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Kumar M, Singh J, Singh R, Tiwari A, Kumar N. Comparison of local versus intramuscular steroid injection in patients with carpal tunnel syndrome: A prospective open label randomized clinical trial. J Clin Neurosci 2024; 123:55-61. [PMID: 38531195 DOI: 10.1016/j.jocn.2024.03.023] [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] [Received: 11/29/2023] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
AIM This study compared the efficacy and safety of local corticosteroid injection (LCI) vs intramuscular (IM) corticosteroid injection in mild to moderate carpal tunnel syndrome (CTS). METHODS This is an open labeled, randomized controlled trial conducted during December 2021 to August 2023. Eighty-six patients with CTS were randomized in 1:1 ratio to receive either single 40 mg methylprednisolone (MP) injection at the wrist (LCI arm), or single 40 mg MP intramuscular injection (IM arm) in the deltoid. Primary outcome was absolute Symptom Severity Scale (SSS) at 3 months. Secondary outcomes were SSS score at 1-month, Functional Status Scale (FSS) score at 1 and 3 months, and recurrence at 3 months and injection site pain assessed on visual analog (VAS) scale. RESULTS Median age was 45 (range 22 - 80) years, and 86 % were females. Baseline characteristics were comparable between groups. Mean SSS score at 3 months was similar in two arms (1.72 ± 0.71 vs 2.0 ± 0.93) with mean difference (MD) -0.03 (-0.31 to 0.25, p = 0.83) after adjusting for baseline SSS scores. LCI, however, resulted in significantly better SSS (1.48 ± 0.51 vs 1.88 ± 0.69, adjusted p = 0.04), and FSS scores (1.57 ± 0.44 vs 1.80 ± 0.66, adjusted p = 0.03) at 1 month compared to IM arm. Response rate (67.4 % vs 55.8 %; p = 0.30) and recurrence rate (17.1 % vs 22.6 %, p = 0.74) at 3 months were similar. Injection site pain was severe in LCI arm[median 5 (range 3 - 8) vs median 3 (range 2 - 6)]. CONCLUSIONS In patients with mild to moderate CTS, LCI resulted in better improvement in the BCTQ scores at 1 month compared to IM steroid. However, 3-month's outcome was similar. Intramuscular steroid injection was better tolerated.
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Affiliation(s)
- Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India.
| | - Jagbir Singh
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Rajni Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Niraj Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India; Department of Neurology, All India Institute of Medical Sciences, Bibinagar, 508126, India
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Warren JR, Link RC, Cheng AL, Sinclair MK, Sorensen AA. Carpal tunnel syndrome and sleep, a systematic review and meta-analysis. HAND SURGERY & REHABILITATION 2024:101698. [PMID: 38641062 DOI: 10.1016/j.hansur.2024.101698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The most common symptom and reason patients seek treatment for carpal tunnel syndrome is lack of sleep. Our purpose was to determine how much sleep-related symptoms of carpal tunnel syndrome improve after carpal tunnel release using validated patient-reported outcome measures (PROMs) and objective sleep data as primary measures of interest. METHODS A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMed, Cochrane, and ClinicalTrials.gov. Only interventional clinical trials that examined primary outcome measures of interest were included. Patient-reported outcome measures underwent meta-analysis to determine how much scores improved following carpal tunnel release. RESULTS The Pittsburgh Sleep Quality Index improved significantly after carpal tunnel release, by 4.43 points and 6.02 points at 1-3 and 6-12 months postoperatively, respectively, and continued to improve up to 2 years. Improvement on the Insomnia Severity Index after carpal tunnel release was also significant, with improvement up to 1 year postoperatively, by 8.54 points and 9.05 points at 1-3 and 6-12 months, respectively. Insomnia Severity Index scores improved significantly after splinting as well. CONCLUSIONS The present meta-analysis determined to what extent patients can expect their sleep to improve after operative and non-operative intervention, as measured by various patient-reported outcome measures that assess sleep. The Pittsburgh Sleep Quality Index and Insomnia Severity Index correlated very well between studies and across hundreds of patients with carpal tunnel syndrome. Data are lacking to define the minimal clinically important difference and assess whether patients achieve a minimal clinically important difference for sleep questionnaires; more information on this topic is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jonathan R Warren
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA.
| | - R Clayton Link
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
| | - An-Lin Cheng
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
| | - Micah K Sinclair
- Department of Orthopaedic Surgery, University of California Davis, 4860 Y St #1700, Sacramento, CA 95817, USA
| | - Amelia A Sorensen
- Department of Orthopaedic Surgery, University of Missouri Kansas City, 2301 Holmes St. Kansas City, MO 64063, USA
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Dabbagh A, MacDermid JC, Yong J, Packham TL, Grewal R, Boutsikari EC. Diagnostic Test Accuracy of Provocative Maneuvers for the Diagnosis of Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis. Phys Ther 2023; 103:pzad029. [PMID: 37366626 PMCID: PMC10294560 DOI: 10.1093/ptj/pzad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/11/2022] [Accepted: 03/26/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE The purpose of this study was to summarize and evaluate the research on the accuracy of provocative maneuvers to diagnose carpal tunnel syndrome (CTS). METHODS The MEDLINE, CINAHL, Cochrane, and Embase databases were searched, and studies that assessed the diagnostic accuracy of at least 1 provocative test for CTS were selected. Study characteristics and data about the diagnostic accuracy of the provocative tests for CTS were extracted. A random-effects meta-analysis of the sensitivity (Sn) and specificity (Sp) of the Phalen test and Tinel sign was conducted. The risk of bias (ROB) was rated using the QUADAS-2 tool. RESULTS Thirty-one studies that assessed 12 provocative maneuvers were included. The Phalen test and the Tinel sign were the 2 most assessed tests (in 22 and 20 studies, respectively). The ROB was unclear or low in 20 studies, and at least 1 item was rated as having high ROB in 11 studies. Based on a meta-analysis of 7 studies (604 patients), the Phalen test had a pooled Sn of 0.57 (95% CI = 0.44-0.68; range = 0.12-0.92) and a pooled Sp of 0.67 (95% CI = 0.52-0.79; range = 0.30-0.95). For the Tinel sign (7 studies, 748 patients), the pooled Sn was 0.45 (95% CI = 0.34-0.57; range = 0.17-0.97) and the pooled Sp was 0.78 (95% CI = 0.60-0.89; range = 0.40-0.92). Other provocative maneuvers were less frequently studied and had conflicting diagnostic accuracies. CONCLUSION Meta-analyses are imprecise but suggest that the Phalen test has moderate Sn and Sp, whereas the Tinel test has low Sn and high Sp. Clinicians should combine provocative maneuvers with sensorimotor tests, hand diagrams, and diagnostic questionnaires to achieve better overall diagnostic accuracy rather than relying on individual clinical tests. IMPACT Evidence of unclear and high ROB do not support the use of any single provocative maneuver for the diagnosis of CTS. Clinicians should consider a combination of noninvasive clinical diagnostic tests as the first choice for the diagnosis of CTS.
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Affiliation(s)
- Armaghan Dabbagh
- Faculty of Health Sciences, School of Physical Therapy, Western University, London, Ontario, Canada
| | - Joy C MacDermid
- Faculty of Health Sciences, School of Physical Therapy, Western University, London, Ontario, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph’s Hospital, London, Ontario, Canada
| | - Joshua Yong
- Occupational Therapy Department, Sengkang General Hospital, Singapore
| | - Tara L Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Ruby Grewal
- Faculty of Health Sciences, School of Physical Therapy, Western University, London, Ontario, Canada
- Department of Surgery, Western University, London, Ontario, Canada
| | - Eleni C Boutsikari
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece
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Hirsiger S, Schlimme N, Rossel JB, Christen S, Grobbelaar AO, Vögelin E. The Inlet and Outlet Ratio: Retrospective and Prospective Study on an Improved Diagnostic Ultrasound Tool for Carpal Tunnel Syndrome. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023. [DOI: 10.1016/j.jhsg.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
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Kamiya Y, Minami A, Tojo Y, Mikami Y, Iwasaki N, Sakai A. The Impact of Carpal Tunnel Release on Two-Point Discrimination, Quick Disabilities of Arm, Shoulder and Hand Score and Distal Motor Latency - A Multi-centre Prospective Study. J Hand Surg Asian Pac Vol 2022; 27:991-999. [PMID: 36550082 DOI: 10.1142/s2424835522500941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: The authors conducted a prospective, multi-centre study to assess the impact of carpal tunnel release (CTR) on Two-Point Discrimination (2-PD), Quick Disabilities of Arm, Shoulder and Hand Score (Q-DASH), and Distal Motor Latency (DL). The primary aim was to determine the change in outcome measurements (2-PD, Q-DASH and DL) preoperatively and postoperatively at 6 months and 1 year. The secondary aims of the study were to determine whether the postoperative outcomes were different at the 6-month and 1-year follow-up and if there was difference in outcomes based on the preoperative severity of carpal tunnel syndrome (CTS). Methods: A total of 205 hands in 171 patients underwent CTR at five hospitals over a 2-year period. A total of 110 hands in 94 patients were followed-up and analysed. The 2-PD, Q-DASH and DL were measured for all patients preoperatively and at 6 months and 1 year postoperatively. Patients were divided into two groups 'mild' and 'severe' based on pre-operative DL score (mild ≤ 8.1 msec). The change in preoperative and postoperative 2-PD, Q-DASH and DL values were compared. The change in pre-operative and post-operative 2-PD and Q-DASH values were also compared between the 'mild' and 'severe' groups. Results: The 2-PD, Q-DASH and DL showed significant improvement at 6-month and 1-year follow-ups compared to pre-operative values. However, there were no significant differences in all three parameters between the 6-month and 1-year measurements. There was significant improvement in preoperative and postoperative 2-PD and Q-DASH scores between the mild and severe groups. Conclusions: CTR is an effective treatment for patients with CTS with significant improvement in all three outcome parameters (2-PD, Q-DASH and DL). The improvement in outcome plateaus at 6 months and additional follow-up may not be useful. Level of Evidence: Level II (Therapeutic).
