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SPINE Volume 28, Number 1, pp 52–62
©2003, Lippincott Williams & Wilkins, Inc.
Reliability and Diagnostic Accuracy of the Clinical
Examination and Patient Self-Report Measures for
Cervical Radiculopathy
LtCol Robert S. Wainner, PhD, PT, OCS, ECS,* Julie M. Fritz,
PhD, PT, ATC,†
James J. Irrgang, PhD, PT, ATC,† Michael L. Boninger, MD,‡
Anthony Delitto, PhD, PT, FAPTA,‡ and COL Stephen Allison,
PhD, PT, ECS§
Study Design. A blinded, prospective diagnostic test
study was conducted.
Objectives. To assess the reliability and accuracy of
individual clinical examination items and self-report in-
struments for the diagnosis of cervical radiculopathy, and
to identify and assess the accuracy of an optimum test-
item cluster for the diagnosis of cervical radiculopathy.
Summary of Background Data. Although cervical ra-
diculopathy remains largely a clinical diagnosis, the reli-
ability and diagnostic accuracy of clinical examination
items, individually or in combination, for cervical radicu-
lopathy is largely unknown.
Methods. Patients with suspected cervical radiculopa-
thy or carpal tunnel syndrome received standardized elec-
trophysiologic examination of the symptomatic upper
quarter followed by a standardized clinical examination
by physical therapist examiners blinded to diagnosis. Di-
agnostic properties were assessed using a neural impair-
ment reference criterion standard.

Results. The study involved 82 patients. More than
two thirds of 34 clinical examination items had reliability
coefficients rated at least fair or better, and 13 items had
likelihood ratio point estimates above 2 or below 0.50. A
single diagnostic test item cluster of four variables was
identified and produced a positive likelihood ratio point
estimate of 30.3. The 95% confidence intervals for all
likelihood ratio point estimates in this study were wide.
Conclusions. Many items of the clinical examination
were found to be reliable and to have acceptable diag-
nostic properties, but the test item cluster identified was
more useful for indicating cervical radiculopathy than any
single test item. Upper limb tension Test A was the most
useful test for ruling out cervical radiculopathy. Further
investigation is required both to validate the test item
cluster and to improve point estimate precision. [Key
words: cervical radiculopathy, clinical examination, diag-
nostic accuracy, diagnostic test cluster, reliability] Spine
2003;28:52– 62
Cervical radiculopathy is, by definition, a disorder of the
cervical spinal nerve root,12 and most commonly is caused
by a cervical disc herniation or other space-occupying le-
sion, resulting in nerve root inflammation, impingement, or
both.47 A number of other less common causes have also
been reported.3,7,14,20,23,37,41,44,45,51,61,63,73 The
diagnostic
criteria for cervical radiculopathy are not well defined, and
no universally accepted criteria for the diagnosis of cervical
radiculopathy have been established.9,47
Diagnostic imaging and electrophysiologic studies are
most commonly used to establish a diagnosis of cervical
radiculopathy. Although not perfect, these tests are con-

sidered to be the most accurate means of diagnosis avail-
able.31,43 Given the expense and discomfort associated
with these studies, it would be useful to establish accu-
rate clinical examination findings for a diagnosis of cer-
vical radiculopathy. Numerous clinical examination
findings are purported to be diagnostic of cervical radic-
ulopathy.40,50 –57 The validity of these findings has been
studied sparsely, and the data that do exist suggest they
are not very accurate.6,66
Given the frequency of surgical intervention50 and the
wide variety of nonsurgical treatment procedures60 of-
fered to patients with cervical radiculopathy, there is a
definite need to establish a cost-effective, reliable, and
accurate means for establishing the diagnosis of cervical
radiculopathy. The purpose of this study was twofold: to
assess the reliability and accuracy of selected clinical ex-
amination findings for the diagnosis of cervical radicu-
lopathy using an electrophysiologic reference criterion,
and to identify and assess the accuracy of an optimum
cluster of clinical examination findings for the diagnosis
of cervical radiculopathy.
Methods
Subjects and Design. A total of 82 patients (41 men and 41
women, mean age 45 � 12 years) from the following four
medical facilities were enrolled in the study from December
From the *U.S. Army-Baylor Graduate Program in Physical
Therapy,
Fort Sam, Houston, Texas, the †Department of Physical
Therapy, Uni-
versity of Pittsburgh, Pittsburgh, Pennsylvania, the ‡Department
of
Physical Medicine and Rehabilitation, University of Pittsburgh

Medi-
cal Center, Pittsburgh, Pennsylvania, and the §U.S. Army
Medical
Department.
Supported by a grant from the Orthopaedic Section of the
American
Physical Therapy Association and the Foundation for Physical
Thera-
py’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 Department of the Air Force, Department of the Army, or
the
Department of Defense.
Acknowledgment date: October 25, 2001. First revision date:
March 4,
2002. Second revision date: May 20, 2002.
Acceptance date: June 3, 2002.
Device status/drug statement: The manuscript submitted does
not con-
tain information about medical device(s)/drug(s).
Conflict of interest: Professional Organization funds were
received to
support this work. No benefits in any form have been or will be
re-
ceived from a commercial party related directly or indirectly to
the
subject of this manuscript.
Address reprint requests to Robert S. Wainner, PT, PhD, 3151
Scott
Road, Suite 1303, Fort Sam Houston, TX 78234-6138. E-mail:
[email protected]
52

1998 to April 2000: University of Pittsburgh, Wilford Hall
USAF Medical Center, Brooke Army Medial Center, and
Blanchfield Army Community Hospital. Consecutive patients,
ages 18 to 70 years, referred to the electrophysiologic labora-
tories of participating facilities with suspected cervical radicu-
lopathy (CR) or carpal tunnel syndrome (CTS) were informed
about the study by laboratory personnel. Only patients judged
by the electrophysiologic laboratory provider to have signs and
symptoms compatible with CR or CTS were eligible to partic-
ipate. Patients with the following conditions were disqualified
from participation in the study:
● systemic disease known to cause a generalized peripheral
neuropathy
● primary report of bilateral radiating arm pain
● history of conditions involving the affected upper extrem-
ity that might adversely affect the individual’s level of
function
● discontinuation of work more than 6 months because of
the condition
● history of surgical procedures for pathologies giving rise
to neck pain or CTS
● previous needle electromyography (EMG) and nerve con-
duction study (NCS) testing the symptomatic limb for CR,
CTS, or both
● workman’s compensation received or pending litigation
for condition.
All the subjects gave informed consent for participation as
approved by the respective facility’s institutional review board.
Patient Self-Report Items
Visual Analog Scale. The patient rated his or her pain on a

10-cm visual analog scale (VAS). Each patient made three VAS
ratings: one for the worst pain in the preceding 24 hours, one
for the least pain in the preceding 24 hours, and one for current
pain. Although the VAS has been used extensively as an out-
come measure,11,39,69 its use for diagnostic purposes has not
been reported.
Neck Disability Index. The NDI, a self-report disability
measure for patients with neck pain,64 contains seven items
related to activities of daily living, two items related to pain,
and one item related to concentration (ability to read). Each
item is scaled from 0 to 5, and the total score is expressed as a
percentage, with higher scores representing greater levels of
disability. The NDI has been studied as an outcome mea-
sure,49,64,68 but not as a diagnostic tool.
Standardized Electrophysiologic Examination Proce-
dure. Needle electromyography and NCS procedures served as
the reference criterion for cervical radiculopathy. All the par-
ticipants underwent the same standardized electrophysiologic
examination. Board certified personnel conducted all the EMG
and NCS procedures. Nerve conduction studies consisted of
palmar sensory and routine motor nerve conduction studies for
both the median and ulnar nerves.8,10,34 Median and ulnar
nerve F-wave responses (minimum latency) were also obtained.
If abnormalities were observed in the median and ulnar nerves
of the same limb, nerves in the opposite upper limb, one lower
limb, or both were performed to rule out a generalized periph-
eral neuropathy27,28 All NCS procedures were performed in
accordance with guidelines for measurement, temperature,
safety precautions, and electrode placement.10
After the NCS, EMG of the following muscles was per-
formed during rest and contraction using a monopolar needle
electrode: middle and lower cervical paravertebral, deltoid, tri-

