Hand Diagram Research Articles

Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome

Werner RA, Franzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome. Objectives To determine whether nocturnal splinting of workers identified through active surveillance with symptoms consistent with carpal tunnel syndrome (CTS) would improve symptoms and median nerve function as well as impact medical care. Design Randomized controlled trial. Setting A Midwestern auto assembly plant. Participants Active workers with symptoms suggestive of CTS based on a hand diagram. Intervention The treatment group received customized wrist splints, which were worn at night for 6 weeks; the control group received ergonomic education alone. Main outcome measures Change in wrist, hand, and/or finger discomfort, carpal tunnel symptom severity index, median sensory nerve function, and the percentage of subjects who had carpal tunnel release surgery. Results The splinted group, unlike the controls, had a significant reduction in wrist, hand, and/or finger discomfort and a similar trend in the Levine carpal tunnel symptom severity index, which was maintained at 12 months. A secondary analysis showed that more median nerve impairment at baseline was associated with less clinical improvement among controls but not among the splinted group. Conclusions Workers identified with CTS symptoms in an active symptom surveillance tended to benefit from a 6-week nocturnal splinting trial, and the benefits were still evident at the 1-year follow-up. The splinted group improved in terms of hand discomfort regardless of the degree of median nerve impairment, whereas the controls showed improvement only among subjects with normal median nerve function. Results suggest that a short course of nocturnal splinting may reduce wrist, hand, and/or finger discomfort among active workers with symptoms consistent with CTS.

Self-Administered Hand Symptom Diagram for Carpal Tunnel Syndrome Diagnosis

In a prospective case series in Singapore we studied whether a hand symptom diagram can be used to predict carpal tunnel syndrome as defined by standardized clinical and neurophysiological protocol. Forty patients (mean age, 48 years, range 18-76) with carpal tunnel syndrome found it difficult to complete the hand diagram, and only four patients were able to mark it helpfully. There was no relation between drawings, clinical and neurophysiological parameters. A self-administered hand symptoms diagram is not useful for supporting a diagnosis of carpal tunnel syndrome amongst Singaporeans. Cultural factors may significantly influence subjective assessment scales such as the self-administered hand symptom diagram, which has been found effective in North American populations.

Clinical and Electrodiagnostic Testing of Carpal Tunnel Syndrome: A Narrative Review

Carpal Tunnel Syndrome (CTS) is a pressure-induced neuropathy that causes sensorimotor disturbances of the median nerve, which impair functional ability. A clear history that elicits relevant personal and work exposures and the nature of symptoms can lead to a high probability of a correct diagnosis. Hand diagrams and diagnostic questionnaires are available to provide structure to this process. A variety of provocative tests have been described and have variable accuracy. The Phalen's wrist flexion and the carpal compression tests have the highest overall accuracy, while Tinel's nerve percussion test is more specific to axonal damage that may occur as a result of moderate to severe CTS. Sensory evaluation of light touch, vibration, or current perception thresholds can detect early sensory changes, whereas 2-point discrimination changes and thenar atrophy indicate loss of nerve fibers occurring with more severe disease. Electrodiagnosis can encompass a variety of tests and is commonly used to assess the presence/severity of neuropathic changes and to preclude alternative diagnoses that overlap with CTS in presentation. The pathophysiologic changes occurring with different stages of nerve compression must be considered when interpreting diagnostic test results and predicting response to physical therapy management.

