SCIENTIFIC ARTICLE

Scratch Collapse Test for Evaluation of Carpal and

Cubital Tunnel Syndrome
Christine J. Cheng, MD, MPH, Brendan Mackinnon-Patterson, MPH, John L. Beck, MD,
Susan E. Mackinnon, MD

Purpose The purpose of this study was to evaluate the clinical usefulness of a new test, the scratch
collapse test, for the diagnosis of carpal tunnel syndrome and cubital tunnel syndrome.
Methods The scratch collapse test was prospectively compared with Tinels sign and flexion/
nerve compression in 169 patients and 109 controls. One hundred nineteen patients were diagnosed
with carpal tunnel syndrome and 70 patients were diagnosed with cubital tunnel syndrome based
on history, examination, and positive electrodiagnostic test. For the new test, the patient resisted
bilateral shoulder external rotation with elbows flexed. The area of suspected nerve compression
was lightly scratched, and then resisted shoulder external rotation was immediately repeated.
Momentary loss of shoulder external rotation resistance on the affected side was considered a
positive test. The sensitivity, specificity, and predictive values were calculated.
Results For carpal tunnel syndrome, sensitivities were 64%, 32%, and 44% for the scratch collapse
test, Tinels test, and wrist flexion/compression test, respectively. For cubital tunnel syndrome,
sensitivities were 69%, 54%, and 46% for the scratch collapse test, Tinel test, and elbow flexion/
compression test, respectively. The scratch collapse test had the highest negative predictive value
(73%) for carpal tunnel syndrome. Tinels test had the highest negative predictive value (98%) for
cubital tunnel syndrome. Specificity and positive predictive values were high for all of the tests.
Conclusions The scratch collapse test had significantly higher sensitivity than Tinels test and
the flexion/nerve compression test for carpal tunnel and cubital tunnel syndromes. Accuracy
for this test was 82% for carpal tunnel syndrome and 89% for cubital tunnel syndrome.
This novel test provides a useful addition to existing clinical maneuvers in the diagnosis
of these common nerve compression syndromes. ( J Hand Surg 2008;33A:1518 1524.
Copyright 2008 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Diagnostic II.
Key words Carpal tunnel syndrome, cubital tunnel syndrome, diagnosis, evaluation, scratch
collapse test.

carpal tunnel syndrome and

cubital tunnel syndrome remains primarily clinical, despite the wide availability of electrodiagnostic testing. Numerous studies have shown that

HE DIAGNOSIS OF

From the Kansas City Bone & Joint Clinic, Overland Park, KS; Division of Plastic and Reconstructive Surgery,
Washington University School of Medicine, St. Louis, MO; and the Southern California Orthopedic/Sports
Medicine Center, Santa Fe Springs, CA.
Received for publication September 21, 2007; accepted in revised form May 23, 2008.
The authors would like to thank Linda Schultz, RN, PhD, for her assistance in collecting data and
obtaining informed consent from the study and control subjects.

1518 ASSH Published by Elsevier, Inc. All rights reserved.

nerve conduction studies are not perfect,1 with reported

sensitivities ranging from 49% to 84% in the evaluation
of carpal tunnel syndrome.2 Thus, without a gold standard, the clinician relies primarily on patient-reported
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Susan E. Mackinnon, MD, Division of Plastic and Reconstructive Surgery,
Washington University School of Medicine, 4990 Childrens Place, Northwest Tower, Suite 1150, St.
Louis, MO 63110; e-mail: mackinnons@wudosis.wustl.edu.
0363-5023/08/33A09-0010$34.00/0
doi:10.1016/j.jhsa.2008.05.022

