Risk factors, symptom severity and functional status among patients with carpel tunnel syndrome
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.232351
Source of Support: None, Conflict of Interest: None
Keywords: Carpal tunnel syndrome, functional status, risk factors, symptom severity
Carpel tunnel syndrome (CTS) is the most common peripheral neuropathy resulting from compression of the median nerve as it passes through the carpel tunnel in the wrist. This can result in various problems including pain, tingling, numbness, swelling, or weakness of the thumb, index, middle, and ring finger. CTS affects the activities of daily living such as brushing teeth, combing hair, holding things by hand, and driving. In severe cases, numbness becomes almost constant and patients begin to develop weakness of movements of the thumb. Early in the disease course, the process is reversible. The persistence of nerve compression, however, results in the wearing away of the insulation on the nerves resulting in permanent nerve damage. There are several risk factors that may predispose to CTS such as the coexistence of comorbidities like arthritis, diabetes mellitus, autoimmune disorders, tumors of the wrist, and the working condition of the individuals. Industry workers such as assembly workers, food industry workers, garment industry workers, and boot and shoe manufacturers are at risk of development of CTS. Extensive physical workload has been widely recognized as a risk factor among such workers. Use of vibratory tools, repetitive hand washing, and use of a heavy grip force also predisposes to CTS.
According to the US Bureau of Labor Statistics, there were 16,440 cases of CTS involving lost work days in 2005. It comprised the second most common cause of absence from work. Le Blanck showed that the prevalence of CTS in the general population was 2.8–5.8%. The mean annual crude incidence of CTS was found to be 329 cases per 100,000 persons per year, and the standardized incidence was 276 cases. Murthy and Meena conducted a study related to the occurrence of CTS among patients with various peripheral nerve disorders in South India. They found that CTS constituted 7% of all the peripheral nerve disorders and 83% of entrapment neuropathies. The exact epidemiology in the Indian population is unknown; however, data from the West suggests an incidence of 1–3.5 cases per 100,000 person years in a region-specific distribution.
Geoghegan et al., conducted a case control study to assess the risk factors responsible for the development of CTS. The multivariate analysis showed that risk factors associated with CTS included patients with previous wrist fractures (OR: 2.29), arthritis, obesity (2.06), and diabetes mellitus (1.51).
Boyd et al., conducted an observational cohort study in Canada to assess the relationship between the severity of symptoms and the success of nonoperative and postoperative treatment among 30 patients who were diagnosed with CTS. The self-reported symptoms and physical impairments were assessed and documented using Levin's symptom severity scale and functional status score. Improvements in the symptom severity score (P < 0.0001) and the functional status score (P = 0.001) were noted following surgery in patients resistant to conservative management.
In this study, we have attempted to determine the risk factors responsible for the development of CTS to gain a better understanding of the preventive strategies for CTS.
Design, sample, and setting
A nonexperimental, descriptive design was adopted in this study. The study sample comprised patients with CTS.
Data collection instruments
The instruments used for the study included:
Tool I: A semi-structured questionnaire to collect demographic variables and clinical variables. It consisted of three sections – personal data, sociodemographic data, and clinical variables.
Tool II: A semi-structured questionnaire to assess the risk factors. The questionnaire included items to assess the ergonomic risk factors of CTS. The researcher developed Tool I and II based on literature review.
Tool III: Standardized questionnaire to assess the symptom severity scale (SSS) and functional status scale (FSS) prepared by Levine et al., in 1991. The content validity index was 0.86 and reliability was 0.92.
Data collection procedure
Consent from the participants was obtained. The participants diagnosed as having a mild, moderate, and severe type of CTS were selected and their data collected on an outpatient basis by administering the semi-structured questionnaire. The approximate time taken to answer the questions was 20 minutes. The clinical data and personal risk factors were collected by the researcher. The nerve conduction velocity (NCV) report was attached with the questionnaire.
Of the 100 participants, 64 (64%) were female patients and only 36 (36%) were male ones. Only 8 (8%) had a family history of CTS. Seventy-five (75%) participants had premorbidities; 53 (53%) had diabetes mellitus, 25 (25%) had hypertension, 24 (24%) had dyslipidemia, 8 (8%) had osteoarthritis, and 10 (10%) had thyroid dysfunction. Forty-seven (47%) participants were on medication. Fifty-one (51%) participants were overweight, 40 (40%) had a normal body mass index (BMI), and 8 (8%) were obese. Of the 100 participants, only 9 (9%) had a history of injury to the upper limbs. Fifty-three (53%) participants were working, and 59 (59%) were engaged in household chores.
