CPR for Carpal Tunnel Syndrome: Difference between revisions

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'''Original Editor '''- [[User:Cheryl Rentchler|Cheryl Rentchler]]  
'''Original Editor '''- [[User:Cheryl Rentchler|Cheryl Rentchler]]  


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== Purpose<br>  ==


Clinical prediction rules (CPRs) combine historical and physical examination findings to help clinicians predict the probability of a particular diagnosis.<ref name="Childs">Childs JD, Cleland JA. Development and Application of Clinical Prediction Rules to Improve Clinical Decision Making in Physical Therapist Practice. Phys Ther. 2006; 122-131.</ref> In 2005, Wainner et al published a level IV CPR to aid clinicians in diagnosing carpal tunnel syndrome.<ref name="Wainner">Wainner R, Fritz J, Irrgang J, Delitto A, Allison S, Boninger M. Development of a Clinical Prediction Rule for the Diagnosis of Carpal Tunnel Syndrome. Arch Phys Med 2005; 86: 609-618.</ref>  
== Clinical Prediction Rules of Carpal Tunnel Syndrome:  ==
[[File:Carpal_tunnel.png|thumb]]
Clinical prediction rules (CPRs) combine '''historical and physical examination findings''' to help clinicians predict the probability of a particular diagnosis.<ref name="Childs">Childs JD, Cleland JA. Development and Application of Clinical Prediction Rules to Improve Clinical Decision Making in Physical Therapist Practice. Phys Ther. 2006; 122-131.</ref> In 2005, Wainner et al published a level IV CPR to aid clinicians in diagnosing [[Carpal Tunnel Syndrome|carpal tunnel syndrome]].<ref name="Wainner">Wainner R, Fritz J, Irrgang J, Delitto A, Allison S, Boninger M. Development of a Clinical Prediction Rule for the Diagnosis of Carpal Tunnel Syndrome. Arch Phys Med 2005; 86: 609-618.</ref> These CPRs help to improve the diagnostic accuracy of a clinician<ref>Lo JK, Finestone HM, Gilbert K. Prospective evaluation of the clinical prediction of electrodiagnostic results in carpal tunnel syndrome. PM&R. 2009 Jul 1;1(7):612-9.</ref>. Carpal Tunnel Syndrome is a compressive or entrapment neuropathy of the '''[[Median Nerve|median nerve]]''' at the carpal tunnel at wrist.<ref>Burton CL, Chesterton LS, Chen Y, van der Vindt DA. Clinical course and prognostic factors in conservatively managed Carpal Tunnel Syndrom: A systematic review.Archives of Physical Medicine and Rehabilitation 2016; 97:836-52</ref><ref>Sears ED, Swiatek PR, Hou H, Chung KC. Utilization of preoperative electrodiagnostic studies for carpal tunnel syndrome: an analysis of national practice patterns. The Journal of hand surgery. 2016 Jun 1;41(6):665-72</ref>
== Clinical Prediction Rule Components: <ref name="Wainner" />  ==


== Clinical Prediction Rule Components <ref name="Wainner" />  ==
1. Shaking hands to relieve symptoms  
 
1. Shaking hands to relieve symptoms<span id="fck_dom_range_temp_1246070608046_19"></span>


2. Wrist ratio &gt;.67  
2. Wrist ratio &gt;.67  
Line 22: Line 20:
5. Age &gt; 45 years old  
5. Age &gt; 45 years old  


== Technique  ==
== Technique: ==
 
'''Wrist ratio index''', as described by Johnson et al,<ref name="Johnson">Johnson E, Gatens T, Poindexter D, Bowers D. Wrist dimensions: correlation with median sensory latencies. Arch Phys Med Rehabil 1993; 64:556-7.</ref> is measured by using a pair of sliding calipers to measure the anteroposterior (AP) wrist width and the mediolateral (ML) wrist width at the distal wrist crease. Wrist ratio index is then calculated by dividing the AP wrist width by the ML wrist width in centimeters. Ratios greater than .70 were found to be a predisposing factor for carpal tunnel syndrome. <ref name="Johnson" />&nbsp;


<br>'''Median nerve sensation '''was measured on the pad of thumb with end of a straightened paper clip, and compared to sensation at the proximal thenar eminence. Sensory tests were grades as absent, reduced, normal or hyperesthestic
'''Wrist ratio index:''' as described by Johnson et al,<ref name="Johnson">Johnson E, Gatens T, Poindexter D, Bowers D. Wrist dimensions: correlation with median sensory latencies. Arch Phys Med Rehabil 1993; 64:556-7.</ref> is measured by using a pair of sliding calipers to measure the antero-posterior (AP) wrist width and the medio-lateral (ML) wrist width at the distal wrist crease. Wrist ratio index is then calculated by dividing the AP wrist width by the ML wrist width in centimeters. Ratios greater than .70 were found to be a predisposing factor for carpal tunnel syndrome. <ref name="Johnson" />