SCRATCH COLLAPSE TEST

symptoms and a battery of clinical maneuvers to diagnose these common conditions. Even the most frequently used tests for diagnosing carpal tunnel syndrome, Tinels and Phalens, vary widely in their
reported sensitivities (44% to 75%) and specificities
(48% to 100%).1,35 Attempts have been made to clarify the diagnostic utility of provocative tests for carpal
tunnel syndrome through systematic reviews of the
literature, but the widespread variation in research
methodology and incomplete reporting has led to inconclusive recommendations.6,7
For a diagnostic test to be clinically useful, it must be
easily performed, reliable, reproducible, and have high
sensitivity and specificity. If the sensitivity of a test is
low, then patients who actually have the condition will
be missed. If the specificity is low, then patients who do
not have the condition will not be eliminated. If available tests have low to moderate sensitivity and specificity, then a combination of tests will be more accurate.
Ideally, the chosen tests should be independent, such as
subjective versus objective measurements, to increase
diagnostic validity.1 Nearly all of the provocative maneuvers for peripheral nerve compression rely on the
patient reporting whether symptoms are elicited, so a
combination of these subjective tests would probably
not be independent.
Peripheral nerve injury, including compression neuropathy, can cause neuropathic pain characterized by
hyperalgesia (increased response to painful stimuli) and
allodynia (painful response from normally nonpainful
stimuli).8,9 Clinically, and in rat models, these occur
with skin stimulation both within and outside of the
territory of the compromised nerve.8 10 Painful cutaneous stimulus has been noted to cause a period of inhibition in tonic voluntary muscle activity in humans.
This period of electrical silence has been termed the
cutaneous silent period.11,12 Although its exact mechanism is poorly understood, it is generally thought to be
an inhibitory spinal reflex that may play a protective
role in facilitating withdrawal of a limb from potentially
harmful stimuli.1214
We introduce a new diagnostic test for carpal tunnel
and cubital tunnel syndrome, which we have termed the
scratch collapse test, in which the examiner scratches
the patients skin lightly over the area of nerve compression while the patient performs sustained resisted
shoulder external rotation bilaterally. If the patient has
allodynia due to compression neuropathy, a brief loss of
muscle resistance will be elicited. This test does not rely
on patient report, providing a more objective evaluation
method than most clinical tests for nerve compression.
We compared the scratch collapse test with other com-

1519

monly used tests for carpal and cubital tunnel syndrome

in a prospective clinical study of patients with compression neuropathy symptoms and asymptomatic controls.
We hypothesized that the scratch collapse test would be
reliable, reproducible, and have comparable sensitivity
and specificity to the other existing tests.
MATERIALS AND METHODS
From January 1, 2004, to December 1, 2005, 169 adult
patients were referred to and evaluated for carpal tunnel
syndrome or cubital tunnel syndrome by a single surgeon (S.E.M.). The clinical diagnosis of carpal tunnel
syndrome was made if the patient had symptoms of
numbness, tingling, and/or pain in the median nerve
distribution, nocturnal or activity-related symptoms in
the median nerve distribution, and the absence of clinical evidence of median nerve compression proximal to
the carpal tunnel. The clinical diagnosis of carpal tunnel
syndrome was supported by electrodiagnostic studies.
Patients were diagnosed with cubital tunnel syndrome if
they had numbness, tingling, and/or pain in the ulnar
nerve distribution, weakness or wasting of the ulnarinnervated intrinsic hand muscles, and the absence of
clinical evidence of ulnar nerve compression at
Guyons canal. The diagnosis of cubital tunnel syndrome was supported by electrodiagnostic studies. Patients with clinical or electrodiagnostic evidence of cervical disk or nerve root disease, those who had
previously had surgery for carpal or cubital tunnel syndrome, and those with normal nerve conduction studies
were also excluded.
There were 79 men and 90 women in the study
group, with a mean age of 52 years (range, 24 87
years). One hundred nineteen patients (49 men, 70
women) were diagnosed with carpal tunnel syndrome.
Seventy-four patients had bilateral involvement. Sixtyfour patients (35 men, 29 women) were diagnosed with
cubital tunnel syndrome. Twenty-two patients had bilateral involvement. A control group of 109 adult controls were recruited from a community church group to
participate in the study, based on their absence of symptoms or signs of carpal and cubital syndrome. Electrodiagnostic studies were not obtained in these control
subjects. All patients in the study group and all of the
control group had the following tests performed in this
order: Tinels test over the median nerve at the wrist
and the ulnar nerve at the elbow; wrist flexion combined with direct compression over the median nerve at
the wrist for 60 seconds; elbow flexion combined with
direct compression over the ulnar nerve at the elbow;
and the scratch collapse test. Positive results for Tinels
test and provocative flexion/compression tests were re-

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TABLE 1.

