Scand J Pain 2018; aop
Clinical pain research
Sadegh Izadi, Bahareh Kardeh, Seied Saeed Hosini Hooshiar, Mojtaba Neydavoodi
and Afshin Borhani-Haghighi*
Correlation of clinical grading, physical tests and
nerve conduction study in carpal tunnel syndrome
https://doi.org/10.1515/sjpain-2017-0164
Received November 13, 2017; revised March 9, 2018; accepted March
14, 2018
Abstract
Background and aims: Carpal tunnel syndrome (CTS) is a
common debilitating condition. As the reliability of CTS-
specific physical tests and its clinical grading remain a
matter of debate, we determined the correlations between
these assessments with nerve conduction study (NCS).
Methods: In this cross-sectional study, patients with uni
or bilateral CTS, which was confirmed in electrodiagnosis,
were enrolled. Clinical grading was based on the modi-
fied criteria of the Italian CTS Study Group. Numeric Pain
Rating Scale (NPRS) and Boston Questionnaire (BQ) were
used. Physical tests [Phalen’s, reverse Phalen’s, Tinel’s and
manual carpal compression test (mCCT)] were performed
by a single blinded neurologist. A p-value < 0.05 was con-
sidered statistically significant.
Results: A total of 100 patients (age = 47.48 ± 11.44  years;
85% female) with 181 involved hands were studied. The
majority of hands (59.7%) were classified as grade 2 of
clinical grading. On NCS, hands with mild (64%), mod-
erate (27%) and severe (9%) CTS were identified. Sensory
(velocity, latency and amplitude) and motor parameters
(latency and amplitude) were significantly correlated with
clinical grades (p-value < 0.001). The correlation of NPRS
(p-value = 0.009) and BQ (p-value < 0.001) scores with NCS
*Corresponding author: Afshin Borhani-Haghighi, Clinical
Neurology Research Center, Shiraz University of Medical Sciences,
Shiraz, Iran; and Department of Neurology, Medical School, Shiraz
University of Medical Sciences, Nemazee Hospital, Shiraz, Iran,
Phone/Fax: +98-711-627-2287, E-mail: neuro.ab@gmail.com
Sadegh Izadi and Seied Saeed Hosini Hooshiar: Clinical Neurology
Research Center, Shiraz University of Medical Sciences, Shiraz, Iran;
and Department of Neurology, Medical School, Shiraz University of
Medical Sciences, Shiraz, Iran
Bahareh Kardeh: Bone and Joint Diseases Research Center, Shiraz
University of Medical Sciences, Shiraz, Iran
Mojtaba Neydavoodi: Clinical Neurology Research Center, Shiraz
University of Medical Sciences, Shiraz, Iran
© 2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
was significant. None of the physical tests were signifi-
cantly correlated with NCS in terms of result or duration
(p-value > 0.05).
Conclusions: We found that physical tests are not a reli-
able screening method for evaluation of CTS severity.
However, the BQ and clinical grading can be more valu-
able due to their significant correlation with NCS.
Implications: Physicians might benefit from employing
clinical grading and BQ in practice for better assessment
of CTS severity.
Keywords: carpal tunnel syndrome; clinical decision-mak-
ing; diagnosis; electrodiagnosis; physical examination.
1 Introduction
Carpal tunnel syndrome (CTS) is the compression neu-
ropathy of median nerve at wrist level, where it passes
through a narrow osteo-fibrous canal, and remains the
most common entrapment neuropathy [1]. The prevalence
of this disabling condition is estimated to range from 2.7%
in general population [2] to 7.8% among employees who
perform hand-intensive activities [3]. A variety of mechan-
ical and medical risk factors contribute to the develop-
ment of CTS [4, 5]. Accurate and timely diagnosis is the
key to achieving the best possible outcome.
Initially, a precise history should provide the clinician
with useful information about symptom onset, timing
(diurnal vs. nocturnal), localization, aggravating and alle-
viating factors, predisposing factors, and patient’s routine
working activities [6]. Presence of pain, paresthesia, and
weakness, particularly within median nerve distribu-
tion, should raise suspicion about nerve damage [7]. In
a precise physical examination, positive signs should be
sought and other concomitant conditions should be ruled
out. Commonly used provocative tests in clinical settings
are Phalen’s test, reverse Phalen’s test, Tinel’s sign, Dur-
kan’s test or carpal compression and the tourniquet test
[8]. Feeling of paresthesia in the median nerve distribu-
tion within 1 min implies positive test [9].
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2      Izadi et al.: Correlation of clinical grading, physical tests and nerve conduction study
As patient history and isolated physical tests have
limited diagnostic value [10–12], paraclinical studies are
essential in establishing the definite diagnosis. Nerve
conduction study (NCS), ultrasound [13] and magnetic
resonance imaging [14] are routinely used. NCS is the
gold standard tool for diagnosis and quantification of the
severity of CTS [15]. Although ultrasound may not replace
NCS as the most sensitive and specific test, it is a feasible
first-line confirmatory alternative [16].
The correlation between CTS-specific physical tests
and clinical grades of CTS with NCS remains uncertain.
Determining the reliability of these simple and low-cost
methods helps physicians obtain a more accurate diag-
nosis and plan optimal treatment. With this aim, we
designed the present study.
2 Materials and methods
2.1 P
 atients and setting
This cross-sectional study was conducted on a sample of
consecutive patients referring to our outpatient neurol-
ogy clinic between 2016 and 2017 (affiliated with Shiraz
University of Medical Sciences, Shiraz, Iran), who had uni
or bilateral CTS confirmed in NCS. Exclusion criteria were
proximal involvement of median nerve, compression of
ulnar nerve, as well as any underlying neuropathies.
2.2 N
 erve conduction study
Neurophysiological evaluation was performed using a
commercially available Medelec Oxford Synergy equip-
ment (Old Woking, Surrey, England). Firstly, it was ensured
that the skin temperature was above 33 °C. If colder, the
hands were warmed up to a suitable temperature. After-
wards, the surface electrodes were utilized for stimulation
and recording of the median sensory and motor ampli-
tude, velocity and latency. For sensory nerve conduction,
the antidromic technique was applied. The sensory delay
was recorded with stimulating electrodes placed at wrist
and recording electrodes placed at 3rd finger. Motor con-
duction studies were carried out using bipolar surface
stimulating electrodes.
Based on the findings of NCS, we classified CTS sever-