<br>
'''Median nerve sensation: '''was measured on the pad of thumb with the end of a straightened paper clip and compared to sensation at the proximal thenar eminence. Sensory tests were graded as absent, reduced, normal or hyperesthestic


'''Symptom Severity Scale''': The symptom severity scale was published in 1993 by Levine et al <ref name="Levine">Levine D, Simmons B, Koris M, Daltroy L, Hohl G, Fossel A, Katz J. A Self- Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome. J Bone Joint Surg Am 1993; 75: 1585-92.</ref>. It is an 11 item questionnaire that examines the six critical domains for the evaluation of CTS: pain, paresthesia, numbness, weakness, nocturnal symptoms and overall functional status. Each question is scored from 1 (mildest symptoms) to 5 (most severe symptoms); therefore, a higher score indicates a more severe case of CTS. The SSS has been shown to have good reliability, validity and responsiveness. <ref name="Levine" />  
'''Symptom Severity Scale''': The symptom severity scale was published in 1993 by Levine et al <ref name="Levine">Levine D, Simmons B, Koris M, Daltroy L, Hohl G, Fossel A, Katz J. A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome. J Bone Joint Surg Am 1993; 75: 1585-92.</ref>. It is an 11 item questionnaire that examines the six critical domains for the evaluation of CTS: pain, paresthesia, numbness, weakness, nocturnal symptoms and overall functional status. Each question is scored from 1 (mildest symptoms) to 5 (most severe symptoms); therefore, a higher score indicates a more severe case of CTS. The SSS has been shown to have good reliability, validity and responsiveness. <ref name="Levine" />  


== Evidence  ==
== Evidence: ==


{| cellspacing="1" cellpadding="1" border="1" width="400"
{| width="400" cellspacing="1" cellpadding="1" border="1"
|+ Validity of CPR for diagnosis of CTS<ref name="Wainner" />  
|+ '''Validity of CPR for diagnosis of CTS''' <ref name="Wainner" />  
|-
|-
|  
|  
| Sensitivity  
| Sensitivity  
| Specificity  
| Specificity  
| + LR&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;
| + LR  
| &nbsp;- LR&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
|- LR
|-
|-
| <u>&gt;</u>&nbsp;3 positive tests  
| <u>&gt;</u> 3 positive tests  
| .98  
| .98  
| .54  
| .54  
| 2.1  
| 2.1  
| .04
|-
|-
| <u>&gt;</u>&nbsp;4 positive tests  
| <u>&gt;</u> 4 positive tests  
| .77  
| .77  
| .83  
| .83  
| 4.6  
| 4.6  
| .28
|-
|-
| All 5 tests positive  
| All 5 tests positive  
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| .99  
| .99  
| 18.3  
| 18.3  
| .83
|}
|}


<br>  
<br>  


{| cellspacing="1" cellpadding="1" border="1" width="400"
{| width="400" cellspacing="1" cellpadding="1" border="1"
|+ Validity of other common individual historical questions and physical exam findings<ref name="Wainner" />  
|+ '''Validity of other common individual historical questions and physical exam findings'''<ref name="Wainner" />  
|-
|-
|  
|  
| Sensitivity  
| Sensitivity  
| Specificity  
| Specificity  
| + LR&nbsp;&nbsp;&nbsp;&nbsp;
| + LR  
| - LR&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
| - LR
|-
|-
| Phalen test  
| Phalen test  
Line 77: Line 70:
| .40  
| .40  
|  
|  
1.3&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
1.3  


| &nbsp;.58&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
| .58
|-
|-
| Tinel Part A  
| Tinel Part A  
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| .58  
| .58  
|  
|  
<br>.98  
.98  


| 1.0
| 1.0
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| .89  
| .89  
|  
|  
<br>1.7  
1.7  


| .91
| .91
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<br>  
<br>  


<br>
{| width="400" cellspacing="1" cellpadding="1" border="1"
 
|+ '''Interpretation of likelihood ratios'''<ref name="Jaeschke">Jaeschke R, Guyatt G, Sackett D. User's Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994; 271:703-707.</ref>  
<br>
 
{| cellspacing="1" cellpadding="1" border="1" width="400"
|+ Interpretation of likelihood ratios<ref name="Jaeschke">Jaeschke R, Guyatt G, Sackett D. User's Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994; 271:703-707.</ref>  
|-
|-
|  
|  
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Interpretation  
Interpretation (shifts in probability)