ceps brachii, extensor carpi radialis longus/brevis, flexor carpi
radialis, abductor pollicus brevis, and first dorsal interosseus.
In addition, EMG/NCS providers sampled additional cervical
and limb muscles when indicated by a patient’s clinical presen-
tation. For each muscle site sampled, the tester used the stan-
dard quadrant/level method for a total of 12 EMG observa-
tions at each sampling site.10 Observations of insertional
activity, normal and abnormal spontaneous activity, and mo-
tor unit firing frequency were made when needle EMG was
recorded.10
Previously published criteria were used to determine the
normality of NCS8,34 and EMG1 parameters. Diagnoses were
based on electrophysiologic examination findings and catego-
rized into six classifications (Table 1). All patients with
cervical
radiculopathy findings (Classifications 5 and 6) were further
classified according to the severity of their respective EMG
findings as follows: mild: (1� spontaneous activity in one or
more muscles, other EMG/NCS parameters normal, moderate
(2� to 3� spontaneous activity in two or more muscles, in-
creased recruitment, polyphasicity, and perhaps increased am-
plitude/duration of some MUAPs). There were no patients with
severe EMG findings, so this classification was eliminated.
Seven different EMG/NCS providers performed the nerve
conduction studies, needle electromyography procedures, and
subsequent diagnostic classification of patients. At one center,
three different evoked potential technicians performed nerve
conduction procedures only.
Needle electromyography is considered the hallmark diag-
nostic sign and the single most accurate electrophysiologic pro-
cedure for establishing the diagnosis of both lumbar and cervi-
cal radiculopathy.15,36,43,54,72 Both EMG and NCS have
moderate sensitivity (Sn) and high specificity (Sp) for establish-

ing the diagnoses of cervical radiculopathy and peripheral
nerve entrapments.1,2
Standardized Clinical Examination Procedure. A stan-
dardized clinical examination consisting of 34 items was per-
formed by a physical therapist (Examiner 1) after the standard-
ized EMG/NCS examination was completed, and after a 15- to
30-minute rest period. The examination was repeated by a
second physical therapist (Examiner 2) after a 10-minute rest
period to assess reliability. Both examiners were blinded to the
subjects’ suspected diagnosis, EMG/NCS test results, and diag-
nostic classification. Nine different physical therapists per-
formed the standardized clinical examination procedures.
History. All the patients were asked six questions thought to
be diagnostic of CR. Examiner 2 obtained responses to the
same questions 1 or 2 days later. The questions and their re-
spective response options are listed in the Appendix.16,58,65
Conventional Neurologic Examination and Provocative
Tests. Strength testing was conducted through manual muscle
testing of the deltoid (C5), biceps brachii and extensor carpi
radialis longus/brevis (C6), triceps brachii and flexor carpi ra-
dialis (C7), abductor pollicus brevis (C8), and dorsal interossei
(T1). All manual muscle testing was conducted using the meth-
ods of Kendall and McCreary.32 Each muscle test was graded
53Cervical Radiculopathy • Wainner et al
as markedly reduced, reduced, or normal, as compared with
the uninvolved extremity. Muscle stretch reflexes of the biceps
(C5–C6), brachioradialis (C5–C6), and triceps (C7) were tested
bilaterally using a standard reflex hammer. Each reflex was
graded as absent/reduced, normal, or increased, as compared

with the uninvolved extremity. Pin-prick sensation testing was
performed for the cervical dermatomes (C5–C8) by touching
the skin in a key area65 for each respective sensory level with a
paper clip, which was discarded after testing. Each sensory
level was graded as reduced, normal, or increased.
Provocative Tests. The following provocative tests were used
in this study: Spurling test (A and B), shoulder abduction test,
Valsalva maneuver, neck distraction test, and upper limb ten-
sion test (A and B). The tests along with their operational def-
initions are listed in the Appendix. The reliability and validity
of both conventional neurologic examination items and pro-
vocative tests used in this study have been summarized and
previously reported.67
Cervical Range of Motion. Cervical flexion, extension, bi-
lateral side bending, and bilateral rotation measurements were
obtained. Before measurement, the patient was seated in a chair
and asked to assume a neutral neck position while the examiner
applied a piece of tape to the wall at eye level. The examiner
referred to this as the “neutral position.” The patient was then
asked to perform warm-up movements consisting of two rep-
etitions in each motion direction. Immediately after the
warm-up procedure, the examiner recorded a single range-of-
motion (ROM) measurement for flexion, extension, and bilat-
eral side bending using an inclinometer as described by Hole et
al.24 Rotation was measured using a standard long-arm goni-
ometer.71 Reliability coefficients for cervical spine ROM pa-
rameters range from 0.81 to 0.84 (ICC 2, 1).24
Examiner Training. A videotape of all clinical examination
procedures and handbooks detailing the performance of each
clinical examination and electrophysiological measure were
distributed to each participating center before data collection.
All the examiners viewed the videotape and read the handbooks

to
familiarize themselves with the procedures. All the examiners
practiced all the clinical examination measures at least twice.
They
practiced applying the specified amount of compression or dis-
traction force required for the Spurling test, distraction test,
me-
chanical traction device, and pinch gauge, respectively.
Data Analysis. Dichotomized findings from the involved limb
were used to compute reliability for each neurologic and pro-
vocative clinical examination measure. Dichotomization of test
results for dermatomes, reflexes, and muscle strength into nor-
mal or abnormal findings was performed because of the low
observed base rates for “increased” or “ markedly reduced”
responses. Reliability for neurologic, ROM, and provocative
tests was assessed by a kappa statistic.56 Reliability for
cervical
ROM was reported as an intraclass correlation coefficient
(ICC 2, 1) and corresponding standard error of measurement
(SEM),55 95% confidence intervals (95CI) were calculated for
all reliability coefficients.
The following qualitative interpretation for kappa de-
scribed by Fleiss et al.18 was used in this study: excellent
(�0.75), fair to good (0.40 – 0.74), poor (�0.40). The clinical
examination results obtained by Examiner 1 were used for all
computations of diagnostic test accuracy. To calculate Sn and
Sp for each test item, 2 � 2 contingency tables were used.
Patients with a diagnosis of CR (Classifications 5 and 6), in-
cluding those with concomitant CTS or ulnar neuropathy,
formed the disease-positive group, and patients classified as
normal or as having CTS (Classifications 1 to 4) served as the
disease-negative or control group. When a zero cell value was
encountered, 0.5 was added to all cell values in the table to
permit calculation of LRs and their 95% CI (Simel, personal

communication). Receiver operator characteristic (ROC)
curves were used to determine cutoff values for self-report and
Table 1. Descriptive Statistics of Subjects Age and Duration of
Symptoms by Diagnostic Classification
EMG/NCS-Based Dx Gender N
Age (y)/Symptoms (d)
Mean/
Median Minimum Maximum SD
1. Normal Female 23 41.4/123.5 24/31 70/5415 12.8
Male 17 39.1/184.5 21/21 68/7220 10.2
2. Unilateral CTS Female 4 58.5/1095 48/92 68/1460 9.1
Male 3 35.6/275 28/184 45/365 8.6
3. Bilateral CTS Female 9 44.7/250 28/31 61/5475 11.5
Male 6 47.2/61 36/21 60/365 10
4. CTS w/ulnar neuropathy Female 1 43.0/30
Male 0 — — — —
5. Radiculopathy Female 2 56.5/42 55/42 58/42 2.1
Male 12 50.3/77 39/42 61/1095 7.7
6. Radiculopathy w/CTS (1 with
concomitant ulnar
neuropathy at the elbow)
Female 2 52.0/97 46/87 52/100 4.2
Male 3 62.0/31.5 60/21 64/42 2.8

Classifications are as follows:
1. Normal: No nerve conduction (NCS) or needle
electromyography (EMG) abnormalities.
2. Unilateral Carpal Tunnel Syndrome (CTS): Any abnormal
median sensory or motor latency of symptomatic extremity;
ulnar sensory and motor NCS parameters
normal
3. Bilateral CTS: Same as unilateral CTS, but findings bilateral
4. CTS with concomitant ulnar neuropathy: Any abnormal
median sensory or motor latency NCS parameters and
concomitant abnormal ulnar sensory and/or motor
NCS parameters
5. Radiculopathy: Muscle membrane instability (fibrillations of
any variety) observed at rest during needle EMG
6. Radiculopathy with concomitant CTS or ulnar neuropathy:
Same radiculopathy with concomitant CTS or ulnar NCS
abnormalities as described above
54 Spine • Volume 28 • Number 1 • 2003
cervical ROM measures.22 Because patients with a diagnosis of
cervical radiculopathy may be treated surgically or with costly
nonsurgical interventions,50 the cutoff value that minimized
false-positive results (i.e., highest specificity) was selected.
Positive and negative likelihood ratios and their associated
95% CIs were computed for all clinical examination items.57
For the multilevel response items (Questions 1 to 3) and the test
item cluster (TIC), positive likelihood ratios were reported for
each response level.13 The positive likelihood ratio (LR�) was
calculated as sensitivity/1-specificity and the negative likeli-
hood ratio (LR�) as 1-sensitivity/specificity. Likelihood ratios
are convenient summary measures of diagnostic test perfor-

