Abstract
Lo et al1Lo JK Finestone HM Gilbert K Woodbury MG. Community-based referrals for electrodiagnostic studies in patients with possible carpal tunnel syndrome: What is the diagnosis?.Arch Phys Med Rehabil. 2002; 83: 598-603Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar must be congratulated on their article reaffirming the value of electrodiagnostic testing in objectifying the presence and/or absence of carpal tunnel syndrome (CTS). They state that “the diagnostic value of various clinical tests is controversial in the literature.”1Lo JK Finestone HM Gilbert K Woodbury MG. Community-based referrals for electrodiagnostic studies in patients with possible carpal tunnel syndrome: What is the diagnosis?.Arch Phys Med Rehabil. 2002; 83: 598-603Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar However, to support their point, they were less than fair to the controversy that has previously surrounded the tethered median nerve stress test (TMNST) when they cited a report suggesting that this clinical test (fig 1) has been demonstrated to lack predictive power in identifying CTS.2Kaul MP Pagel KJ Dryden JD. Lack of predictive power of the “tethered” median nerve stress test in suspected carpal tunnel syndrome.Arch Phys Med Rehabil. 2000; 81: 348-350PubMed Google ScholarRaudino,3Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome.Electromyogr Clin Neurophysiol. 2000; 40: 57-60PubMed Google Scholar in an article published almost concurrently, stated that in “some chronic cases the Stress Test was the only clinical positive sign, in addition to electrophysiological examination, [and it] may be helpful in clinical practice. This test is of the greatest value in cases where sensory complaints predominate and motor signs are minimal. The palmar sensory orthodromic delays are the most sensitive electrodiagnostic test in this regard.”3Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome.Electromyogr Clin Neurophysiol. 2000; 40: 57-60PubMed Google Scholar Raudino also noted that the TMNST was positive in 42.8% of cases, the Phalen sign in 56.4% of cases, and the Tinel sign in 42.1% of cases.3Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome.Electromyogr Clin Neurophysiol. 2000; 40: 57-60PubMed Google Scholar In initially describing this test, we4LaBan MM Friedman NA Zemenick GA. “Tethered” median nerve stress test in chronic carpal tunnel syndrome.Arch Phys Med Rehabil. 1986; 67: 803-804PubMed Google Scholar hypothesized that adhesions between the median nerve and the overlying transverse carpal ligament contributed to ischemia of the nerve during this maneuver. Subsequently, Nakamichi and Tachibana5Nakamichi K Tachibana S. Restricted motion of the median nerve in carpal tunnel syndrome.J Hand Surg [Br]. 1995; 20: 460-464Crossref PubMed Scopus (118) Google Scholar noted that the median nerve functionally slides in a transverse direction beneath the flexor retinaculum with passive motion of the index finger, having a mean value of 1.75mm as compared with 0.51mm in patients with CTS. Anatomically, both flexor tendons of the index finger lie immediately below the median nerve. As stated in our original description4LaBan MM Friedman NA Zemenick GA. “Tethered” median nerve stress test in chronic carpal tunnel syndrome.Arch Phys Med Rehabil. 1986; 67: 803-804PubMed Google Scholar of the TMNST and in a subsequent communication, “a positive response [is] not pathomonic evidence of a CTS.”6LaBan MM. Carpal tunnel syndrome: the tethered median nerve test revisited.Arch Phys Med Rehabil. 2000; 81 ([letter]): 1002Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar As Lo and others might agree, the electromyographic examination, although the criterion standard for diagnosing CTS (like the clinical tests it compliments), is also not infallible. The TMNST with or without the clinical tests cited are the “tools” by which CTS will continue to be recognized and subsequently confirmed by electrodiagnostic testing. doi:10.1053/apmr.2002.36078
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