&nbsp;&nbsp;&nbsp; (shifts in probablitity)
| + LR
 
| - LR
| &nbsp;&nbsp; + LR&nbsp;&nbsp;&nbsp;
| &nbsp;&nbsp; - LR
|-
|-
|  
|  
&nbsp; large shifts, often conclusive  
large shifts, often conclusive  


| &nbsp;&nbsp;&nbsp; &gt; 10&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;
| &gt; 10
| &nbsp;&lt;&nbsp;0.1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
| &lt; 0.1
|-
|-
|  
|  
&nbsp;&nbsp;&nbsp;&nbsp; moderate shifts&nbsp;&nbsp;&nbsp;&nbsp;
moderate shifts  


| &nbsp;&nbsp;&nbsp;&nbsp; 5-10  
| 5-10  
| &nbsp;&nbsp;0.1-0.2
| 0.1-0.2
|-
|-
|  
|  
&nbsp;small shifts, sometimes important&nbsp; &nbsp;
small shifts, sometimes important  


| &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2-5  
| 2-5  
| &nbsp;&nbsp;&nbsp; 0.2-0.5
| 0.2-0.5
|-
|-
| &nbsp;small and rarely important shifts&nbsp;
| small and rarely important shifts  
|  
|  
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;1-2  
1-2  


| &nbsp;&nbsp;&nbsp;&nbsp; 0.5-1
| 0.5-1
|}
|}


<br>  
<br>  


<br>
== Suggestions for Use in the Clinic:  ==
 
== Suggestions for Use in the Clinic ==
 
In 2005 Wainner et al published a level IV CPR to assist in identifying patients presenting with carpal tunnel syndrome. When 4/5 tests are positive the + LR is 4.6, and if all of the tests are positive the + LR&nbsp;increases to&nbsp;18.3.<ref name="Wainner" /> These are significantly higher + LRs than other individual tests used to diagnose carpal tunnel syndrome. However,&nbsp;a level IV CPR means the rule has been developed but not validated and further evaluation is required before the rule can be applied clinically; therefore, further research is needed to validate this CPR.<ref name="Childs" />
 
== Resources  ==
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=14EXV6AaFU8etrIgDd5r0YxDAuggk81ofzOsqe4OhgS-NWOkf|charset=UTF-8|short|max=10</rss>
</div>
== References ==


References will automatically be added here, see [[Adding References|adding references tutorial]].
In 2005, Wainner et al published a level IV CPR to assist in identifying patients presenting with carpal tunnel syndrome.  When 4/5 tests are positive the positive Likelihood Ratio is 4.6, and if all of the tests are positive it increases to&nbsp;18.3.<ref name="Wainner" /> These are significantly higher than positive Likelihood Ratio of other individual tests used to diagnose carpal tunnel syndrome. However, a level IV CPR means the rule has been developed but not validated and further evaluation is required before the rule can be applied clinically, therefore, further research is needed to validate this CPR.<ref name="Childs" />
== References:  ==


<references />  
<references />  


[[Category:Articles]] [[Category:Clinical_Prediction_Rules]] [[Category:EIM_Student_Project]] [[Category:Hand]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Wrist]]
[[Category:Clinical_Prediction_Rules]]
[[Category:Hand]]
[[Category:Wrist]]  
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Neurological - Conditions]]  
[[Category:EIM_Residency_Project]]
[[Category:Assessment]]
[[Category:Wrist - Assessment and Examination]]
[[Category:Hand - Assessment and Examination]]

Latest revision as of 16:06, 22 November 2021

Original Editor - Cheryl Rentchler

Top Contributors - Cheryl Rentchler, Admin, Shaimaa Eldib, Kim Jackson, Laura Ritchie, Vidhu Sindwani, WikiSysop, Rachael Lowe, Evan Thomas, Amanda Ager and Shreya Pavaskar

Clinical Prediction Rules of Carpal Tunnel Syndrome:[edit | edit source]

Carpal tunnel.png

Clinical prediction rules (CPRs) combine historical and physical examination findings to help clinicians predict the probability of a particular diagnosis.[1] In 2005, Wainner et al published a level IV CPR to aid clinicians in diagnosing carpal tunnel syndrome.[2] These CPRs help to improve the diagnostic accuracy of a clinician[3]. Carpal Tunnel Syndrome is a compressive or entrapment neuropathy of the median nerve at the carpal tunnel at wrist.[4][5]

Clinical Prediction Rule Components: [2][edit | edit source]