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Affiliation(s)
- Yukinobu Kamiya
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Yasuaki Tojo
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Yoji Mikami
- Department of Orthopaedic Surgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akinori Sakai
- Department of Orthopaedic Surgery, University of Occupational and Environmental Health, Kitakyusyu, Japan
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Chan Y, Selvaratnam V, Manickavasagar T, Shetty V, Sahni V. Liverpool carpal tunnel scoring system to predict nerve conduction study results: A prospective correlation study. World J Orthop 2022; 13:171-177. [PMID: 35317399 PMCID: PMC8891662 DOI: 10.5312/wjo.v13.i2.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/30/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is one of the most common peripheral nerve compressive neuropathies. The clinical symptoms and physical examinations of CTS are widely recognised, however, there is still debate around what is the best approach for assessment of CTS. Clinical assessment is still considered the gold standard, however, controversies do exist regarding the need for investigations such nerve conduction studies (NCS) to aid with management decisions.
AIM To correlate the severity of NCS results to a scoring system which included symptoms, signs and risk factors.
METHODS This was a prospective correlation study. We scored patients’ signs and symptoms using our CTS scoring system. This was then correlated with the findings of the NCS. The scoring system included - four symptoms (2 Katz hand diagrams – one for tingling and one for numbness; nocturnal paresthesia and bilateral symptoms) and four clinical signs (weak thumb abduction test; Tinel’s sign; Phalen sign and hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). We classified the NCS results to normal, mild, moderate and severe.
RESULTS There were 61 scores in 59 patients. The mean scores for the categories were as follows: 6.75 for normal NCS; 5.50 for mild NCS; 9.17 for moderate NCS and 9 for severe NCS. All scores of 8 or more matched with NCS results of moderate and severe intensity apart from three scores which were greater than seven that had normal NCS. Eta score was 0.822 for the CTS score being the dependent value and the NCS category being the independent variable showing a strong association between the scoring system and the NCS group.
CONCLUSION We feel that this simple scoring system can be used to predict and correlate the severity of NCS in patients with CTS.
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Affiliation(s)
- Yuen Chan
- Department of Trauma and Orthopaedics, Mersey Deanery, Prescot L35 5DR, Merseyside, United Kingdom
| | - Veenesh Selvaratnam
- Department of Trauma and Orthopaedics, Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL, United Kingdom
| | - Tharjan Manickavasagar
- Department of Trauma and Orthopaedics, Southport and Ormskirk NHS Trust, Southport L39 2AZ, United Kingdom
| | - Vishwanath Shetty
- Department of Trauma and Orthopaedics, Southport and Ormskirk NHS Trust, Southport L39 2AZ, United Kingdom
| | - Vishal Sahni
- Department of Trauma and Orthopaedics, Southport and Ormskirk NHS Trust, Southport L39 2AZ, United Kingdom
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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.
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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
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Masci F, Spatari G, Giorgianni CM, Pernigotti E, Antonangeli LM, Bordoni V, Magenta Biasina A, Pietrogrande L, Colosio C. Hand-Wrist Disorders in Chainsaw Operators: A Follow-Up Study in a Group of Italian Loggers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147217. [PMID: 34299668 PMCID: PMC8307102 DOI: 10.3390/ijerph18147217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/16/2022]
Abstract
Despite the mechanization process implemented in arboriculture, logging tasks are still manually performed by chainsaw operators, which therefore are exposed to the risk of developing hand-wrist musculoskeletal disorders. Our research aimed to: (a) define whether the slight changes observed in 2017 showed an evolution to overt diseases; (b) study some risk determinants for these diseases such as age, working experience, and performing a secondary job. We recruited in a two-year follow-up study, 38 male forestry workers performing logging tasks employed in the Sicilian Forestry Department located in Enna. All the subjects underwent: (1) personal data collection; (2) administration of questionnaire addressed at upper limbs symptoms with a hand chart; (3) physical examination of the upper limbs, including Tinel’s and Phalen’s maneuvers; (4) ultrasound investigation of the hand-wrist area. In the two-year follow-up study we registered an overall increasing in wrist disorders, thus we can assume that forestry workers may be a target population for wrist diseases and deserve a particular attention in workers’ health surveillance programs. Interestingly, the prevalence of wrist-hand disorders resulted to be higher in younger workers.
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Affiliation(s)
- Federica Masci
- Department of Health Sciences of the University of Milano and International Centre for Rural Health of the Occupational Health Unit of the Hospitals Santi Paolo e Carlo, 20142 Milano, Italy; (L.M.A.); (C.C.)
- Correspondence:
| | - Giovanna Spatari
- Department of Biomedical, Dental and Morphological and Functional Imaging, University of Messina, 98125 Messina, Italy; (G.S.); (C.M.G.)
| | - Concetto Mario Giorgianni
- Department of Biomedical, Dental and Morphological and Functional Imaging, University of Messina, 98125 Messina, Italy; (G.S.); (C.M.G.)
| | - Elisa Pernigotti
- Post Graduate School in Orthopedics and Traumatology, University of Milan, 20142 Milano, Italy;
| | - Laura Maria Antonangeli
- Department of Health Sciences of the University of Milano and International Centre for Rural Health of the Occupational Health Unit of the Hospitals Santi Paolo e Carlo, 20142 Milano, Italy; (L.M.A.); (C.C.)
| | - Vittorio Bordoni
- Post Graduate School in Occupational Medicine, University of Milan, 20122 Milano, Italy;
| | - Alberto Magenta Biasina
- Diagnostic and Interventional Radiology School of Santi Paolo and Carlo ASST of Milan, 20142 Milano, Italy;
| | - Luca Pietrogrande
- Department of Health Sciences, University of Milan, 20142 Milano, Italy;
| | - Claudio Colosio
- Department of Health Sciences of the University of Milano and International Centre for Rural Health of the Occupational Health Unit of the Hospitals Santi Paolo e Carlo, 20142 Milano, Italy; (L.M.A.); (C.C.)
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Dabbagh A, MacDermid JC, Yong J, Packham TL, Macedo LG, Ghodrati M. Diagnostic accuracy of sensory and motor tests for the diagnosis of carpal tunnel syndrome: a systematic review. BMC Musculoskelet Disord 2021; 22:337. [PMID: 33827512 PMCID: PMC8028143 DOI: 10.1186/s12891-021-04202-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is the most common entrapment mononeuropathy of the upper extremity. The previous systematic review of the diagnostic tests for CTS was outdated. The objective of this study was to compile and appraise the evidence on the accuracy of sensory and motor tests used for the diagnosis of CTS. METHODS MEDLINE, CINAHL, and Embase databases were searched on January 20, 2020. Studies assessing at least one diagnostic accuracy property of the sensory or motor tests for CTS diagnosis were selected by two independent reviewers. Diagnostic test accuracy extension of the PRISMA guidelines was followed. Risk of bias and applicability concerns were rated using QUADAS-2 tool. Any reported diagnostic accuracy property was summarized. Study characteristics and any information on the accuracy of the sensory and motor tests for CTS diagnosis were extracted. RESULTS We included sixteen clinical studies, assessing thirteen different sensory or motor tests. The most sensitive test for CTS diagnosis was the Semmes-Weinstein monofilament test (with 3.22 in any radial digit as the normal threshold) with sensitivity from 0.49 to 0.96. The tests with the highest specificity (Sp) were palmar grip strength (Sp = 0.94), pinch grip strength (Sp from 0.78 to 0.95), thenar atrophy (Sp from 0.96 to 1.00), and two-point discrimination (Sp from 0.81 to 0.98). CONCLUSIONS The evidence was inconclusive on which sensory or motor test for CTS diagnosis had the highest diagnostic accuracy. The results suggest that clinicians should not use a single sensory or motor test when deciding on CTS diagnosis. TRIAL REGISTRATION PROSPERO CRD42018109031 , on 20 December 2018.