Clinical features of 1039 patients with neurophysiological diagnosis of carpal tunnel syndrome

Purpose: To describe the clinical features of patients with a neurophysiologic diagnosis of carpal tunnel syndrome (CTS) in the state of Rio Grande do Sul, Brazil. Methods: We prospectively studied 1039 patients with a neurophysiologic diagnosis of CTS in southern Brazil. All patients completed a clinicoepidemiological questionnaire which included a drawing of the arm and hand, in which they were asked to paint the areas in which paresthesia and pain occurred. In part of the sample, we also investigated the presence of clinical signs such as Tinel's, Phalen, and tenar atrophy. The diagnosis of CTS was performed using a predetermined neurophysiological protocol. Results: A total of 1528 hands were diagnosed with CTS. The severity of CTS was mild in 42% of cases, moderate in 18% and severe in 40%. Patients had a mean age of 48.3 ± 12.4 years old, and a ratio of 5.6 females to 1 male was observed. Symptoms restricted to the hand and wrist was observed in 51.8% of cases with paresthesia and in 18.5% of cases with pain. In 92.5% of the partially affected hands, paresthesia was present in at least one of the first three fingers, while pain affected the three first fingers in 78.8% of these hands. Pain with a distribution which did not involve the hand occurred in 18.5% of cases, while paresthesia without involvement of the hand occurred in only 1.9%. Distribution of symptoms, according to Katz's hand diagram, showed a classic pattern in 12.6% of affected hands, a pattern classified as probable CTS in 66.3%, and an unlikely CTS pattern in 4.1%. Tinel's and Phalen's sign were observed in 34.2 and 56.3% of the hands, respectively. Conclusion: The clinical presentation of CTS is pleomorphic, ranging from the absence of symptoms to very severe cases. This variation probably is dependent on coexistent diseases, such as tendinitis and fibromyalgia, as well as on subjective aspects of the patients.

Outcome assessment of hand function after radial artery harvesting for coronary artery bypass

The radial artery has gained widespread acceptance as a conduit for coronary artery bypass. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported. We performed an outcome study utilizing the Short Form-36, the Upper Limb-Disabilities of Arm, Shoulder and Hand, and a modified self-administered hand diagram to compare 288 patients undergoing coronary artery bypass utilizing the radial artery with a control group of 174 patients undergoing coronary artery bypass without the radial artery. The data were analyzed by the t test for continuous variables and the chi-square test for categorical variables, and subsequently a multivariate regression model was constructed. No patients developed hand claudication or ischemia. Although there was an incidence of radial sensory neuropathy of 9.9% associated with radial artery harvest, it was not significantly higher than the incidence in the control group (5.2%, p = .16). Intrinsic patient factors such as obesity, age, diabetes, and peripheral vascular disease were the principal determinants of overall health and quality of life issues.

Criteria for assessing pain and nonarticular soft-tissue rheumatic disorders of the neck and upper limb

Objective: To critically review the criteria used to diagnose nonarticular soft-tissue rheumatic disorders of the neck and upper limb. Methods: An extensive search of the literature, including a search of Medline and EMBASE, authoritative recent reviews, and relevant textbooks, was completed. The diagnostic criteria used in epidemiologic studies were compared and the reliability and validity of these criteria were assessed. Results: Altogether, the search identified 117 relevant research articles, among which 69 included a physical examination component, but few specified diagnostic criteria. Evidence supported respectable levels of between-observer repeatability regarding: symptom questionnaires (κ, 0.52 to 0.79); measurement of shoulder range of motion with a goniometer (intraclass coefficients > 0.70); tests for carpal tunnel syndrome (Tinel’s and Phalen’s κ, 0.53 to 0.80); and demonstration of neck tenderness (κ = 0.43). The Katz hand diagram, and combinations of physical signs of carpal tunnel syndrome, show reasonable sensitivity and specificity for that diagnosis but only among patients referred to specialists with that putative diagnosis; no such validity has been shown among the general population. Only 1 diagnostic examination schedule has published data on both the reliability and the validity of its criteria and diagnoses. For the remaining soft-tissue upper-limb disorders, diagnostic criteria rely apparently on face and content validity and reliability data have not been published. Conclusion: Classification of specific disorders of the neck and upper limb requires a back to basics approach. At present, the diagnosis of most of these conditions relies heavily on the clinical opinions of investigators and there are insufficient data to indicate that these criteria are repeatable, sensitive, or specific. Recent European initiatives offer scope to follow a more disciplined approach, but more work is urgently required.