Risk factors responsible for the development of carpel tunnel syndrome
The risk factors responsible for the development of CTS were assessed using the ergonomic risk factor questionnaire, which showed that 47 (47%) participants had no risk, 45 (45%) had a mild risk, 6 (6%) had a moderate risk, and 2 (2%) had a severe risk.
Symptom severity and functional status
[Figure 2] shows that 61 (61%) of the participants with CTS had a moderate degree of symptom severity score, while 18 (18%) had a mild, 13 (13%) had a severe, and 8 (8%) had a very severe degree of symptom severity score.
[Figure 3] depicts that 64 (64%) of the participants with CTS had a moderate level of functional status score, while 20 (20%) had a mild, 15 (15%) had a severe, and 1 (1%) had a very severe functional status score.
Correlation between symptom severity and functional status
There was a significant negative correlation between the symptom severity and functional status among patients with CTS.
Correlation between symptom severity, functional status, and body mass index
There was a significant mild positive correlation between the symptom severity, the functional status, and the BMI among patients with CTS.
The first objective of the study was to identify the risk factors among CTS patients. Among the 100 patients with CTS, it was identified that 64 (64%) were female subjects, 8 (8%) had a family history of CTS, only 9 (9%) had an injury to the upper limb, and 75 (75%) were having comorbidities, of which 53 (53%) had diabetes mellitus, 25 (25%) had hypertension, 24 (24%) had dyslipidemia, 8 (8%) had osteoarthritis, and 10 (10%) had a thyroid disease. Fifty-one (51%) of the participants were overweight. The ergonomic risk factors assessed showed that 53 (53%) of the participants were currently working and 59 (59%) were engaged in household chores. The ergonomic risk assessed showed that 45 (45%) of the participants had a mild risk, 6 (6%) had a moderate risk, and 2 (2%) had a severe risk of development of CTS [Figure 1]. These findings are consistent with the findings of a cross-sectional study conducted in Iran by Farzan et al., on the contributing factors of CTS among 362 hospitalized patients. The results showed that the most common occupation in women was household chores followed by hair dressing, while in men it was being a worker. The study also revealed diabetes mellitus and hypothyroidism as the leading causes of CTS.
The second objective of the study was to identify the symptom severity and functional status among patients with CTS. The symptom severity identified showed that 61 (61%) patients with CTS had a moderate degree of symptom severity score, 18 (18%) had a mild, 13 (13%) had a severe, and 8 (8%) had a very severe degree of symptom severity score. The functional status showed 64 (64%) of the patients with CTS had a moderate level of functional status score, 20 (20%) had a mild, 15 (15%) had a severe, and 1 (1%) had a very severe functional status score. Tamburin et al., conducted a study on pain and motor function in CTS among 129 patients. Patients were asked about the presence and severity of hand weakness (HW) and hand clumsiness (HC). The results showed that HW and HC may be found in 56% and 48% of CTS hands, respectively. HW was related to the severity of sensory symptoms (pain, numbness, and tingling). HC was related to the severity of sensory symptoms and the clinical-neurographic signs of motor but not sensory nerve damage. Motor symptoms were significantly more frequent in the right hand.
On statistical analysis, it was found that there was a significant relationship between the symptom severity and the functional status of patients with CTS (r = −0.705, P = 0.000) [Table 1]. As the symptom severity increased, the functional ability decreased among patients with CTS. Bhatt et al., conducted a study on the relationship of electrodiagnostic findings with severity of symptoms and function in 30 participants with CTS in Ahmedabad. The results of the study showed a statistically significant moderate correlation between the severity of symptoms and functional limitations.
There was a significant mild positive correlation between the symptom severity (r = 0.492***; P = 0.000), functional status (0.618***; P = 0.000), and BMI among patients with CTS [Table 2]. These findings are consistent with a study conducted to identify the factors associated with patient satisfaction after decompression of the median nerve at the carpal tunnel; 55 patients with CTS who underwent surgery for median nerve decompression and were distributed into two groups based upon their degree of satisfaction with the surgical outcome reported that majority of the patients with CTS had a higher BMI (29.0 ± 3.6 vs. 25.5 ± 3.9; P = 0.0028). Similar findings were reported by other studies.,,,, There was a correlation between the BMI and CTS that can be explained by the accumulation of fat tissue within the carpal tunnel or by the increase in the hydrostatic pressure inside the tunnel in obese patients.,,
Early identification of CTS can be performed both clinically and electrophysiologically. Information regarding the risk factors responsible for the development and persistence of CTS permits the provision of health education on various risk factors and their modification measures. Occupational health personnel have a greater role to play in the early identification of CTS in selected groups. The symptom severity scale and functional status scale can be used in the clinical settings to assess the severity of CTS. CTS risk reduction guidelines may be developed so that patients can make adequate lifestyle changes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]