mance that indicate how much a given diagnostic test will raise
or lower the pretest probability of the target disorder of inter-
est.13,30 The diagnostic accuracy of individual clinical exami-
nation variables was considered acceptable if either LR� was 2
or more or LR� was 0.50 or less.29 On the basis of an esti-
mated prevalence or pretest probability for CR of 20% in this
sample, LR� values exceeding 2 and LR� values less than 0.5
would result in posttest probability changes of at least 15%.
A binary logistic regression model was used to identify the
most accurate TIC for diagnosing CR.25 Only variables with
acceptable accuracy as defined previously were entered into the
model. A forward stepwise selection procedure was used to
enter variables, with P values of 0.1 for entrance to the model
and 0.15 for exit from the model. The method of entry and
liberal P values were chosen to prevent potentially useful vari-
ables from being excluded from the model.19 The Hosmer–
Lemeshow (HL) summary goodness-of-fit statistic was used to
assess the fit of the model to the data, and to test the hypothesis
that the model fits the data. Higher P values indicated a better
fit.26 Variables selected by the regression model as diagnostic
of
CR were combined into a TIC and treated as a single test item.
The sensitivity, specificity, and LRs for the TIC were calculated
as previously described for other dichotomous variables.
Results
The descriptive statistics for age and duration of symp-
toms of the 82 participants in the study are listed by
diagnostic classification in Table 1. The prevalence of
CR and CTS was 23% (19 patients) and 35% (28 pa-
tients), respectively. The diagnostic report indicated in-
volvement of the C6 or C7 root for 18 subjects, with
possible involvement of the C5 root in two of these pa-

tients, and the C8 root for 1 subject. The left extremity
was involved in 11 subjects, and the right extremity in 8
subjects. The patients with cervical radiculopathy were
classified according to severity of EMG findings, with 13
classified as mild, 6 as moderate, and none as severe. One
patient classified as having CR (mild) with concomitant
CTS and ulnar neuropathy at the elbow dropped out of
the study after the standardized electrophysiologic ex-
amination. Diagnostic accuracy was computed using the
remaining 18 patients classified as having CR.
Table 2. Reliability of Clinical Examination Items
Variable Kappa 95 CI ICC 95 CI SEM (°)
Question 1—“Most bothersome symptoms. . .” 0.74 (0.55–0.93)
Question 2—“Where most bothersome. . .” 0.82 (0.68–0.96)
Question 3—“Symptom behavior. . .” 0.57 (0.35–0.79)
Question 4—“Entire limb numb. . .” 0.53 (0.26–0.81)
Question 5—“Symptoms keep from sleep. . .” 0.70 (0.48–0.92)
Question 6—“Neck movement improves. . .” 0.67 (0.44–0.90)
C5 Dermatome 0.67 (0.33–1.0)
C6 Dermatome 0.28 (0.00–0.58)
C7 Dermatome 0.40 (0.06–0.74)
C8 Dermatome 0.16 (0.00–0.50)
T1 Dermatome 0.46 (0.04–0.88)
MMT deltoid 0.62 (0.28–0.96)
MMT biceps brachii 0.69 (0.36–1.0)
MMT extensor carpi radialis longus/brevis 0.63 (0.26–1.0)
MMT triceps brachii 0.29 (0.00–0.79)
MMT flexor carpi radialis 0.23 (0.00–0.69)
MMT abductor pollicus 0.39 (0.00–0.80)
MMT first dorsal interrosseus 0.37 (0.00–0.80)
Biceps brachii MSR 0.73 (0.38–1.0)
Spurling’s A 0.60 (0.32–0.87) — —
Spurling’s B 0.62 (0.25–0.99) — —

Shoulder abduction 0.20 (0.00–0.59) — —
Valsalva 0.69 (0.36–1.0) — —
Distraction 0.88 (0.64–1.0) — —
ULTT A 0.76 (0.51–1.0) — —
ULTT B 0.83 (0.65–1.0) — —
Cervical flexion — 0.79 (0.65–0.88) 4.6
Cervical extension — 0.84 (0.70–0.95) 4.8
Cervical left rotation — 0.75 (0.59–0.85) 6.6
Cervical right rotation — 0.63 (0.22–0.82) 7.3
Cervical left sidebending — 0.63 (0.40–0.78) 5.3
Cervical right sidebending — 0.68 (0.62–0.87) 5.4
ICC � intraclass correlation coefficient; SEM � standard error
of the mean; 95 CI � 95% confidence intervals.
Reliability of tricep brachii and brachioradialis not assessed
because of low prevalence.
Reliability
Reliability was computed using the results from one rater
pair that examined 50 patients. The 32 subjects not in-
cluded in the reliability analysis did not differ from the
other 50 subjects with regard to age, NDI, or pain ratings
(P � 0.05).
Nineteen variables had kappa values at least fair or bet-
ter (kappa, �0.40). No abnormal findings for the triceps
and brachioradialis muscle stretch reflexes were recorded,
so reliability was not computed for these variables. The
reliability coefficients for the items of clinical examination
and their associated 95% CIs are listed in Table 2.
Diagnostic Accuracy

The following 11 variables were found to have accept-
able diagnostic accuracy: upper limb tension test A
(ULTTA), cervical rotation to the involved side less than
60°, cervical flexion less than 55°, involved biceps muscle
stretch reflex (MSR), distraction test, MMT-involved bi-
cep, Question 2 (“Where are your symptoms most both-
ersome?”), Valsalva test, Spurling test A, shoulder ab-
duction test, Question 9 (“Do your symptoms improve
with moving or positioning of your neck?”), and in-
volved C5 dermatome sensation. The sensitivity, speci-
ficity, and likelihood ratios for each variable and their
associated 95% CIs, are listed in Tables 3 and 4.
Diagnostic Test Item Cluster
The aforementioned 11 variables were entered into the
regression model as potential predictors for CR. After
list-wise deletion, a total of 73 subjects (16 subjects with
cervical radiculopathy and 57 control subjects) were
Table 3. Validity of Historical Questions
Variable Sn 95 CI Sp 95 CI LR� 95 CI LR� 95 CI
Question 1—“Most bothersome Sx’s.”
i. Pain 0.47 (0.23–0.71) 0.52 (0.41–0.65) * 0.99 (0.56–1.7)
ii. Numb/tingling 0.47 (0.23–0.71) 0.56 (0.42–0.68) 1.1 (0.6–
1.9)
iii. Loss of feeling 0.06 (0.00–0.17) 0.92 (0.85–0.99) 0.74
(0.09–5.9)
Question 2—“Where most bothersome. . .”
i. Neck 0.19 (0.00–0.35) 0.90 (0.83–0.98) 1.9 (0.54–6.9)
ii. Shoulder/scap. 0.38 (0.19–0.73) 0.84 (0.75–0.93) * 2.3 (1.0–
5.4)
iii. Arm AE 0.03 (0.14–0.61) 0.93 (0.86–0.99) 0.41 (0.02–7.3)

iv. Arm BE 0.06 (0.0–0.11) 0.84 (0.75–0.93) 0.39 (0.05–2.8)
v. Hand or fingers 0.38 (0.14–0.48) 0.48 (0.36–0.61) 0.73
(0.37–1.4)
Question 3—“Sx. behavior. . .”
i. Constant 0.12 (0.00–0.27) 0.84 (0.75–0.93) * 0.74 (0.18–3.1)
ii. Intermittent 0.35 (0.13–0.58) 0.62 (0.50–0.74) 0.93 (0.45–
1.9)
iii. Variable 0.53 (0.29–0.77) 0.54 (0.42–0.66) 1.2 (0.68–1.9)
Question 4—“Entire limb numb. . .” 0.24 (0.03–0.44) 0.73
(0.62–0.84) 1.1 (0.77–1.4) 0.87 (0.34–2.3)
Question 5—“Sx’s. keep from sleep. . .” 0.47 (0.23–0.71) 0.60
(0.48–0.72) 0.88 (0.54–1.4) 1.19 (0.66–2.1)
Question 6—“Neck move improves. . .” 0.65 (0.42–0.87) 0.71
(0.60–0.82) 0.50 (0.26–0.97) 2.23 (1.3–3.8)
Sensitivity � Sn; specificity � Sp, negative likelihood ratios �
LR�; positive likelihood ratios � LR�; 95 CI � 95%
confidence intervals.
Table 4. Validity of Conventional Neurologic Examination
Items, Provocative Tests, and Cervical ROM
Variable Sn 95 CI Sp 95 CI LR� 95 CI LR� 95 CI
C5 Dermatome 0.29 (0.08–0.51) 0.86 (0.77–0.94) 0.82 (0.60–
1.1) 2.1 (0.79–5.3)
C6 Dermatome 0.24 (0.03–0.44) 0.66 (0.54–0.78) 1.16 (0.84–
1.6) 0.69 (0.28–1.8)
C7 Dermatome 0.18 (0.0–0.36) 0.77 (0.66–0.87) 1.07 (0.83–1.4)
0.76 (0.25–2.3)
C8 Dermatome 0.12 (0.0–0.27) 0.81 (0.71–0.90) 1.09 (0.88–1.4)
0.61 (0.15–2.5)
T1 Dermatome 0.18 (0.0–0.36) 0.79 (0.68–0.89) 1.05 (0.81–1.4)
0.83 (0.27–2.6)