ity as follows: (a) mild: distal sensory latency >3.5 ms with
normal motor study; (b) moderate: abnormal sensory
study and distal motor latency between 4.4 and 6.5  ms
and (c) severe: abnormal sensory study and distal motor
latency >6.5  ms with or without decreased motor ampli-
tude [17].
2.3 Data gathering
Demographic characteristics of patients including age,
gender and occupation were recorded and related medical
profile was assessed. Subsequently, a single neurologist,
who was blinded to the results of NCS, carried out subjec-
tive and objective investigations for each individual. The
neurologist inquired the patients about clinical manifes-
tations; such as, pain, paresthesia, or numbness. Numeric
Pain Rating Scale (NPRS) was used to measure pain inten-
sity. Using this information and according to the modified
criteria of the Italian CTS Study Group [18–20], involved
hands were classified into the following clinical grades:
grade 0: asymptomatic, grade 1: nocturnal paresthesia,
grade 2: diurnal paresthesia, grade 3: numbness and
grade 4: atrophy. Grades 0 and 1 were considered as mild,
grades 2 and 3 as moderate and grade 4 as severe CTS.
Furthermore, Boston questionnaire (BQ) was completed.
This self-administered questionnaire was first developed
by Levine et  al. [21], and is widely used for CTS [22, 23].
It has two parts for assessment of severity of symptoms
(BQ-SS) and functional status (BQ-FS), which consist of
eight and 11 questions, respectively. Rezazadeh et al. [24]
has verified the validity and reliability of the Persian BQ
in Iranian patients with CTS. Also, the Persian format
has been shown to be a valid and reliable tool in diabetic
patients [25]. Finally, the neurologist performed the fol-
lowing CTS-specific physical tests: Phalen’s test, reverse
Phalen’s test, Tinel’s test and manual carpal compression
test (mCCT). A resting time from 3 to 5 min was considered
in intervals between the tests to allow for subsidence of
pain induced by the previous test.
2.4 Ethical considerations
Informed written declaration of consent was obtained
from each patient and data confidentiality was guaran-
teed. Our study was designed according to the Helsinki
Declaration and approved by Ethics Committee of Shiraz
University of Medical Sciences.
2.5 Statistical analysis
Data were analyzed by IBM SPSS Statistics (Chicago, IL,
USA), windows version 16.0. Variables are represented as
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 Izadi et al.: Correlation of clinical grading, physical tests and nerve conduction study      3
frequency (percentage) or mean and standard deviation
(SD) as applicable. Kruskal-Wallis test and χ2 test were
used wherever applicable. A p-value less than 0.05  was
considered statistically significant.
3 Results
3.1 Demographics
Of a total of 200 hands, diagnosis of CTS was confirmed
for 181 hands in NCS; at least one involved hand in each
patient. The average age of patients was 47.48 ± 11.44
(Mean ± SD) years. The difference between men
(50.73 ± 13.12) and women (46.99 ± 11.11) was not statisti-
cally significant (p-value = 0.23). Female patients consti-
tuted 85% of cases. The majority of participants (60%)
were housewives, 31 patients were hired in blue-collar jobs
and nine had clerical occupations. Top medical comor-
bidities were hypothyroidism (n = 14), diabetes (n = 10),
concomitant hypothyroidism and diabetes (n = 2), and
rheumatic disorders (n = 6). The other 68 patients reported
to be otherwise healthy.
3.2 Clinical grades
Unilateral right-sided CTS was noticed in six patients, while
13 patients had only left hand involvement. The remainder
(81%) had bilateral CTS. Regarding CTS-related symptoms,
51 patients stated that they suffered from both pain and par-
esthesia. Fewer patients were solely affected by paresthesia
(n = 28) or pain (n = 11). Ten patients complained of concur-
rent paresthesia, pain and muscular weakness. In addition,
the clinical grading of CTS in involved hands is demon-
strated in Figure  1. Out of 181  hands with confirmed CTS
on NCS, 20 hands were asymptomatic and the patients did
not have complaints about them. Therefore, these 20 hands
belonged to grade 0.
120
108
100
80
60
40 36
20
20
12
5
0 population. Diabetes is a well-established risk factor for
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
Figure 1: Clinical grades of CTS in involved hands.
3.3 N
 erve conduction study
As shown in NCS, the number of hands affected by mild,
moderate and severe CTS, was 117 (64.6%), 47 (26%) and 17
(9.4%), respectively. The correlation of NCS severity with
the frequency of clinical grades was investigated (Table 1).
In addition, we evaluated the correlation of clinical
grading with specific parameters of NCS (Table 2). Sensory
velocity, latency and amplitude, as well as motor distal
latency and amplitude were shown to be significantly dif-
ferent among the clinical grades (p-value < 0.001).
3.4 Subjective scores
The values of NPRS and BQ were assessed in comparison
to the NCS severity; both of which proved to be highly sig-
nificant (Table 3).
3.5 Physical tests
There were no significant correlations between the results
of physical tests and the severity of nerve compromise in
NCS (Table 4). In cases with positive tests, we examined if
the duration until the patient declared to feel the pain was
related with CTS severity base on NCS. This item was also
non-significant (Table 5).
4 Discussion
Similar to a number of previous studies [26, 27], female
gender was shown to be a risk factor in our study. The
mean age of patients was in the 5th decade of life, close to
the peak reported by Bland [28]. The distribution of jobs
was in accordance to previous literature and is supported
by an Italian study conducted by Mattioli et  al., which
showed that rates of surgically-treated CTS in women
were highest among blue-collar workers, housewives and
white-collar workers in descending order. The incidence
of CTS in blue-collar men was higher than their white-col-
lar counterparts; however, it was lower as compared to all
professional groups in women. The authors pointed out,
that domestic chores should be considered a potential risk
factor in full-time housewives [29]. Diabetes and hypothy-
roidism were seen in more than a quarter of our study
CTS [30–32]. On the other hand, a recent meta-analysis
showed that hypothyroidism is a weak risk factor [33].
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4      Izadi et al.: Correlation of clinical grading, physical tests and nerve conduction study

