The reliability of physical examination for carpal tunnel syndrome

Sensitivity, Specificity, and Reliability of the CTS-6 for Carpal Tunnel Syndrome Administered by Medical Assistants

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.

Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound

BACKGROUND

Although idiopathic median neuropathy at the carpal tunnel (IMNCT) is objective and verifiable, distinction of normal and abnormal nerves is imprecise and probabilistic. The associated symptoms and signs (carpal tunnel syndrome [CTS]) vary, particularly for nonsevere (mild and moderate) median neuropathy. Discordance between diagnosis of mild or moderate median neuropathy at the carpal tunnel using symptoms and signs and diagnosis based on objective tests is a measure of the potential for overdiagnosis and overtreatment.

QUESTION/PURPOSE

What is the difference in the estimated prevalence of mild-to-moderate IMNCT using nonsevere signs and symptoms compared with the estimated prevalence using electrodiagnostic studies (EDS) and ultrasound (US)?

METHODS

We used data from an existing cross-sectional data registry. To create this registry, between January 2014 and January 2019, we considered all new adult English-speaking people who had an EDS that included the median nerve or people with a diagnosis of CTS who did not have surgery yet. A small and unrecorded number of people declined participation. The cross-sectional area of the median nerve at the distal wrist crease using US in people who already had EDS was measured. People with a diagnosis of CTS underwent both EDS and US. The six signs and symptoms of Carpal Tunnel Syndrome 6 (CTS-6, a validated tool to estimate the probability of IMNCT using ratings of symptoms and signs of CTS) were recorded. This resulted in a registry of 185 participants; we excluded 75 people for obvious, severe IMNCT (defined as nonrecordable nerve conduction velocity, thenar atrophy, or greater than 5 mm 2-point discrimination). Three of the 110 qualifying patients had missing information on ethnicity or race, but we accounted for this in our final analysis. Without a reference standard, as is the case with IMNCT, latent class analysis (LCA) can be used to establish the probability that an individual has specific pathophysiologic findings. LCA is a statistical method that identifies sets of characteristics that tend to group together. This technique has been used, for example, in diagnosing true scaphoid fractures among suspected fractures based on a combination of demographic, injury, examination, and radiologic variables. The prevalence of mild-to-moderate IMNCT was estimated in two LCAs using four signs and symptoms characteristic of mild-to-moderate IMNCT, as well as EDS and US measures of median neuropathy.

RESULTS

The estimated prevalence of mild-to-moderate IMNCT based on signs and symptoms was 73% (95% CI 62% to 81%), while the estimated prevalence using EDS and US measurements was 51% (95% CI 37% to 65%).

CONCLUSION

The notable discordance of 22% between the estimated prevalence of mild-to-moderate IMNCT using signs and symptoms and prevalence based on EDS and US criteria, and the overlapping CIs of the probability estimations, indicate considerable uncertainty and a corresponding notable potential for underdiagnosis or overdiagnosis. When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. We might benefit from a more accurate and reliable diagnostic strategy or tool for mild-to-moderate IMNCT; this might be the focus of a future study.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Reliability of Ulnar Nerve Sensation Tests in Patients with Cubital Tunnel Syndrome and Healthy Subjects

Static two-point discrimination (2PD) and Semmes–Weinstein monofilament (SWM) tests are commonly used to evaluate sensory disorders in the hand. The aim of this study was to evaluate the reliability of 2PD and SWM tests in the ulnar nerve innervation area in patients with cubital tunnel syndrome (CuTS) and healthy individuals. This was a two-group repeated-measures inter-rater and intra-rater reliability study. Twenty-one patients with CuTS and 30 healthy adults participated. The static 2PD test was performed using a standardized Dellon discriminator, whereas the SWM test was conducted using TOUCH TEST monofilaments. Two examiners performed both tests at the hypothenar eminence and the fourth and fifth digits (ulnar nerve innervation hand territory). First, examiner A conducted three series of 2PD and SWM tests twice with a 15-min rest period (within-day intra-rater reliability). Next, examiner B repeated the same examination 5 min after (inter-rater reliability). Examiner A conducted the same examination 7 days after (between-day intra-rater reliability). For single measurements, the inter-rater reliability and within-day intra-rater reliability in the 2PD was at least 0.81 in patients with CuTS or healthy subjects. The between-days intra-rater reliability for a single measurement varied from 0.56 to 0.95 in CuTS patients and healthy subjects. The between-days intra-rater reliability for mean value from three measurements was above 0.80. The kappa for SWM was above 0.8 and the percentage of agreement was at least 90% for all sessions and trials. In conclusion, the 2PD and SWM tests are reliable for assessing sensation in the ulnar nerve innervation area of the hand in patients with CuTS and healthy subjects.

