Translation and validation of the Arabic version of the Boston carpal tunnel syndrome questionnaire

Objectives:To translate and validate the Arabic version of the Boston carpal tunnel questionnaire (BCTQ-A).Methods:We recruited consecutive patients with carpal tunnel syndrome (CTS). Reliability was assessed with Cronbach α, reproducibility with intraclass correlation coefficients, construct validity with factor analysis, and responsiveness post carpal tunnel release (CTR) with the Wilcoxon signed-rank test.Results:In 134 patients, the mean total scores for the symptom severity scale (SSS) and functional status scale (FSS) were 32.0±8.4 (α=0.88, ICC=0.88) and 18.5±7.6 (α=0.87, ICC=0.89), respectively. As in the original Boston carpal tunnel questionnaire (BCTQ), a 3-factor model of the BCTQ-A best fitted the data. The BCTQ-A, SSS, and FSS scores were significantly lower post-CTR.Conclusion:The BCTQ-A is reliable, valid, reproducible, and responsive to interventions. The Arabic version can be now used with Arabic-speaking patients with CTS.

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy affecting the median nerve at the wrist. The diagnosis of CTS is made clinically and supported by the finding of median neuropathy at the wrist on electrodiagnostic studies (EDX). Atroshi et al1 reported a prevalence of clinically certain CTS of 3.8%, and a prevalence of clinically and EDX confirmed CTS of 2.7%.1 Both carpal tunnel release (CTR) and conservative interventions are used for the treatment of CTS; the former may be more effective in relieving symptoms and improving hand function.2 A recent study has estimated a lifetime prevalence of CTR of 3.1%.3 The use of a validated outcome measure is imperative to monitor the response to CTS therapy.The Boston carpal tunnel questionnaire (BCTQ) is a patient-reported outcome measure of proven reliability, validity, and responsiveness to surgical and non-surgical treatment.4-7 The BCTQ is composed of 2 scales, the symptom severity scale (SSS) and the functional status scale (FSS). The SSS consists of 11 items, incorporating 6 domains (pain, numbness, paresthesia, nocturnal symptoms, weakness, and overall functional status) scored on a 5-point scale ranging from 1 (never/none) to 5 (most severe). The FSS consists of 8 functional activities commonly affected by CTS scored on a 5-point scale ranging from 1 (no difficulty) to 5 (cannot perform the activity at all). The BCTQ score reflects CTS severity in a typical 24-hour period within the last 2 weeks before completing the questionnaire.4,8 The BCTQ has been translated and validated in many languages,5,9-13 but not yet in Arabic. Validation of an Arabic version of the BCTQ would be useful to help physicians assess the impact of CTS from the patients’ perspective and objectively assess post-intervention improvement. This study sought to translate and culturally adapt the BCTQ into Arabic and to assess its psychometric properties, including reliability, reproducibility, validity, and responsiveness to CTR.     

Electrodiagnostic evaluation of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment. Electrodiagnostic (EDX) studies are a valid and reliable means of confirming the diagnosis. This monograph addresses the various EDX techniques used to evaluate the median nerve at the wrist. It also demonstrates the limitations of EDX studies with a focus on the sensitivity and specificity of EDX testing for CTS. The need to use reference values for populations such as diabetics and active workers, where normative values differ from conventional cutoffs used to confirm suspected CTS, is presented. The value of needle electromyography (EMG) is examined.     

Evolution of hand dysfunction and symptoms in untreated carpal tunnel syndrome

The Italian Carpal Tunnel Syndrome (CTS) Study Group assessed the evolution of symptoms and hand dysfunction through validated, patient-oriented measures in 264 patients with 354 hands affected by untreated idiopathic CTS (follow-up 10-15 months). The evolution of symptoms and hand dysfunction was positively related. Only in 3% was there discordance between hand dysfunction and symptom evolution. Thus, in patients with CTS, hand dysfunction and symptoms evolve in parallel.     