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Affiliation(s)
- Armaghan Dabbagh
- School of Physical Therapy, Faculty of Health Science, Elborn College, Western University, London, ON, Canada.
| | - Joy C MacDermid
- School of Physical Therapy, Faculty of Health Science, Elborn College, Western University, London, ON, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.,Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, ON, Canada
| | - Joshua Yong
- Sengkang General Hospital, Singapore, Singapore
| | - Tara L Packham
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Luciana G Macedo
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Maryam Ghodrati
- School of Physical Therapy, Faculty of Health Science, Elborn College, Western University, London, ON, Canada
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Diagnosing Carpal Tunnel Syndrome: Diagnostic Test Accuracy of Scales, Questionnaires, and Hand Symptom Diagrams-A Systematic Review. J Orthop Sports Phys Ther 2020; 50:622-631. [PMID: 32938312 DOI: 10.2519/jospt.2020.9599] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To summarize and evaluate research on the accuracy of clinical diagnostic scales, questionnaires, and hand symptom diagrams/maps used for diagnosis of carpal tunnel syndrome (CTS). DESIGN Systematic review of diagnostic test accuracy. LITERATURE SEARCH A comprehensive literature search of the MEDLINE, CINAHL, and Embase databases was conducted on January 20, 2020. STUDY SELECTION CRITERIA Studies that assessed at least 1 diagnostic accuracy property of the scales, questionnaires, and hand symptom diagrams used for the diagnosis of CTS. DATA SYNTHESIS The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Diagnostic accuracy properties were summarized. RESULTS Out of 4052 citations after removing duplicates, 21 articles met the inclusion criteria. Twelve articles reported on the diagnostic accuracy of scales and questionnaires, including the Bland questionnaire, Kamath and Stothard questionnaire, 6-item carpal tunnel syndrome symptoms scale (CTS-6), Boston Carpal Tunnel Questionnaire, Wainner clinical prediction rule, and Lo clinical prediction rule. Positive likelihood ratios ranged from 0.94 for the Boston Carpal Tunnel Questionnaire to 10.5 for the CTS-6, and negative likelihood ratios ranged from 1.04 to 0.05 for the same diagnostic tools, respectively. Nine studies reported the diagnostic accuracy of the Katz and Stirrat hand symptom diagram. Positive and negative likelihood ratios ranged from 1.42 to 8 and from 0.78 to 0.05, respectively. Only 4 studies had high methodologic quality. CONCLUSION Limited evidence supports high accuracy of the CTS-6, Kamath and Stothard questionnaire, and Katz and Stirrat hand symptom diagram. Other scales have lesser and more conflicting evidence. Further high-quality studies are necessary to examine the diagnostic accuracy of these tests to assist ruling in or ruling out CTS. J Orthop Sports Phys Ther 2020;50(11):622-631. Epub 16 Sep 2020. doi:10.2519/jospt.2020.9599.
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Sartorio F, Dal Negro F, Bravini E, Ferriero G, Corna S, Invernizzi M, Vercelli S. Relationship between nerve conduction studies and the Functional Dexterity Test in workers with carpal tunnel syndrome. BMC Musculoskelet Disord 2020; 21:679. [PMID: 33054739 PMCID: PMC7558696 DOI: 10.1186/s12891-020-03651-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/15/2020] [Indexed: 12/31/2022] Open
Abstract
Background Dexterity impairments caused by carpal tunnel syndrome (CTS) make working and daily activities challenging. We aimed to investigate: i) the relationship between dexterity and nerve conduction studies (NCS) in workers with classic symptoms presentation; ii) the ability of the Functional Dexterity Test (FDT) to discriminate different levels of CTS severity as classified by NCS; iii) the diagnostic accuracy of a clinical battery composed of the FDT, Phalen’s test and Tinel’s sign. Methods In a convenience sample of individuals diagnosed with CTS, we correlated FDT net scores with the NCS-based classification by means of Spearman’s (rho) test. Discriminative ability of the FDT was assessed by ANOVA, and a ROC curve determined cutoff thresholds. Sensitivity, specificity, and likelihood ratios (LRs) were used to investigate the diagnostic accuracy of the clinical battery. Results Data from 180 hands were collected. The FDT was significantly correlated (rho = 0.25, p < 0.001) with NCS. The FDT was able to discriminate subjects with severe/extreme NCS findings, and two thresholds (0.29–0.36) were identified. Adding the FDT to the provocative tests improved the overall diagnostic accuracy (specificity: 0.97, CI95% 0.83–0.99; LR+: 14.49, CI95% 2.09–100.53). Conclusions Sensorimotor impairments related to CTS can affect hand dexterity. The FDT discriminated patients with severe NCS involvement. Positive results on the clinical battery (Phalen, Tinel, and FDT) could help to confirm the CTS diagnosis, showing a very high specificity and LR+. On the contrary, the low sensitivity is not able to rule out CTS in individuals with negative results.
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Affiliation(s)
- Francesco Sartorio
- Institute of Veruno, Istituti Clinici Scientifici Maugeri IRCCS, Gattico-Veruno (NO), Italy
| | - Francesca Dal Negro
- Institute of Veruno, Istituti Clinici Scientifici Maugeri IRCCS, Gattico-Veruno (NO), Italy
| | | | - Giorgio Ferriero
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Tradate (VA), Via Maugeri 4, I-27100, Pavia, Italy.
| | - Stefano Corna
- Institute of Veruno, Istituti Clinici Scientifici Maugeri IRCCS, Gattico-Veruno (NO), Italy
| | - Marco Invernizzi
- Physical and Rehabilitation Medicine, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Stefano Vercelli
- Institute of Veruno, Istituti Clinici Scientifici Maugeri IRCCS, Gattico-Veruno (NO), Italy
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Abdouni YA, Brunelli JPF, Munia MAS. Síndrome do túnel do carpo aguda por trombose da artéria mediana: Relato de caso. Rev Bras Ortop 2020; 58:347-350. [DOI: 10.1055/s-0040-1714228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/05/2020] [Indexed: 10/23/2022] Open
Abstract
ResumoA síndrome do túnel do carpo é a neuropatia compressiva mais comum do membro superior, afetando ∼ 4% da população geral. O quadro clínico caracteriza-se por dor e, principalmente, parestesia no território do nervo mediano, de início insidioso e, nos casos mais graves, observa-se perda de força e atrofia da musculatura tenar. Trata-se de patologia extremamente comum na prática diária de cirurgia da mão, e na maior parte dos casos pode ser tratada com métodos conservadores. Apresentamos aqui um caso atípico de síndrome do túnel do carpo, de surgimento agudo, desencadeado pela trombose da artéria mediana persistente, quadro associado com embolização distal e hipoperfusão do membro.
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Affiliation(s)
- Yussef Ali Abdouni
- Departamento de Ortopedia e Traumatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil
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13
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Affiliation(s)
- Thomas R. Hales
- Medical Epidemiologist, NIOSH, Denver, CO, formerly Acting Director, OSHA Office of Occupational Medicine
| | - Patricia K. Bertsche
- Health Science Specialist, U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), Washington, D.C
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Abstract
PURPOSE OF REVIEW To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.