The Relationship among Five Common Carpal Tunnel Syndrome Tests and the Severity of Carpal Tunnel Syndrome

The purpose of this research was to examine the relationship among clinical carpal tunnel syndrome (CTS) tests and the severity of CTS. A total of 66 subjects with electrodiagnostically confirmed CTS were tested on five CTS tests, then classified according to the severity of CTS. An association was found between testing positive on Phalen's test and the severity of CTS (p<0.05). In contrast, no association was found between the severity of CTS and results on Tinel's sign, manual version of the carpal compression test (mCCT), Katz-Stirrat hand diagram, or carpal tunnel outcomes assessment tool. The more severe the CTS, the more likely one is to test positive on Phalen's test. Tinel's sign and the mCCT are not influenced by the severity of CTS. This study suggests that Tinel's sign and mCCT may not be useful in assessing the effectiveness of treatment. The Katz-Stirrat hand diagram and the carpal tunnel outcomes assessment tool are not influenced by the severity of CTS, indicating that numerous factors can influence a patient's response on subjective questionnaires.

Predicting the outcome of carpal tunnel release

Purpose: To test the hypothesis that the result of steroid injection in the carpal tunnel provides a better predictor of the outcome of later surgery. We also explored other possible factors that might predict the outcome directly or interact with the results of steroid injection to better predict the outcome. Method: We performed a historical cohort study on 57 patients who had carpal tunnel release. Care was taken to avoid problems of statistical nonindependence caused by both hands being studied and confounding from previous surgeries. Results: We found a large and significant difference in the success rate of surgery for patients who had obtained some relief from injection (87%) versus those who had not (54%). No other significant predictor was found. We discovered factors that may interact with the results of injection in predicting the outcome of surgery (eg, Katz and Stirrat hand diagram assessment of the probability of carpal tunnel syndrome) although not significant in our study. Conclusions: Some relief from steroid injection is the best predictor for success of surgery. Further study is warranted to identify factors that interact with this predictor. (J Hand Surg 2003;28A:255-261. Copyright © 2003 by the American Society for Surgery of the Hand.)

El síndrome del túnel del carpo en el síndrome del aceite tóxico

The toxic oil syndrome (TOS) is an autoimmune disease caused by the ingestion of aniline-denatured rapeseed oil. The carpal tunnel syndrome (CTS) is an entrapment neuropathy due to the median nerve entrapment, which is associated with both occupational activities and autoimmune diseases. The objective of this work was to know the frequency and characteristics of CTS in TOS patients. Between December 1977 and July 2000, 744 TOS patients were evaluated. The inclusion criteria were: the clinical records for patients diagnosed between May 1981 and November 1997; and for patients diagnosed between December 1997 and July 2000, symptoms with the classical or likely pattern according to the Katz's hand diagram and one of the following findings: a) abnormal electromyogram, and b) hypalgesia in the median nerve territory and positive Tinel and/or Phalen signs. A total of 70 patients (63 women, 90%) were diagnosed; 48 of them had been diagnosed before 1997 and 22 subsequently. The mean age of patients was 47.6 (20-78) years. In 36 patients (51.4%), a bilateral CTS was present. Fifty-six patients (81.4%) had a diagnostic EMG, and 31 (44.2%) were obese, 13 (18.6%) diabetic, and 4 (6%) had hypothyroidism. Most of these cases (48; 68.6%) were housewives. TOS patients have a high frequency of CTS; therefore, this condition must be suspected in patients with associated obesity and diabetes mellitus.

