Manual Therapy 17 (2012) 589e592

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Manual Therapy
journal homepage: www.elsevier.com/math

Technical and measurement report

Description, reliability and validity of a novel method to measure carpal tunnel

pressure in patients with carpal tunnel syndrome
Michel W. Coppieters a, *, Annina B. Schmid a, Paul A. Kubler b, c, Paul W. Hodges a
a
Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, Division of Physiotherapy School of Health and Rehabilitation Sciences,
The University of Queensland, St. Lucia, Brisbane QLD 4072, Australia
b
Department of Clinical Pharmacology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
c
School of Medicine, The University of Queensland, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Elevated carpal tunnel pressure is an important pathomechanism in carpal tunnel syndrome (CTS).
Received 11 November 2011 Several invasive methods have been described for direct measurement of carpal tunnel pressure, but all
Received in revised form have two important limitations. The pressure gauge requires sterilisation between uses, which makes
1 March 2012
time-efficient data collection logistically cumbersome, and more importantly, the reliability of carpal
Accepted 5 March 2012
tunnel pressure measurements has not been evaluated for any of the methods in use. This technical note
describes a new method to measure carpal tunnel pressure using inexpensive, disposable pressure
Keywords:
sensors and reports the within and between session reliability of the pressure recordings in five different
Carpal tunnel syndrome
Pathophysiology
wrist positions and during typing and computer mouse operation. Intraclass correlation coefficients (ICC
Compression neuropathy [3,1]) were calculated for recordings within one session for healthy participants (n ¼ 7) and patients with
CTS (n ¼ 5), and for recordings between two sessions for patients with CTS (n ¼ 5). Overall, the reliability
was high. With the exception of two coefficients, the reliability of the recordings at different wrist angles
varied from 0.63 to 0.99. Reliability for typing and mouse operation ranged from 0.86 to 0.99. The new
method described in this report is inexpensive and reliable, and data collection can be applied more
efficiently as off-site sterilisation of equipment is not required. These advances are likely to promote
future research into carpal tunnel pressure, such as investigation of the therapeutic mechanisms of
various conservative treatment modalities that are believed to reduce elevated carpal tunnel pressure.
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction
Although the pathophysiology of carpal tunnel syndrome (CTS)
is not completely understood, elevated carpal tunnel pressure is
considered an important factor (Werner and Andary, 2002; Rempel
and Diao, 2004). It is well-established that carpal tunnel pressure is
increased in CTS (Gelberman et al., 1981; Seradge et al., 1995; Weiss
et al., 1995) and that this elevated pressure alters median nerve
function in a dose-dependent manner (Diao et al., 2005).
The impact of wrist, forearm and finger position on carpal
tunnel pressure and the impact of fingertip loading (e.g., pinch grip)
have been well-documented for both healthy participants and
patients with CTS (Seradge et al., 1995; Keir et al., 1998b). However,
the impact of many functional tasks, such as typing (Rempel et al.,
2008) and computer mouse operation (Keir et al., 1999), has only
been investigated for healthy people. With respect to the effect of
* Corresponding author. Tel.: þ61 7 3365 1644; fax: þ61 7 3365 1622.
E-mail address: m.coppieters@uq.edu.au (M.W. Coppieters).
non-invasive treatment, only the effect of wearing a splint has been
investigated. No significant reduction in pressure was observed in
healthy participants (Rempel et al., 1994) or patients with CTS
(Luchetti et al., 1994). To further improve management, further
research is required to investigate the impact of functional tasks on
carpal tunnel pressure in patients with CTS, and whether other
treatment modalities reduce carpal tunnel pressure.
Several methods have been used to measure carpal tunnel
pressure, but all have important drawbacks. A wick-in-needle
(Gelberman et al., 1981), slit catheter (Werner et al., 1997) or
epidural catheter (Weiss et al., 1995) connected to an in-line
pressure transducer are the most commonly used techniques.
Another technique, which so far has only been used intra-
operatively (Uchiyama et al., 2010), uses a transducer-tipped
catheter. An important disadvantage of all described methods is
that the fluid in or against the pressure transducer is in continuum
with the patient’s bodily fluids. To meet sterilisation standards, the
transducer must be sterilised between uses. The long duration of
ethylene oxide sterilisation and the infrequent onsite availability
of gamma radiation hinder time-efficient and practical data