Comparative Efficacy of Routine Physical Therapy with and without Neuromobilization in the Treatment of Patients with Mild to Moderate Carpal Tunnel Syndrome

Background

Median nerve mobilization is a relatively new technique that can be used to treat carpal tunnel syndrome. But literature about additional effects of neuromobilization for the management of carpal tunnel syndrome is scarce.

Objective

To examine and compare the role of median nerve neuromobilization at the wrist as compared to routine physical therapy in improving pain numeric pain rating scale (NPRS), range of motion (Ballestero-Pérez et al., 2017), muscle strength, and functional status.

Methods

A sample size of 66 patients was recruited using convenient sampling and distributed randomly in two groups. After assessing both groups using ROM, manual muscle strength, pain at NPRS, and functional status on the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), which consists of two further scales (the symptom severity scale (SSS) and the functional status scale (FSS)), Group 1 received conservative treatment including ultrasound therapy two days a week for six weeks, using a pulsed mode 0.8 W/cm² and frequency 1 MHz, wrist splinting, and tendon gliding exercises, while Group 2 received both conservative treatments including ultrasound, splinting, and tendon gliding exercises as well as a neuromobilization technique. Treatment was given for 6 weeks, 2 sessions/week, and patients were reassessed at the end of the 3^rd and 6^th weeks.

Results

Although both groups improved significantly in terms of all the outcome measures used, the neuromobilization groups showed a statistically more significant increase in flexion, extension, decrease in pain, decrease in SSS, decrease in FSS, and BCTQ as compared to the routine physical therapy group.

Conclusions

The addition of neuromobilization in the rehabilitation program of carpal tunnel syndrome has better effects on treatment outcomes.

A 15-Year Review of Clinical Practice Patterns in Carpal Tunnel Syndrome Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery has been collecting practice data on carpal tunnel syndrome treatment since 2004 as part of its Continuous Certification Program. These data allow plastic surgeons to compare their surgical experience to national trends and analyze those trends in relation to current evidence-based medicine.

METHODS

Data on carpal tunnel syndrome treatment from 2004 to 2014 were compared to those from 2015 to 2020. National practice trends observed in these data were evaluated relative to current literature regarding evidence-based practices.

RESULTS

A total of 11,090 carpal tunnel syndrome cases were included from 2004 to 2020. Electrodiagnostic and imaging studies were performed on most patients despite adding little sensitivity and specificity when physical examination tests are performed and not being considered cost-effective. An open "mini" approach has remained the most common surgical technique in carpal tunnel release for the last 15 years, with growing usage (53 percent versus 59 percent, p < 0.001). Splinting has decreased significantly over the last 15 years, from usage in 39 percent of patients to 28 percent (p < 0.001). Formal postoperative hand therapy has declined from 27 percent of patients to 22 percent (p < 0.001). Despite their low efficacy, 63 percent of patients received one or more perioperative doses of antibiotics.

CONCLUSIONS

Analysis of the Continuous Certification Program tracer data from the American Board of Plastic Surgery provides an excellent overview of current practice and its development over the 15 years since its inception. This analysis provides insight into how effectively plastic surgeons have remained aligned with developments in best practices in treating carpal tunnel syndrome.

The Reliability of the CTS-6 for Examiners With Varying Levels of Clinical Experience

PURPOSE

To assess the interrater reliability of the CTS-6 for examiners with varying levels of clinical expertise. We also aimed to analyze this instrument's sensitivity (Sn) and specificity (Sp), using the CTS-6 score obtained by a hand surgeon as a reference standard.