MMT deltoid 0.24 (0.03–0.44) 0.89 (0.81–0.97) 0.86 (0.65–1.1)
2.1 (0.70–6.4)
MMT biceps brachii 0.24 (0.03–0.44) 0.94 (0.88–1.0) 0.82
(0.62–1.1) 3.7 (1.0–13.3)
MMT extensor carpi radialis longus/brevis 0.12 (0.0–0.27) 0.90
(0.83–0.98) 0.98 (0.81–1.2) 1.2 (0.27–5.6)
MMT triceps brachii 0.12 (0.0–0.27) 0.94 (0.88–1.0) 0.94
(0.78–1.1) 1.9 (0.37–9.3)
MMT flexor carpi radialis 0.06 (0.0–0.17) 0.89 (0.82–0.97) 1.05
(0.91–1.2) 0.55 (0.07–4.2)
MMT abductor pollicus brevis 0.06 (0.0–0.17) 0.84 (0.75–0.93)
1.12 (0.95–1.3) 0.37 (0.05–2.7)
MMT first dorsal interosseus 0.03 (0.0–0.10) 0.93 (0.87–0.99)
1.05 (0.94–1.2) 0.40 (0.02–7.0)
Biceps brachii MSR 0.24 (0.3–0.44) 0.95 (0.90–1.0) 0.80 (0.61–
1.1) 4.9 (1.2–20.0)
Brachioradialis MSR 0.06 (0.0–0.17) 0.95 (0.90–1.9) 0.99
(0.87–1.1) 1.2 (0.14–11.1)
Triceps MSR 0.03 (0.0–0.10) 0.93 (0.87–0.99) 1.05 (0.94–1.2)
0.40 (0.02–7.0)
Spurling’s A 0.50 (0.27–0.73) 0.86 (0.77–0.94) 0.58 (0.36–
0.94) 3.5 (1.6–7.5)
Spurling’s B 0.50 (0.27–0.73) 0.74 (0.63–0.85) 0.67 (0.42–1.1)
1.9 (1.0–3.6)
Shoulder abduction 0.17 (0.0–0.34) 0.92 (0.85–0.99) 0.91
(0.73–1.1) 2.1 (0.55–8.0)
Valsalva 0.22 (0.03–0.41) 0.94 (0.88–1.0) 0.83 (0.64–1.1) 3.5
(0.97–12.6)
Distraction 0.44 (0.21–0.67) 0.90 (0.82–0.98) 0.62 (0.40–0.90)
4.4 (1.8–11.1)
Upper limb tension test A 0.97 (0.90–1.0) 0.22 (0.12–0.33) 0.12
(0.01–1.9) 1.3 (1.1–1.5)
Upper limb tension test B 0.72 (0.52–0.93) 0.33 (0.21–0.45)
0.85 (0.37–1.9) 1.1 (0.77–1.5)
Cervical flexion (�55°) 0.89 (0.74–1.0) 0.41 (0.29–0.53) 0.27
(0.07–1.0) 1.5 (1.2–2.0)

Involved rotation (�60°) 0.89 (0.74–1.0) 0.49 (0.37–0.62) 0.23
(0.06–0.85) 1.8 (1.3–2.4)
Sensitivity � Sn; specificity � Sp; negative likelihood ratios �
LR�; positive likelihood ratios � LR�; 95 CI � 95%
confidence intervals.
used in the analysis. The results of the HL test indicated
that the model fit the data (P � 0.92). The following four
test variables were chosen by the model and are therefore
considered the best CR TIC: ULTTA, involved cervical
rotation less than 60°, distraction test, and Spurling A.
The four variables and their diagnostic properties ac-
cording to the number of abnormalities required for a
positive test are listed in Table 5. Figures 1 through 9
show the provocative tests included in the CR TIC.
Discussion
This is the first study to assess simultaneously the diagnostic
properties of historical questions, patient self-report mea-
sures, and cervical ROM for cervical radiculopathy. Several
observations can be made from the study results. First, most
of the clinical examination items demonstrated a fair or
better level of reliability. Second, test items from each major
component of the clinical examination demonstrated useful
diagnostic properties. Finally, a single TIC was identified
that produced larger posttest probability changes than any
single test item. None of the patient self-report measures
had acceptable diagnostic accuracy values, which is not
surprising because these instruments were developed for

evaluative and not predictive purposes.35
Although similarities exist between the current results
and the only other comparable published study,66 there
are some notable differences. Viikari-Juntura65 reported
Figure 1. Spurling A.
Figure 2. Neck distraction test.
Figure 3. ULTT A, Step 1: Scapular depression.
Figure 4. ULTT A, Step 2: Shoulder abduction.
Table 5. Test Item Cluster for the Diagnosis of Cervical
Radiculopathy
Criteria for a Positive Test Sn 95 CI Sp 95 CI LR� 95 CI
Post-test
Probability
Two positive tests 0.39 (0.16–0.61) 0.56 (0.43–0.68) 0.88 (1.5–
2.5) 21%
Three positive tests 0.39 (0.16–0.61) 0.94 (0.88–1.0) 6.1 (2.0–
18.6) 65%
All four tests positive 0.24 (0.05–0.43) 0.99 (0.97–1.0) 30.3
(1.7–538.2) 90%
ULTTA, involved cervical rotation �60°, Distraction, and
Spurling’s A. Sensitivity (Sn), Specificity (Sp), and Positive
Likelihood Ratio (LR�) of clinical examination
variables with 95% confidence intervals (95 CI). The associated
post-test probability values for each criteria level is based on a
pre-test probability of 23%.

poor and fair reliability for the ULTT and distraction
test, both of which demonstrated excellent reliability in
the current study and resulted in the best LR� and sec-
ond best LR�, respectively. The difference in ULTT re-
liability was most likely the result of the authors’ opera-
tional definition, but would not account for the higher
reliability of the distraction test found in the study. The
authors also found much lower Sn for the shoulder ab-
duction test. One possible reason is that they repeatedly
questioned patients regarding the symptoms throughout
the test in an open-ended fashion (i.e., “Does that change
your symptoms in any way?”). It is unclear whether this
was done in the study by Viikari-Juntura.65 Viikari-
Juntura et al66 did not directly study the validity of the
conventional neurologic examination. However, calcu-
lation of the diagnostic accuracy of their neurologic ex-
amination items compared with the myelography refer-
ence criterion was possible according to the data
presented in their report. Depending on the number of
root dysfunction signs (atrophy, strength, MSRs, and
sensation) required for a positive test, Sn and Sp values
were computed that ranged from 0.59 to 0.80, with
sensitivity values always predominating.66 In contrast,
items of the neurologic examination that had accept-
able values in the current study were associated with
high Sp and low Sn values, which is consistent with
reports of the validity of neurologic examination items
for lumbar radiculopathy.62
Figure 5. ULTT A, Step 3: Forearm supination, wrist and finger
extension.

Figure 6. ULTT A, Step 4: Shoulder lateral rotation.
Figure 7. ULTT A, Step 5: Elbow extension.
Figure 8. ULTT A, Step 6a: Contralateral side-bending.
Figure 9. ULTT A, Step 6b: Ipsilateral cervical side-bending.
Items of the patient’s history have demonstrated pow-
erful diagnostic properties in other reports.21,52 Two
questions in the current study were found to have accept-
able LR� values (Questions 2 and 6). Question 2 per-
tains to predominant scapula symptoms and appears to
support Cloward’s5 work. Question 6 pertains to how
neck movement influences symptoms. Unfortunately,
these two questions generate only small posttest proba-
bility changes. Whereas the six questions in this study are
thought to be important historical items for the diagnosis
of CR,42,70 the inclusion of other important questions
may have been neglected.
The three test items with the best transformed LR val-
ues25 in this study were items of the physical component of
the clinical examination (ULTTA, biceps MSR, and distrac-
tion test). The ULTTA in this study was perfectly sensitive
and appeared to support the claim by Kenneally et al33 that
the ULTT is the “straight-leg raise test” of the upper ex-
tremity. The ULTTA appears to be a useful screening test
for CR given its high Sn and small LR� value, and is anal-
ogous to the straight-leg-raise test for lumbar radiculopa-
thy.4 Both the biceps MSR and distraction test had high Sp

and large LR� values, which are useful for diagnostic pur-
poses. Although these three tests have been described in the
literature, the descriptions either have been unclear65 or
have differed.53,58 Disparate diagnostic properties were
found for the two variations of the ULTT and Spurling test
used in this study. The current results demonstrate that a
clear operational definition is critical to defining a test’s
diagnostic properties.
A large number of single clinical examination items were
found to have high point estimates of Sn and Sp for assess-
ing the presence or absence of cervical radiculopathy (Ta-
bles 3 and 4). Faced with an array of potentially useful tests,
the obvious question is “Which test or tests should I use?”
Using the single best test (ULTTA) in this study to screen for
CR results in a change in probability of the condition from
23% to 3%, a 20% decrease when the test is negative. If the
ULTTA is negative, then CR can essentially be ruled out,
and the need for further workup or treatment for CR is
minimized. Use of the single best test (biceps brachii MSR)
to diagnose CR results in a change in probability of the
condition from 23% to 59%, a 36% increase when the
biceps MSR is reduced or absent. In contrast, use of a par-
simonious cluster of test items (TIC) identified in this study
to diagnose CR produces larger posttest probability
changes than the best single test item. If a patient has posi-
tive findings for three of the four TIC variables (ULTTA,
involved cervical rotation less than 60°, distraction, and
Spurling A) the probability of the condition increases to
65%, and if all four variables are present, the probability
increases to 90%. Patients with positive test results for three
or more variables are likely to have the condition and may
indicate a need for further definitive diagnostic procedures
and intervention. The clinical utility of the TIC for diagno-
sis of cervical radiculopathy compared with that of the sin-
gle best test item is illustrated in Figure 1, as is the utility of

