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]] | ||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | ||
</div> | </div> | ||
== Purpose | |||
== Purpose == | |||
[[Image:Carpal tunnel.png|thumb|right|350px|The Carpal Tunnel]] | [[Image:Carpal tunnel.png|thumb|right|350px|The Carpal Tunnel]] | ||
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== 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 | ||
2. Wrist ratio >.67 | 2. Wrist ratio >.67 | ||
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== 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" /> | '''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" /> | ||
<br>'''Median nerve sensation '''was measured on the pad of thumb with end of a straightened paper clip | <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 | ||
<br> | <br> | ||
'''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 == | ||
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| Sensitivity | | Sensitivity | ||
| Specificity | | Specificity | ||
| + LR | | + LR | ||
| | |- LR | ||
|- | |- | ||
| <u>></u> | | <u>></u> 3 positive tests | ||
| .98 | | .98 | ||
| .54 | | .54 | ||
| Line 55: | Line 56: | ||
| .04 | | .04 | ||
|- | |- | ||
| <u>></u> | | <u>></u> 4 positive tests | ||
| .77 | | .77 | ||
| .83 | | .83 | ||
| Line 76: | Line 77: | ||
| Sensitivity | | Sensitivity | ||
| Specificity | | Specificity | ||
| + LR | | + LR | ||
| - LR | | - LR | ||
|- | |- | ||
| Phalen test | | Phalen test | ||
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| .40 | | .40 | ||
| | | | ||
1.3 | 1.3 | ||
| | | .58 | ||
|- | |- | ||
| Tinel Part A | | Tinel Part A | ||
| Line 91: | Line 92: | ||
| .58 | | .58 | ||
| | | | ||
.98 | |||
| 1.0 | | 1.0 | ||
| Line 99: | Line 100: | ||
| .89 | | .89 | ||
| | | | ||
1.7 | |||
| .91 | | .91 | ||
| Line 115: | Line 116: | ||
| .47 | | .47 | ||
|} | |} | ||
<br> | <br> | ||
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|- | |- | ||
| | | | ||
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 | ||
|} | |} | ||
<br> | <br> | ||
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== 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 | 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 increases to 18.3.<ref name="Wainner" /> These are significantly higher + LRs than 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" /> | ||
== Resources == | == Resources == | ||
== References == | == References == | ||
<references /> | <references /> | ||
[[Category:Clinical_Prediction_Rules]] [[Category:Hand]] [[Category:Wrist]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Neurological_Conditions]] [[Category:EIM_Residency_Project]] | |||
[[Category:Clinical_Prediction_Rules]][[Category: | |||
Revision as of 19:19, 2 October 2017
Original Editor - Cheryl Rentchler
Top Contributors - Cheryl Rentchler, Admin, Shaimaa Eldib, Kim Jackson, Laura Ritchie, Rachael Lowe, Vidhu Sindwani, WikiSysop, Evan Thomas, Amanda Ager and Shreya Pavaskar
Purpose[edit | edit source]
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]
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,[3] 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. [3]
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 [4]. 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. [4]
Evidence[edit | edit source]
| [5] |
| Sensitivity | Specificity | + LR | ||
| > 3 positive tests | .98 | .54 | 2.1 | .04 |
| > 4 positive tests | .77 | .83 | 4.6 | .28 |
| All 5 tests positive | .18 | .99 | 18.3 | .83 |
| 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 (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 + LR is 4.6, and if all of the tests are positive the + LR increases to 18.3.[2] These are significantly higher + LRs than 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]
Resources[edit | edit source]
References[edit | edit source]
- ↑ 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.
- ↑ 2.0 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.
- ↑ 3.0 3.1 Johnson E, Gatens T, Poindexter D, Bowers D. Wrist dimensions: correlation with median sensory latencies. Arch Phys Med Rehabil 1993; 64:556-7.
- ↑ 4.0 4.1 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.
- ↑ ehansondpt. Evidence-based Clinical Prediction Rule for Carpal Tunnel Syndrome . Available from: http://www.youtube.com/watch?v=6izWfWCi_qw [last accessed 09/02/13]
- ↑ 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.