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Affiliation(s)
- Peter J. Ostergaard
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Maximilian A. Meyer
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Brandon E. Earp
- Division of Hand Surgery, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
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Lewis KJ, Coppieters MW, Ross L, Hughes I, Vicenzino B, Schmid AB. Group education, night splinting and home exercises reduce conversion to surgery for carpal tunnel syndrome: a multicentre randomised trial. J Physiother 2020; 66:97-104. [PMID: 32291222 DOI: 10.1016/j.jphys.2020.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 01/08/2023] Open
Abstract
QUESTION In people with carpal tunnel syndrome who are waitlisted for surgical consultation, does a therapist-led care pathway involving education, splinting and exercises reduce the need for surgery and improve patient outcomes? DESIGN A multicentre, randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis. PARTICIPANTS One hundred and five people with electrodiagnostically confirmed carpal tunnel syndrome on a waitlist for surgical consultation and recruited from four public hospitals in Australia. INTERVENTIONS The experimental group (n = 52) received a one-off group session of education, splinting, and nerve and tendon gliding exercises. The control group (n = 53) continued on the waitlist without additional care. OUTCOME MEASURES The primary outcome measures were conversion to surgery by 24 weeks, the global rating of change (GROC) scale and patient satisfaction. Secondary outcomes included symptom severity and functional limitation. RESULTS At 24 weeks, conversion to surgery was 59% in the experimental group and 80% in the control group (risk difference -0.21, 95% CI -0.38 to -0.03). More participants in the experimental group identified as improved at 6 weeks (20% vs 4%; risk difference 0.15, 95% CI 0.03 to 0.28) but not at 24 weeks (24% vs 10%; risk difference 0.14, 95% CI -0.01 to 0.29). The intervention was also estimated to be beneficial on some measures of satisfaction, symptom severity and functional limitation. The study's estimates of the benefits came with some uncertainty, which makes it unclear whether the wider population of people awaiting carpal tunnel surgery would consider that the benefits make the intervention worthwhile. No serious adverse effects were reported. CONCLUSIONS A therapist-led pathway reduced conversion to carpal tunnel surgery and increased perceived improvement and satisfaction in people who were already on a waitlist for surgical consultation. REGISTRATION ACTRN12613001095752.
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Affiliation(s)
- Karina J Lewis
- Occupational Therapy Department, Gold Coast University Hospital, Gold Coast, Australia; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Michel W Coppieters
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia; Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Leo Ross
- Allied Health Department, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia
| | - Ian Hughes
- Gold Coast University Hospital, Southport, Australia
| | - Bill Vicenzino
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom.
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Miyaji Y, Kobayashi M, Oishi C, Mizoi Y, Tanaka F, Sonoo M. A new method to define cutoff values in nerve conduction studies for carpal tunnel syndrome considering the presence of false-positive cases. Neurol Sci 2019; 41:669-677. [PMID: 31760512 DOI: 10.1007/s10072-019-04145-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/07/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nerve conduction studies (NCS) are useful tools for diagnosing carpal tunnel syndrome (CTS). Establishing the normal values is the first step required for utilizing NCS for diagnosis. Previous epidemiological studies demonstrated the presence of fairly large number of false-positive subjects regarding NCS among control population, which has not been properly considered in past studies. This study proposed a new method to address this issue. METHODS Non-diabetic 144 CTS patients were retrospectively enrolled using clinically defined inclusion criteria. Controls consisted of 73 age-matched volunteers without hand symptoms. Six NCS parameters were evaluated including peak-latency difference by the thumb method (thumbdif) and that by the ring-finger method (ringdif). The Youden index of the receiver operator characteristic curve was used both to judge the sensitivity of a parameter and to identify false-positive cases that were thought to have subclinical median neuropathy at the wrist. The linear function of six parameters was constructed, and the coefficient for each parameter was variously changed. RESULTS When the Youden index took on the maximum value, seven control subjects (10%) were identified as false-positive and were excluded from the calculation of normal values. The most sensitive parameter before exclusion was thumbdif, whereas ringdif became the most sensitive after exclusion. The cut-off value for ringdif was 1.15 ms before exclusion, but was 0.37 ms after exclusion. CONCLUSION This method can be widely applied to solve the statistical problem when the gold standard is lacking, and the outside reference standard is not completely reliable.
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Affiliation(s)
- Yosuke Miyaji
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.,Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Chizuko Oishi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.,Department of Neurology, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Yoshikazu Mizoi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.,Department of Neurology, Saitama Medical University, Saitama, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.
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Kuroiwa T, Matsumoto M, Kato R, Nimura A, Yoshii T, Okawa A, Fujita K. Activation of cancer-related and mitogen-activated protein kinase signaling pathways in human mature osteoblasts isolated from patients with type 2 diabetes. Bone Rep 2019; 10:100199. [PMID: 30891471 PMCID: PMC6406057 DOI: 10.1016/j.bonr.2019.100199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/05/2019] [Accepted: 02/20/2019] [Indexed: 01/04/2023] Open
Abstract
Diabetes mellitus is a disease of glucose metabolism, and it adversely affects bone metabolism and increases the risk of cancer development. Previously, we reported a method for the direct isolation of human mature osteoblasts and indicated that osteoblasts were associated with type 2 diabetes mellitus-related signaling pathways. In addition, a recent report suggested that osteoblasts are involved in glucose metabolism. Thus, we sought to examine the effects of diabetes on osteoblast signaling in vivo. We recruited eight patients with type 2 diabetes and eight non-diabetic individuals. We isolated human mature osteoblasts from the resected femoral heads during orthopaedic surgery and extracted their RNA. We compared the gene expression between the two groups by RNA microarray and pathway analyses. Microarray analysis showed significant differences in 885 of 19,463 genes between the two groups (p < 0.05), and pathway analysis revealed that pathways related to cancer and the mitogen-activated protein kinase signaling pathway were significantly activated in the diabetes group (p < 0.01). These preliminary findings suggest that diabetes affects intracellular signaling in human mature osteoblasts and that osteoblasts might not only play a key role in the regulation of bone and glucose metabolism, but might also be related to cancer metabolism. We plan to conduct further studies to examine signaling in diabetic osteoblasts and to further investigate the genes and pathways identified here. Compared microarray data from in vivo DM and healthy control osteoblasts MAPK and cancer-related signaling genes were enriched in DM osteoblasts. DM may increase cancer risk by activating cancer-related pathways in osteoblasts.
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Affiliation(s)
- Tomoyuki Kuroiwa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Megumi Matsumoto
- Laboratory of Cell and Molecular Bioengineering, Division of Biosciences, Department of Basic Medicinal Sciences, Graduate School of Pharmaceutical Sciences, Nagoya University, Room 302, Pharmaceutical Sciences Building Graduate School of Pharmaceutical Sciences, Furo-cho, Chikusa-ku, Nagoya, Aichi 464-8601, Japan
| | - Ryuji Kato
- Laboratory of Cell and Molecular Bioengineering, Division of Biosciences, Department of Basic Medicinal Sciences, Graduate School of Pharmaceutical Sciences, Nagoya University, Room 302, Pharmaceutical Sciences Building Graduate School of Pharmaceutical Sciences, Furo-cho, Chikusa-ku, Nagoya, Aichi 464-8601, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Atsushi Okawa
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Koji Fujita
- Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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Colombo J, Shah S. Utilization of Electrodiagnostic Testing for Carpal Tunnel Syndrome by General Practitioners Prior to Hand Surgery Consultation. Hand (N Y) 2019; 14:56-58. [PMID: 30188191 PMCID: PMC6346367 DOI: 10.1177/1558944718798849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy and thus is frequently encountered by general practitioners (GPs). The aim of this study is to investigate the referral pattern of GPs with regard to electrodiagnostic (EDX) testing for suspected CTS prior to hand surgery consultation, as well as to investigate the results of EDX testing for suspected CTS when requested by GPs prior to evaluation by a hand surgeon. METHODS We retrospectively reviewed patients referred to our hand surgery clinic over a consecutive 2-year period for suspected CTS. RESULTS A total of 403 patients were referred to our hand surgery clinic from January 1, 2016, to December 31, 2017. Of the 403, 295 (73.2%) were referred by GPs. GPs obtained prereferral EDX testing in 198 (67.1%) of these patients. EDX testing confirmed their diagnosis in 177 patients (89.4%). There were 21 patients (10.6%) identified with normal EDX testing and a more likely diagnosis reached based on clinical examination. CONCLUSIONS GPs make up the majority of our referrals for CTS, and they obtain EDX testing prior to consultation in two-thirds of referrals. GPs appear to accurately utilize EDX testing to confirm their diagnosis prior to referral and have a low rate of normal testing where symptoms are more readily explained by an alternative diagnosis.