The lumbrical provocation test in subjects with median inclusive paresthesia

Karl AI, Carney ML, Kaul MP. The Lumbrical Provocation Test and discriminating among subjects with median inclusive paresthesia. Arch Phys Med Rehabil 2001;82:935-7. Objective: To investigate the value of the Lumbrical Provocation Test (LPT) in predicting carpal tunnel syndrome (CTS) among patients with symptoms suspicious for CTS. Design: Prospective unigroup technique with blinded comparison of a clinical diagnostic test with 2 commonly used methods of diagnosing CTS: electrodiagnosis and a hand diagram. Setting: Outpatient veterans referred by a heterogeneous group of specialists and generalists to a Veterans Affairs medical center electrodiagnostic laboratory. Patients: Ninety-six consecutive patients who were referred to the electrodiagnostic laboratory with median inclusive paresthesia were evaluated. Interventions: LPT: hold hand as fist for 1 minute (to evaluate changes in paresthesia); electrodiagnostic evaluations: median and ulnar mixed nerve, antidromic sensory, and motor latencies; and hand symptom diagram to describe pain. Main Outcome Measures: Evaluation of symptoms of paresthesia (with or without pain) inclusive of the median nerve distribution distal to the wrist. Prevalence sensitivity, specificity, and positive and negative predictive value of LPT, and electrodiagnosis, and hand diagram tests. Results: Compared with the findings obtained with electrodiagnosis, the sensitivity of the LPT was.37; specificity,.71; positive predictive value,.59; and negative predictive value,.50. Compared with the findings obtained with the use of the hand diagram as a clinical measure, the sensitivity of the LPT was.43, specificity,.71, positive predictive value,.59, and negative predictive value,.56. Conclusion: The LPT has minimal use in predicting CTS in patients with median inclusive paresthesia compared with 2 commonly used methods of diagnosing CTS. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

The prevalence and characteristics of nerve compression symptoms in the general population.

The purpose of this cross-sectional study was to evaluate the prevalence and intensity of nerve compression symptoms and to estimate the prevalence of carpal tunnel syndrome (CTS) in the general population. A survey that included the Katz hand diagram, the Carpal Tunnel Instrument (CTI), and the Short Form-36 questionnaire was sent to 1,559 people. A short telephone survey was conducted to a random sample of 110 nonresponders to determine if they were systematically different from the responders. Of the responders 35.1% had a symptom severity (CTI subscale) score of > or =1.5. Of the responders and the nonresponders 23.2% and 14.5%, respectively, reported waking at least once per night with numbness; 37.3% of the responders and 33.6% of the nonresponders experienced pain in the hand at least once per day. As determined by the Katz hand diagrams, 58 (16.3%) of the responders had classic or probable distributions of symptoms (likely to have CTS) and 298 (83.7%) had possible and unlikely distributions. After correcting for nonresponders our lowest possible estimate of CTS prevalence in the general US population is 3.72%, indicating a larger pool of symptomatic people than previously reported.

Does This Patient Have Carpal Tunnel Syndrome?

History taking and physical examination maneuvers, including Tinel and Phalen signs, are widely used for the diagnosis of carpal tunnel syndrome (CTS). To systematically review the precision and accuracy of history taking and physical examination in diagnosing CTS in adults. English-language literature was searched using MEDLINE (January 1966-February 2000) as well as bibliographies of relevant articles. Studies of patients presenting to clinicians with symptoms suggestive of CTS in which findings from clearly described physical examination maneuvers were independently compared with electrodiagnostic testing. Twelve of 42 initially identified articles met these criteria and were included in the review. Two authors independently reviewed and abstracted data from all of the articles and reached consensus about any discrepancies. In patients presenting with hand dysesthesias, the findings that best distinguish between patients with electrodiagnostic evidence of CTS and patients without it are hypalgesia in the median nerve territory (likelihood ratio [LR], 3. 1; 95% confidence interval [CI], 2.0-5.1), classic or probable Katz hand diagram results (LR, 2.4; 95% CI, 1.6-3.5), and weak thumb abduction strength (LR, 1.8; 95% CI, 1.4-2.3). Findings that argue against the diagnosis of carpal tunnel syndrome are unlikely Katz hand diagram results (LR, 0.2; 95% CI, 0.0-0.7) and normal thumb abduction strength (LR, 0.5; 95% CI, 0.4-0.7). Several traditional findings of CTS have little or no diagnostic value, including nocturnal paresthesias; Phalen and Tinel signs; thenar atrophy; and 2-point, vibratory, and monofilament sensory testing. Other less commonly used maneuvers, including the square wrist sign, flick sign, and closed fist sign, require validation by other studies before they can be recommended. Hand symptom diagrams, hypalgesia, and thumb abduction strength testing are helpful in establishing the [corrected] electrodiagnosis of CTS. The utility of these results is limited, however, by problems inherent in using nerve conduction studies as a criterion standard. JAMA. 2000.