METHODS

Three examining groups consisting of medical students, occupational hand therapists, and hand surgeons examined a consecutive series of patients in an academic upper-extremity clinic. A total of 3 examiners (1 from each group) recorded a CTS-6 score for each patient. The examiners were blinded to the scores from the other groups. The interrater reliability was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 components. Sn and Sp were calculated for each of the groups using the CTS-6 obtained by the hand surgeons as the reference standard.

RESULTS

Two hundred seven patients were included. For the diagnosis of CTS (CTS-6 score of 12 or greater as determined by a hand surgeon), there was substantial agreement between the 3 groups (Fleiss kappa 0.73; 95% CI [0.65 -0.82]; P < .05). For individual CTS-6 components, the agreement between the groups was highest for assessing subjective numbness and lowest for assessing a Tinel sign (Fleiss kappa of 0.77 and 0.49, respectively). The Sn/Sp for diagnosing CTS was 87%/91% for the medical student group and 81%/95% for the occupational hand therapist group.

CONCLUSIONS

The CTS-6 can be reliably used as a screening and diagnostic tool for CTS by clinicians with a variety of experience levels and without specific fellowship training in upper-extremity surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic I.

Subclinical Peroneal Neuropathy Affects Ambulatory, Community-Dwelling Adults and Is Associated with Falling

BACKGROUND

Peroneal neuropathy with an overt foot drop is a known risk factor for falling. Subclinical peroneal neuropathy caused by compression at the fibular neck is subtler and does not have foot drop. A previous study found subclinical peroneal neuropathy in 31 percent of hospitalized patients. This was associated with having fallen. The purpose of this study was to determine the prevalence of subclinical peroneal neuropathy in ambulatory adults and investigate if it is associated with falling.

METHODS

A cross-sectional study of 397 ambulatory adults presenting to outpatient clinics at a large academic hospital was conducted from 2016 to 2017. Patients were examined for dorsiflexion weakness and signs of localizing peroneal nerve compression to the fibular neck. Fall risk was assessed with the Activities-Specific Balance Confidence Scale and self-reported history of falling. Multivariate logistic regression was used to correlate subclinical peroneal neuropathy with fall risk and a history of falls.

RESULTS

The mean patient age was 54 ± 15 years and 248 patients (62 percent) were women. Thirteen patients (3.3 percent) were found to have subclinical peroneal neuropathy. After controlling for various factors known to increase fall risk, patients with subclinical peroneal neuropathy were 3.74 times (95 percent CI, 1.06 to 13.14) (p = 0.04) more likely to report having fallen multiple times in the past year than patients without subclinical peroneal neuropathy. Similarly, patients with subclinical peroneal neuropathy were 7.22 times (95 percent CI, 1.48 to 35.30) (p = 0.02) more likely to have an elevated fall risk on the Activities-Specific Balance Confidence fall risk scale.

CONCLUSION

Subclinical peroneal neuropathy affects 3.3 percent of adult outpatients and may predispose them to falling.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

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.

Recovery of mechanical detection thresholds after direct digital nerve repair versus conduit implantation

The purpose of this study was to assess sensory and functional nerve recovery after digital nerve injury in patients with an end-to-end suture (S) or with implantation of a collagen conduit (C) to bridge a nerve gap. Fifteen S and 11 C with a follow-up of 6-36 months and 28 healthy control participants were enrolled. Methods of assessments were quantitative sensory testing, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), range of motion and the painDetect questionnaire. After both procedures, sensory profiles showed largely recovered function of C and Aδ fibres but severe loss of Aβ-fibre function leading to increased mechanical detection thresholds. There was only minimal allodynia. Severe pain was absent. Patients with conduits reported more functional impairment, especially in work performance, which correlated with the assessed loss of Aß-fibre function.

LEVEL OF EVIDENCE

III.

Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Create a safe and effective plan for management of carpal tunnel syndrome. 2. Support his or her rationale for the use of diagnostic tests. 3. Discuss elements of management that have been controversial, including anesthesia, the use of a tourniquet, postoperative pain control, and cost of care.

SUMMARY

This is the fourth MOC-PS CME article on carpal tunnel syndrome. Each of the prior three has had a slightly different focus, and the reader is invited to review all to generate a comprehensive view of the management of this common, and often controversial, topic. The operative goal-to release the transverse carpal ligament-is straightforward: diagnosis, cause, and technique have generated more vibrant discussions.