the ULTTA for screening purposes.
The TIC found in this study to have the best clinical
utility included three provocative tests and a range-of-
motion measure. None of the history questions and none
of several test items of the conventional neurologic ex-
amination with acceptable LRs were included in the TIC.
The current findings are in contrast to classic reports42,70
and expert opinion17 that muscle stretch reflexes, loss of
sensation, and motor weakness are classic diagnostic
findings of CR. However, this should not be surprising
considering the methodology and severely involved pa-
tients in these earlier studies.42,70
The current study has several shortcomings. The min-
imal EMG findings required to establish the diagnosis of
CR in this study may arguably have resulted in misdiag-
nosis in some cases (i.e., false-positives), but the specific-
ity of EMG is considered to be high and minimizes this
concern.1 The increased variability resulting from the
number of EMG/NCS providers, clinical examiners, and
practice locations included in this study may have atten-
uated the properties of the clinical examination items
studied. Although this possibility exists, the results ob-
tained from the large number of examiners and sites in
the project enhances the generalizability of the current
findings. Finally, the CR patients in the study sample
represented predominantly mild to moderate cases and
were almost exclusively representative of C6 and C7 root
level involvement. Although the incidence of root level
involvement in this study is consistent with all reported
case series,67 the diagnostic properties of the tests in this
study and the posttest probabilities generated from them
may be different when the C5 or C8 root level is involved
or in a different spectrum of disease.38

Despite the numerous textbooks devoted to the de-
scription and application of diagnostic tests for neuro-
musculoskeletal lesions,40,48 descriptions of the diagnos-
tic properties of the tests are almost uniformly omitted.59
The current study assessed the reliability and diagnostic
properties of common clinical examination items and
patient self-report measures used in the management of
cervical radiculopathy. No single clinical examination
item had diagnostic properties that produced larger post-
test probability changes than that produced by a parsi-
monious, single TIC. Although the TIC with a positive
test criterion of three findings produced an LR with a 95%
CI lower limit of 2, which met the lower limit of acceptabil-
ity, point estimates of the Sn/Sp and LRs for most test items
were associated with wide 95% CIs. Therefore, these esti-
mates are imprecise and should be interpreted cautiously.
A study using a larger sample is required to increase
the precision of the diagnostic accuracy point estimates
obtained in this study, and to validate the items and
properties of the CR TIC. The validation of a CR TIC
will enhance the diagnostic utility of the clinical exami-
nation, thereby allowing clinicians to select better the
need for additional diagnostic studies and the most ap-
propriate therapeutic interventions, and researchers to
establish a more homogeneous patient sample for clinical
trials. If validated, a trial assessing patient outcomes and
cost outlays to determine whether patients are benefited
by having the tests would be a next logical step. Cur-

rently, however, studies of the clinical examination for
other common peripheral mononeuropathies (e.g., car-
pal tunnel syndrome and lumbar radiculopathy) using
methodology similar to that described in this study are
necessary to distinguish between useful and useless diag-
nostic tests.
Key Points
● The diagnostic criteria for cervical radiculopathy
are not well defined, and no universally accepted
criteria for the diagnosis of cervical radiculopathy
have been established.
● Cervical radiculopathy remains primarily a clin-
ical diagnosis, but the diagnostic accuracy of nu-
merous clinical examination items purported to be
useful for the diagnosis of cervical radiculopathy
has seldom, if ever, been studied.
● Most individual items of the clinical examination
in this study were found to have at least a fair level
of reliability, and several were found to have an
acceptable level of accuracy for the diagnosis of
cervical radiculopathy using a neural impairment
reference criterion standard.
● A parsimonious test item cluster composed of indi-
vidual items of the clinical examination was identified
that produced larger posttest probability changes for
the diagnosis of cervical radiculopathy than any sin-
gle test item of the clinical examination.
● The 95% CIs associated with the diagnostic ac-
curacy point estimates for individual clinical exam-
ination items and the test item cluster were wide
because of the limited sample size and condition
prevalence. Further investigation is required both
to validate the test item cluster and to improve
point estimate precision.

Acknowledgment
The lead author acknowledges LtCol Howard Gill, MD,
for the use of his laboratory and his gracious assistance
with this project. Lt Col Manuel Dominich and Maj
Monge Wilson are acknowledged for their assistance
with clinically examining the patients enrolled in this
study.
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Appendix

THE RATIONAL CLINICAL
EXAMINATION
Does This Patient Have
Carpal Tunnel Syndrome?
Christopher A. D’Arcy, MD
Steven McGee, MD
CLINICAL SCENARIO
In the following patient, the clinician
would like to know which items from
the patient interview and physical ex-
amination accurately predict the diag-
nosis of carpal tunnel syndrome (CTS):
A 55-year-old woman has difficulty
sleeping because of numbness and tin-
gling in her right hand for 6 months.
On a hand diagram, she uses a pencil
to locate precisely her numbness and
tingling over the dorsal and palmar as-
pects of all 5 fingers, sparing the palm.
On inspection the patient has no evi-
dence of thenar atrophy, but thumb ab-
duction is weak on the affected side.
Sensory examination using monofila-
ments and a vibrating tuning fork is
normal. Tinel sign is positive, and
Phalen sign is negative.
Why Is the Diagnosis Important?
Carpel tunnel syndrome is an impor-

tant cause of pain and functional im-
pairment of the hand due to compres-
sion of the median nerve at the wrist
(FIGURE 1). Patients are usually be-
tween their third and fifth decades when
diagnosed, and women are affected 3
times as often as men.2,3 About 0.5% of
the general population reports being di-
agnosed with CTS.2 It is likely, how-
ever, that few affected patients con-
sult clinicians because population-
based studies reveal that about 3% of
adults have symptomatic electrodiag-
nostically confirmed CTS.4
In many patients, symptoms are self-
limited or resolve with conservative
measures, such as splinting the wrist,
using anti-inflammatory medication,
and modifying their activities. Corti-
costeroid injection into or near the car-
pal tunnel results in improvement for
49% to 81% of those affected, al-
though 50% to 86% of those experi-
ence recurrence.5-9 In patients whose
condition fails conservative treat-
ment, surgical division of the trans-
verse carpal ligament, either by an open
or endoscopic procedure, promptly im-
proves or relieves sensory complaints
(dysesthesias) 75% to 99% of the
time.10-18 Permanent complications from
surgery occur in less than 1%,19 but the
subsequent recovery often requires

leave from work lasting days to sev-
eral weeks.18
Author Affiliations: University of Washington Health
Sciences Center (Dr D’Arcy) and University of Wash-
ington, Seattle-Puget Sound Veterans Affairs Health
Care System (Dr McGee), Seattle.
Corresponding Author and Reprints: Christopher A.
D’Arcy, MD, Division of Rheumatology, University of
Washington Health Sciences Center, 1959 NE Pacific
St, Box 356428, Seattle, WA 98195 ([email protected]
.washington.edu).
The Rational Clinical Examination Section Editors:
David L. Simel, MD, MHS, Durham Veterans Affairs
Medical Center and Duke University Medical Center,
Durham, NC; Drummond Rennie, MD, Deputy Edi-
tor, JAMA.
Context History taking and physical examination maneuvers,
including Tinel and Phalen
signs, are widely used for the diagnosis of carpal tunnel
syndrome (CTS).
Objective To systematically review the precision and accuracy
of history taking and
physical examination in diagnosing CTS in adults.
Data Sources English-language literature was searched using
MEDLINE (January
1966-February 2000) as well as bibliographies of relevant
articles.
Study Selection Studies of patients presenting to clinicians with
symptoms sug-
gestive of CTS in which findings from clearly described
physical examination maneu-

vers were independently compared with electrodiagnostic
testing. Twelve of 42 ini-
tially identified articles met these criteria and were included in
the review.
Data Extraction Two authors independently reviewed and
abstracted data from
all of the articles and reached consensus about any
discrepancies.
Data Synthesis In patients presenting with hand dysesthesias,
the findings that best
distinguish between patients with electrodiagnostic evidence of
CTS and patients with-
out it are hypalgesia in the median nerve territory (likelihood
ratio [LR], 3.1; 95% con-
fidence 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 diag-
nostic 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 vali-
dation by other studies before they can be recommended.
Conclusions Hand symptom diagrams, hypalgesia, and thumb
abduction strength

