[Show abstract][Hide abstract] ABSTRACT: Electrodiagnostic studies (electromyography and nerve conduction velocity; EMG/NCV) are used to confirm the diagnosis of carpal tunnel syndrome (CTS) and to evaluate its severity. We investigated the hypothesis that normal electrodiagnostic median nerve testing is predicted by 1) Physician pre-test confidence in the diagnosis of CTS, and 2) Puzzling patient factors. One hundred and forty consecutive patients who underwent electrodiagnostic testing to evaluate for possible CTS were reviewed retrospectively. Both physician confidence in the diagnosis of CTS and puzzling patient factors (heightened illness concern, disproportionate complaints, and vague/nonanatomical/noncharacteristic symptoms) were recorded. Electrodiagnostic testing was used as the reference standard for diagnosis of CTS. Electrodiagnostic testing confirmed CTS in 115 patients and was within normal limits in 25 patients. Low physician confidence in the diagnosis of CTS was highly predictive of a normal electrodiagnostic test (p < 0.001), with high sensitivity (97%), moderate specificity (40%), and high overall accuracy (87%). Puzzling patient factors were moderately predictive of normal electrodiagnostic testing (p < 0.001), with low sensitivity (16%), high specificity (96%), and high overall accuracy (81%). The best multivariable model retained younger age, negative Phalen's test, and low physician confidence as the best predictors of normal electrodiagnostic testing and explained 35% of the variation in test results. A model with low confidence alone explained 19% of the variation in test results. Physician intuition as recorded in the medical record in terms of puzzlement and low confidence are very specific and accurate predictors of normal electrodiagnostic testing in the setting of suspected carpal tunnel syndrome.
[Show abstract][Hide abstract] ABSTRACT: Psychological illness influences the experience and expression of pain and disability. We tested three null hypotheses: (1) patients with nonspecific pain (medically unexplained and idiopathic) and patients with specific pain (discrete and verifiable) are equally likely to screen for psychiatric illnesses based on a validated screening questionnaire; (2) the presence of psychiatric illness (from a screening questionnaire) will not predict whether patients have specific or nonspecific pain type; and (3) across all patients and regardless of whether they have specific or nonspecific pain, psychiatric illness will not predict disability as measured by the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. We rejected all null hypotheses. The 41 patients with nonspecific arm pain were more likely than the 40 patients with specific arm pain to screen for a somatoform disorder (34% versus 7.5%), posttraumatic stress disorder (24% versus 7.5%), and panic disorder (12.2% versus 5%). The presence of anxiety and somatoform disorders predicted pain type (nonspecific versus specific) and arm-specific disability (DASH). Somatoform disorder was the strongest predictor of pain type and DASH scores. Based on a screening questionnaire, a comorbid psychiatric illness, a somatoform disorder in particular, is associated with nonspecific arm pain and arm-specific disability. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 11/2008; 466(11):2820-6. DOI:10.1007/s11999-008-0378-1 · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cognitive behavioral therapists may have a unique and growing role in orthopedics departments. In helping patients cope with pain, particularly where there is no specific biomedical treatment or cure, cognitive behavioral practitioners can help prevent, early on, the transition from an acute pain complaint to a costly, disabling, and interfering chronic pain syndrome (CPS; see Singh, M. K., Patel, J., & Galagher, R. (2005). Chronic pain syndrome. Physical Medicine and Rehabilitation. Retrieved April 25, 2008, from. http://www.emedicine.com/pmr/topic32.htm for a thorough description). Idiopathic hand and arm pain is a prevalent, costly, and distressing condition. It is defined as pain in the hand or arm that is vague, diffuse, with unclear pathology, or pain that is over and above what is expected based on an objective medical finding ([Ring, D., Katzielsky, J., Malhotra, L., Lee, S. G., & Jupiter, J. B. (2005). Psychological factors associated with idiopathic arm pain. Journal of Bone and Joint Surgery, 87, 374 --380]). Diagnosing and treating pain in general is challenging, and it is particularly challenging when there is no clear objective pathology, as in idiopathic pain. Patients with vague, diffuse, nonspecific pain complaints often present to orthopedic departments in hope of pain relief or cure via surgical procedures, yet surgeons are poorly equipped to deal with situations where pure medical management is unwarranted. This may be detrimental to patient care and lead to chronic pain syndrome. This article reviews research and common clinical issues in patients with idiopathic hand and arm pain who present to orthopedic departments; presents a multidisciplinary team approach in coordinating and providing care for these patients; and describes two case examples of the use of cognitive and behavioral interventions as part of this team approach. Utilizing cognitive and behavioral approaches may be a way to increase the quality of life of patients presenting with idiopathic arm pain, prevent transition to chronic pain syndrome, and circumvent costly and largely ineffective surgical procedures.
Cognitive and Behavioral Practice 08/2008; 15(3-15):244-254. DOI:10.1016/j.cbpra.2007.04.003 · 1.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study was designed to test the hypothesis that patients with an initial diagnosis of cubital tunnel syndrome are more likely to present with muscle atrophy than patients with an initial diagnosis of carpal tunnel syndrome.
A list of patients presenting to the office of a single hand surgeon from January 2000 to June 2005 with an initial diagnosis of isolated, idiopathic carpal tunnel syndrome or cubital tunnel syndrome was generated from billing records. The medical records of 58 patients with cubital tunnel syndrome and 370 patients with carpal tunnel syndrome were reviewed for age, gender, diabetes, and presence of atrophy.
Twenty-three of 58 patients with an initial diagnosis of cubital tunnel syndrome had atrophy compared with only 62 out 370 patients with an initial diagnosis of carpal tunnel syndrome. Multiple logistic regression revealed that age (odds ratio, 1.06; 95% CI, 1.04-1.08) and diagnosis (cubital tunnel patients were more likely than carpal tunnel patients to present with atrophy; odds ratio, 4.5; 95% CI, 2.7-8.6) were factors significantly associated with atrophy at presentation.
Patients with carpal tunnel syndrome present earlier in the course of their disease than patients with cubital tunnel syndrome. Patients with cubital tunnel syndrome are more likely to present with muscle atrophy, reflecting advanced nerve damage that may not respond to surgery.
The Journal Of Hand Surgery 07/2007; 32(6):855-8. DOI:10.1016/j.jhsa.2007.03.009 · 1.66 Impact Factor