Practice Parameter and Literature Review of the Usefulness of ...

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segments of the median nerve in the samelimb (Technique A) (Standard).3. Motor NCS of the median nerve recordingfrom the thenar muscle (Technique H) and ofone other nerve in the symptomatic limb toinclude measurement of distal latency(Guideline).4. Supplementary NCS: comparison of themedian motor nerve distal latency (secondlumbrical) to the ulnar motor nerve distallatency (second interossei) (Technique J);median motor terminal latency index(Technique I); median motor nerve conductionbetween wrist and palm (Technique E);median motor nerve compound muscle actionpotential (CMAP) wrist-to-palm amplituderatio to detect conduction block; mediansensory nerve action potential (SNAP) wristto-palmamplitude ratio to detect conductionblock; short segment (1 cm) incrementalmedian sensory nerve conduction across thecarpal tunnel (Option).5. Needle electromyography (EMG) of a sampleof muscles innervated by the C5 to T1 spinalroots, including a thenar muscle innervated bythe median nerve of the symptomatic limb(Option).Based on the second AAEM CTS LiteratureReview, 2 the following EDX studies are notrecommended to confirm a clinical diagnosis ofCTS either because the EDX studies recommendedabove have greater sensitivity and specificity orthe test is best described as investigational at thistime.1. Low sensitivity and specificity compared toother EDX studies: multiple median F-waveparameters, median motor nerve residuallatency, and sympathetic skin response(Technique K).2. Investigational studies: evaluation of the effecton median NCS of limb ischemia, dynamichand exercises, and brief or sustained wristpositioning.RECOMMENDATIONS FOR FUTURE RESEARCHSTUDIES IN CTSThe AAEM recommends that future clinicalresearch studies of the usefulness of EDX studiesto confirm the diagnosis of CTS meet three clinicalstudy criteria:1. Prospective study.2. Clinical diagnosis of CTS independent ofEDX studies. For example, a diagnosis ofprobable CTS as defined in the second CTSLiterature Review 2 which is based on aconsensus recommendation by Rempel andcolleagues. 63. A uniform protocol for data collection andmeasurement with the physicians performingand interpreting the EDX studies underinvestigation blinded to the clinical diagnosisof all the human subjects (normal, CTS,disease control) in the study at least until thedata collection and measurements arecompleted.The AAEM recommends that future clinicalresearch studies of the usefulness of EDX studiesto confirm the diagnosis of CTS meet fouradditional methodological study criteria:1. Description of EDX technique sufficient topermit replication of the study.2. Monitor limb temperature continuously duringthe EDX study.3. Normal values for EDX technique obtainedwith concomitant studies or with previousstudies in the same laboratory.4. Criteria of EDX abnormality obtained fromnormal population and defined in statisticalterms.The first and second AAEM CTS LiteratureReviews 1,2 used six CTS LIC. The second CTSLiterature Review 2 recommends (1) the addition ofcriterion 3, and (2) that future AAEM CTSLiterature Reviews use all seven CTS LIC toreview reports of the usefulness of EDX studies inthe evaluation of CTS patients. The second AAEMCTS Literature Re-view 2 also provides a set ofspecific criteria to make a clinical diagnosis ofCTS based on expert opinion.Both the first and second AAEM CTS LiteratureReviews recommend that outcome studies shouldbe performed to assess the harms, benefits, andcosts of performing NCSs and needle EMG inpatients with symptoms suggestive of CTS.The AAEM CTS Task Force has addressed futureresearch principles over future research topics(except for outcome studies) because the TaskForce concluded that future research studies needto meet these principles (1) to provide reliable and922 AAEM Practice Topic MUSCLE & NERVE June 2002
eproducible data to evaluate the usefulness ofEDX studies to confirm the clinical diagnosis ofCTS, and (2) to permit comparison of the relativeutility of different EDX studies for that purpose.DISCLAIMERThis report is provided as an educational service ofthe AAEM, AAN, and AAPM&R. It is based onan assessment of the current scientific and clinicalinformation. It is not intended to include allpossible methods of care of a particular clinicalproblem, or all legitimate criteria for choosing touse a specific procedure. Neither is it intended toexclude any reasonable alternative methodologies.The AAEM recognizes that specific patient caredecisions are the prerogative of the patient andhis/her physician and are based on all of thecircumstances involved.REFERENCES1. Jablecki CK, Andary MT, So YT, Wilkins DE, Williams FH.Literature review of the usefulness of nerve conduction studiesand electromyography for the evaluation of patients withcarpal tunnel syndrome. Muscle Nerve 1993;16:1392–1414.2. Jablecki CK, Andary MT, Floeter MK, Miller RG, QuartlyCA, Vennix MJ, Wilson JR. Second literature review of theusefulness of nerve conduction studies and electromyographyfor the evaluation of patients with carpal tunnel syndrome.Muscle Nerve 2002; Published online 1 June 2002 in WileyInterScience (www.interscience.wiley.com). DOI 10.1002/mus.10215.3. American Academy of Neurology, American Association ofElectrodiagnostic Medicine, and American Academy ofPhysical Medicine and Rehabilitation. Practice parameter forelectrodiagnostic studies in carpal tunnel syndrome (summarystatement). Neurol 1993;43:2404–2405. [See correction,Neurol 1994;44:304.]4. American Academy of Physical Medicine and Rehabilitation,American Association of Electrodiagnostic Medicine, andAmerican Academy of Neurology. Practice parameter forelectrodiagnostic studies in carpal tunnel syndrome summarystatement). Arch Phys Med Rehab 1994;75:124–125.5. American Association of Electrodiagnostic Medicine,American Academy of Neurology, American Academy ofPhysical Medicine and Rehabilitation. Practice parameter forelectrodiagnostic studies in carpal tunnel syndrome: summarystatement. Muscle Nerve 1993;16:1390–1391.6. Rempel D, Evanoff B, Amadio PC, de Krom M, Franklin G,Franzblau A, Gray R, Gerr F, Hagberg M, Hales T, Katz JN,Pransky G. Consensus criteria for the classification of carpaltunnel syndrome in epidemiologic studies. Am J Public Health1998;88:1447–1451.AAEM Practice Topic MUSCLE & NERVE June 2002 923
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