SCRATCH COLLAPSE TEST

Demographic Data of Study and Control Groups

Controls

n
Men/women, n (%)

All Subjects

Subjects With Carpal

Tunnel Syndrome

Subjects With Cubital

Tunnel Syndrome

109

169

119

64

48/61 (44/56)

70/90 (47/53)

49/70* (41/59)

35/29 (55/45)

Mean age in years (range)

52 (1992)

52 (2487)

53 (2687)

49* (2486)

Mean BMI in kg/m2 (range)

26 (1838)

30 (1758)

31 (1758)

29 (1845)

No. affected hands, dominant/nondominant

N/A

57/112

95/98

45/41

Mean symptom duration in months

N/A

36

40

42

Diabetes mellitus, n (%)

N/A

22 (13)

19 (16)

6 (9)

Tobacco use, n (%)

N/A

40 (24)

23 (19)

18 (28)

Workers compensation, n (%)

N/A

64 (38)

42 (35)

34 (53)

Litigation, n (%)

N/A

14 (8)

9 (8)

6 (9)

BMI, body mass index; N/A, not applicable.

*p .05 compared with rest of experimental subjects.
p .01 compared with control subjects.

FIGURE 1: The figure illustrates the scratch collapse test. The patient and examiner are labeled. The patient faces the examiner
with arms adducted, elbows flexed, and hands outstretched with wrists at neutral. Step A: The patient resists bilateral shoulder
adduction/internal rotation to the forearms applied by the examiner. Step B: Next, the examiner scratches or swipes with
fingertips over the course of the compressed nerve (ulnar nerve at elbow illustrated). Step C: Step A is immediately repeated. Brief
temporary loss of the patients external resistance tone is considered a positive scratch collapse test.

corded if the patient experienced paresthesias in the

appropriate nerve distribution. Demographic data for
the study and control groups are given in Table 1.
The new clinical test was performed with the patient
facing the examiner, with arms adducted, elbows
flexed, and both hands outstretched with wrists at neutral position (Fig. 1). The patient was asked to perform
simultaneous resisted bilateral shoulder external rotation, keeping the arms abducted. The examiner gently
pushed against both of the patients forearms, asking
him or her to sustain steady resistance. With fingertips,
the examiner then scratched or swiped the skin overlying the course of the potentially compressed nerve. The

median nerve was scratched over the carpal tunnel at

the volar wrist. The ulnar nerve was scratched over the
cubital tunnel at the medial elbow. A positive scratch
collapse test was recorded for the median or ulnar nerve
if the patient demonstrated a momentary loss of external resistance tone on the affected side after scratching over the carpal tunnel or cubital tunnel, respectively. This loss of muscle resistance was quite brief,
with the patient regaining strength essentially immediately with repeat resistance testing. However, the test
could be repeated successfully without evidence of fatigue or habituation (this video may be viewed at the
Journals Web site, www.jhandsurg.org).

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TABLE 2.

Clinical Tests Results Summary

Study Group

Control Group

Extremities With
Positive Result
n, (%)

Extremities With
Negative Result
n, (%)

Extremities
Unknown/
Not Recorded

Tinel sign at wrist

70 (29)

148 (62)

20

3 (1)

215 (99)

Median nerve flexion/compression

at wrist

90 (38)

116 (49)

32

2 (1)

216 (99)

Clinical Test

Scratch collapse test at wrist

Extremities With
Positive Result
n, (%)

Extremities With
Negative Result
n, (%)

140 (59)

78 (33)

20

2 (1)

216 (99)

Tinel sign at elbow

61 (48)

51 (40)

16

2 (1)

216 (99)

Ulnar nerve flexion/compression

at elbow

51 (40)

60 (47)

17

218

Scratch collapse test at elbow

76 (59)

34 (27)

18

1 (1)

217 (99)

TABLE 3.