1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2012.03.005
590 M.W. Coppieters et al. / Manual Therapy 17 (2012) 589e592
collection. Critically, the reliability of carpal tunnel pressure
measurement has not been established for any of the described
methods. This is problematic as the size of the difference or change
to be considered a true difference or true change rather than
measurement error remains unclear.
This Technical Report describes a new method using a dispos-
able pressure transducer and epidural catheter to bypass the need
for off-site sterilisation encountered with existing methods. We
also evaluated the reliability and face validity of this novel method.
2. Methods
2.1. Pressure recordings
Following preparation of the skin with chlorhexidine in alcohol
(BD Persist Plus, Becton Dickinson Infusion Therapy Systems, Sandy,
Utah), a local anaesthetic was administered (Xylocaine, 1.5 ml)
(Fig. 1A). The injection technique was comparable to a local steroid
injection for CTS except that rather than a single bolus being
administered in the carpal tunnel, a series of small boluses was
injected along the path to the carpal tunnel. To administer the
anaesthetic, a needle with a small gauge was used to minimise
discomfort (23G [0.64 mm]  50 mm hypodermic needle). The
needle was inserted w2 cm proximal to the distal wrist crease,
medial to the palmaris longus tendon, at an angle of 30 and in the
direction of the space between the second and third finger.
The Tuohy needle (18G [1.27 mm]  80 mm) used to insert an
epidural catheter was inserted under sterile conditions (Fig. 1B). The
same entry point was used as for the local anaesthetic and the same
track was followed. The needle was inserted for w4 cm at a 30 angle
so that the tip of the needle was located in the carpal tunnel at the
level between the hook of hamate and the pisiform bone. This
position corresponds with the mid region of the carpal tunnel,
where pressure is reported to be most significantly elevated in
patients with CTS (Luchetti et al., 1998). In each patient, the correct
needle position was verified with ultrasound imaging (Fig. 1C&F).
We used a multiperforated epidural catheter (20G [0.91 mm],
Multiport 100/391/818, Epidural Minipack, Portex, Smith Medical,
Australia). In addition to the three side ports in the distal w3 mm,
the closed tip of the catheter was cut off with a sterile surgical blade
to create an additional end port (diameter: 0.45 mm). The catheter
was inserted via the needle (Fig. 1D) so that the tip of the catheter
Fig. 1. Carpal tunnel pressure measurement procedure. A: Administration of a local anaesthetic. B: Insertion of the Tuohy needle. C: Verification of the needle position with
ultrasound imaging. D: Insertion of the epidural catheter. E: The pressure transducer taped to the skin and connected to the epidural catheter. F: The labelled ultrasound image (T:
tendon).
was in the centre of the carpal tunnel. The needle was then with-
drawn over the catheter. The catheter was taped to the skin to
maintain its correct position and connected to a disposable, sterile
pressure transducer (TranStar Pressure Monitoring System, Smith
Medical, Australia) (Fig. 1E).
The procedure was performed by a rheumatologist experienced
with steroid injections for CTS. To reduce the likelihood of light-
headedness, the procedure was performed with the participant
lying supine.
In accordance with previously described methods (Weiss et al.,
1995), a minimal positive flow of physiologic saline (0.9% NaCl) at
a rate of 0.5 ml/h was maintained using a syringe driver (Asena
Syringe Pump, Alaris Medical Systems, USA) to minimise the
possibility of occlusion of the catheter’s side and end ports. Data of
the pressure sensor were amplified (WT127 Strain Gauge Trans-
mitter, APSC, Seven Hills, Australia) and sampled at 100 Hz using
a Micro1401 data acquisition system and Spike2 software (Cam-
bridge Electronic Design, Cambridge, UK). Once all pressure
measurements were completed, the pressure transducer was cali-
brated using a MLA1052 pressure gauge (AD Instruments, Bella
Vista, Australia). A linear calibration equation was generated based
on pressure measurements at 20, 40, 60, 80, 100 and 120 mm Hg.
All participants provided written informed consent. The study
was approved by the institutional ethics committee.
2.2. Tasks
Carpal tunnel pressure was measured during three tasks with
the patient in a seated position. In the first task, pressure was
measured with the wrist placed in 60 , 45 , 30 , 15 and 0 exten-
sion. The wrist was moved passively from extension to flexion as
decreases in pressure associated with smaller wrist angles were
nearly instantaneous (as opposed to pressure increases associated
with larger wrist angles). This allowed for fast visual inspection of
the quality of the traces. Based on previous findings in healthy
participants (Keir et al., 1998a), the trace was considered to be good
quality if there were clear differences in pressure values for
different wrist angles and constant plateaus when the wrist was
held steady in each positions. Wrist angles were monitored with an
electrogoniometer (Model SG 110; Biometrics Ltd, Gwent, UK). To
maintain a comparable hand position in the different wrist posi-
tions, the patient’s fingers were placed comfortably around
 M.W. Coppieters et al. / Manual Therapy 17 (2012) 589e592 591

