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An evaluation of sensitivity of provocative tests used in the carpal tunnel syndrome diagnosis depending on clinical severity of the syndrome

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Georgiew F., Otfinowska E., Adamczyk T.

Medical Rehabilitation

2009

vol. 13(2)

17-22

Background: Using popular provocative tests to diagnose the carpal tunnel syndrome (CTS) facilitates referring patients for specialist treatment and is indispensable to the performance of epidemiologic studies. Patients with severe carpal tunnel syndrome (CTS) are frequently referred for surgery, whereas people with mild CTS are commonly referred for conservative therapy. Finding out which provocative tests are most effective in diagnosing mild cases can aid clinicians in making decisions about further treatment.Objectives: The purpose of this study was to evaluate the sensitivity of provocative tests used for diagnosis of CTS such as Phalen’s, Durkan’s and Tinel’s sign and to find out if the time of paresthesia occurrence during the tests depended on the severity of the syndrome assessed using Levine’s Questionnaire.Material and methods: The study involved 130 women and 33 men with carpal tunnel syndrome confirmed by ENG. 52 patients had bilateral symptoms so a total number of cases examined was 215. Subjects were tested using four CTS provocative tests in random order: Phalen’s, Durkan’s, Provocative and Tinel’s sign. The examiner waited 2 – 3 minutes between each provocative test to ensure that any nerve irritation caused by previous test had abated. Severity level of CTS was assessed using Levine’s Questionnaire .Results: Sensitivity values were: for Phalen’s Test – 85.6%, Durkan’s Test – 86.5%, Provocative Test 84.6%, and Tinel’s sign – 46%. Sensitivity values for Phalen’s, Durkan’s and Provocative tests are higher than 93,1% for moderate, severe and extreme CTS. There is a relationship between testing positive on CTS provocative tests and severity of clinical symptoms. As the severity of CTS increases, the average time of paresthesia occurrence in median nerve distribution decreases. Conclusions: (1) Tinel’s sign should not be recommended as a CTS diagnostic tool because of its low sensitivity. (2) If Levine’s Questionnaire reveals small progression of CTS the sensitivity of the tests is insufficient to confirm CTS. (3) In the case of patients with moderate, severe or extreme CTS according to Levine’s Questionnaire, the diagnosis can be confirmed using valid provocative tests such as Phalen’s, Durkan’s and Provocative.

Diagnostic tests used in diagnosis of carpal tunnel syndrome

100%

Georgiew F., Otfinowska E., Adamczyk T.

Medical Rehabilitation

2008

vol. 12(3)

24-35

In 1854 Paget described for the first time that carpal tunnel syndrome (CTS) results from compression of the median nerve within the carpal tunnel. CTS predominantly involves tingling and numbness in the typical median nerve distribution. Pain, described as deep, aching, or throbbing, occurs diffusely in the hand and radiates up the forearm. Atrophy of the muscles of the thenar is usually seen later in the course of the nerve compression. CTS is most frequent among persons between the ages of 30 to 60 and is two to three times more common in women than in men (peak prevalence in women older than 55 years). Carpal tunnel syndrome may affect 1% to 10% of the population. Incorrect diagnosis of CTS has been identified as one of the most common causes of CTS treatment failure. CTS should be diagnosed clinically. Electro-diagnostic studies are a standard method of establishing the diagnosis. Electrodiagnostic studies are performed to confirm the clinical diagnosis, to assess the severity of median nerve compression and to rule out more proximal compression sites. Abnormalities in nerve conduction study results can be the only objective evidence of carpal tunnel syndrome. Lack of objective data, such as ENG can lead to incorrect diagnosis and inappropriate treatment. Clinical diagnosis should be reinforced by valuable diagnostic tests: the Semmes–Weinstein monofilaments test – performed in neutral and Phalen’s positions, vibration threshold measured by means of tuning forks or a vibrometer, by observation of thenar atrophy and using provocative tests. The use of common, sensitive and specific diagnostic tests should improve decision making about patients referral for specific therapies, facilitate the performance of epidemiologic studies, increase the accuracy of diagnosis. The combination of a results obtained using various methods might be more powerful than a single test in establishing the diagnosis of CTS. The combination of hand diagram, questionnaires, abnormal sensibility, thenar weakness or thenar atrophy and positive provocative tests constitutes a sensitive and specific diagnostic tool to establish the diagnosis of CTS. Standardized clinical criteria for CTS would be an important step in reducing inconsistencies and misdiagnoses.

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An evaluation of sensitivity of provocative tests used in the carpal tunnel syndrome diagnosis depending on clinical severity of the syndrome

Diagnostic tests used in diagnosis of carpal tunnel syndrome