343patients’ histories. It is an interesting theory that emphasizes the vascular etiology
of the disorder. Alternatively, it may be that patients hold their wrists fl exed while
sleeping, thus increasing the pressure on the median nerve and causing pain.
Therefore, preventing wrist fl exion would be expected to decrease symptoms, and
may be why many patients fi nd it benefi cial to wear neutral-position wrist splints at
night. Alternatively, in patients who do not have signifi cant infl ammatory changes
within the carpal tunnel, thenar muscle atrophy or signifi cant sensory impairment,
which refl ect an advanced CTS state of long-standing duration, tend to develop
without any nocturnal symptoms. This usually occurs in older adults [ 59 ].
Considering the patients’ symptoms and the possible underlying pathology,
sounds attractive to the treating doctors when the appropriate treatment approach is
set. Questionnaires helping to diagnose the condition as well as the possible predis-
posing factors in one go would be the most preferred in standard clinical practice.
Questionnaires such as the BCTQ, CTS-6 items, and CTS-PROMs would be of help
in this aspect. The outcome of these questionnaires had shown signifi cant correla-
tions when setting up the treatment algorithm for the patient. Outcomes of the CTS-
PROMs Severity Scale study [ 51 ] revealed that relative severity assessment helped
to identify the attributable risk factors, e.g., tendonitis. There was positive signifi -
cant association between repetitive stress pain and diurnal pain. Similarly, there was
a positive signifi cant association between paresthesia and nocturnal pain.
PROMs and CTS Diagnosis
Several attempts have been made at formalizing diagnostic criteria for CTS, yet there
has not been a clear-cut consensus on the best diagnostic criteria for the syndrome.
In view of this and in an attempt to fi nd an alternative diagnostic tool, mathematical
approaches based upon the degree of association between clinical features and diag-
nosis have been suggested. In this approach for any clinical feature, which is either
present or absent, the association with the diagnosis can be expressed as sensitivity
and specifi city, or positive and negative predictive values. Several diagnostic tools
have been assessed, some of them Web-based aiming at screening people and the
others are used for diagnostic purposes. An example is the questionnaire developed
by Kamath and Stothard [ 49 ], which is a scored clinical questionnaire for the initial
assessment of patients presenting with CTS symptoms. The questionnaire was pro-
posed to replace nerve conduction studies, and was validated in secondary care for
the diagnosis of CTS. A score of 5 or more was recommended for use as a diagnostic
screening tool to replace nerve conduction studies, whereas a score of 3 or more has
been submitted to analysis in comparison to nerve conduction studies. The CTS-6 is
another diagnostic scale for carpal tunnel syndrome, suggested to estimate the likeli-
hood that carpal tunnel syndrome is present. A total score of 12 or more suggests a
strong probability (80 % chance) that the patient has carpal tunnel syndrome. A total
score less than 5 indicates a very small chance (25 %) that the patient has carpal tun-
nel syndrome. Comparing the results of the CTS-6 test with the results of the nerve
13 PROMs for Carpal Tunnel Syndrome