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Affiliation(s)
- Joshua Colombo
- Carolinas HealthCare System NorthEast, Concord, NC, USA,Joshua Colombo, Department of Orthopedics, Carolinas HealthCare System NorthEast, 1090 NE Gateway Court, Suite 204, Concord, NC 28025, USA.
| | - Smiresh Shah
- Carolinas HealthCare System NorthEast, Concord, NC, USA
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Küçükakkaş O, Yurdakul OV. The diagnostic value of clinical examinations when diagnosing carpal tunnel syndrome assisted by nerve conduction studies. J Clin Neurosci 2018; 61:136-141. [PMID: 30396816 DOI: 10.1016/j.jocn.2018.10.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/28/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our study aims to evaluate the reliability of clinical findings in diagnosing carpal tunnel syndrome (CTS), with the help of nerve conduction studies (NCSs) and the detection of comorbidities likely to be risk factors. METHODS 512 patients were included in the study who described pain or paresthesia in the median nerve sensory distribution. Sensory and motor NCSs were performed on the median and ulnar nerves of all patients. 49 patients who showed pathological abnormalities of the ulnar nerve were excluded. Demographic information, clinical findings and comorbidities were recorded. According to the results of the NCSs, the patients were divided and analyzed as either positive and negative for the diagnosis of CTS. RESULTS The highest sensitivity was seen from the Durkan test (95.6%) and the lowest was from thenar atrophy (22.1%). The highest specificity and positive predictive values were seen for thenar atrophy (100%) and the lowest were from the Tinel test (40.9% and 59.1%). The highest negative predictive value was the Durkan test (94%) and thenar atrophy was the lowest (57.4%). There was a significant difference in NCSs groups for clinical findings and comorbidities. CONCLUSIONS Thenar atrophy and sensory loss were highly specific in CTS but had limited value in early detection. Due to their low specificity, provocative tests do not appear sufficient enough to establish a definite CTS diagnosis. Only Durkan's test could possibly be considered initially as it has more balanced values. Diabetes, obesity, rheumatoid arthritis, hypothyroidism and gout significantly increase the risk of CTS.
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Affiliation(s)
- Okan Küçükakkaş
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - Ozan Volkan Yurdakul
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Jiménez del Barrio S, Bueno Gracia E, Hidalgo García C, Estébanez de Miguel E, Tricás Moreno J, Rodríguez Marco S, Ceballos Laita L. Conservative treatment in patients with mild to moderate carpal tunnel syndrome: A systematic review. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Jiménez del Barrio S, Bueno Gracia E, Hidalgo García C, Estébanez de Miguel E, Tricás Moreno J, Rodríguez Marco S, Ceballos Laita L. Tratamiento conservador en pacientes con síndrome del túnel carpiano con intensidad leve o moderada. Revisión sistemática. Neurologia 2018; 33:590-601. [DOI: 10.1016/j.nrl.2016.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/19/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022] Open
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Scratch Collapse Test for Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1933. [PMID: 30349795 PMCID: PMC6191240 DOI: 10.1097/gox.0000000000001933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/13/2018] [Indexed: 02/03/2023]
Abstract
Background: Despite the fact that carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, the diagnostic accuracy of clinical screening examinations for CTS is controversial. The scratch collapse test (SCT) is a novel test that may be of diagnostic advantage. The purpose of our study was to determine the diagnostic accuracy of the SCT for CTS. Methods: A literature search was performed using PubMed (1966 to April 2018); Ovid MEDLINE (1966 to April 2018); EMBASE (1988 to April 2018); and Cochrane Central Register of Controlled Trials (The Cochrane Library, to April 2018). We examined the studies for the pooled sensitivity, specificity, and likelihood ratios of the SCT. This review has been registered with PROSPERO (CRD42018077115). Results: The literature search generated 13 unique articles. Seven articles were included for full text screening and 3 articles met our inclusion criteria, all of which were level II evidence with low risk of bias (165 patients). Pooled sensitivities, specificities, positive likelihood ratio, and negative likelihood ratios were 0.32 [95% CI (0.24–0.41)], 0.62 [95% CI (0.45–0.78)], 0.75 [95% CI (0.33–1.67)], and 1.03 [95% CI (0.61–1.74)], respectively. The calculated area under the summary receiver operating characteristic (AUSROC) curve was 0.25, indicating a low diagnostic accuracy. Conclusion: The SCT has poor sensitivity; however, it is moderately specific. Based on the current literature and their variable quality of the evidence, we conclude that the SCT is not an adequate screening test for detecting CTS.
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Abstract
INTRODUCTION Diagnostic screening tests for carpal tunnel syndrome (CTS) have not been rigorously assessed in large populations. METHODS This study is a cross-sectional analysis from a prospective cohort study. Participants' (n = 1,194) symptoms and disease prevalence were measured. Sensitivity, specificity, and positive and negative predictive values (NPVs) were calculated. RESULTS When defining CTS as tingling/numbness in at least two median nerve-served digits and an abnormal median nerve conduction study, the prevalence was 8.9%. The sensitivity of paresthesias with nocturnal awakening was 77.4%. The sensitivity of the Phalen sign was 52.8% and that of the Hoffman-Tinel sign was only 37.7%. DISCUSSION The highest sensitivity (77.4%) for a case definition of CTS in this population of workers was for nocturnal tingling/numbness in a median nerve distribution, and the highest specificity (97.5%) was for continuous tingling/numbness. The Phalen sign has a sensitivity of 52.8% and NPV of 95%, suggesting that the NPV is of particular diagnostic value. Hoffman-Tinel signs seem primarily helpful for the NPV (93.7%). LEVEL OF EVIDENCE Level II diagnostic study.
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Sonoo M, Menkes DL, Bland JD, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: Do they add value? Clin Neurophysiol Pract 2018; 3:78-88. [PMID: 30215013 PMCID: PMC6133914 DOI: 10.1016/j.cnp.2018.02.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/31/2022] Open
Abstract
This paper summarises the views of four experts on the place of neurophysiological testing (EDX) in patients presenting with possible carpal tunnel syndrome, in guiding their treatment, and in reevaluations. This is not meant to be a position paper or a literature review, and heterogeneous viewpoints are presented. Nerve conduction studies should be performed in patients presenting with possible carpal tunnel syndrome to assist diagnosis, and may need to be repeated at intervals in those managed conservatively. There is evidence that local corticosteroid injection is safe and effective for many patients, thereby avoiding or deferring surgical decompression. All patients should undergo EDX studies before any invasive procedure for CTS (injection or surgery). Needle EMG studies are not obligatory, but may be needed in those with severe disease and those in whom an alternate or concomitant diagnosis is suspected.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo 1738605, Japan
| | - Daniel L. Menkes
- Department of Neurology, Beaumont Health, Beaumont Neuroscience Building, Royal Oak, MI 48073, United States
| | - Jeremy D.P. Bland
- East Kent Hospitals University NHS Foundation Trust, Ethelbert Road, Canterbury, Kent, UK
| | - David Burke
- Department of Neurology, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
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Farrag DA, El-Zohiery AK. Electrophysiological Phalen’s provocation test in carpal tunnel syndrome. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2018. [DOI: 10.4103/err.err_39_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dinarvand V, Abdollahi I, Raeissadat SA, Mohseni Bandpei MA, Babaee M, Talimkhani A. The Effect of Scaphoid and Hamate Mobilization on Treatment of Patients with Carpal Tunnel Syndrome. Anesth Pain Med 2017; 7:e14621. [PMID: 29696114 PMCID: PMC5903255 DOI: 10.5812/aapm.14621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/07/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022] Open
Abstract
Background This study was to evaluate the effect of hamate and scaphoid bone mobilization alongside splinting in women with carpal tunnel syndrome. Methods In this randomized clinical trial, 40 participants were randomly assigned into 2 groups. The intervention group received splinting with scaphoid and hamate mobilization, while the control group received splinting only. Outcome variables were pain (based on visual analogue scale), symptom severity and functional status (based on Boston questionnaire), and nerve conduction study measured before and 10 weeks after the treatments. Results At the end of study, both groups showed an improvement in pain and symptom severity, functional status as well as median nerve conduction study. Although there was no statistically significant difference between groups regarding changes in median nerve sensory and motor distal latencies; the improvement was significantly higher in pain and symptom severity as well as functional status in mobilization group (P-Value < 0.05). Conclusions Hamate and scaphoid mobilization can be used as an effective option in women with mild to moderate carpal tunnel syndrome. Further investigation is required for determining long-term effects and cost-effectiveness of mobilization in carpal tunnel syndrome.
