Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health and Rehabilitation Sciences

Collaborative Specialization

Musculoskeletal Health Research


MacDermid, Joy C


Research problem: Carpal tunnel syndrome (CTS) is nerve damage to the median nerve at the wrist level. It causes pain, numbness, tingling, and loss of hand use. The lifetime probability of getting CTS is 10%. The cost of work disability and suffering are high. Early detection through expedient clinical diagnosis is needed so that activity modification, wrist orthoses, nerve gliding exercises, and ergonomics can resolve CTS before surgery is required; or people with severe CTS can get surgery before nerve damage is permanent.

Methods: This thesis was a mixed methods development and evaluation of an online patient-report diagnostic tool. First a systematic review and a meta-analysis of literature on existing diagnostic tests determined the accuracy of 12 provocative maneuvers. The next systematic review synthesized the evidence on 14 clinical examination tests for screening CTS among workers with suspected CTS. Iterative mixed methods examining content, acceptability and diagnostic accuracy were used to finalize a diagnostic tool for the new Carpal Tunnel Syndrome Diagnosis Online (CTS-DO). The last chapter reports an umbrella overview of the electrophysical agents for treating CTS, accompanied by a novel approach to quantify study overlap.

Findings: Evidence synthesis found a lack of evidence on diagnostic tests that are highly accurate and confirmed by high-quality studies (31 studies in the first and 12 studies in the second systematic review, with low to moderate quality). In contrast, the development and validation of the CTS-DO in Chapter 4 and 5 shows immense promise. The CTS-DO was developed and validated in a sample of 228 people with upper limb disorders (age = 28.94 ± 7.91, 62% women). The test-retest reliability for the total score was excellent (intraclass correlation coefficient = 0.83). The content validity of the CTS-DO was established by conducting cognitive interviews with patients, clinicians, and researchers. The CTS-DO was linked to two domains of the International Classification of Functioning, Disability, and Health (sensory impairment (code b840) and pain (code b2801)). The diagnostic accuracy of the CTS-DO in a ‘virtual’ setting on a sample of 44 participants (age = 32.00 ± 9.76, 68% women) demonstrated a specificity of 96%, and a sensitivity of 83%, which signifies high accuracy in ruling in CTS.

Conclusion and significance: The newly developed CTS-DO is a 12-item and hand-diagram self-report diagnostic questionnaire that can be delivered online or in paper format. Its high accuracy and reliability are superior to the performance of previously reported clinical and self-report tools. The CTS-DO offers a new low-cost solution for virtual and in-person care that can be used for clinical diagnosis or screening for CTS since it is accurate and acceptable to patients. Broad-scale implementation and evaluation in different contexts are warranted.

Summary for Lay Audience

Carpal tunnel syndrome (CTS) is one of the most common hand and wrist problems among workers. Annually, a considerable number of people must stop working and seek treatment because of this condition. The lost work and health care cost millions of dollars every year. The earlier a diagnosis is made; the faster treatment strategies can be started to prevent worsening of the symptoms. The focus of this thesis was to develop and validate an online diagnostic method for the early-stage diagnosis of CTS.

We reviewed and summarized the existing literature relevant to the different approaches for diagnosing CTS in a general and worker population. After this phase, we picked the most accurate tests and used them to develop the Carpal Tunnel Syndrome- Diagnosis Online (CTS-DO) tool. We recruited a sample of workers through different social media platforms to participate in our study and assess how user friendly the CTS-DO is. We also interviewed some injured workers and clinicians to read the questionnaire word-by-word and provide additional feedback. Lastly, we summarized the evidence on some non-surgical treatment options for CTS.

We developed the CTS-DO and pilot tested it on 228 participants of whom 62% were women. All participants were currently working and had some sort of hand or upper limb problem. We established the usefulness and readability of the CTS-DO through the interviews. We also established the accuracy of CTS-DO which means that CTS-DO can be a useful test in determining who has CTS and who does not.

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Available for download on Wednesday, August 20, 2025