Subclinical Peroneal Neuropathy: A Common, Unrecognized, and Preventable Finding Associated With a Recent History of Falling in Hospitalized Patients

PURPOSE

Identification of modifiable risk factors for falling is paramount in reducing the incidence and morbidity of falling. Peroneal neuropathy with an overt foot drop is a known risk factor for falling, but research into subclinical peroneal neuropathy (SCPN) resulting from compression at the fibular head is lacking. The purpose of our study was to determine the prevalence of SCPN in hospitalized patients and establish whether it is associated with a recent history of falling.

METHODS

We conducted a cross-sectional study of 100 medical inpatients at a large academic tertiary care hospital in St Louis, Missouri. General medical inpatients deemed at moderate to high risk for falling were enrolled in the summer of 2013. Patients were examined for findings that suggest peroneal neuropathy, fall risk, and a history of falling. Multivariate logistic regression was used to correlate SCPN with fall risk and a history of falls in the past year.

RESULTS

The mean patient age was 53 years (SD = 13 years), and 59 patients (59%) were female. Thirty-one patients had examination findings consistent with SCPN. After accounting for various confounding variables within a multivariate logistic regression model, patients with SCPN were 4.7 times (95% CI, 1.4-15.9) more likely to report having fallen 1 or more times in the past year.

CONCLUSIONS

Subclinical peroneal neuropathy is common in medical inpatients and is associated with a recent history of falling. Preventing or identifying SCPN in hospitalized patients provides an opportunity to modify activity and therapy, potentially reducing risk.

Inter- and intra-tester reliability of sensibility testing in digital nerve repair

The aim of this study was to investigate the inter- and intra-tester reliability of the static two-point discrimination and Semmes-Weinstein monofilament tests in digital nerve repair. A total of 100 digital nerves from 67 patients were included into the study. An experienced orthopaedic surgeon and a physiotherapist examined the sensory nerve recovery. The reproducibility score of both tests was at a poor level, but the reliability of the Semmes-Weinstein monofilament test was higher than the static two-point discrimination test. These tests should not be used alone in the quantitative monitoring of sensory recovery, but should be interpreted with the clinical findings.Level 3 non-randomized controlled study.

Interobserver agreement in case history evaluation in carpal tunnel syndrome

OBJECTIVES

The case history is the cornerstone for the diagnosis of carpal tunnel syndrome (CTS). The value of neurological examination in CTS seems limited. In this study, we investigated the interobserver agreement in case history of CTS and the potential additional value of neurological examination.

METHODS

Case history was taken and neurological examination was done in all patients referred for a possible CTS during a 6-month period. This was done independently by 2 senior neurologists.

RESULTS

We studied 119 patients. The interobserver agreement for the conclusion of CTS after history was high (k = 0.79). Neurological examination rarely changed the diagnosis based on the case history.

CONCLUSIONS

This study shows a high interobserver agreement in the diagnosis of CTS based on patient history alone. Neurological examination rarely changed this diagnosis, suggesting a prominent role for the case history and a limited role for neurological examination. This may have practical implications.

Tactile assessment in children with cerebral palsy: a clinimetric review

This review evaluates the clinimetric properties of tactile assessments for children with cerebral palsy. Assessment of registration was reported using Semmes Weinstein Monofilaments (SWMs) or exteroception. Assessment of two-point discrimination was reported using the Disk-Criminator® or paperclip methods; Single point localization and double simultaneous were reported from the Neurosensory Motor Developmental Assessment (NSMDA); graphaesthesia was reported from the Sensory Integration and Praxis Test (SIPT); and stereognosis was assessed using Manual Form Perception from the SIPT and the Klingels method (Klingels, K. et al. (2010). Upper limb motor and sensory impairments in children with hemiplegic cerebral palsy. Can they be measured reliably? Disability and Rehabilitation, 32(5), 409-416) and the Cooper method (Cooper, J., Majnemer, A., Rosenblatt, B., & Birnbaum, R. (1995). The determination of sensory deficits in children with hemiplegic cerebral palsy. Journal of Child Neurology, 10, 300-309). The SIPT and NSMDA demonstrated stronger content validity. Inter-rater reliability was excellent for SIPT (ICC = 0.99) and exteroception (k = 0.88). Test-retest reliability was excellent for exteroception (k = 0.89) and stereognosis (ICC = 0.86; 100%), moderate for SIPT (r = 0.69-0.74) and poor for SWM (k = 0.22). Together these assessments measure tactile registration and spatial perception. Temporal and textural tests are to be developed for comprehensive tactile examination.