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Affiliation(s)
- Vida Dinarvand
- Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Shahid Modarres Hospital, Tehran, Iran
| | - Iraj Abdollahi
- Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Seyed Ahmad Raeissadat
- Physical Medicine and Rehabilitation Research Center, Clinical Research Development Center of Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Seyed Ahmad Raeissadat, Physical Medicine and Rehabilitation Department, Shahid Modarres Hospital, Kaj Sq, Saadat Abad, Tehran, Iran. Tel/Fax: +98-2122731112, E-mail:
| | | | - Marzieh Babaee
- Physical Medicine and Rehabilitation Research Center, Clinical Research Development Center of Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ailin Talimkhani
- Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Shahid Modarres Hospital, Tehran, Iran
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Soon B, Vicenzino B, Schmid AB, Coppieters MW. Facilitatory and inhibitory pain mechanisms are altered in patients with carpal tunnel syndrome. PLoS One 2017; 12:e0183252. [PMID: 28854251 PMCID: PMC5576684 DOI: 10.1371/journal.pone.0183252] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 08/01/2017] [Indexed: 11/19/2022] Open
Abstract
Preliminary evidence from studies using quantitative sensory testing suggests the presence of central mechanisms in patients with carpal tunnel syndrome (CTS) as apparent by widespread hyperalgesia. Hallmarks of central mechanisms after nerve injuries include nociceptive facilitation and reduced endogenous pain inhibition. Methods to study nociceptive facilitation in CTS so far have been limited to quantitative sensory testing and the integrity of endogenous inhibition remains unexamined. The aim of this study was therefore to investigate changes in facilitatory and inhibitory processing in patients with CTS by studying hypersensitivity following experimentally induced pain (facilitatory mechanisms) and the efficacy of conditioned pain modulation (CPM, inhibitory mechanisms). Twenty-five patients with mild to moderate CTS and 25 age and sex matched control participants without CTS were recruited. Increased pain facilitation was evaluated via injection of hypertonic saline into the upper trapezius. Altered pain inhibition through CPM was investigated through cold water immersion of the foot as the conditioning stimulus and pressure pain threshold over the thenar and hypothenar eminence bilaterally as the test stimulus. The results demonstrated that patients with CTS showed a greater duration (p = 0.047), intensity (p = 0.044) and area (p = 0.012) of pain in response to experimentally induced pain in the upper trapezius and impaired CPM compared to the control participants (p = 0.006). Although typically considered to be driven by peripheral mechanisms, these findings indicate that CTS demonstrates characteristics of altered central processing with increased pain facilitation and reduced endogenous pain inhibition.
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Affiliation(s)
- Benjamin Soon
- Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Singapore Institute of Technology, Singapore, Singapore
| | - Bill Vicenzino
- Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Annina B. Schmid
- Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Michel W. Coppieters
- Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Amsterdam Movement Sciences, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Menzies Health Institute Queensland and School of Allied Health Sciences, Faculty of Health, Griffith University, Gold Coast Campus, Queensland, Australia
- * E-mail:
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Lumbrical-interosseous recording technique versus routine electrodiagnostic methods in the diagnosis of carpal tunnel syndrome. Turk J Phys Med Rehabil 2017; 63:230-238. [PMID: 31453459 DOI: 10.5606/tftrd.2017.311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/27/2016] [Indexed: 11/21/2022] Open
Abstract
Objectives We aimed to evaluate the sensitivity of second lumbrical-interosseous (L-I) technique and to compare the results with other electrophysiological methods in patients with carpal tunnel syndrome (CTS). Patients and methods This cross-sectional study was conducted in an electrophysiology laboratory of a university hospital between January 2003 and January 2004. A total of 102 patients with CTS (174 hands) and 40 healthy controls (80 hands) were included. Median motor nerve conduction studies were obtained with recordings from the abductor pollicis brevis (APB), median sensory nerve conduction studies from digits I-III and at palm-wrist segment (P-W), median-ulnar sensory comparison at digit IV (M-U), and median-radial sensory comparison at digit I (M-R) were along with L-I technique. Results The highest sensitivities were found in the median sensory conduction velocity across the palm-wrist (88%), and digit I-wrist segments (80%), median motor distal latency over the APB (77%), and L-I study (76%). The specificities of conventional tests were higher than the sensitivity of L-I method (63%). Conclusion L-I method has a good diagnostic sensitivity in CTS; however, P-W, median sensory nerve conduction velocity at digit I and median distal motor latency are more sensitive than L-I method. Therefore, L-I method can be applied as a supportive technique in the evaluation of patients with CTS.
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Does electrodiagnostic evidence correlate with mood and function in patients with a pre-diagnosis of carpal tunnel syndrome? Turk J Phys Med Rehabil 2017; 63:335-339. [PMID: 31453476 DOI: 10.5606/tftrd.2017.453] [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: 04/20/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to investigate if function and mood involvement correlate in female patients who have a pre-diagnosis of carpal tunnel syndrome (CTS) and its correlation with physical examination and electrodiagnostic findings. Patients and methods A total of 170 patients between the ages of 18-65 who applied to Physical Medicine and Rehabilitation outpatient clinics with CTS symptoms between May 2014 and December 2015 were enrolled. The mean age of patients was 44.6±11 years. Before electrophysiological testing (electromyography; EMG), Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), Beck Depression Inventory, Tinnel, Phalen and Durkan tests, grip and pinch strength measurement by JAMAR hand dynamometer were performed. The patients also used a Visual Analog Scale (VAS) to determine the severity of their symptoms during the day and at night. Results In 98 patients (57.6%) the diagnosis of CTS was confirmed by EMG, while 72 patients (42.4%) had normal electrodiagnostic findings. In patients who had normal EMG, Beck Depression Inventory and QuickDASH scores were not significantly different from the patients who had an electrodiagnosis of CTS. Pain experienced in the night was significantly higher in patients who had an electrodiagnosis of CTS, and these patients had significantly higher Beck Depression Inventory and QuickDASH scores. Conclusion The lack of electrodiagnostic evidence in patients who have CTS symptoms does not show that function and mood are not affected in these patients. However, mood is significantly affected in patients with severe CTS.
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Yunoki M, Kanda T, Suzuki K, Uneda A, Hirashita K, Yoshino K. Importance of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review. Neurol Med Chir (Tokyo) 2017; 57:172-183. [PMID: 28154344 PMCID: PMC5409271 DOI: 10.2176/nmc.ra.2016-0225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Idiopathic carpal tunnel syndrome (CTS) is a common complaint, reflecting entrapment neuropathy of the upper extremity. CTS produces symptoms similar to those of other conditions, such as cervical spondylosis or ischemic or neoplastic intracranial disease. Because of these overlaps, patients with CTS are often referred to a neurosurgeon. Surgical treatment of CTS was started recently in our department. Through this experience, we realized that neurosurgeons should have an increased awareness of this condition so they can knowledgeably assess patients with a differential diagnosis that includes CTS and cervical spinal and cerebral disease. We conducted a literature review to gain the information needed to summarize current knowledge on the clinical, pathogenetic, and therapeutic aspects of CTS. Because the optimal diagnostic criteria for this disease are still undetermined, its diagnosis is based on the patient’s history and physical examination, which should be confirmed by nerve conduction studies and imaging modalities such as magnetic resonance imaging and ultrasonography. Treatment methods include observation, medication, splinting, steroid injections, and surgical intervention. Understanding the clinical features and pathogenesis of CTS, as well as the therapeutic options available to treat it, is important for neurosurgeons if they are to provide the correct management of patients with this disease.
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Affiliation(s)
| | | | - Kenta Suzuki
- Department of Neurosurgery, Kagawa Rosai Hospital
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Chesterton LS, Dziedzic KS, van der Windt DA, Davenport G, Myers HL, Rathod T, Blagojevic-Bucknall M, Jowet SM, Burton C, Roddy E, Hay EM. The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol. BMC Musculoskelet Disord 2016; 17:415. [PMID: 27716159 PMCID: PMC5053124 DOI: 10.1186/s12891-016-1264-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/23/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months. METHOD/DESIGN A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up. DISCUSSION The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions. TRIAL REGISTRATION Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).
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Affiliation(s)
- Linda S. Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Krysia S. Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Danielle A. van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Graham Davenport
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Helen L. Myers
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Trishna Rathod
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Milica Blagojevic-Bucknall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Sue M. Jowet
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Claire Burton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Elaine M. Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
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Lewis KJ, Ross L, Coppieters MW, Vicenzino B, Schmid AB. Education, night splinting and exercise versus usual care on recovery and conversion to surgery for people awaiting carpal tunnel surgery: a protocol for a randomised controlled trial. BMJ Open 2016; 6:e012053. [PMID: 27638495 PMCID: PMC5051399 DOI: 10.1136/bmjopen-2016-012053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Carpal tunnel syndrome (CTS) is a prevalent upper limb condition that results in significant individual and socioeconomic costs. Large patient numbers, long outpatient waiting times and traditional referral pathways in public health systems create delays in accessing treatment for this condition. Alternative care pathways aimed at streamlining access to treatment and reducing the need for surgical intervention warrant further investigation. METHODS A randomised, single-blind controlled clinical trial will be conducted. 128 participants aged 18-75 years with CTS will be recruited from the carpal tunnel surgery waitlists of participating public hospitals. Suitable participants will be stratified for severity and randomly allocated to either receive therapy (education, provision of splints and a home exercise programme) or standard care (continuing on the waitlist without hand therapy intervention for the duration of the study). Outcomes will be measured at baseline and after 6 weeks and 6 months. Primary outcomes are conversion to surgery ratio and perceived effect via the Global Rating of Change Scale.Secondary measures include patient satisfaction, and monitoring of symptoms and function using outcome measures including the Boston CTS Questionnaire, Disability of Arm, Shoulder and Hand Questionnaire, Patient-Specific Functional Scale, patient completed diagram of symptoms and Self-reported Leeds Assessment of Neuropathic Symptoms and Signs pain scale. DISCUSSION This paper outlines the design and rationale for a randomised controlled trial that aims to assess the efficacy of an alternative care pathway for the management of patients with CTS while on the surgery waitlist. It is anticipated that the outcomes of this study will contribute to improved and expedited management of this common condition in a public hospital setting. ETHICS AND DISSEMINATION Ethics approval was granted by the Princess Alexandra Hospital Centres for Health Research (HREC/13/QPAH/434-SSA/13/QPAH/447) and the Medical Research Ethics Committee at the University of Queensland. Results will be disseminated via conferences and peer-reviewed publications. TRIAL REGISTRATION NUMBER ACTRN12613001095752.
