blacks and women are well documented, but less is known regarding the impact of patient-provider concordance on treatment recommendations. To investigate this, we surveyed hand surgeons using hypothetical scenarios to evaluate variations in treatment recommendations for carpal tunnel syndrome based on patient-related factors and patient-provider concordance. Methods Three pairs (six total) of hypothetical scenarios with clinical symptoms of carpal tunnel syndrome were created varying sex, race, and occupation. We used names as a proxy for sex and race. Occupation included manual laborers, secretaries, athletes, and retirees. American Society for Surgery of the Hand members were emailed an anonymous web-based link to participate. We used descriptive statistics to analyze the scenario-based treatment recommendations. Results We identified 3,067 eligible members for participation; 770 surgeons responded (25%) and provided recommendations for 3,742 scenarios. For scenarios involving symptomatic patients without electrodiagnostic studies (EDS), with normal EDS, and with abnormal EDS, no difference was noted in surgeon treatment recommendations based on patients' race, sex, and occupation. Surgeons recommended EDS for 31% and 32.8% of the scenarios with Black female and White male patients, respectively, who did not have EDS at presentation and CTR for 32.3% and 33% of White females and Black males with normal EDS, respectively. Among retired Black female and White male patients older than 80 years of age with abnormal EDS, surgeons recommended CTR in 89.9% and 89.3% of them, respectively. For patient-provider racially concordant pairs, White surgeons recommended CTR to a similar proportion of Black and White hypothetical patients; however, Black surgeons recommended CTR to a greater proportion of patients with Black-sounding names. Conclusions We found that surgeon treatment recommendation was not associated with patient race, sex, or occupation; however, differences did emerge based on patient-provider racial concordance, suggesting that alignment of patient and provider identities may influence treatment recommendations. Type of study/level of evidence Prognostic III.
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Affiliation(s)
- Rachel C. Hooper
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI
| | | | - Noelle Thompson
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH
| | - Zhaohui Fan
- Department of Surgery, University of Michigan, Medical School, Ann Arbor, MI
| | | | - Jennifer F. Waljee
- Department of Surgery, Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, University of Michigan, Medical School, Ann Arbor, MI
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Zhang D, Earp BE, Blazar P. Carpal Tunnel Syndrome Electrodiagnostic Severity is Not Associated with PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. J Hand Surg Asian Pac Vol 2024; 29:17-23. [PMID: 38299249 DOI: 10.1142/s2424835524500036] [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: 02/02/2024]
Abstract
Background: The primary objective of this study was to determine the association between preoperative electrodiagnostic study (EDS) parameters and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments in patients with EDS-confirmed carpal tunnel syndrome (CTS). Methods: A retrospective study of 45 patients with EDS-confirmed CTS was conducted. Patients completed the PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Explanatory variables included EDS disease severity (mild, moderate and severe), sensory peak latency, sensory amplitude, motor latency, motor amplitude, the presence of nonrecordable sensory latency and the presence of nonrecordable sensory amplitude. Explanatory variables also included patient-related factors, such as age, sex and diabetes mellitus. Associations between variables were assessed using simple linear regression, analysis of variance (ANOVA) and Student's t-test. Results: In our cohort, the EDS severity was mild in 38%, moderate in 42% and severe in 20% of patients. The mean PROMIS Upper Extremity score was 44.4, the mean PROMIS Pain Interference score was 53.5 and the mean PROMIS Pain Intensity score was 49.9. Bivariate analysis demonstrated no association between EDS severity overall or any EDS parameter individually and PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Diabetes mellitus was associated with poorer PROMIS Upper Extremity scores. Conclusions: EDS severity is not associated with PROMIS Upper Extremity, PROMIS Pain Interference and PROMIS Pain Intensity. Carpal tunnel release is commonly indicated for pain and dysfunction, but validated measures of pain and dysfunction do not correlate with EDS severity. Level of Evidence: Level III (Diagnostic).
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Baylor JL, Rae M, Manzar S, Pallis M, Olsen HP, Akoon A, Grandizio LC. Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures. J Hand Surg Am 2023; 48:1091-1097. [PMID: 37578400 DOI: 10.1016/j.jhsa.2023.07.004] [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: 02/12/2023] [Revised: 06/16/2023] [Accepted: 07/04/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Although the initial description of the distal biceps tendon (DBT) hook test (HT) reported 100% sensitivity (Sn) and specificity (Sp), subsequent retrospective series have demonstrated imperfect validity. The purpose of this investigation was to prospectively assess the validity and reliability of the HT for complete DBT ruptures. We aimed to determine the Sn/Sp and interrater reliability for the HT. METHODS A consecutive series of adult patients presenting to our outpatient clinics with an elbow complaint was prospectively examined. Patients were included if they had undergone advanced imaging (magnetic resonance imaging or ultrasound) that imaged the DBT and underwent DBT repair. There were four participating surgeons, all of whom were blinded to magnetic resonance imaging/ultrasound prior to performing the HT. To determine the Sn/Sp of the HT and advanced imaging, intraoperative findings served as the primary reference standard. The interrater reliability of the HT was calculated for cases in which a primary examiner (surgeon) and secondary examiner (physician assistant or resident) performed the HT. RESULTS Of 64 patients who had undergone advanced imaging, 28 (44%) underwent DBT surgery and were included in the assessment of Sn/Sp. The mean age was 49 years, and all patients were men. The Sn and Sp of the HT were 96% and 67%, respectively. Advanced imaging demonstrated 100% Sn and Sp. Twenty-five patients were evaluated by a primary and secondary examiner. The interrater reliability was substantial (Cohen kappa, 0.71). CONCLUSIONS The Sn and Sp of the HT were 96% and 67%, respectively, when assessed prospectively. Advanced imaging findings (magnetic resonance imaging/ultrasound) demonstrated 100% Sn and Sp. The HT can be performed reliably by examiners with varying experience levels. Considering the imperfect validity of the HT, we caution against the use of this examination alone to diagnose DBT ruptures. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Jessica L Baylor
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Matthew Rae
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Shahid Manzar
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Mark Pallis
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Hans P Olsen
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA.