Sensitivity, Specificity, and Predictive Values of Clinical Tests

Sensitivity
(%)

Specificity
(%)

Positive
Predictive Value
(%)

Negative
Predictive Value
(%)

Accuracy
(%)

Wrist Tinel

32*

99

96

59

65

Wrist provocative

44*

99

98

65

72

Wrist scratch collapse

64

99

99

73

82

Elbow Tinel

54*

99

97

98

84

Elbow provocative

46*

99

96

78

81

Elbow scratch collapse

69

99

99

86

89

Prevalence of carpal tunnel syndrome 70%; prevalence of cubital tunnel syndrome 32%.
*p .001 compared with scratch collapse test.

Data analysis used 2 2 contingency tables to

calculate the sensitivity and specificity of each test. The
presence or absence of each nerve compression syndrome was recorded in the rows, and the results of each
test were recorded in the columns. Sensitivity is the
likelihood that the test is positive if the condition is
present. Specificity is the likelihood that a test is negative if the condition is absent. The prevalence of carpal
tunnel syndrome and cubital syndrome was determined
in the study population, and the associated positive and
negative predictive values were calculated for each test
using 2 2 contingency tables. Prevalence is the percentage of people who are affected in the study group.
Positive predictive value is the likelihood that the condition is present if the test is positive. Negative predictive value is the likelihood that the condition is absent if
the test is negative. These reflect the usefulness of a test
and are dependent on prevalence in the population.
Screening tests are more useful when the condition is

more common. The McNemar test of correlated proportions was used to compare the sensitivity and specificity of the diagnostic tests.15 Chi-square analysis was
used to evaluate all categorical variables, and independent t-test was used to evaluate all continuous variables
between the study and control groups. Kappa statistic
was calculated for agreement between clinical tests and
for interrater reliability of the scratch collapse test. Data
were analyzed with statistical software (SPSS; SPSS,
Inc., Chicago, IL).
RESULTS
Details of the study and control groups are shown in
Tables 1, 2, and 3. The study subjects had significantly
higher body mass index than the control subjects (p
.01). All other demographic parameters were similar
between the 2 groups. The patients diagnosed with
carpal tunnel syndrome were more likely to be female
(59%, p .03), have bilateral involvement (62%, p

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SCRATCH COLLAPSE TEST

.002), and were less likely to report an injury associated

with their diagnosis (26%, p .02). The patients diagnosed with cubital tunnel syndrome were younger than
the rest of the study group (mean age 49 years, p .05),
more likely to report an injury associated with their
diagnosis (50%, p .001), and were more likely to
have workers compensation insurance (53%, p
.005).
The scratch collapse test was reproducible, with
excellent interrater reliability ( .98, p .001).
For patients with carpal tunnel syndrome, the results
of the 3 clinical tests showed only slight to fair
agreement, with the least agreement between the
scratch collapse and wrist flexion/nerve compression
tests ( .18, p .001). Correlation between the
clinical tests was much better in patients with cubital
tunnel syndrome. The results of the 3 clinical tests
showed moderate to substantial correlation, with the
least agreement between the scratch collapse and
elbow flexion/nerve compression tests ( .458, p
.001). Chi-square for trend analysis of the clinical
tests showed no relationship between duration of
symptoms and frequency of positive test results in
any of the study subgroups.
The scratch collapse test was more sensitive than any
of the other clinical tests in both carpal tunnel syndrome
and cubital tunnel syndrome patients, as shown in Table
3. For carpal tunnel syndrome, the scratch collapse test
had better sensitivity (64%) compared with that of wrist
flexion/nerve compression test (44%; p .001) and
Tinel test (32%; p .001). For cubital tunnel syndrome, the scratch collapse test was more sensitive
(69%) than elbow flexion/nerve compression test (46%;
p .001) and Tinel test (54%; p .002). All of the
clinical tests were highly specific (99%), without notable differences between tests.
In our study population, the prevalence of carpal
tunnel syndrome was 70%. The positive predictive values for the clinical tests were high, with the scratch
collapse test having the highest positive predictive
value (99%), followed by the wrist flexion/nerve compression test (98%) and Tinel test (96%). Negative
predictive values for the tests for carpal tunnel syndrome were also highest for the scratch collapse test
(73%), followed by the wrist flexion/compression test
(65%) and Tinel test (59%). The prevalence of cubital
tunnel syndrome was much lower in our study group
(32%). Nevertheless, the positive predictive values for
the clinical tests remained high, with the scratch collapse test having the highest positive predictive value
(99%), followed by Tinel test (97%) and elbow flexion/
nerve compression test (96%). Negative predictive