testing are helpful in the establishing electrodiagnosis of CTS.
The utility of these re-
sults is limited, however, by problems inherent in using nerve
conduction studies as a
criterion standard.
JAMA. 2000;283:3110-3117 www.jama.com
3110 JAMA, June 21, 2000—Vol 283, No. 23 (Reprinted)
©2000 American Medical Association. All rights reserved.
at University Of New Mexico on May 11, 2011jama.ama-
assn.orgDownloaded from
http://jama.ama-assn.org/
Many conditions, including preg-
nancy, rheumatoid arthritis, diabetes
mellitus, and previous wrist trauma, are
associated with CTS,19 although histo-
logic sections from the carpal tunnel of
most affected patients are normal.20,21
Many patients have an abnormally high
tissue pressure within the carpal tun-
nel,22 which presumably causes intra-
neural ischemia that leads to dysesthe-
sias and abnormal results of sensory
testing.23-25
This article systematically reviews the
diagnostic accuracy of bedside find-
ings for CTS. Presentation of this in-
formation, however, first requires un-
d e r s t a n d i n g s o m e o f t h e i s s u e s
surrounding electrodiagnosis, the cur-

rent CTS diagnostic standard.
The Diagnostic Standard for CTS
In his original definition of CTS,
Phalen26 required patients to have 1 or
more of 3 bedside findings: sensory
changes restricted to the median nerve
distribution of the hand, a positive Ti-
nel sign, and a positive Phalen sign
(TABLE 1). Though electrodiagnosis was
not part of Phalen’s definition, clini-
cians now use electrodiagnosis fre-
quently to confirm the diagnosis, and
some third-party payers require it
before compensating claims.34 Consen-
sus committees from professional so-
cieties have endorsed electrodiagnosis
as the diagnostic test of choice.35,36 Di-
agnostic standards for nerve conduc-
tion studies in CTS have been devel-
oped, which report sensitivities of 49%
to 84% and specificities of 95% to 99%.37
The sensitivity and specificity of elec-
trodiagnosis in CTS need to be care-
fully interpreted. For the sensitivity
calculation, the criterion standard
was bedside findings alone (eg, com-
patible symptoms plus a positive
Tinel sign),38-40 which then begs the
question whether electrodiagnosis or
bedside findings are the more accu-
rate standard. False-negative test re-
sults probably occur because the con-
dition is intermittent41 or because the
patient’s symptoms emanate from small,

unmyelinated fibers that are invisible
to surface electrodes (electrodiagno-
sis detects only larger myelinated
fibers).42
The high specificity figures in these
studies are also misleading, being ar-
bitrarily set at 2 SDs above the mean of
observations of normal hands. The val-
ues of 95% to 99% are based on the as-
sumption that nerve conduction re-
cordings follow a standard gaussian
distribution, which has been shown to
be inaccurate.43,44 False-positive test re-
sults are well documented when these
test thresholds are applied to other
populations.10,45-47
It is well documented that many hand
surgeons perform carpal tunnel release
successfully in patients with normal elec-
trodiagnostic findings.15,34,48-50 Even in pa-
tients with positive electrodiagnostic
findings who undergo surgery, symp-
toms usually resolve within days de-
spite nerve conduction abnormalities that
persist for months or longer.11,17,42,51,52
Nonetheless, most physicians rely on
electrodiagnosis as the best available diag-
nostic standard. Electrodiagnostic stud-
ies may help identify other conditions
that also cause hand dysesthesias, such
as cervical radiculopathy, polyneuropa-
thy, or other median nerve entrapment

syndromes.41,53-55 Furthermore, the over-
whelming majority of patients in surgi-
cal studies have compatible symptoms
and electrodiagnostic studies positive for
CTS.10,12,17,56 Electrodiagnosis may not
predict recovery after carpal tunnel
release, but neither does any other clini-
cal variable with any certainty. The poten-
tial utility of computed tomography,
magnetic resonance imaging, and ultra-
sonography is still being determined, and
they remain primarily research tools.57-61
For these reasons, our review addresses
the accuracy of the history and physical
examination in diagnosing CTS, as con-
firmed by electrodiagnostic studies.
Figure 1. Normal Anatomy of the Carpal Tunnel
Ulnar
Artery
Ulnar
Nerve Flexor
Retinaculum
Median Nerve
Flexor Tendons
Hamate
Capitate Trapezoid
Trapezium

The carpal tunnel consists of the median nerve and 9 flexor
tendons surrounded by the rigid carpal bones and
transverse carpal ligament (flexor retinaculum). The distal wrist
crease marks the proximal edge of the carpal
tunnel. Within the tunnel, the median nerve divides into a motor
branch that innervates the thenar muscles
(opponens, abductor, short flexor) and distal sensory branches
that supply the thumb, index, and middle fin-
gers, and the radial half of the ring finger. Because the sensory
branches to the radial palm do not usually pass
through the carpal tunnel, palm sensation is preserved in a
classic case of carpal tunnel syndrome.1
CARPAL TUNNEL SYNDROME
(Reprinted) JAMA, June 21, 2000—Vol 283, No. 23 3111
METHODS
Using the MEDLINE database for ar-
ticles from January 1966 to February
2000, both authors independently used
the following search strategy, limited to
the English language and human sub-
jects, to retrieve all relevant publica-
tions on the diagnosis of CTS in adults:
exp carpal tunnel syndrome and exp diag-
nosis. In addition text word searches were
completed for Tinel or Tinels or Hoffman-

Tinels, and Phalen or Phalens. Based on
review of titles and abstracts, relevant
publications were retrieved. To com-
plete the search, the authors reviewed the
bibliographies of these articles and re-
trieved all relevant articles.
To be included in this review, a study
had to satisfy the following criteria: (1)
the patients presented to a clinician for
symptoms suggestive of CTS, (2) the
physical examination maneuvers were
clearly described, (3) there was an in-
dependent comparison with one or more
electrodiagnostic parameters (which had
to include at least some measurement of
motor or sensory nerve conduction), and
(4) the authors could extract from fig-
ures or tables in the articles the num-
bers needed to construct 2 3 2 tables and
calculate sensitivity, specificity, and like-
lihood ratios (LRs).
Twelve articles met these criteria and
are included.27-33,62-66 Thirty articles were
excluded: 14 because the control group
was asymptomatic,67-80 8 because the
data were incomplete,15,49,57,81-85 4 be-
cause the subjects were identified by
population surveys,45,86-88 3 because the
criterion standard was unacceptable (ie,
electromyography alone,89 electrodiag-
nosis and abnormal monofilament test-
ing,90 or criterion standard missing91),
and 1 because the examination maneu-

vers were not clearly defined.92
Sensitivity, specificity, and LRs and
their confidence intervals (CIs) were cal-
culated using conventional defini-
tions.93 When a cell of a 2 3 2 table was
0, 0.5 was added to all cells before sum-
marizing the data for a particular test.
Our summary measures pooled all the
data using the Dersimonian and Laird
random-effects model,94 which consid-
ers both within-study variance and vari-
ability among studies. Our test for ho-
mogeneity between studies was the
effectiveness score, a test of overall
accuracy.95
Likelihood ratios are the odds that a
given finding would occur in a patient
with CTS as opposed to one without
CTS. If a particular LR, positive or nega-
tive, had a value close to 1 that out-
come of the test is unhelpful in making
diagnostic decisions at the bedside.
PRECISION AND ACCURACY
How to Elicit Symptoms
and Signs of CTS
Table 1 summarizes how to elicit the
physical examination signs of CTS ana-
lyzed in this review. When examining
thumb strength, the clinician should
focus on abduction of the thumb
(FIGURE 2), not flexion or opposition,
which sometimes can be accom-

plished by muscles innervated by nerves
other than the recurrent motor branch
of the median nerve.54,59 The Katz hand
diagram is a self-administered dia-
gram that depicts both the dorsal and
palmar aspect of the patient’s hands and
arms (FIGURE 3). Patients use this dia-
gram to mark the specific location of
their symptoms, characterizing them as
pain, numbness or tingling, or other.
Diagrams are then graded as classic,
probable, possible, or unlikely to be
Table 1. Definition of Abnormal Physical Findings
Physical Finding Definition of Abnormal Finding
Motor examination
Weak thumb abduction Weakness of resisted abduction, ie,
movement of the thumb at right
angles to the palm*
Thenar atrophy A concavity of the thenar muscles when
observed from the side
Sensory examination
Hypalgesia Diminished ability to perceive painful stimuli
applied along the palmar
aspect of the index finger when compared with the ipsilateral
little
finger†
Diminished 2-point
discrimination