Muscle echogenicity ratio can indicate severity of carpal tunnel syndrome

Introduction: The purpose of this study was to investigate the usefulness of the echogenicity (EI) ratio of the thenar to hypothenar muscle measured using ultrasonography in assessing the severity of carpal tunnel syndrome (CTS). Methods: Fifty‐nine hands of 30 patients electrodiagnostically confirmed as having CTS were classified into 3 subgroups (mild, moderate, and severe). The EI of the thenar and hypothenar muscles was measured with ultrasonography, and the EI ratio was calculated in the patients and 13 normal participants (26 hands). Results: The average EI ratio was higher in the CTS group than in the control group. We also found a positive correlation between the severity of CTS and a high EI ratio measured with ultrasonography. Discussion: The EI ratio of the thenar to hypothenar muscle is a useful parameter that can indicate the severity of CTS. Muscle Nerve 58 : 304–306, 2018     

Electrophysiologic severity of carpal tunnel syndrome in diabetic patients of the Saudi population

Objectives:To study the frequency of multiple vascular risk factors and electrophysiological severity of carpal tunnel syndrome (CTS) in Saudi diabetic patients.Methods:This retrospective cross-sectional study was conducted in Neurology Department, King Fahd Hospital of University, Al-Khobar, Kingdom of Saudi Arabia from April 2017 to March 2018 and included 200 patients with CTS. Body parameters, such as blood pressure (BP), weight, height, and body mass index (BMI), along with laboratory and median nerve electrophysiological parameters, of diabetic and non-diabetic patients were compared, and a p-value<0.05 was considered significant.Results:Frequency of hypertension (HTN) and obesity was significantly higher in diabetic patients (p<0.05). Mean median nerve sensory amplitude (MNSA) was lower in diabetic patients (p<0.05).Non-recordable nerves, as well as bilateral and extremely severe CTS (p<0.05), were more frequently seen in diabetic patients. Age, BMI, systolic BP, low serum high density lipoprotein (HDL), high triglycerides, high fasting blood sugar, and high glycated hemoglobin (Hba1c) levels, known to affect the electrophysiological severity of CTS, had a statistically significant association with diabetes.Conclusion:Diabetes mellitus (DM) and obesity are the most commonly identified risk factors of CTS. Dyslipidemia, HTN and obesity are more frequently seen in diabetic patients with CTS. These concurrent risk factors are confounding the electrophysiological severity of CTS in these patients. Further larger-scale studies with the control of confounding factors are recommended.

Carpal tunnel syndrome (CTS) is known to have a frequent nerve entrapment syndrome and encompasses 45% of non-traumatic nerve lesions.1,2 Carpal tunnel syndrome can result in various problems, including pain and paresthesia in the median nerve distribution, swelling, and in severe cases weakness of the thumb and lateral 3 fingers.3 It affects the daily life activities, such as holding and gripping things by hand, brushing teeth, and driving.4 Carpal tunnel syndrome can be associated with any risk factor that causes pressure on the median nerve inthe wrist, including coexisting comorbidities and working conditions of the individuals.5 Some common conditions that can lead to CTS includes obesity, DM, oral contraceptives, smoking, corticosteroid use, pregnancy, hypothyroidism, rheumatoid arthritis, osteoarthritis, and wrist fracture.6The prevalence of CTS in diabetic patients is 14% without diabetic neuropathy and 30% with diabetic neuropathy.7 Literature has shown a high incidence of CTS in pre-diabetic states.8 Some researchers have also found a relationship between duration of diabetes, Hba1c, and micro vascular complications.9 Although type 2 diabetes is more frequently diagnosed among CTS patients, some studies had reported that the association between diabetes and CTS represents a confusion bias, most likely due to the strong relationship between obesity and type 2 diabetes.10 It has been shown that age, BMI, and other vascular risk factors, including metabolic syndrome, could affect the electrophysiological severity of CTS. Elevated low density lipoprotein (LDL) cholesterol and hyperglycemia were reported as independent risk factors for CTS in some studies.8,11,12 Similarly, obesity, elevated triglycerides, elevated LDL cholesterol and hypertension were shown to be strongly associated with CTS.13 In the study conducted by Balci et al,14 75% of the CTS patients were found to have metabolic syndrome, and the electrophysiological parameters (median nerve sensory onset latency, sensory conduction velocity, sensory amplitude, distal motor latency, motor conduction velocity, and motor amplitude) were worse in patients with metabolic syndrome. Gül et al,15 similarly showed that severity of CTS was even more severe in patients with metabolic syndrome than in those with diabetes.The aim of the present study was to study the frequency of multiple vascular risk factors, such as HTN, dyslipidemia and obesity in CTS patients, and to compare the electrophysiological severity of CTS in Saudi diabetic and non diabetic patients. This population is facing a high burden of multiple vascular risk factors, which are also affecting the severity of CTS.     