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Affiliation(s)
- Karina J Lewis
- Occupational Therapy Department, Gold Coast University Hospital, Queensland, Australia School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Leo Ross
- Occupational Therapy Department, Gold Coast University Hospital, Queensland, Australia
| | - Michel W Coppieters
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Annina B Schmid
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia Nuffield Department of Clinical Neurosciences, University of Oxford, England, UK
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de Saboya Lenzi LG, Fernandes CH, Myiamoto Meirelles L, Baptista Gomes dos Santos J, Faloppa F, Raduan Neto J. Triggering of Carpal Tunnel Syndrome Symptoms in Patients Using Urban Public Transportation. Hand (N Y) 2016; 11:257-261. [PMID: 27698625 PMCID: PMC5030866 DOI: 10.1177/1558944715628007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy found in clinical practice. Recent studies evaluated which external factors could be involved in the CTS symptoms, including prolonged exposure to vibration, especially in the upper limb. This study investigated signs and symptoms in patients with CTS after using urban transport on (1) both upper limbs, (2) how long before these symptoms appear, and (3) the hands position or body reaction during the act of pressing the safety bars. Methods: The study was conducted from July 2012 to April 2013. A total of 205 (178 women and 27 men) patients were evaluated. CTS was diagnosed in 285 hands. All participants answered a questionnaire formulated by the authors. The questionnaire was applied by researchers who were single-blinded and not involved in the research. Results: Most of the participants (87%) were women, but there was no statistical significance in age between groups (women = 51.24 ± 8.47 years, men = 51.10 ± 6.52 years, P > .05). The symptoms appeared significantly in the first 15 minutes after boarding when compared with patients who had no symptoms during the journey. There was no difference between hands position along the journey and the onset of symptoms. Conclusions: The onset of symptoms in patients with CTS using urban public transportation most commonly occurred in the first 15 minutes after boarding. Public transport vibration seems to be, at least in part, directly related to the development of symptoms. Questionnaires for the assessment of paresthesia symptoms during the use of public transport may be useful for CTS diagnosis.
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Affiliation(s)
- Luiz Guilherme de Saboya Lenzi
- Federal University of São Paulo, Brazil,Luiz Guilherme de Saboya Lenzi, Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Disciplina de Cirurgia da Mão e Membro Superior, Rua Borges Lagoa 786, Vila Clementino, São Paulo 04038-001, Brasil.
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Abstract
Details of the clinical history were elicited by questionnaire from 8,223 patients with suspected carpal tunnel syndrome and compared with the neurophysiological findings. Distribution of symptoms to the radial part of the hand and nocturnal exacerbation of symptoms showed the strongest individual correlations with positive nerve conduction studies. The regression model derived from the complete questionnaire achieved an overall sensitivity of 79% and specificity of 55% for the diagnosis of carpal tunnel syndrome when compared with the nerve conduction study results as a gold standard. A simple regression model for evaluating the history compares favourably with widely used clinical signs in its ability to predict the findings of nerve conduction studies.
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Bilgin Topçuoğlu Ö, Oruç Ö, Saraç S, Çetintaş Afşar G, Uluç K. Carpal Tunnel Syndrome in Obstructive Sleep Apnea Patients. ACTA ACUST UNITED AC 2016; 54:307-311. [PMID: 29321702 DOI: 10.5152/npa.2016.15907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/07/2016] [Indexed: 01/07/2023]
Abstract
Introduction Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity. It is usually associated with the compression of the median nerve in the median groove. Because the main symptoms of CTS pain and numbness worsen at night, sleep disorders in CTS patients and the impact of preferred sleeping position on CTS development have been formerly studied. However, to the best of our knowledge, this is the first study assessing the frequency of CTS in obstructive sleep apnea (OSA) patients. This study aimed to determine the frequency of CTS in OSA patients and evaluate the causative relation between the two diseases. Methods Records of individuals who were admitted to our sleep laboratory were retrospectively scanned. Eighty patients who were diagnosed with OSA and did not have comorbidities that might cause OSA (e.g., diabetes mellitus, hypothyroiditis, rheumatic diseases, and cervical radiculopathy) were included in the study along with 80 healthy controls who matched for age, sex, and BMI of OSA patients. To maintain observer blindness, patients were not questioned regarding their symptoms or the clinical data that would be used in the study. All participants underwent nerve conduction studies. Those who were diagnosed with CTS were questioned regarding CTS symptoms and the preferred sleeping position. Subsequently, patients were given the Boston CTS questionnaire. Results CTS frequency in OSA patients was found to be 27.5%. There was no significant relation between preferred sleeping position or being a manual worker and having CTS. Conclusion CTS frequency in OSA patients is significantly higher than that in healthy individuals. In contrast to previous studies that have been performed in the absence of polysomnographic and electrophysiological data, in our study biomechanical factors were not associated with CTS presence. Therefore, we conclude that intermittent hypoxemia is the main etiological factor for CTS in OSA patients. Inflammation may be a common factor for etiopathogenesis for both diseases, but this hypothesis needs further investigation.
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Affiliation(s)
- Özgür Bilgin Topçuoğlu
- Clinic of Neurology, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey.,Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | - Özlem Oruç
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Sema Saraç
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Gülgün Çetintaş Afşar
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Kayıhan Uluç
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
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Abstract
OBJECTIVES 1) Assess which electrodiagnostic studies Canadian clinicians use to aid in the diagnosis of carpal tunnel syndrome (CTS). 2) Assess whether Canadian clinicians follow the American Association of Neuromuscular & Electrodiagnostic Medicine/American Academy of Neurology/American Academy of Physical Medicine and Rehabilitation Practice Parameter for Electrodiagnostic Studies in CTS. 3) Assess how Canadian clinicians manage CTS once a diagnosis has been established. METHODS In this prospective observational study, an electronic survey was sent to all members of the Canadian Neuromuscular Group (CNMG) and the Canadian Association of Physical Medicine and Rehabilitation (CAPM&R) Neuromuscular Special Interest Group. Questions addressed which electrodiagnostic tests were being routinely used for the diagnosis of carpal tunnel syndrome. Management recommendations for CTS was also explored. RESULTS Of the 70 individuals who completed the survey, fourteen different nerve conduction study techniques were reported. Overall, 36/70 (51%) of participants followed the AANEM/AAN/AAPM&R Practice Parameter. The standard followed by the fewest of our respondents with 64% compliance (45/70) was the use of a standard distance of 13 to 14 cm with respect to the median sensory nerve conduction study. Regarding management, 99% would recommend splinting in the case of mild CTS. In moderate CTS, splinting was recommended by 91% of clinicians and 68% would also consider referral for surgery. In severe CTS, most recommended surgery (93%). CONCLUSIONS There is considerable variability in terms of which electrodiagnostic tests Canadian clinicians perform for CTS. Canadian clinicians are encouraged to adhere to the AANEM/AAN/AAPM&R Practice Parameter for Electrodiagnostic Studies in CTS.