Diagnostic accuracy of ultrasonography vs. electromyography in carpal tunnel syndrome: a systematic review of literature

A plethora of research investigates sonography vs. electrodiagnostic testing (EDX) for diagnosis of carpal tunnel syndrome (CTS). Through database searches, hand searches and communication with authors, 582 abstracts published from 1999 to 2009 were identified. A comprehensive systematic review process resulted in inclusion of 23 studies. Significant methodologic discrepancies among the studies limited the ability to complete a meta-analysis to identify specific diagnostic thresholds. Instead, the data were reviewed to provide implications for clinical utility of sonography as a screening tool as a compliment to EDX and to suggest continued and future research. The largest cross-sectional area of the median nerve within the carpal tunnel region has high potential for clinical screening, especially in individuals with severe CTS. Identifying swelling of the nerve through comparative measurements, qualitative analysis and Doppler techniques all require further investigation. Screening protocols may be enhanced through exploration of sonography in patients with mild CTS and false-negative EDX.

Utility of quantitative sensory testing and screening tools in identifying HIV-associated peripheral neuropathy in Western Kenya: pilot testing

BACKGROUND/AIM

Neuropathy is the most common neurologic complication of HIV but is widely under-diagnosed in resource-constrained settings. We aimed to identify tools that accurately distinguish individuals with moderate/severe peripheral neuropathy and can be administered by non-physician healthcare workers (HCW) in resource-constrained settings.

METHODS

We enrolled a convenience sample of 30 HIV-infected outpatients from a Kenyan HIV-care clinic. A HCW administered the Neuropathy Severity Score (NSS), Single Question Neuropathy Screen (Single-QNS), Subjective Peripheral Neuropathy Screen (Subjective-PNS), and Brief Peripheral Neuropathy Screen (Brief-PNS). Monofilament, graduated tuning fork, and two-point discrimination examinations were performed. Tools were validated against a neurologist's clinical assessment of moderate/severe neuropathy.

RESULTS

The sample was 57% male, mean age 38.6 years, and mean CD4 count 324 cells/µL. Neurologist's assessment identified 20% (6/30) with moderate/severe neuropathy. Diagnostic utilities for moderate/severe neuropathy were: Single-QNS--83% sensitivity, 71% specificity; Subjective-PNS-total--83% sensitivity, 83% specificity; Subjective-PNS-max and NSS--67% sensitivity, 92% specificity; Brief-PNS--0% sensitivity, 92% specificity; monofilament--100% sensitivity, 88% specificity; graduated tuning fork--83% sensitivity, 88% specificity; two-point discrimination--75% sensitivity, 58% specificity.

CONCLUSIONS

Pilot testing suggests Single-QNS, Subjective-PNS, and monofilament examination accurately identify HIV-infected patients with moderate/severe neuropathy and may be useful diagnostic tools in resource-constrained settings.

Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects

PURPOSE

To determine the intrarater-reliability, interrater-reliability and normal reference scores of the Semmes Weinstein Monofilament test (SWM) of the feet of healthy subjects. In addition, the stability of the SWM for prospective use was assessed by determining systematic changes in sensory thresholds.

METHODS

Interrater-reliability was assessed on five locations of the plantar side of both feet using monofilaments 1.65, 2.36, 2.44, 2.83, 3.22, 3.61, 3.84, 4.08, 4.31, 5.56, 6.65 in 60 healthy subjects by two or three investigators (test day 1). Intrarater-reliability and systematic changes in sensory thresholds were assessed 3 weeks later (test day 22) by one investigator.

RESULTS

Median interrater-reliability for the five test locations for both feet was poor to moderate. Median intrarater-reliability was good for the left foot and poor to moderate for the right foot. Significantly lower median sensory thresholds were found for the first SWM measurement at test day 22 compared to the first and second measurement of test day 1. Given the observed reliability of the SWM, a normal sensory score for the feet was situated between monofilament 3.22 and 4.08.

