Articles
Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome

Presented in part to the American Physical Therapy Association’s Combined Sections Meeting, 2001, San Antonio TX.
https://doi.org/10.1016/j.apmr.2004.11.008Get rights and content

Abstract

Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Med Rehabil 2005;86:609–18.

Objectives

To develop a clinical prediction rule (CPR) and to assess the reliability and diagnostic accuracy of individual clinical examination items for the diagnosis of carpal tunnel syndrome (CTS).

Design

Prospective diagnostic test study with blind comparison to a reference criterion of a compatible clinical presentation and abnormal electrophysiologic findings.

Setting

Multicenter medical center and community hospital with patient referrals from ambulatory primary care and specialty practice settings.

Participants

Eight-two consecutively referred patients (50% men; mean age, 45±12y) with suspected cervical radiculopathy or CTS referred for electrophysiologic examination.

Interventions

Not applicable.

Main outcome measures

Sensitivity, specificity, and likelihood ratios.

Results

The CPR identified in this study consisted of 1 question (shaking hands for symptom relief), wrist-ratio index greater than .67, Symptom Severity Scale score greater than 1.9, reduced median sensory field of digit 1, and age greater than 45 years. The likelihood ratio for the CPR was 18.3 when all 5 tests were positive. Interrater reliability was acceptable for all but 2 clinical examination items.

Conclusions

The CPR identified was more useful for the diagnosis of CTS than any single test item and resulted in posttest probability changes of up to 56%. Further investigation is required both to validate the test-item cluster and to improve point-estimate precision.

Section snippets

Participants and design

A total of 82 patients were enrolled in the study from December 1998 to April 2000 from 4 medical facilities: University of Pittsburgh, Wilford Hall USAF Medical Center, Brooke Army Medical Center, and Blanchfield Army Community Hospital. Consecutive patients between the ages of 18 and 70 years were recruited directly from the primary care clinic, from the orthopedic department, and from patients referred to the electrophysiologic laboratories of participating facilities. All had suspected

Results

The descriptive statistics for age and duration of symptoms of the 82 patients (41 men, 41 women; mean age, 45±12y) who participated in the study are listed by diagnostic classification in table 1. The prevalences of CTS and cervical radiculopathy were 34% (n=28) and 23% (n=19), respectively. The mean age and median symptom duration of patients with CTS (mean age, 48.4±11.5y; symptom duration, 183.5d) did not differ significantly (α<.05) from patients without CTS (mean age, 43.2±11.7y; symptom

Discussion

A CPR has been defined as “a tool used by clinicians to assist with medical decision making that provides either a probability of disease or outcome or suggest a diagnostic or therapeutic course of action.”29(p488) Our study is the first to propose a clinically useful CPR for the diagnosis of CTS that meets all major methodologic criteria for a level IV CPR.29, 30 The rule derived in our study comprises age, a question (shaking hands for symptom relief), SSS score, wrist-ratio index, and median

Conclusions

This study represents a level IV CPR and the first step in developing a clinically sensible CPR for the diagnosis of CTS. Validation is required before this rule can be applied clinically, and it has yet to be determined whether patients presenting in primary care, orthopedic, and other specialty clinic settings will be better off for undergoing these tests.

Acknowledgments

The lead author acknowledges LtCol Howard Gill, MD, for the use of his laboratory and gracious assistance with this project as well as LtCol Manuel Domenich and Maj Monte Wilson for their assistance with data collection and clinical support.

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    Supported by the Orthopaedic Section of the American Physical Therapy Association and the Foundation for Physical Therapy’s Clinical Research Center at the University of Pittsburgh.

    The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Air Force, Department of the Army, or the Department of Defense.

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated.

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    Copyright © 2005 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.