Diminished ability to identify correctly the number of points
using
calipers whose points are set 4 to 6 mm apart, comparing the
index with little finger‡
Abnormal vibratory
sensation
Diminished ability to perceive vibratory sensations using a
standard
vibrating tuning fork (128 of 256 Hz), comparing the distal
interphalangeal joint of the index finger to the ipsilateral fifth
finger
Abnormal monofilament
testing
Using a Semmes-Weinstein monofilament applied to the pulp of
the
index finger, the patient’s threshold is greater than the 2.83
monofilament
Other tests
Square wrist sign27 The anteroposterior dimension of the wrist
divided by the
mediolateral dimension equals a ratio of greater than 0.70, when
measured with calipers at the distal wrist crease
Closed-fist sign28 Paresthesias in the distribution of the median
nerve when the patient
actively flexes the fingers into a closed fist for 60 seconds
Flick sign29 When asking the patient, “What do you actually do
with your hand(s)

when the symptoms are at their worst?” the patient
demonstrates a flicking movement of the wrist and hand, similar
to that used in shaking down a thermometer§
Tinel sign Paresthesias in the distribution of the median nerve
when the
clinician taps on the distal wrist crease over the median nerve
Phalen sign Paresthesias in the distribution of the median nerve
when the patient
flexes both wrists 90° for 60 seconds
Pressure provocation
test30
Paresthesias in the distribution of the median nerve when the
examiner presses with his/her thumb on the palmar aspect of the
patient’s wrist at the level of the carpal tunnel for 60 seconds
Tourniquet test31 Paresthesias in the distribution of the median
nerve when a blood
pressure cuff around the patient’s arm is inflated above systolic
pressure for 60 seconds
*Most clinicians define weakness as muscle power less than that
of the companion muscle in contralateral hand (which
has the disadvantage of assuming the opposite hand has normal
strength) or that of a standard of normal strength
based on the experience of examining many normal individuals
(Figure 2).
†Most clinicians use an open safety pin or broken applicator
stick, which must be discarded after use to prevent trans-
mission of infection.
‡The studies in this review separated the points of the calipers 4

mm,32 5 mm,33 and 6 mm.31
§Any other response is a negative result.
CTS based on criteria that appear in
Figure 3.32,63
Precision of the History and
Physical Examination for CTS
Few studies have addressed the preci-
sion of findings for CTS. In one study,
simple agreement was 84% for 2 physi-
cians rating 54 of the Katz hand dia-
grams.63 In another small study, the in-
terobserver agreement was substantial for
Tinel sign (k = 0.77) and Phalen sign
(k = 0.65), moderate for vibration
(k = 0.40), and fair for motor strength
(k = 0.25).96 Tinel test, however, is prob-
ably much less precise than these data
suggest, because the proportion of
healthy, asymptomatic hands with a posi-
tive Tinel sign ranges from 0%28 to 45%.71
Some of this variability with Tinel sign
may relate to technique; in one study, a

greater percussion force increased sen-
sitivity at the expense of specificity.89
Diagnostic Accuracy
of Physical Findings
TABLE 2 summarizes the studies ad-
dressing the diagnostic accuracy of the
history and physical examination for
CTS. Based on the CIs of LRs, the fol-
lowing findings favor the electrodiag-
nosis of CTS when they are present in
patients who present with hand dyses-
thesias: decreased sensitivity to pain
(hypalgesia) in the median nerve ter-
ritory (LR, 3.1; 95% CI, 2.0-5.1), clas-
Figure 2. Testing Thumb Abduction
The patient is instructed to raise his/her thumb per-
pendicular to the palm as the examiner applies down-
ward pressure on the distal phalanx. This maneuver
reliably isolates the strength of the abductor pollicis
brevis, which is innervated only by the median nerve.
Figure 3. Katz Hand Diagram
Numbness Pain Tingling Decreased Sensation
A
B
C
Classic Pattern
Symptoms affect at least 2 of

digits 1, 2, or 3. The classic
pattern permits symptoms in
the fourth and fifth digits, wrist pain,
and radiation of pain proximal
to the wrist, but it does not allow
symptoms on the palm or
dorsum of the hand.
Probable Pattern
Same symptom pattern
as classic, except palmar
symptoms are allowed unless
confined solely to the ulnar
aspect. In the possible pattern,
not shown, symptoms involve
only 1 of digits 1, 2, or 3.
Unlikely Pattern
No symptoms are present
in digits 1, 2, or 3.
Figure adapted with permission.64
sic or probable Katz hand diagram re-

sults (LR, 2.4; 95% CI, 1.6-3.5), and
weak thumb abduction strength (LR,
1.8; 95% CI, 1.4-2.3). Using a slightly
different system for grading hand dia-
grams, another study also found that the
definite or possible hand diagram ar-
gued for CTS (LR, 2.1; 95% CI, 1.5-3.0).92
In our analysis, 2 findings argued against
the electrodiagnosis of CTS: a Katz hand
diagram classified as unlikely (LR, 0.2;
95% CI, 0.0-0.7; not shown in Table 2)
and normal thumb abduction strength
(LR, 0.5; 95% CI, 0.4-0.7).
The following findings had limited or
no value in distinguishing patients with
CTS from those without it: the pa-
tient’s age, presence of bilateral or noc-
turnal symptoms, thenar atrophy, other
sensory abnormalities (2-point, vibra-
tion, monofilament), Tinel sign, Phalen
sign, pressure provocation test, and the
tourniquet test.
Several studies addressed the diagnos-
tic accuracy of combined findings,32,65,90
but no combination consistently proved
significantly more helpful than the indi-
vidual findings themselves. One study did
find that the combined finding of a posi-
tive Tinel sign and a classic or probable
hand diagram was slightly more discrimi-
nating (LR, 3.6; 95% CI, 1.6-8.1) than ei-
ther finding alone (LR, 1.8 for positive Ti-

nel sign and 2.4 for classic or probable
hand diagram),32 though this result re-
quires validation given the problems with
Tinel sign in other studies.
According to our analysis, several un-
conventional findings—flick sign, closed
fist sign, and square wrist sign—show
promise in diagnosing CTS. However,
these maneuvers are not widely used and
have been tested in only 1 or 2 studies.
Two letters to the editor have suggested
that the sensitivity of the flick sign is
much lower (only 25%-36%) than indi-
cated in Table 2.84,85 Therefore, before any
of these 3 findings can be recom-
mended for clinical practice, further sup-
portive evidence is necessary.
There are several reasons why some
findings are not as helpful diagnosti-
cally as traditionally thought. Thenar at-
rophy is probably not useful because it
occurs only in long-standing or ne-
glected cases of CTS and can also result
from lower cervical radiculopathies or
polyneuropathies. Tinel intended his
sign to be used in patients after blunt
traumatic nerve injury to follow the
course of the regenerating nerve.30,76,87
The idea that patients with CTS would
also have a stub of continually regener-
ating nerve at the distal wrist crease
seems unlikely, limiting the diagnostic

utility of this particular test. Our analy-
sis shows that hypalgesia in the me-
dian nerve distribution is a more useful
diagnostic finding than abnormalities of
other sensory modalities, in part be-
cause hypalgesia is a more specific find-
ing. It is not clear why this should be,
though it may indicate that the thresh-
old for abnormal results when testing
sensation for vibration, 2-point discrimi-
nation, and monofilaments is set too low
(in one study, for example, 20% of
Table 2. Diagnostic Accuracy of History and Physical
Examination for Carpal Tunnel
Syndrome*
Findings by
Reference and Year
No. of
Hands† Sensitivity Specificity
LR+
(95% CI)
LR−
(95% CI)
Patient Interview
Classic or probable hand diagram
Katz et al,63 1990 145 0.64 0.73 2.4 (1.6-3.5) 0.5 (0.3-0.7)
Age .40 years

Katz et al,32 1990 110* 0.80 0.41 1.3 (1.0-1.7) 0.5 (0.3-1.0)
Nocturnal paresthesia
Buch-Jaeger and Foucher,31
1994
112* 0.51 0.68 1.6 (1.0-2.6) 0.7 (0.5-1.0)
Gupta and Benstead,62 1997 92 0.84 0.33 1.2 (1.0-1.6) 0.5 (0.2-
1.1)
Katz et al,32 1990 110* 0.77 0.27 1.1 (0.9-1.3) 0.8 (0.4-1.6)
Pooled results . . . . . . . . . 1.2 (1.0-1.4) 0.7 (0.5-0.9)
Bilateral Symptoms
Katz et al,32 1990 110* 0.61 0.58 1.4 (1.0-2.1) 0.7 (0.4-1.0)
Motor Examination
Weak thumb abduction
Gerr et al,33 1995 115 0.63 0.62 1.7 (1.1-2.4) 0.6 (0.4-0.9)
Kuhlman and Hennessey,30
1997
228 0.66 0.66 2.0 (1.4-2.7) 0.5 (0.4-0.7)
Pooled results . . . . . . . . . 1.8 (1.4-2.3) 0.5 (0.4-0.7)
Thenar atrophy
Gerr et al,33 1995 115 0.28 0.82 1.6 (0.8-3.2) 0.9 (0.7-1.1)
Golding et al,64 1986 110 0.04 0.99 5.4 (0.2-129.5) 1.0 (0.9-
1.0)

