DVT

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This case will require you to combine information from the neck/trunk, wrist/hand, and nervous system chapters.

As occupational therapists, you will see someone at some point (most likely many people, at many points) with the diagnosis of carpal tunnel syndrome. One of the most important skills you will need to develop as an autonomous practitioner is the ability to generate a differential diagnosis list and rule in/rule out other plausible causes of a patient’s symptoms. Regarding carpal tunnel syndrome, you need to be able to differentiate between a mono-neuropathy and a mono-radiculopathy (or more broadly stated is it the hand or is it the neck?)

 I really…Truly….Can’t….Emphasize…. How important this is a clinician to be able to have the skills to do this. If you can get this skill down, you will be saving many…many…many...patients across your careers from unnecessary or ineffective treatments and surgeries

I am going to give you longer to complete this assignment and pour over the resources (i.e. there will be no case next week). As always, I am here for you if you have questions.

Case A

Mary is a 48-year-old female presenting to OT with a diagnosis of right carpal tunnel syndrome.

Primary complaint: hand numbness and tingling most pronounced at the right thumb, hand pain with activity

Mechanism of injury: No specific inciting event.

Nocturnal paresthesia: endorses

Hand pain: endorses

Arm pain: denies

Neck pain: denies

Symptoms relieved by- shaking & flicking her hands

Cervical ROM: WNL, no pain with overpressure

Elbow/wrist/hand ROM: WNL, no pain with overpressure

Sensation: WNL to pin prick with exception of diminished sensation at thumb finger pad as compared to thenar eminence

Reflexes: Biceps 2+, Brachioradialis 2+, Triceps 2+

UE Myotomes: WNL

Non-myotomal strength assessment: abductor pollicis brevis strong and painless

Special Tests: Upper limb tension test Positive, Spurling’s Negative, Distraction Negative, Wrist ratio-index 0.70.

Outcome measures: Symptom Severity Scale 2.0

Case B

Meghan is a 48-year-old female presenting to OT with a diagnosis of right carpal tunnel syndrome

Primary complaint: hand numbness and tingling most pronounced at the right thumb

Mechanism of injury: No specific inciting event.

Nocturnal paresthesia: endorses

Hand pain: denies

Arm pain: endorses

Neck pain: endorses with movement

Symptoms relieved by: unable to identify any relieving positions

Cervical ROM: WNL with the exception of limited right-side bending (20 degrees) and right rotation (40 degrees)

Elbow/wrist/hand ROM: WNL

Sensation: WNL to pin prick with exception of diminished sensation of thumb finger pad and thenar eminence

Reflexes: Biceps 2+, Brachioradialis 1+, Triceps 2+

UE Myotomes: WNL

Non-myotomal strength assessment: abductor pollicis brevis strong

Special Tests: Upper limb tension test Positive, Spurling’s Positive, Distraction Positive, Wrist ratio-index 0.70.

Outcome measures: Symptom Severity Scale 1.5

1)      What is cervical radiculopathy? What are some of its defining characteristics? Do you expect upper motor or low motor neuron signs? (10 pts)

2)      According to Chow (2005), what are useful pieces of symptomatology that one can use to distinguish between carpal tunnel syndrome and cervical spine spondylosis? (10 pts)

3)      According to Wainner et al. (2005), what 5 tests are included in the clinical prediction rule for carpal tunnel syndrome? In their patient population if all 5 tests are positive, what is the post-test probability that a patient has carpal tunnel syndrome? What is the post-test probability if the patient has 4 positive tests? (hint- tables tend to be a good place to find this kind of information) (10pts)

4)      According to Wainner et al (2003), what 4 tests are included in the clinical prediction rule for cervical radiculopathy? In their patient population if all 4 tests are positive, what is the post-test probability that a patient has cervical radiculopathy? What is the post-test probability the patient has 3 positive tests? (hint- tables tend to be a good place to find this kind of information) (10pts)

5)      Using the above clinical examinations, determine which case most likely has carpal tunnel syndrome and which case most likely has cervical radiculopathy. For the radiculopathy case, which level of the cervical spine to you expect is involved? (10pts)

6)      Discuss with a classmate which pieces of the clinical examination you used to determine which case has carpal tunnel and which case has cervical radiculopathy. (10pts)