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Hogaboom NS, Diehl JA, Oyster ML, Koontz AM, Boninger ML. Ultrasonographic Median Nerve Changes After Repeated Wheelchair Transfers in Persons With Paraplegia: Relationship With Subject Characteristics and Transfer Skills. PM R 2015; 8:305-313. [DOI: 10.1016/j.pmrj.2015.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 08/01/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Nathan S. Hogaboom
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA
| | | | - Michelle L. Oyster
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
| | - Alicia M. Koontz
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206; Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA
| | - Michael L. Boninger
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
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Saint-Lary O, Rébois A, Mediouni Z, Descatha A. Carpal tunnel syndrome: primary care and occupational factors. Front Med (Lausanne) 2015; 2:28. [PMID: 26000277 PMCID: PMC4419845 DOI: 10.3389/fmed.2015.00028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/17/2015] [Indexed: 12/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) affects about 1% of working-aged people and is the commonest cause of hand pain in manual workers. CTS is a clinical diagnosis and does not warrant any further investigation in the presence of mild and suggestive CTS. Although the recommended non-surgical management is still a matter of debate, nocturnal splinting or steroid injection are recommended in most countries, with strong to moderate level of evidence for short-term efficacy. Patients with an uncertain diagnosis or severe symptoms, should undergo nerve conduction studies with referral to a hand specialist.
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Affiliation(s)
- Olivier Saint-Lary
- Department of Family Medicine, Faculty of Health Sciences Simone Veil, Université de Versailles Saint-Quentin-en-Yvelines , Montigny le Bretonneux , France ; Centre de Recherche en Épidémiologie et Santé des Populations (CESP) - INSERM U1018 Team 1 , Villejuif , France
| | - Arnaud Rébois
- Medical Home Primary Care of Montcient , Oinville , France
| | - Zakia Mediouni
- Occupational Health Unit/EMS (Samu92), Assistance Publique - Hôpitaux de Paris, Poincaré University Hospital , Garches , France ; Population-Based Epidemiologic Cohorts Unit, UMS 011, INSERM , Villejuif , France ; UMS 011 UMR-S 1168, Université de Versailles Saint-Quentin-en-Yvelines , Versailles , France
| | - Alexis Descatha
- Occupational Health Unit/EMS (Samu92), Assistance Publique - Hôpitaux de Paris, Poincaré University Hospital , Garches , France ; Population-Based Epidemiologic Cohorts Unit, UMS 011, INSERM , Villejuif , France ; UMS 011 UMR-S 1168, Université de Versailles Saint-Quentin-en-Yvelines , Versailles , France ; VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, INSERM , Villejuif , France
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Duckworth AD, Jenkins PJ, McEachan JE. Diagnosing carpal tunnel syndrome. J Hand Surg Am 2014; 39:1403-7. [PMID: 24818965 DOI: 10.1016/j.jhsa.2014.03.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 03/30/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew D Duckworth
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom.
| | - Paul J Jenkins
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jane E McEachan
- Department of Orthopaedic Surgery, Queen Margaret Hospital, Fife, United Kingdom; Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
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Blok RD, Becker SJE, Ring DC. Diagnosis of carpal tunnel syndrome: interobserver reliability of the blinded scratch-collapse test. J Hand Microsurg 2013; 6:5-7. [PMID: 24876682 DOI: 10.1007/s12593-013-0105-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022] Open
Abstract
The reliability of the scratch-collapse test for diagnosis of carpal tunnel syndrome (CTS) has not been tested by independent investigators. This study measured the reliability of the scratch-collapse test comparing the treating hand surgeon and blinded evaluators. We performed a prospective observational study of 41 patients with a provisional diagnosis of CTS or a combination of CTS and cubital tunnel syndrome and prescribed electrodiagnostic testing. The treating hand surgeon performed the scratch-collapse test. Next, the test was administered by one of the six observers, unaware of the patient's symptoms and the diagnosis made by treating hand surgeon. The kappa statistic (κ) was used to calculate the interrater reliability between the treating hand surgeons and blinded scratchers. The agreement between the blinded observers and the hand surgeons on the scratch-collapse test was substantial 0.63 (95 % CI, 0.34-0.87; p < 0.001). The sensitivity of the blinded scratch test in our sample was 32 %. In a small study with a spectrum bias favoring electrophysiologically confirmed CTS the reliability was lower than that reported by the inventors of the test, but was still substantial. We propose a larger study of patients with a greater variety of electrodiagnostic test results using fewer observers with more experience.
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Affiliation(s)
- Robin D Blok
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - Stéphanie J E Becker
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - David C Ring
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
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Ntani G, Palmer KT, Linaker C, Harris EC, Van der Star R, Cooper C, Coggon D. Symptoms, signs and nerve conduction velocities in patients with suspected carpal tunnel syndrome. BMC Musculoskelet Disord 2013; 14:242. [PMID: 23947775 PMCID: PMC3765787 DOI: 10.1186/1471-2474-14-242] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 08/09/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To inform the clinical management of patients with suspected carpal tunnel syndrome (CTS) and case definition for CTS in epidemiological research, we explored the relation of symptoms and signs to sensory nerve conduction (SNC) measurements. METHODS Patients aged 20-64 years who were referred to a neurophysiology service for investigation of suspected CTS, completed a symptom questionnaire (including hand diagrams) and physical examination (including Tinel's and Phalen's tests). Differences in SNC velocity between the little and index finger were compared according to the anatomical distribution of symptoms in the hand and findings on physical examination. RESULTS Analysis was based on 1806 hands in 908 patients (response rate 73%). In hands with numbness or tingling but negative on both Tinel's and Phalen's tests, the mean difference in SNC velocities was no higher than in hands with no numbness or tingling. The largest differences in SNC velocities occurred in hands with extensive numbness or tingling in the median nerve sensory distribution and both Tinel's and Phalen's tests positive (mean 13.8, 95% confidence interval (CI) 12.6-15.0 m/s). Hand pain and thumb weakness were unrelated to SNC velocity. CONCLUSIONS Our findings suggest that in the absence of other objective evidence of median nerve dysfunction, there is little value in referring patients of working age with suspected CTS for nerve conduction studies if they are negative on both Tinel's and Phalen's tests. Alternative case definitions for CTS in epidemiological research are proposed according to the extent of diagnostic information available and the relative importance of sensitivity and specificity.
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Affiliation(s)
- Georgia Ntani
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton SO16 6YD, UK.
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The value of provocative tests for the wrist and elbow: a literature review. J Hand Ther 2013; 26:32-42; quiz 43. [PMID: 23062797 DOI: 10.1016/j.jht.2012.08.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 08/25/2012] [Accepted: 08/29/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED To describe and determine the usefulness of provocative tests for the wrist and elbow a literature search was performed. A total of 31 diagnostic studies were identified, assessed, and ranked. The highest ranking tests had a mean positive likelihood ratio of ≥2.0, or a mean negative likelihood ratio of ≤0.5, from more than one study. The highly recommended tests were found to be the Phalen's, Tinel's test for carpal tunnel and cubital tunnel, and modified compression test, scaphoid shift test, and elbow flexion test. A total of 14 tests met our requirements to be considered a recommended test. A greater number of provocative tests either do not have adequate data to support their usefulness or their clinical utility has not been assessed. This information may assist hand therapists in choosing which provocative tests are considered clinically useful in improving the probability of the presence or absence of pathology in the hand, wrist, and elbow. LEVEL OF EVIDENCE NA.
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Abstract
PURPOSE OF REVIEW Musculoskeletal complaints are a feature of several endocrine diseases. This review will update clinicians on their association, presentation, and treatment. RECENT FINDINGS To update clinicians on the recent literature as it is related to pathophysiology, genetic, and clinical findings on the association of these diseases and musculoskeletal complaints. SUMMARY Rheumatologists in the clinic are faced with different presentations of various musculoskeletal complaints every day. Every new patient encounter requires the differential diagnosis of these complaints. The first task is usually to decide with what disease in internal medicine these complaints are associated. The endocrinopathies are a group of illnesses that either present initially or exhibit sometime during the course of the disease as a variety of musculoskeletal complaints. Rheumatic manifestations may often be the initial presentation of an endocrine disorder. Each endocrine disorder may also have its own arthritic complaints, which can present as a definitive rheumatic disease such as calcium pyrophosphate dihydrate deposition disease or as a rheumatic symptom such as diffuse arthralgia. The rheumatologist as well as the primary care physician should be knowledgeable about the ways in which muscles, tendons, ligaments, and joints are affected by diseases of the endocrine system.
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Affiliation(s)
- Leilei Wang
- Department of Rehabilitation Medicine, University of Washington, School of Medicine, Seattle, WA 98195, USA.
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Ladak A, Spinner RJ. Carpal tunnel syndrome: when excellent is not good enough. World Neurosurg 2012; 79:655-7. [PMID: 23159645 DOI: 10.1016/j.wneu.2012.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 11/09/2012] [Indexed: 12/31/2022]
Affiliation(s)
- Adil Ladak
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Mondelli M, Rossi S, Ballerini M, Mattioli S. Factors influencing the diagnostic process of carpal tunnel syndrome. Neurol Sci 2012; 34:1197-205. [DOI: 10.1007/s10072-012-1222-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 10/05/2012] [Indexed: 12/21/2022]
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