Clinical diagnosis of carpal tunnel syndrome: a systematic review

doi:10.1197/j.jht.2004.02.015

Journal of Hand Therapy

Volume 17, Issue 2, April–June 2004, Pages 309-319

https://doi.org/10.1197/j.jht.2004.02.015 Get rights and content

Abstract

The purposes of this systematic review were to examine the properties of clinical tests usd in the diagnosis of carpal tunnel syndrome (CTS) and to provide estimates of their sensitivity and specificity. A literature search was conducted using two databases—PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)—from 1986 to June 2003, and hand-searching reference lists of retrieved articles. Two reviewers evaluated the papers for quality using an evaluation tool developed by one of the authors. Estimates of sensitivity and specificity were determined by averaging values across studies weighted by sample size. Although 60 studies were reviewed in detail, many were of poor quality (mean quality score was 6.6 of 12, with only 15 of 60 obtaining a score of 8 or greater). The most frequently studied test was Phalen's, with an overall estimate of 68% sensitivity and 73% specificity. Next was Tinel's, with estimates of 50% and 77%, and then carpal compression, with estimates of 64% and 83% for sensitivity and specificity, respectively. Two-point discrimination and testing of atrophy or strength of the abductor pollicis brevis proved to be specific but not very sensitive. The estimates determined in this review should help therapists choose clinical tests with the appropriate balance of sensitivity and specificity required for diagnosing carpal tunnel syndrome in their specific clinical environments.

Section snippets

Literature search

A literature search was conducted using two databases—PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)—and hand-searching reference lists of retrieved articles. The search terms and resultant hits were as follows:

A.
PubMed (limitations—English only, abstract and human) from 1986 to June 2003
- 1.
  (carpal tunnel syndrome) AND (diagnosis) NOT (electrodiagnosis) AND (sensitivity and specificity [MESH]) OR sensitivity (WORD) OR (diagnosis [SH] OR diagnostic use [SH] OR

Results

Of the 75 papers reviewed, four were rejected because they did not specifically address diagnostic accuracy. These studies typically looked at differences in a clinical criterion in patients versus cases, but did not specify cutoff criteria or use specific criteria to classify patients. Eleven studies6., 7., 8., 9., 10., 11., 12., 13., 14., 15., 16. were not included in data synthesis because they only addressed tests that were classified as “unable to make recommendations.” Tests were

Discussion

Clinical diagnosis of CTS is an important issue given the high prevalence of CTS, the potential resulting disability, and the predictable response to treatment.⁴⁰ In fact, of the conditions seen by hand therapists, there is no other single condition for which so many different clinical diagnostic tests have been described.

The large number of articles retrieved and evaluated in this review reflects this emphasis on diagnostic tests for CTS, and exceeds the 21 papers reported on in a previous