Katz et al,32 1990 110* 0.14 0.90 1.5 (0.5-4.1) 0.9 (0.8-1.1)
Pooled results . . . . . . . . . 1.6 (0.9-2.8) 1.0 (0.9-1.0)
Sensory Examination
Hypalgesia
Golding et al,64 1986 110 0.15 0.93 2.2 (0.7-6.7) 0.9 (0.8-1.1)
Kuhlman and Hennessey,30
1997
228 0.51 0.85 3.4 (2.0-5.8) 0.6 (0.5-0.7)
Pooled results . . . . . . . . . 3.1 (2.0-5.1) 0.7 (0.5-1.1)
2-Point discrimination
1994, 6 mm
167 0.06 0.99 4.5 (0.6-36.9) 1.0 (0.9-1.0)
Gerr et al,33 1995, 5 mm 115 0.28 0.64 0.8 (0.5-1.3) 1.1 (0.9-
1.5)
Katz et al,32 1990, 4 mm 110* 0.32 0.80 1.6 (0.8-3.1) 0.8 (0.7-
1.1)
Pooled results . . . . . . . . . 1.3 (0.6-2.7) 1.0 (0.9-1.1)
Abnormal vibration
1994
172 0.20 0.81 1.1 (0.6-2.0) 1.0 (0.8-1.1)

Gerr et al,33 1995 115 0.61 0.71 2.1 (1.3-3.3) 0.5 (0.4-0.8)
Pooled results . . . . . . . . . 1.6 (0.8-3.0) 0.8 (0.4-1.3)
Abnormal monofilament findings
1994
167 0.59 0.59 1.5 (1.1-2.0) 0.7 (0.5-0.9)
asymptomatic hands also displayed ab-
normal monofilament results76).
In our analysis, only results for Tinel
sign were heterogeneous. The hetero-
geneity is not explained by differences
in the electrodiagnostic parameters used
as criterion standards in the individual
studies, variations in examination tech-
nique (ie, whether the clinician tapped
over the median nerve using his index
finger or a reflex hammer), differences
in prevalence of CTS in each of the stud-
ies (mean prevalence was 57%), differ-

ences in the age and sex composition
(mean age was 50 years, 77% were wom-
en), or by an apparent workup bias. Ex-
cluding the 2 studies that account for the
heterogeneity62,64 does not change the
summary measure in any meaningful
way, and therefore these studies are in-
cluded in our analysis.
THE BOTTOM LINE
When evaluating patients with hand
dysesthesias, the findings most help-
ful in predicting the electrodiagnosis of
CTS are hand symptom diagrams, hyp-
algesia, and weak thumb abduction
strength testing. The square wrist sign,
flick sign, and closed fist sign also show
promise, but require validation by other
investigators. Many traditional find-
ings, including Phalen and Tinel signs,
have limited ability to predict the elec-
trodiagnosis of CTS.
The main limitation of the existing lit-
erature is the lack of an ideal criterion
standard, which complicates all clinical
research in the field of CTS. It is also
important to note that these data are
derived from symptomatic patients pre-
senting to an orthopedic surgeon, physi-
cal therapist, or an electrodiagnostic labo-
ratory. There are no data addressing the
value of physical diagnosis in patients
presenting to a primary care physician
with symptoms suggestive of CTS. Our

analysis, therefore, is most applicable to
patients with severe enough symptoms
to warrant such a referral.
Returning to the case presented at
the beginning of the article, the find-
ings of a classic hand diagram and
thumb abduction weakness both sup-
port the diagnosis of CTS. The find-
ings of a normal thenar eminence, a
positive Tinel sign, and negative
Phalen sign do not contribute signifi-
cant diagnostic information. Her clini-
cian believed she probably had CTS
and chose to manage her symptoms
by splinting her wrists and recom-
mending anti-inflammatory medica-
tions. If the patient’s symptoms fail to
improve, nerve conduction testing,
a d d i t i o n a l e m p i r i c t h e r a p e u t i c
modalities (eg, corticosteroid injec-
tions), or referral for surgical assess-
ment should be considered.
Table 2. Diagnostic Accuracy of History and Physical
Examination for Carpal Tunnel
Syndrome (cont)*
Findings by
Reference and Year
No. of
Hands† Sensitivity Specificity
LR+
(95% CI)

LR−
(95% CI)
Other Tests
Square wrist sign
Kuhlman and
Hennessey,30 1997
228 0.69 0.73 2.6 (1.8-3.7) 0.4 (0.3-0.6)
Radecki,27 1994 665 0.47 0.83 2.8 (2.1-3.8) 0.6 (0.6-0.7)
Pooled results . . . . . . . . . 2.7 (2.2-3.4) 0.5 (0.4-0.8)
Closed fist sign
De Smet et al,28 1995 35 0.61 0.92 7.3 (1.1-49.1) 0.4 (0.2-0.7)
Flick sign
Pryse-Phillips,29 1984 396 0.93 0.96 21.4 (10.8-42.1) 0.1 (0.0-
0.1)
Tinel sign
Gerr et al,33 1995 115 0.25 0.67 0.7 (0.4-1.3) 1.1 (0.9-1.4)
Golding et al,64 1986 110 0.26 0.80 1.3 (0.6-2.6) 0.9 (0.7-1.2)
Heller et al,65 1986 80 0.60 0.77 2.7 (1.2-5.9) 0.5 (0.3-0.8)
Katz et al,32 1990 110* 0.59 0.67 1.8 (1.2-2.7) 0.6 (0.4-0.9)
Kuhlman and
Hennessey,30 1997
228 0.23 0.87 1.8 (1.0-3.4) 0.9 (0.8-1.0)

Buch-Jaeger and
Foucher,31 1994
172 0.42 0.64 1.1 (0.8-1.7) 0.9 (0.7-1.2)
Pooled results . . . . . . . . . 1.4 (1.0-1.9) 0.8 (0.7-1.0)
Phalen sign
Buch-Jaeger and
Foucher,31 1994
166 0.58 0.54 1.3 (0.9-1.7) 0.8 (0.6-1.1)
Gerr et al,33 1995 115 0.75 0.33 1.1 (0.9-1.4) 0.7 (0.4-1.3)
Heller et al,65 1986 80 0.67 0.59 1.6 (1.0-2.8) 0.6 (0.3-0.9)
Katz et al,32 1990 110* 0.75 0.47 1.4 (1.1-1.9) 0.5 (0.3-0.9)
Kuhlman and
Hennessey,30 1997
228 0.51 0.76 2.1 (1.4-3.2) 0.6 (0.5-0.8)
Golding et al,64 1986 110 0.10 0.86 0.7 (0.2-2.2) 1.0 (0.9-1.2)
Burke et al,66 1999 200 0.51 0.54 1.1 (0.7-1.8) 0.9 (0.6-1.3)
De Smet et al,28 1995 66 0.91 0.33 1.4 (0.9-2.0) 0.3 (0.1-0.9)
Pooled results . . . . . . . . . 1.3 (1.1-1.6) 0.7 (0.6-0.9)
Pressure provocation test
Kuhlman and

Hennessey,30 1997
228 0.28 0.74 1.1 (0.7-1.7) 1.0 (0.8-1.1)
Burke et al,66 1999 205 0.52 0.38 0.8 (0.6-1.2) 1.3 (0.7-2.2)
Buch-Jaeger and
Foucher,31 1994
155 0.49 0.54 1.1 (0.8-1.5) 0.9 (0.7-1.3)
De Smet et al,28 1995 66 0.63 0.33 0.9 (0.6-1.5) 1.1 (0.5-2.7)
Pooled results . . . . . . . . . 1.0 (0.8-1.3) 1.0 (0.9-1.1)
Tourniquet test
Buch-Jaeger and
Foucher,31 1994
145 0.52 0.36 0.8 (0.6-1.1) 1.3 (0.9-2.0)
Golding et al,64 1986 110 0.21 0.87 1.6 (0.7-3.9) 0.9 (0.8-1.1)
Pooled results . . . . . . . . . 1.0 (0.5-1.9) 1.0 (0.7-1.5)
*LR indicates likelihood ratio; CI, confidence interval; and
ellipses, not applicable. A positive LR indicates a positive
finding for carpal tunnel syndrome; a negative LR indicates
either a negative finding or an absent finding.
†Refers to individual subjects instead of individual hands.

Acknowledgment: We thank Jaya Rao, MD, MHS, and
Richard W. Tim, MD, who reviewed this article and
provided many helpful comments.
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Science cannot solve the ultimate mystery of nature.
And that is because, in the last analysis, we ourselves
are part of nature and therefore part of the mystery
that we are trying to solve.
—Max Planck (1858-1947)
methylnaltrexone levels. Mean (SD [range]) peak plasma level
for the other 4 patients (1 from the 1.0 mg/kg group and 3 from
the 3.0 mg/kg group) was 17.8 (6.6 [10-26]) ng/mL.
Comment. Tertiary opioid antagonists, such as naloxone, cross
the blood-brain barrier and reverse both the pain-relieving ben-
efits and the adverse effects of opiates. Although oral naloxone
may relieve opioid-induced constipation, the therapeutic index
is very narrow,5 and naloxone may induce opioid withdrawal
symptoms. Many patients receiving opioid pain medications
face
a difficult choice between burdensome adverse effects or inef-
fective analgesia. Methylnaltrexone may allow for more aggres-
sive use of opioid analgesics with fewer adverse effects. The
low
methylnaltrexone plasma levels observed in our study suggest

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