CONCLUSIONS

The SWM are reliable when measured by one researcher. Systematic changes in sensory thresholds were observed; therefore, the stability of the SWM for use in prospective studies could not be verified.

Using evidence-based practice to select diagnostic tests

Diagnosis is a primary activity of hand surgeons and therapists. Diagnostic tests can be used to assist in "ruling in" or "ruling out" a condition to best direct prognosis and treatment. However, the assigning of the diagnostic label is not always obvious. Principles of evidence-based practice may help hand care professionals improve their practice in the diagnosis of their patients. Evidence-based practice can be defined in terms of five steps that serve the structure for decision making and ensure optimum use of clinicians' expertise in the diagnosis.

Diagnosing soft tissue rheumatic disorders of the upper limb in epidemiological studies of vibration-exposed populations

OBJECTIVES

To investigate approaches adopted to diagnose soft tissue rheumatic disorders of the upper limb (ULDs) in vibration-exposed populations and in other settings, and to compare their methodological qualities.

METHODS

Systematic searches were made of the Medline, Embase, and CINAHL electronic bibliographic databases, and of various supplementary sources (textbooks, reviews, conference and workshop proceedings, personal files). For vibration-exposed populations, qualifying papers were scored in terms of the provenance of their measuring instruments (adequacy of documentation, standardisation, reliability, criterion-related and content validity). Similar criteria were applied to general proposals for whole diagnostic schemes, and evidence was collated on the test-retest reliability of symptom histories and clinical signs.

RESULTS

In total, 23 relevant reports were identified concerning vibration-exposed populations--21 involving symptoms and 9 involving examination/diagnosis. Most of the instruments employed scored poorly in terms of methodological quality. The search also identified, from the wider literature, more than a dozen schemes directed at classifying ULDs, and 18 studies of test-retest reliability of symptoms and physical signs in the upper limb. Findings support the use of the standardised Nordic questionnaire for symptom inquiry and suggest that a range of physical signs can be elicited with reasonable between-observer agreement. Four classification schemes rated well in terms of content validity. One of these had excellent documentation, and one had been tested for repeatability, agreement with an external reference standard, and utility in distinguishing groups that differed in disability, prognosis and associated risk factors.

CONCLUSIONS

Hitherto, most studies of ULDs in vibration-exposed populations have used custom-specified diagnostic methods, poorly documented, and non-stringent in terms of standardisation and supporting evidence of reliability and/or validity. The broader literature contains several question sets and procedures that improve upon this, and offer scope in vibration-exposed populations to diagnose ULDs more systematically.

Randomized clinical trial of surgery versus conservative therapy for carpal tunnel syndrome [ISRCTN84286481]

BACKGROUND

Conservative treatment remains the standard of care for treating mild to moderate carpal tunnel syndrome despite a small number of well-controlled studies and limited objective evidence to support current treatment options. There is an increasing interest in the usefulness of wrist magnetic resonance imaging could play in predicting who will benefit for various treatments.

METHOD AND DESIGN

Two hundred patients with mild to moderate symptoms will be recruited over 3 1/2 years from neurological surgery, primary care, electrodiagnostic clinics. We will exclude patients with clinical or electrodiagnostic evidence of denervation or thenar muscle atrophy. We will randomly assign patients to either a well-defined conservative care protocol or surgery. The conservative care treatment will include visits with a hand therapist, exercises, a self-care booklet, work modification/ activity restriction, B6 therapy, ultrasound and possible steroid injections. The surgical care would be left up to the surgeon (endoscopic vs. open) with usual and customary follow-up. All patients will receive a wrist MRI at baseline. Patients will be contacted at 3, 6, 9 and 12 months after randomization to complete the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ). In addition, we will compare disability (activity and work days lost) and general well being as measured by the SF-36 version II. We will control for demographics and use psychological measures (SCL-90 somatization and depression scales) as well as EDS and MRI predictors of outcomes.