Table 1: The correlation of clinical grades with CTS severity based on NCS.

NCS severity Clinical grading Total p-Valuea

0 1 2 3 4

Mild 16 (8.8%) 33 (18.25%) 66 (36.44%) 2 (1.1%) 0 117 (64.6%) <0.001

Moderate 4 (2.2%) 3 (1.65%) 33 (18.26%) 6 (3.34%) 1 (0.55%) 47 (26%)
Severe 0 0 9 (5%) 4 (2.2%) 4 (2.2%) 17 (9.4%)
Total 20 (11.0%) 36 (19.9%) 108 (59.7%) 12 (6.6%) 5 (2.8%) 181 (100.0%)
a 2
χ test.

Table 2: The correlation of clinical grading with components of NCS.

NCS parameters Clinical grading Total p-Value a

0 1 2 3 4

Sensory
 Velocity 44.32 ± 4.03 42.00 ± 4.55 37.81 ± 10.23 26.30 ± 14.12 18.06 ± 16.53 38.06 ± 10.68 <0.001
 Latency 3.73 ± 0.25 3.87 ± 0.315 3.99 ± 1.13 4.39 ± 2.25 3.03 ± 2.77 3.94 ± 1.147 <0.001
  Amplitude 37.13 ± 14.45 40.20 ± 17.45 34.86 ± 17.54 15.28 ± 11.04 12.68 ± 15.05 34.26 ± 17.94  < 0.001
Motor
 Distal latency 3.77 ± 0.56 3.96 ± 0.57 4.51 ± 1.29 5.66 ± 1.52 7.45 ± 1.29 4.48 ± 1.31 <0.001
 Amplitude 7.75 ± 2.07 8.92 ± 2.11 7.91 ± 3.01 6.65 ± 1.89 3.43 ± 1.05 7.89 ± 2.79  < 0.001

Kruskal-Wallis test.
a

Table 3: The correlation of NPRS and BQ with CTS severity based on NCS.