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Ozdag Y, Hu Y, Hayes DS, Manzar S, Akoon A, Klena JC, Grandizio LC. Sensitivity and Specificity of Examination Maneuvers for Carpal Tunnel Syndrome: A Meta-Analysis. Cureus 2023; 15:e42383. [PMID: 37621797 PMCID: PMC10446104 DOI: 10.7759/cureus.42383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Our purpose was to assess the diagnostic validity (sensitivity (Sn) and specificity (Sp)) of physical examination maneuvers for carpal tunnel syndrome (CTS). This meta-analysis utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Studies assessing exam maneuvers (including components of the CTS-6) for CTS were identified in MEDLINE (Medical Literature Analysis and Retrieval System Online) and Embase (Excerpta Medica Database) databases. Assessed maneuvers assessed included: Phalen's test, Tinel's sign, Durkan test, scratch-collapse test, Semmes-Weinstein monofilament (SWM), and static 2-point discrimination (2PD) test. Data extracted included: article name, total number of subjects/hands, type of exam, and exam Sn/Sp. Forest plots were presented to display the estimated Sn/Sp and boxplots were used to demonstrate the locality, spread, and skewness of the Sn/Sp through the quartiles. After screening 570 articles, 67 articles involving 8924 hands were included. Forty-eight articles assessed Phalen's test, 45 assessed Tinel's sign, 21 assessed the Durkan test, seven assessed the scratch-collapse test, 11 assessed SWM, and six assessed the static 2PD test. Phalen's test demonstrated the greatest median Sn (0.70, (Q1, Q3): (0.51, 0.85)), followed by the Durkan test (0.67, (Q1, Q3): (0.46, 0.82)). 2PD demonstrated the highest median Sp (0.90, (Q1, Q3): (0.88, 0.90)), followed by SWM (0.85, (Q1, Q3): (0.51, 0.89)). There is considerable variability with respect to the validity of physical exam tests used in the diagnosis of CTS. Upper-extremity surgeons should be aware of inherent limitations for individual exam maneuvers. In the absence of a uniformly accepted diagnostic gold standard, a combination of exams, along with pertinent patient history, should guide the diagnosis of CTS.
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Affiliation(s)
- Yagiz Ozdag
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Yirui Hu
- Epidemiology and Health Administration, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Daniel S Hayes
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Shahid Manzar
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Anil Akoon
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Joel C Klena
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Louis C Grandizio
- Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Danville, USA
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Bohn DC. What's New in Hand and Wrist Surgery. J Bone Joint Surg Am 2023; 105:428-434. [PMID: 36727929 DOI: 10.2106/jbjs.22.01326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Deborah C Bohn
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
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Zhuang T, Shapiro LM, Schultz EA, Truong NM, Harris AHS, Kamal RN. Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline? J Hand Surg Am 2023; 48:19-27. [PMID: 36460552 DOI: 10.1016/j.jhsa.2022.09.019] [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: 04/27/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG. METHODS Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release. RESULTS Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (-11.50 per 1,000 patients [95% CI, -1.47 to -0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97-2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by -23.57 per 1,000 patients (95% CI, -37.72 to -9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG. CONCLUSIONS The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS. CLINICAL RELEVANCE Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.
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Affiliation(s)
- Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Emily A Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Nicole M Truong
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Alex H S Harris
- Department of Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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John A, Rossettie S, Rafael J, Cox CT, Ducic I, Mackay BJ. Patient-Reported Outcomes and Provocative Testing in Peripheral Nerve Injury and Recovery. J Brachial Plex Peripher Nerve Inj 2023; 18:e10-e20. [PMID: 37089516 PMCID: PMC10121318 DOI: 10.1055/s-0043-1764352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 02/03/2023] [Indexed: 04/25/2023] Open
Abstract
Background Peripheral nerve function is often difficult to assess given the highly variable presentation and subjective patient experience of nerve injury. If nerve assessment is incomplete or inaccurate, inappropriate diagnosis and subsequent treatment may result in permanent dysfunction. Objective As our understanding of nerve repair and generation evolves, so have tools for evaluating peripheral nerve function, recovery, and nerve-related impact on the quality of life. Provocative testing is often used in the clinic to identify peripheral nerve dysfunction. Patient-reported outcome forms provide insights regarding the effect of nerve dysfunction on daily activities and quality of life. Methods We performed a review of the literature using a comprehensive combination of keywords and search algorithms to determine the clinical utility of different provocative tests and patient-reported outcomes measures in a variety of contexts, both pre- and postoperatively. Results This review may serve as a valuable resource for surgeons determining the appropriate provocative testing tools and patient-reported outcomes forms to monitor nerve function both pre- and postoperatively. Conclusion As treatments for peripheral nerve injury and dysfunction continue to improve, identifying the most appropriate measures of success may ultimately lead to improved patient outcomes.
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Affiliation(s)
- Albin John
- Texas Tech University Health Sciences Center, Lubbock, Texas
- Address for correspondence Albin John, MBA Department of Orthopaedic SurgeryTexas Tech University Health Sciences Center, 3601 4th Street, Mail Stop 9436, Lubbock 79430TX
| | | | - John Rafael
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Cameron T. Cox
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ivica Ducic
- Washington Nerve Institute, McLean, Virginia
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