value, however, was highest for Tinel test (98%), followed by the scratch collapse test (86%) and elbow
flexion/nerve compression test (78%).
DISCUSSION
There is no perfect gold standard for the diagnosis of
compression neuropathy. For carpal tunnel syndrome, a
combination of positive electrodiagnostic findings and
clinical symptoms combined with positive clinical testing is believed to be the most accurate method.16 Accuracy of diagnosis can be improved by combining
tests, especially when the tests have limited sensitivity
and/or specificity. Systematic review of the literature on
the diagnosis of carpal tunnel syndrome found reported
sensitivities for Tinels test to range from 45% to 75%
and wrist flexion/compression test to range from 49% to
89%.6,7 The analogous tests have performed better in
diagnosing cubital tunnel syndrome, with reported sensitivities for Tinels test and elbow flexion/compression
test of 70% and 91%, respectively,17 although 20% to
30% false-positive rates have been reported in asymptomatic individuals.18,19 In our study, the sensitivities of
the Tinels and flexion/compression tests for both carpal and cubital tunnel syndrome were in the lower range
of previously reported values. Because we only included study subjects who had positive electrodiagnostic findings, some subjects who had mild nerve compression with normal electrodiagnostic findings might
have been excluded, potentially increasing the falsenegative rate and decreasing the computed sensitivity.
On the other hand, the specificities of the same tests
were high, which reflects our use of an asymptomatic
control group that did not undergo electrodiagnostic
testing. These patients would be expected to have negative results for most diagnostic tests, which would
falsely elevate specificity.7 Electrodiagnostic testing
was not performed in the control group because carpal
and cubital tunnel syndromes are believed to be clinical
diagnoses. The diagnosis would be unclear for individuals without signs and symptoms of compression neuropathy but with abnormal electrodiagnostic studies.
This combination of findings has been considered by
expert panel consensus for carpal tunnel syndrome to
have poor positive predictive value.16
The high prevalence (70%) of carpal tunnel syndrome in our subjects reflects their referral to a hand
surgeons practice and is much higher than the reported prevalence of 5% to 15% in population-based
studies.3,20 Positive and negative predictive values of
screening tests are dependent on disease prevalence
and can markedly affect the utility of a test. All of the
clinical tests in this study had positive predictive