Table 1 wrist angles, a two-way analysis of variance (ANOVA) was con-

Reliability of the pressure recordings in healthy participants for the different passive ducted to test whether carpal tunnel pressure was higher in
wrist extension positions.
patients with CTS compared to healthy volunteers, and whether
Within one insertion progressively larger wrist extension angles were associated with
ICC(3,1) 95% CI SEM SDD90% higher pressures.
0 0.97 0.85e0.99 0.98 2.28
15 0.63 0.14e0.92 2.38 5.52
30 0.79 0.20e0.96 2.57 5.95
3. Results & discussion
45 0.92 0.63e0.99 3.67 8.51
60 0.94 0.63e0.99 3.57 8.28 3.1. Quality of the recordings
ICC(3,1): Intraclass correlation coefficient; SEM: standard error of measurement; CI:
confidence interval; SDD: smallest detectable difference. Good quality recordings were obtained for all participants,
except for one patient with CTS in whom recordings were unstable
when the wrist was maintained in a steady position. As the
pressure recording continued to rise in this participant, we believe
a truncated cone (lower base: 9.1 cm; upper base: 6.6 cm; height:
that obstruction of the small positive flow of saline through the
9.9 cm). An investigator, blinded to the pressure readings, moved
catheter was responsible for this anomaly. Due to the inability to
the wrist passively through the different extension angles. In the
obtain stable readings this participant was excluded from the
second task, carpal tunnel pressure was monitored during a 5-min
analysis.
typing task which involved copying a text. The third task consisted
of a 5-min clicking task using a standard computer mouse to
highlight specific words in an electronic document. 3.2. Reliability