DISCUSSION

We have designed a randomized controlled trial which will assess the effectiveness of surgery for patients with mild to moderate carpal tunnel syndrome. An important secondary goal is to study the ability of MRI to predict patient outcomes.

Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome

OBJECTIVE

To determine the utility of the flick maneuver (flicking motion of hands and wrists when most symptomatic) in the clinical evaluation of carpal tunnel syndrome (CTS).

DESIGN

Review of standardized data collection on 142 subjects referred for electrodiagnostic evaluation of possible CTS at a university hospital electrodiagnostic clinic. Subjects were first clinically evaluated with the flick, Phalen, and Tinel maneuvers. Subsequently, they all underwent nerve conduction studies. Electrodiagnostic results were used as the gold standard for patient group assignments. Sensitivities, specificities, and predictive values for individual and combined clinical tests were determined. McNemar chi square values were calculated to determine whether one test identified more patients with CTS. The sensitivities of clinical maneuvers were also evaluated in relation to electrodiagnostic severity of CTS.

RESULTS

Of the 142 subjects, 67% had CTS. The sensitivities of the flick, Tinel, and Phalen signs were 37%, 27%, and 34%, respectively. False-positive results ranged from 8% (Tinel) to 26% (flick and Phalen). Positive predictive values for the flick, Tinel, and Phalen maneuvers were 74%, 87%, and 73%, respectively, and negative predictive values were 37%, 39%, and 35%. McNemar chi square results revealed that the flick maneuver detected more subjects with CTS than the Tinel sign. With increasing electrodiagnostic severity, the sensitivity of all clinical tests tended to improve slightly.

CONCLUSION

The flick sign is of limited clinical utility in diagnosing CTS, with low sensitivity and specificity.

Criteria for assessing pain and nonarticular soft-tissue rheumatic disorders of the neck and upper limb

OBJECTIVE

To critically review the criteria used to diagnose nonarticular soft-tissue rheumatic disorders of the neck and upper limb.

METHODS

An extensive search of the literature, including a search of Medline and EMBASE, authoritative recent reviews, and relevant textbooks, was completed. The diagnostic criteria used in epidemiologic studies were compared and the reliability and validity of these criteria were assessed.

RESULTS

Altogether, the search identified 117 relevant research articles, among which 69 included a physical examination component, but few specified diagnostic criteria. Evidence supported respectable levels of between-observer repeatability regarding: symptom questionnaires (kappa, 0.52 to 0.79); measurement of shoulder range of motion with a goniometer (intraclass coefficients > 0.70); tests for carpal tunnel syndrome (Tinel's and Phalen's kappa, 0.53 to 0.80); and demonstration of neck tenderness (kappa = 0.43). The Katz hand diagram, and combinations of physical signs of carpal tunnel syndrome, show reasonable sensitivity and specificity for that diagnosis but only among patients referred to specialists with that putative diagnosis; no such validity has been shown among the general population. Only 1 diagnostic examination schedule has published data on both the reliability and the validity of its criteria and diagnoses. For the remaining soft-tissue upper-limb disorders, diagnostic criteria rely apparently on face and content validity and reliability data have not been published.

CONCLUSION

Classification of specific disorders of the neck and upper limb requires a back to basics approach. At present, the diagnosis of most of these conditions relies heavily on the clinical opinions of investigators and there are insufficient data to indicate that these criteria are repeatable, sensitive, or specific. Recent European initiatives offer scope to follow a more disciplined approach, but more work is urgently required.

Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome

BACKGROUND

Non-surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown.

OBJECTIVES

To evaluate the effectiveness of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions in improving clinical outcome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non-surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non-surgical treatments.

MAIN RESULTS

Twenty-one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) -1.07; 95% confidence interval (CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to -0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21) which was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti-inflammatory drugs) versus placebo. Compared to placebo, pooled data for two-week oral steroid treatment demonstrated a significant improvement in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also showed improvement after four weeks (WMD -10.8; 95% CI -15.26 to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control.

REVIEWER'S CONCLUSIONS

Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non-surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit.

Reliability of physical examination of the upper extremity among keyboard operators

BACKGROUND

Physical examination is a traditional outcome measure in epidemiological research. Its value as a reliable measure depends, in part, on the prevalence of positive findings. The purpose of this paper is to determine the empirical reliability of physical examination and anthropometry in a field study of upper extremity disorders among keyboard operators.