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SCRATCH COLLAPSE TEST

values greater than 95%, which is high compared

with previously reported values of 79% to 91%.21
These values would be expected to be lower in a
population with lower disease prevalence, such as
patients who might present to a general practitioners
office for evaluation.
The scratch collapse test had significantly (p .001)
higher sensitivity than that of Tinel test and of the
flexion/nerve compression test for both carpal tunnel
and cubital tunnel syndrome patients. The accuracy rate
for this test was 82% for diagnosing carpal tunnel
syndrome and 89% for diagnosing cubital tunnel syndrome. There is definitely a learning curve associated
with this test. The patient is instructed to only match the
force of the examiners resistance and not try to push as
hard as they can. The patients shoulders should remain
adducted, with their elbows at their sides. The examiner
gently pushes against the patients forearms and not the
hands or wrists. The test seems to be quite anatomically
exact and will be negative if stimulation does not occur
over the nerve. Thus, the scratch needs to be along the
course of the nerve. If the surface landmarks for a nerve
are unclear to the examiner, then all of the fingers
should be used to swipe over the general location of
the nerve, rather than only scratching over the nerve.
Because it is a test that does not rely on the patients
subjective report of whether symptoms are elicited, the
scratch collapse test provides a more objective addition
to other clinical maneuvers. Combining tests that tap
into different aspects of a condition helps meet the
assumption of conditional independence, which increases the diagnostic validity of the full complement of
tests when a gold standard is not available.1 Because
this is a novel test, the patient has not likely had it
administered before, making it potentially more difficult to feign a positive result. We have found this test
useful in patients with potential secondary gain as a
complicating factor. Those patients who exhibit a positive scratch collapse test when other tests have been
equivocal or negative can feel validated that a diagnosis
has been established. The test can also be repeated in a
patient in rapid succession, without any observed fatigue, so several trials can be performed for verification.
In the setting of multiple sites of peripheral nerve compression, the most severely affected site will collapse,
whereas the less severe ones may not. This can be
helpful when trying to assign the appropriate treatment
options for each site.
Rat models have been developed for the study of
neuropathic pain, using chronic constriction of either
the sciatic nerve9,10 or spinal nerves.8 Mechanical allodynia (painful response from normally nonpainful stim-

1523

uli) and heat hyperalgesia (increased response to painful

stimuli) within the cutaneous territory of the injured
nerves were produced after nerve injury.8 10 The spontaneous and elicited electrical axonal activity disappeared with chemical or physical inactivation of the
dorsal root ganglia.9,10 Abnormal electrical response
was also noted with stimulation of adjacent nerve territories or even in the contralateral limb, which suggests
a component of central sensitization.10 This experimental animal response to chronic constriction neuropathy
seems similar to the exaggerated neurogenic pain response that can occur in humans.
In response to painful cutaneous stimulation, humans
also exhibit a temporary inhibition of tonic voluntary
muscle activity, with a brief period of electromyographic silence. This cutaneous silent period was first
described by Hoffmann in 192211 and has been recorded in healthy volunteers as well as in patients with
central nervous system disorders such as Friedreichs
ataxia22 and complete spinal cord injury.12 Maximal
EMG suppression occurs only with painful stimulus,
begins within 100 milliseconds after the stimulus, lasts
50 to 100 milliseconds, does not show habituation, and
has been recorded in various upper- and lower-extremity
muscles after stimulation of digital nerves.1114,22 The
exact mechanism is poorly understood, with synergistic13 and antagonistic11 muscle groups being simultaneously affected and the inhibitory period is more rapid
than the voluntary muscle relaxation.13 Most investigators feel that it is mediated primarily by slowconducting A- fibers and may be a protective inhibitory spinal reflex.11-14,22
We believe that the scratch collapse test uses the
phenomenon of the cutaneous silent period to briefly
inhibit tonic shoulder external rotation as a response to
noxious stimulus of the skin overlying a chronically
constricted nerve. We have tested and demonstrated its
usefulness in the clinical diagnosis of carpal tunnel
syndrome and cubital tunnel syndrome. It has shown
similar or improved diagnostic ability when compared
with other widely used clinical tests. Although it is easy
to perform and has excellent reproducibility between
examiners, a learning curve is involved in using the
scratch collapse test. The scratch stimulus needs to be
directly over the course of the compromised nerve to
elicit a consistent positive response. Further studies to
try to elucidate the underlying physiologic mechanism
of this test would be useful. Whereas the patients in this
study had positive electrodiagnostic findings, this test is
most useful as an additional diagnostic tool in individuals with positive symptoms but negative electrodiagnostic studies. Future investigations may address the

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SCRATCH COLLAPSE TEST

utility of this test for compression neuropathies in other

anatomic sites or for other painful conditions.