2.3. Reliability
Two experiments were conducted to establish the reliability of
the pressure measurements. In the first study, carpal tunnel pres-
sure was measured for a cycle of different wrist angles in 7 healthy
participants (1 female, 6 males; mean [SD] age: 28.1 [5.8] years).
Two cycles of wrist positions were performed and the catheter
remained in place between cycles. In the second study, carpal
tunnel pressure was measured in 6 patients with CTS (4 female, 2
male; mean [SD] age: 52.8 [6.8] years). The different wrist posi-
tions, and the typing and mouse operation tasks were performed
twice in a first session (within-session reliability), and repeated
once in a second session one week later. Comparison of the results
between two sessions allowed investigation of the impact of rein-
sertion of the catheter on reliability. High reliability between
sessions is important for the technique to be useful for evaluation of
the effect of treatment or the natural history of elevated pressure in
patients with CTS. Both of these issues remain largely unknown.
Intraclass correlation coefficients (ICC[3,1]) were calculated to
establish the reliability of the pressure recordings (Shrout and
Fleiss, 1979). Standard error or measurement (SEM) and the
smallest detectable difference (SDD90%) were also calculated.
2.4. Face validity
To evaluate the face validity of the novel method, we verified
whether differences in pressure were of similar order of magnitude
as previously published data. For pressure recordings at the various
Overall, the reliability of the pressure measurements was high,
in both healthy participants (Table 1) and patients with CTS
(Table 2). The relatively small sample size is likely to explain the
large confidence intervals around the ICCs. A small sample size was
considered appropriate because of the invasive nature of the
procedure. The reason for lower reliability between two sessions at
0 and 60 wrist extension is unclear. At 0 wrist extension, lower
pressure values and less variability between patients might be
a possible explanation. Towards the end of the available movement
range (60 ), the proximal side port of the catheter may have moved
towards (or beyond) the proximal border of the tunnel in one of the
sessions, resulting in inconsistent recordings between sessions.
An uncharacteristically large error in a small sample size may be
another explanation. Further research is required to elucidate
this issue.
3.3. Face validity
Carpal tunnel pressure recordings for patients with CTS and
healthy participants are presented in Fig. 2. Measurements in CTS
were higher than in the absence of pathology (p ¼ 0.035), which is
consistent with other studies (Gelberman et al., 1981; Seradge et al.,
1995). The large variability in pressure recordings between patients
also agrees with previous reports (Gelberman et al., 1981).
For patients and healthy participants, larger wrist extension
positions were associated with higher carpal tunnel pressures
(p < 0.005). This agrees with previous findings in healthy partici-
pants (Keir et al., 1998a).

Table 2
Reliability of the pressure recordings in patients with CTS for the different passive wrist extension positions and the computer typing and mouse task.

Within one session (same insertion) Between two sessions (separate insertions, one week apart)

ICC(3,1) 95% CI SEM SDD90% ICC(3,1) 95% CI SEM SDD90%

0 0.99 0.94e0.99 5.29 12.3 0.37 0.63e0.91 33.51 77.7
15 0.86 0.16e0.98 14.20 32.9 0.68 0.29e0.96 19.42 45.0
30 0.92 0.42e0.99 9.74 22.6 0.87 0.19e0.99 13.96 32.4
45 0.88 0.25e0.99 16.90 39.2 0.89 0.29e0.99 17.28 40.1
60 0.89 0.30e0.99 21.46 49.8 0.34 0.65e0.90 54.38 126.1
Typing task 0.89 0.27e0.99 10.18 23.6 0.93 0.47e0.99 10.38 24.1
Mouse task 0.99 0.99e1.00 2.30 5.3 0.86 0.15e0.98 11.41 25.9

ICC(3,1): Intraclass correlation coefficient; SEM: standard error of measurement; CI: confidence interval; SDD: smallest detectable difference.
592 M.W. Coppieters et al. / Manual Therapy 17 (2012) 589e592
Fig. 2. Carpal tunnel pressure at different wrist extension angles in both healthy
participants and people with CTS. Pressure was significantly higher in patients
with CTS compared to healthy people at all wrist positions. Error bars represent one
standard deviation.
3.4. Adverse events
Participants were contacted one and three days after partici-
pation to check for adverse events. One healthy participant re-
ported discomfort in his wrist in the 48 h following the procedure.
There was no suspicion of a neuropathic origin of these symptoms
and symptoms subsided without the need for medication or
treatment.
4. Conclusions
The novel method described in this report produced reliable
measures of carpal tunnel pressure in healthy participants and
patients with CTS, when made within one session (same insertion)
and between two sessions (separate insertions). Agreement with
previous observations adds to the face validity of the novel tech-
nique. The use of widely available and low cost disposable materials
make this an accessible and practical method.
Acknowledgement
The National Health and Medical Research Council of Australia
(NHMRC) funded the study (Project Grant 511161). The study
sponsor had no role in the study design, collection, analysis and
interpretation of data, manuscript preparation or the decision to
submit the manuscript for publication.
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