Test CTS severity based on NCS Total (n = 181) p-Valuea

Mild (n = 117) Moderate (n = 47) Severe (n = 17)

NPRS (Mean ± SD) 3.56 ± 3.20 3.74 ± 3.26 6.17 ± 3.32 3.85 ± 3.30 0.009

BQ (Mean ± SD) 19.91 ± 6.53 20.48 ± 7.10 28.52 ± 9.62 20.87 ± 7.40 <0.001

Kruskal-Wallis test.
a

Table 4: The correlation of physical tests with CTS severity based on NCS.

Test CTS severity based on NCS Total p-Valuea

Mild (n = 117) Moderate (n = 47) Severe (n = 17)

Phalen’s
  +  62 (34.2%) 19 (10.5%) 10 (5.5%) 91 (50.2%) 0.264
  −  55 (30.4%) 28 (15.5%) 7 (3.9%) 90 (49.8%)
Reverse Phalen’s
  +  78 (43.1%) 27 (14.9%) 15 (8.3%) 120 (66.3%) 0.070
  −  39 (21.5%) 20 (11.1%) 2 (1.1%) 61 (33.7%)
Tinel’s
  +  88 (48.7%) 35 (19.3%) 12 (6.6%) 135 (74.6%) 0.919
  −  29 (16%) 12 (6.6%) 5 (2.8%) 46 (25.4%)
mCCT
  +  70 (38.6%) 21 (11.6%) 13 (7.2%) 104 (57.4%) 0.210
  −  47 (26%) 26 (14.4%) 4 (2.2%) 77 (42.6%)
a 2
χ test.

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 Izadi et al.: Correlation of clinical grading, physical tests and nerve conduction study      5

Table 5: The correlation of duration of positive physical tests with CTS severity based on NCS.

Test CTS severity based on NCS Total p-Valuea

Mild (n = 117) Moderate (n = 47) Severe (n = 17)

Phalen’s
 No. 62 19 10 91 0.486
 Duration 28.24 28.52 22.30 27.62
Reverse Phalen’s
 No. 78 27 15 120 0.289
 Duration 42.10 53.77 47.33 45.38
mCCT
 No. 70 21 13 104 0.938
 Duration 22.42 21.47 23.15 22.32

Kruskal-Wallis test.
a

Unsurprisingly, NPRS and BQ were highly correlated
with CTS severity on NCS. Considering physical tests, we
found no associations, neither in regards to the absolute
positive or negative results and nor the duration to repro-
duce symptoms. However, it’s noteworthy that reverse
Phalen’s had the lowest p-value. Dale et  al. investigated
Semmes-Weinstein sensory testing, Tinel’s test, and Pha-
len’s maneuver on a large population of 1,108 newly-hired
workers in diverse industries and concluded that physical
examinations have a low yield in screening for CTS [11],
which is also supported in another study by Descatha
et al. [10].
The relationship between various NCS parameters and
clinical grading of CTS was investigated by Srikanteswara
et al. Patients were divided into mild, moderate and severe
CTS groups based on Mackinnson’s classification. Tinel’s
and Phalen’s sign were positive in 36 (72%) and 44 (88%)
patients, respectively. Although the rate for Tinel’s was
similar to our findings, we only had 51% positive for Pha-
len’s test. The authors also mentioned that sensory con-
ductions were more sensitive than motor conductions [34].
In contrast, Ansari et  al. showed that Phalen’s 30  s was
associated with electrodiagnosis [35]. In another study
by Ogura et  al., prolonged delays were noted in forearm
sensory and motor conduction velocity, which were con-
sistent with the increased severity of clinical grade. Yet,
there were no significant differences between the severity
groups [36].
However, the BQ and clinical grading, which were highly
correlated with NCS, can be more reliable.
Acknowledgement: This article was extracted from the
thesis conducted by Seied Saeed Hosini Hooshiarand with
the support of the dean of medical school and research
vice-chancellor of Shiraz University of Medical Sciences.
The authors appreciate the assistance of Dr. Laleh Kho-
jasteh for proofreading this manuscript.
Authors’ statements
Research Funding: Funded by a grant from the Shiraz Uni-
versity of Medical sciences (grant no. 10972).
Conflict of interest: Authors declare no conflict of interest.
Informed Consent: Informed written declaration of
consent was obtained from each patient and data confi-
dentiality was guaranteed.
Ethical approval: Our study was designed according to the
Helsinki Declaration and approved by the Ethics Commit-
tee of Shiraz University of Medical Sciences.
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