12.

REFERENCES
1. LaJoie AS, McCabe SJ, Thomas B, Edgell SE. Determining the
sensitivity and specificity of common diagnostic tests for carpal
tunnel syndrome using latent class analysis. Plast Reconstr Surg
2005;116:502507.
2. American Academy of Neurology, American Association of Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic
studies in carpal tunnel syndrome. Neurology 1993;43:2404 2405.
3. Katz JN, Larson MG, Sabra A, Krarup C, Stirrat CR, Sethi R, et al.
The carpal tunnel syndrome: diagnostic utility of the history and
physical examination findings. Ann Intern Med 1990;112:321327.
4. Durkan JA. A new diagnostic test for carpal tunnel syndrome. J Bone
Joint Surg 1991;73A:535538.
5. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L.
Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg 1992;29:8 11.
6. Massy-Westropp N, Grimmer K, Bain G. A systematic review of the
clinical diagnostic tests for carpal tunnel syndrome. J Hand Surg
2000;25A:120 127.
7. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther 2004;17:309 319.
8. Sheen K, Chung JM. Signs of neuropathic pain depend on signals
from injured nerve fibers in a rat model. Brain Res 1993;610:62 68.
9. Tal M, Eliav E. Abnormal discharge originates at the site of nerve
injury in experimental constriction neuropathy (CCI) in the rat. Pain
1996;64:511518.
10. Sotgiu ML, Biella G. Contribution of central sensitization to the
pain-related abnormal activity in neuropathic rats. Somatosens Mot
Res 2000;17:3238.
11. Uncini A, Kujirai T, Gluck B, Pullman S. Silent period induced by

13.

14.

15.
16.

17.
18.

19.
20.

21.

22.

cutaneous stimulation. Electroencephalogr Clin Neurophysiol 1991;

81:344 352.
Logigian EL, Plotkin GM, Shefner JM. The cutaneous silent period
is mediated by spinal inhibitory reflex. Muscle Nerve 1999;22:467
472.
Leis AA, Stokic DS, Fuhr P, Kofler M, Kronenberg MF, Wissel J, et
al. Nociceptive fingertip stimulation inhibits synergistic motoneuron
pools in the human upper limb. Neurology 2000;55:13051309.
Kofler M. Functional organization of exteroceptive inhibition following nociceptive electrical fingertip stimulation in humans. Clin
Neurophysiol 2003;114:973980.
Fleiss JL. Statistical methods for rates and proportions. 3rd ed.
Hoboken, NJ: John Wiley & Sons, 2003:374 380.
Rempel D, Evanoff B, Amadio PC, deKrom M, Franklin G, Franzblau A, et al. Consensus criteria for the classification of carpal tunnel
syndrome in epidemiologic studies. Am J Public Health 1998;88:
14471451.
Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for
cubital tunnel syndrome. J Hand Surg 1994;19A:817 820.
Kuschner SH, Ebramzadeh E, Mitchell S. Evaluation of elbow
flexion and Tinel tests for cubital tunnel syndrome in asymptomatic
individuals. Orthopedics 2006;29:305308.
Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal
population. J Hand Surg 1992;17A:86 89.
de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi PF,
Spaans F. Carpal tunnel syndrome; prevalence in the general population. J Clin Epidemiol 1992;45:373376.
Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity
and specificity of clinical testing for carpal tunnel syndrome. Can J
Plast Surg 2003;11:70 72.
Serrao M, Parisi L, Pierelli F, Rossi P. Cutaneous afferents mediating the cutaneous silent period in the upper limbs: evidences for a
role of low-threshold sensory fibres. Clin Neurophys 2001;112:
20072014.

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