Practice standards in carpal tunnel syndromeelectrodiagnosis

Szabo et al 1 Szabo RM Slater Jr, RR Farver TB Stanton DB Sharman WK The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg. 1999; 24A: 704-714 Crossref Google Scholar compared the sensitivity of several clinical tests (Semmes-Weinstein, Durken's, and Phalen's tests, hand diagram, and symptom history) with the sensitivity of electrodiagnostic testing in diagnosing carpal tunnel syndrome (CTS). They conclude that “…the addition of the electrodiagnostic tests did not increase the diagnostic power of the combination of the 4 clinical tests” and that “the addition of nerve conduction studies is unnecessary in most cases.”

Agreement between symptom surveys, physical examination procedures and electrodiagnostic findings for the carpal tunnel syndrome.

The goal of this study was to evaluate the concordance between various clinical screening procedures for carpal tunnel syndrome. The subject population consisted of 824 workers from 6 facilities. The evaluated procedures included bilateral sensory nerve conduction testing, physical examinations, and symptom surveys, including hand diagrams. The agreement between the outcomes of various combinations of these procedures was assessed by determining the kappa coefficient. There was relatively poor overlap between the reported symptoms, the physical examination findings, and the electrodiagnostic results consistent with carpal tunnel syndrome. Overall, only 23 out of 449 subjects (5%) with at least 1 positive finding met all 3 criteria (symptoms, physical examination findings, and electrophysiological results consistent with carpal tunnel syndrome) for the dominant hand. The screening procedures showed poor or no agreement with kappa values ranging between 0.00 and 0.18 for all the case definitions evaluated for carpal tunnel syndrome. The poor overlap between the various screening procedures warns against the use of electrodiagnostic findings alone without the symptom presentation being considered. The results of this study also point to a need for the further development and evaluation of methods for detecting carpal tunnel syndrome.

The value of diagnostic testing in carpal tunnel syndrome.

The purpose of this study was to determine the validity of tests or a combination of tests for the diagnosis of carpal tunnel syndrome. Three groups of 50 subjects each were studied: group 1 had definite carpal tunnel syndrome as defined by history, clinical presentation, and improvement of symptoms following carpal tunnel release; group 2 had a variety of nontraumatic upper extremity disorders other than carpal tunnel syndrome; and group 3 subjects were asymptomatic healthy volunteers. Subjects submitted a self-administered hand diagram, and were queried about night pain, symptom duration, and coexistent medical conditions. Phalen's test, Tinel's sign, Durkan's compression test, and Semmes-Weinstein monofilament testing both before and after a Phalen's maneuver for 5 minutes were performed on each subject. Grip and pinch strengths were measured. Univariate analysis of groups 1 and 2 showed that the tests with the highest sensitivity were Durkan's compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores (76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%) and Tinel's sign (71%). Analysis of groups 1 and 3 without group 2 increased the specificity and predictive value of a positive test. A regression model was used to develop a multivariate equation with 4 variables. If a patient has an abnormal hand diagram, abnormal sensibility by Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal tunnel syndrome will be correctly diagnosed is 0.86. If all 4 of these conditions are normal, the probability that the patient has carpal tunnel syndrome is 0.0068. We found that the addition of electrodiagnostic tests did not increase the diagnostic power of the combination of 4 clinical tests.