METHODS

Two experienced examiners independently performed common provocative tests and procedures in physical examinations of the neck and upper extremity among 160 keyboard operators. Two additional examiners conducted anthropometric surveys among 137 workers. Inter-examiner reliability was assessed with observed agreement, kappa statistics, and intra-class correlations (ICC).

RESULTS

Observed agreement was between 96% and 100% for neck and upper extremity signs, muscle stretch reflexes, and muscle strength, however, with the exception of provocative tests, reliability statistics were unstable. Among the provocative tests, Phalen and Tinel tests had modest agreement after adjusting for chance (kappa range: 0.20-0.43). The carpal compression test had the best reliability (kappa=0.60 and kappa=0.67, left and right side, respectively). The ICCs for anthropometry ranged from 0.36-0.91.

CONCLUSIONS

Results from the study showed that statistically, except for the carpal compression test, physical examination contributed minimal reliable information. This was attributed mainly to the low prevalence of positive findings, and generally mild nature of upper extremity disorders in this population. The results are the best estimate of what would be found in a field study with experienced examiners. While it may reduce bias, separating physical examination from medical history may contribute to the poor reliability of findings. With a shift toward reliable measures, resources can be allocated to more effective tools, like questionnaires, in epidemiological research of upper extremity disorders among keyboard operators.

Work-related musculoskeletal disorders

Work-related musculoskeletal disorders continue to be extremely common and to present an important challenge to clinicians. Debate regarding terminology and case definitions has discouraged practitioners from aggressively approaching the diagnosis and management of these conditions. Considerable progress has, however, been made recently. Previously more commonly referred to as repetitive strain injuries or cumulative trauma disorders, the new term work-related musculoskeletal disorders has fewer etiological implications. These disorders, affecting the back, lower limbs, and especially upper limbs and neck, can be extremely costly if not addressed appropriately. Generally resulting from a combination of physical factors (including repetition, force, and awkward postures) as well as other workplace environmental or organizational factors (including excessive work rates or durations, inadequate breaks, and a variety of psychosocial workplace characteristics), work-related musculoskeletal disorders can often be remediated when these factors are appropriately assessed and addressed. Clinicians must play a positive role in ensuring that this approach prevails.

The Alderson-McGall hand function questionnaire for patients with Carpal Tunnel syndrome: a pilot evaluation of a future outcome measure

The Alderson-McGall hand function questionnaire (AMHFQ) was developed to evaluate outcomes for patients with carpal tunnel syndrome (CTS). This pilot evaluation of 17 subjects with CTS involved the same battery completed twice prior to CTS release. The complete battery included evaluation of grip and pinch strength, static and dynamic two-point discrimination, dexterity using the Valpar Worksample for upper extremity range of motion, pain and hand function using visual analog scales (VASs), and the AMHFQ. The results indicated high internal consistency, with a Cronbach alpha value of 0.97. Intraclass correlation showed test-retest reliability in the 95th percentile for all items except one. Validity was demonstrated by AMHFQ correlations with all other battery items in the correct direction and significant correlations with dynamic two-point discrimination (r = -0.32), functional VAS (r = 0.3688), pain VAS (r = 0.36), and grip strength (r = 0.3867). These results suggest that the AMHFQ has clinical utility for patients with CTS. Further research to confirm these findings and determine sensitivity to change is required.

What do we know about the reliability and validity of physical examination tests used to examine the upper extremity?

The literature regarding the reliability and validity of commonly used clinical tests for disorders of the upper extremity was reviewed. Formal literature search, standard texts, and experts in the field of upper extremity were consulted to locate relevant articles. Range of motion and strength testing of the upper limb have been shown to be reliable, while various tests used for the diagnosis of conditions in the upper limb, such as carpal tunnel syndrome and rotator cuff tendinopathy, have been shown to have varying degrees of validity. Overall, however, we determined that there is little evidence regarding the reliability and validity of physical examination for the upper extremity and specifically less information available regarding the reliability of diagnostic physical examination tests and the validity of impairment measures used for the upper limb. Further studies in this area are warranted in view of the impact of these findings on the treatment of patients.