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Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.
This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.
A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.
We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.
This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.
MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.
Updates on Evaluation and Treatment of Common Complaints in Pregnancy
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Efficacy of rehabilitation treatment for carpal tunnel syndrome: A randomized controlled clinical trial
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El síndrome del túnel carpiano es la neuropatía del nervio mediano más frecuente. Existen múltiples tratamientos invasivos y no invasivos, incluyen férulas, ultrasonido terapéutico (UST) e infiltraciones con esteroides (IE) que han demostrado una mejora en los estudios de conducción nerviosa (ECN), sin embargo, se desconoce el efecto de los tratamientos conservadores combinados. El objetivo fue determinar la eficacia del tratamiento conservador para mejorar los ECN y las manifestaciones clínicas en pacientes con síndrome del túnel carpiano.
Pacientes con diagnóstico de síndrome del túnel carpiano mediante ECN, sin enfermedades que afecten al nervio periférico. Todos firmaron consentimiento informado y fueron aleatorizados en 3 grupos de tratamiento (G1: férula + UST; G2: férula + IE; G3; férula + UST + IE). Participaron 3 médicos especialistas en rehabilitación (médico 1: realizó los ECN; médico 2: realizó evaluaciones clínicas; médico 3: realizó la IE). Tratamientos: UST (10 sesiones continuas de lunes a viernes durante dos semanas, 3 MHz, 0,8W/cm², 8 min) aplicado por el mismo fisioterapeuta. Infiltración: dosis única, 1 ml de metilprednisolona (40 mg/ml) mezclado con 1 ml de (0,5%) bupivacaína. Férula: férulas neutras volares hechas a la medida, de fibra de vidrio para uso nocturno.
Se incluyeron 30 pacientes y 30 manos, con una edad de 50,5 ± 7,5 años, todas ellas mujeres. Los grupos no tenían diferencias en las variables electrofisiológicas y clínicas al inicio del estudio. Tras la intervención (4 semanas) los grupos 2 y 3 mostraron mejoría en el ECN (p< 0,05) siendo mayor en el grupo 3. En la evaluación final (8 semanas) todos los grupos mostraron una mejoría en las variables electrofisiológicas y clínicas.
El tratamiento combinado de férula + UST + IE presenta resultados significativos en el ECN a las 4 semanas de seguimiento, en comparación a los otros dos grupos. Al final del seguimiento (8 semanas) todos los grupos presentan mejoría en las variables electrofisiológicas y clínicas, sin diferencias intergrupo.
Carpal tunnel syndrome is the most common median nerve mononeuropathy. There are multiple conservative treatments, invasive (corticoid injections [CI]) and non-invasive (splinting, therapeutic ultrasound [TUS], laser, exercise). However, the treatment choice is controversial. The aim was to determine the efficacy of conservative treatment to improve the clinical and electrophysiological evaluations.
Outpatients referred whit carpal tunnel syndrome clinical diagnosis to perform nerve conduction study (NCS) were included, without chronic or metabolic diseases that affect the peripheral nerves, without carpal tunnel syndrome treatment and with mild or moderate axonotmesis or neuropraxia in NCS baseline. Patients who signed informed consent forms were randomized in three treatment groups (Group 1: TUS + splint; Group 2: CI + splint and Group 3: TUS + CI + splint) were referred for clinical evaluations. The NCS was performed in each patient at baseline, fourth and eighth weeks by the same physiatrist and the clinical evaluations were performed at baseline and the final follow-up.
Thirty patients were included; mean age was 50.7 ± 7.5 years and all of them females, without differences in NCS or clinical variables in the baseline evaluations. All groups exhibited improvement in some clinical and electrophysiological variables in the final evaluation, though only group 3 showed improvement on median/ulnar nerves sensory peak latency difference (1.2 ± 0.4 vs. 0.4 ± 0.4; p = 0.001) starting in week four.
The conservative treatment in patients with CTS improves NCS and clinical variables, including the most sensitive electrophysiological test (medial/ulnar difference), though if we combined three treatments (splint + TUS + CI), the improvement was found to be faster and remarkable.
Cross-Sectional Area of the Median Nerve as a Prognostic Indicator in Carpal Tunnel Syndrome Treated With Local Steroid Injection
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We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm² (large-CSA group; n = 16) or ≤15 mm² (small-CSA group; n = 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period.
The treatment success rate was 45% (n = 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively.
Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection.
Therapeutic IV.
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Certain sports can be a risk factor for carpal tunnel syndrome: tennis, squash, badminton and ping-pong, golf, weight-lifting, baseball, cycling, etc. The risk is greater with increasing speed of execution of the causal gesture. Awareness of this pathology is essential for all physicians providing care for athletes.
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Ulnar dysmelia is a congenital anatomic disorder characterized by abnormal development of the ulna and subsequent distal bones. This rare disorder has a heterogeneous presentation in patients described in the literature. We present the case of a 23-year-old woman with ulnar dysmelia who lacked the ulnar attachments of the transverse carpal ligament and developed carpal tunnel syndrome at a relatively young age, requiring carpal tunnel release. This case report presents an interesting and unique cause of carpal tunnel syndrome and reviews the literature on ulnar dysmelia.

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Scientific/Clinical ArticlesClinical diagnosis of carpal tunnel syndrome: a systematic review

Abstract

Section snippets

Literature search

Results

Discussion

J Hand Ther

J Hand Ther

J Hand Surg

J Hand Surg [Br]

J Hand Surg [Am]

J Hand Surg [Br]

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Surg [Br]

J Hand Surg [Am]

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Hand Ther

J Hand Surg [Br]

Arch Phys Med Rehabil

J Hand Surg [Am]

J Hand Surg [Am]

J Hand Ther

Phys Med Rehabil Clin N Am

Arch Phys Med Rehabil

J Hand Surg

J Hand Surg [Am]

J Hand Ther

J Hand Surg [Br]

J Hand Surg

J Hand Surg

Pain

Clin Neurol Neurosurg

J Hand Surg [Am]

J Hand Surg [Br]

Lancet

J Hand Surg [Am]

Arch Phys Med Rehabil

Occupational upper extremity disorders in the federal workforce. Prevalence, health care expenditures, and patterns of work disability

J Occup Environ Med

Evidence Based Medicine

Preliminary evaluation of a sensory and psychomotor functional test battery for carpal tunnel syndrome:part 1—confirmed cases and normal subjects

Am Ind Hyg Assoc J

Preliminary evaluation of a sensory and psychomotor functional test battery for carpal tunnel syndrome:part 2 industrial subjects

Am Ind Hyg Assoc J

Interview data versus questionnaire data in the diagnosis of carpal tunnel syndrome in epidemiological studies

Occup Med

Relationships between clinical symptom severity scales and nerve conduction measures in carpal tunnel syndrome

Muscle Nerve

Palmar cold threshold test and median nerve electrophysiology in carpal tunnel compression neuropathy

Clin Exp Neurol

The association between different patterns of hand symptoms and objective evidence of median nerve compression: a community-based survey

Arthritis Rheum

Symptoms experienced by patients with carpal tunnel syndrome

Can J Neurol Sci

Development of Diagnostic Criteria for Carpal Tunnel Syndrome

Scientific/Clinical Articles
Clinical diagnosis of carpal tunnel syndrome: a systematic review