Assessment of the carpal tunnel outcome instrument in patients with nerve-compression symptoms

The outcome movement in medicine has encouraged the development of patient-answered questionnaires as measures of well-being. A disease-specific questionnaire for carpal tunnel syndrome (CTS) was introduced by Levine et al. in 1993. We evaluated this questionnaire in 156 consecutive new patients presenting with pain, numbness, or tingling of the upper extremity. Of these, 114 correctly filled out the carpal tunnel outcome instrument. In addition, these patients completed the self-administered hand diagram developed by Katz and Stirrat for the diagnosis of CTS. The 114 patients were classified according to their hand diagram as classic or probable CTS (n = 47), possible CTS (n = 31), and unlikely CTS (n = 36). The mean symptom severity score in patients classified as classic or probable CTS was significantly higher than the mean score in patients classified as possible or unlikely CTS (p < .01). The mean scores of items regarding sensory symptoms were significantly higher in patients with classic or probable CTS compared to patients with possible or unlikely CTS (p < .0001). The scores were similar for CTS and non-CTS patients on the functional status subscale.

Workplace surveillance for carpal tunnel syndrome using hand diagrams

Four hundred and eleven workers from 4 different companies participated in a worksite screening program designed, in part, to estimate the prevalence of carpal tunnel syndrome (CTS). Each worker completed a discomfort survey and underwent limited nerve conduction testing of the median and ulnar sensory nerves in both wrists. The discomfort survey included a hand diagram which allowed subjects to shade in area(s) affected by numbness, burning, tingling, or pain. The discomfort survey also asked each worker to indicate whether she or he had experienced neuropathic symptoms (i.e., numbness, burning, tingling, or pain) in the wrist, hand or fingers of each hand, without regard to localization (i.e., median versus ulnar versus radial distribution), and also nocturnal occurrence of symptoms. Analyses involved comparing hand diagram scores and non localized wrist/hand/finger symptoms with electrodiagnostic test results. All configurations of hand diagram scores of the dominant hands had a statistically significant association with electrophysiologically determined median nerve dysfunction, but so did non localized symptom reports. The sensitivity, specificity, and positive predicted values of hand diagrams were poorer than those reported previously. While some test performance characteristics of hand diagrams were better than those for non localized distal extremity symptoms consistent with CTS, some were worse. Overall, our data suggest that hand diagrams are no better than using a questionnaire to determine if workers have experienced symptoms consistent with CTS in their wrists, hands or fingers without regard to localization. The choice of screening tool would depend on the goal of screening, in particular, whether it is more desirable to have slightly higher sensitivity or positive predictive value.

A self-administered hand diagram for the diagnosis of carpal tunnel syndrome

A self-administered hand diagram has been developed to assist in the evaluation of upper extremity paresthesias. A rating system was devised to classify diagrams into four categories: classic, probable, possible, or unlikely carpal tunnel syndrome. Diagram ratings of 63 patients (85 hands) evaluated in a hand clinic were compared with diagnoses established independent of diagram results by objective clinical criteria. The sensitivity of diagrams rated classic or probable was 80% and specificity was 90%. We conclude that the hand diagram is valuable in the diagnosis of carpal tunnel syndrome among patients with upper extremity paresthesias.

Physical therapy hand evaluation form.

At the University of Chicago Hospitals Physical Therapy Department, we needed an organized hand-assessment form for recording the information necessary for effective treatment of hand injuries. We reviewed leading resources to identify the necessary data to obtain when evaluating hand function.1-4 The form we devised has seven categories for assessing a traumatic hand injury. Included are a brief history of the injury; measurements of active and passive range of motion of the wrist and all digital joints, including thumb opposition; and measurements of pulp to palm and thumb/index web spaces. A thorough section on hand sensibility contains hand diagrams on which the therapist may shade in areas of absent or dulled sensations. Space is provided for any additional comments the therapist may have.