1. Shaking hands to relieve symptoms

2. Wrist ratio >.67

3. Symptom Severity Scale > 1.9

4. Diminished sensation in median sensory field 1 (thumb)

5. Age > 45 years old

Technique:[edit | edit source]

Wrist ratio index: as described by Johnson et al,[6] is measured by using a pair of sliding calipers to measure the antero-posterior (AP) wrist width and the medio-lateral (ML) wrist width at the distal wrist crease. Wrist ratio index is then calculated by dividing the AP wrist width by the ML wrist width in centimeters. Ratios greater than .70 were found to be a predisposing factor for carpal tunnel syndrome. [6]

Median nerve sensation: was measured on the pad of thumb with the end of a straightened paper clip and compared to sensation at the proximal thenar eminence. Sensory tests were graded as absent, reduced, normal or hyperesthestic

Symptom Severity Scale: The symptom severity scale was published in 1993 by Levine et al [7]. It is an 11 item questionnaire that examines the six critical domains for the evaluation of CTS: pain, paresthesia, numbness, weakness, nocturnal symptoms and overall functional status. Each question is scored from 1 (mildest symptoms) to 5 (most severe symptoms); therefore, a higher score indicates a more severe case of CTS. The SSS has been shown to have good reliability, validity and responsiveness. [7]

Evidence:[edit | edit source]

Validity of CPR for diagnosis of CTS [2]
Sensitivity Specificity + LR
> 3 positive tests .98 .54 2.1
> 4 positive tests .77 .83 4.6
All 5 tests positive .18 .99 18.3


Validity of other common individual historical questions and physical exam findings[2]
Sensitivity Specificity + LR - LR
Phalen test .77 .40

1.3

.58
Tinel Part A .41 .58

.98

1.0
MMT APB .19 .89

1.7

.91
c/o symptoms waking at night .73 .31 1.1 .86
c/o fumbling or dropping objects with affected hand .73 .57 1.7 .47


Interpretation of likelihood ratios[8]

Interpretation (shifts in probability)

+ LR - LR

large shifts, often conclusive

> 10 < 0.1

moderate shifts

5-10 0.1-0.2

small shifts, sometimes important

2-5 0.2-0.5
small and rarely important shifts

1-2

0.5-1


Suggestions for Use in the Clinic:[edit | edit source]

In 2005, Wainner et al published a level IV CPR to assist in identifying patients presenting with carpal tunnel syndrome. When 4/5 tests are positive the positive Likelihood Ratio is 4.6, and if all of the tests are positive it increases to 18.3.[2] These are significantly higher than positive Likelihood Ratio of other individual tests used to diagnose carpal tunnel syndrome. However, a level IV CPR means the rule has been developed but not validated and further evaluation is required before the rule can be applied clinically, therefore, further research is needed to validate this CPR.[1]

References:[edit | edit source]

  1. ↑ 1.0 1.1 Childs JD, Cleland JA. Development and Application of Clinical Prediction Rules to Improve Clinical Decision Making in Physical Therapist Practice. Phys Ther. 2006; 122-131.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Wainner R, Fritz J, Irrgang J, Delitto A, Allison S, Boninger M. Development of a Clinical Prediction Rule for the Diagnosis of Carpal Tunnel Syndrome. Arch Phys Med 2005; 86: 609-618.
  3. ↑ Lo JK, Finestone HM, Gilbert K. Prospective evaluation of the clinical prediction of electrodiagnostic results in carpal tunnel syndrome. PM&R. 2009 Jul 1;1(7):612-9.
  4. ↑ Burton CL, Chesterton LS, Chen Y, van der Vindt DA. Clinical course and prognostic factors in conservatively managed Carpal Tunnel Syndrom: A systematic review.Archives of Physical Medicine and Rehabilitation 2016; 97:836-52
  5. ↑ Sears ED, Swiatek PR, Hou H, Chung KC. Utilization of preoperative electrodiagnostic studies for carpal tunnel syndrome: an analysis of national practice patterns. The Journal of hand surgery. 2016 Jun 1;41(6):665-72
  6. ↑ 6.0 6.1 Johnson E, Gatens T, Poindexter D, Bowers D. Wrist dimensions: correlation with median sensory latencies. Arch Phys Med Rehabil 1993; 64:556-7.
  7. ↑ 7.0 7.1 Levine D, Simmons B, Koris M, Daltroy L, Hohl G, Fossel A, Katz J. A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome. J Bone Joint Surg Am 1993; 75: 1585-92.
  8. ↑ Jaeschke R, Guyatt G, Sackett D. User's Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994; 271:703-707.
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