The potential value of ultrasonography in the evaluation of carpal tunnel syndrome

The authors compared ultrasonography with electrophysiology for the diagnosis of carpal tunnel syndrome (CTS) on 110 clinically affected wrists. An increased cross sectional area in the proximal carpal tunnel larger than 0.11 cm(2) in combination with compression signs on longitudinal scans proved to be highly predictive for CTS (sensitivity, 89.1%; specificity, 98.0%). Ultrasound was comparable to electrophysiology in the diagnosis of CTS, and in 35% of cases changes in morphology suggested a specific therapeutic strategy.     

Correlation of median forearm conduction velocity with carpal tunnel syndrome severity.

OBJECTIVE: Median nerve entrapment neuropathy at the wrist can be accompanied by slowed motor conduction within the forearm. Existing studies conflict regarding a correlation between the severity of the entrapment neuropathy in carpal tunnel syndrome (CTS) and slowing of median motor nerve conduction velocity (MNCV) in the forearm. Here, it was asked if there is a correlation between markers of CTS severity and median forearm MNCV, and if there is an explanation for the preceding conflicting results. METHODS: Median MNCV in the forearm was correlated with neurophysiologic markers of severity of a median neuropathy at the wrist in 91 hands from 64 patients with clinical and electrodiagnostic evidence of CTS. RESULTS: Median MNCV within the forearm segment was negatively correlated with the median nerve distal motor latency (r=-0.64, P<0.001, n=91) and positively correlated with the CMAP amplitude of the abductor pollicis brevis muscle (r=0.45, P<0.001, n=91). These correlations only occurred in patients with a prolonged median distal motor latency. Previous investigations that failed to find such correlations used variable or non-standardized methods or analyzed smaller numbers of patients. CONCLUSIONS: Slowing of median MNCV in the forearm is related to the severity of the entrapment of median motor fibers at the wrist. SIGNIFICANCE: Slowed forearm median MNCV can be a marker of motor nerve injury at the wrist.     

Sensory distribution indicates severity of median nerve damage in carpal tunnel syndrome.

OBJECTIVE: Sensory symptoms within the median nerve distribution are a primary clinical diagnostic criterion for the diagnosis of carpal tunnel syndrome (CTS). However, the distribution of the sensory symptoms in CTS varies from patient to patient. This study identifies the clinical and electrophysiological findings that correlate with the distribution of sensory symptoms in an Asian population with CTS. METHODS: In a prospective study of 105 patients with electrophysiologically confirmed CTS, clinical and educational data were correlated with sensory symptom distribution. RESULTS: Median nerve distribution was strongly associated with more severe nerve conduction abnormality, male gender, and relief by movement. Patients with a complete median sensory distribution had more electrophysiological abnormality than those with an incomplete median distribution. Extra-median distribution was associated with the least nerve conduction abnormality. Educational qualification, age, symptom duration and body mass index were not associated with the pattern of sensory symptoms. CONCLUSIONS: In carpal tunnel syndrome, sensory symptom distribution is strongly dependant on the degree of electrophysiological median nerve damage. Median nerve sensory distribution is associated with severe nerve damage. SIGNIFICANCE: This study provides clinicians with a simple clinical rule for assigning the degree of median nerve damage in patients with CTS based on sensory distribution patterns.     

Mutilating hand syndrome in an infant with familial carpal tunnel syndrome

A 7-month-old infant, son of consanguinous Indian parents, presented with recurrent chewing of his digits in a median nerve distribution as the primary manifestation of carpal tunnel syndrome, in conjunction with features consistent with congenital insensitivity to pain. Electromyography (EMG) demonstrated severe median nerve entrapment at the wrist bilaterally, but other nerves were normal. In spite of clinical evidence of diffuse pain insensitivity, sural nerve and skin biopsies were normal, and he had no evidence of autonomic dysfunction. Hand findings evolved with scarring and infection of median innervated digits and loss of fine motor skills. Carpal tunnel release resulted in complete clinical resolution and significant EMG improvement. Milder symptoms and EMG evidence of median nerve entrapment were demonstrated in both parents, paternal grandparents, and several of his father's siblings. We hypothesize this child may be homozygous for a mutant allele that in its heterozygous state predisposes to familial autosomal dominant carpal tunnel syndrome. Homozygosity for this or another mutant allele may be responsible for his congenital insensitivity to pain. © 1998 John Wiley & Sons, Inc. Muscle Nerve, 21: 104–111, 1998.     

Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation

In clinically classic carpal tunnel syndrome (CTS) without symptoms or signs to suggest other disorders that can mimic CTS, it remains somewhat controversial as to whether performing nerve conduction studies is necessary or cost-effective. MR imaging reliably depicts normal carpal tunnel anatomy. It can also identify pathologic nerve compression and mass lesions, such as ganglion cysts, that compress nerves. Currently, MR imaging is most commonly used to image patients with ambiguous electrodiagnostic studies and clinical examinations. MR diffusion-weighted imaging of peripheral nerves might prove to be the most sensitive imaging sequence for the detection of early nerve dysfunction. Electrodiagnostic studies are likely to remain the pivotal diagnostic examination in patients with suspected CTS for the foreseeable future. With advances in both software and hardware, however, high-resolution MR imaging of peripheral nerves will become faster, cheaper, and likely more accurate, possibly paving the way for an expanded role in the diagnosis of this common syndrome.     

Relationships between clinical symptom severity scales and nerve conduction measures in carpal tunnel syndrome

This study examined the severity of symptoms in carpal tunnel syndrome (CTS) in relation to nerve conduction measures of the median nerve. Clinical symptom severity and nerve conduction studies were evaluated for 64 hands with CTS in 45 patients. We found the following: (1) significant relationships identified among the clinical scales resulted in a dichotomous symptom classification scheme into primary and secondary symptoms, with the former being more specific for those symptoms usually seen in association with nerve injury; (2) there were significant relationships between symptom severity and nerve conduction abnormality; (3) the primary symptom scale correlated more strongly with the electrodiagnostic measures of nerve injury than did the secondary symptom scale. Based on these findings, we believe that these clinical scales have biological significance and reflect median nerve injury. This would support their potential utility for evaluating the outcome of CTS treatment and developing a model for exposure-severity relationship.     

Utility of the cutaneous silent period in the evaluation of carpal tunnel syndrome

ObjectiveThis study investigates the utility of the cutaneous silent period (CuSP) in evaluating patients with carpal tunnel syndrome (CTS).MethodsThe authors measured the CuSP from the abductor pollicis brevis muscle in 135 hands of patients with idiopathic CTS and 30 hands of age- and gender-matched controls. The patient group was further divided into subgroups according to the Canterbury scale. The differences in parameters between the patient subgroups and control group were analysed. A predetermined analysis looked at the possible correlation between the CuSP and symptom severity as measured by the Boston-Questionnaire.ResultsThe mean CuSP latencies in the patient group (72.4 ± 16.1 ms) was significantly longer than the control group (64.6 ± 13.4 ms; P = 0.014), although there was no difference in the duration of the CuSP between groups. The duration and latency of the CuSP correlated to a higher severity on the Canterbury scale (r = 0.273, P < 0.001 and r = −0.164, P = 0.036, respectively). However, the CuSP parameters did not correlate with the Boston-Questionnaire scores.ConclusionsAlthough patients with CTS had significantly prolonged CuSP latency, the CuSP did not correlate with the clinical symptoms scale.SignificanceThe CuSP is a useful ancillary test to evaluate Aδ fibre function; however, it is not a reliable tool to quantify clinical severity.     

腕管综合征夜间夹板治疗的临床和电生理评估

目的 运用临床评分和神经传导检测(NCS)评估夜间夹板治疗对腕管综合征(CTS)的疗效,并探讨其间的相关性.方法 自2009年4月至2010年1月武汉大学人民医院神经内科就诊的CTS患者共66例,符合纳入标准者41例(64只腕).对其进行症状严重程度评分(SSS)、功能状态评分(FSS)以及常规NCS,记录腕-拇短展肌末端运动潜伏期(DML)、腕-食指/环指感觉传导速度(SCV)以及正中/尺神经感觉潜伏期差(△DSL).嘱患者以远侧腕皱褶为中心,掌面和背面各一块夹板,入睡前将腕部固定于中立位制动.夹板治疗前、(3.03±1.16)月后分别进行临床评分和NCS.共20例(31只腕)完成随访.结果 (1)DML、腕-食指SCV、腕-环指SCV和△DSL异常率分别为85.9%、78.1%、81.3%和96.9%.(2)与夹板治疗前比较,夹板后SSS和FSS减少、DML缩短、△DSL减小,治疗前、后SSS分别为1.77±0.38、1.55±0.38,FSS为1.53±0.31、1.40±0.27;DML为(4.53±1.25)ms、(4.14±0.76)ms;△DSL为1.24±0.61、0.97±0.60;9例(14只腕)夹板后临床评分无改善.(3)SSS与DML(r=0.420,P=0.019)、腕-食指SCV(r=-0.425,P=0.017)、腕-环指SCV(r=-0.519,P=0.003)之间存在较弱的相关性,与△DSL无相关(r=0.189,P=0.309);FSS与NCS各参数之间均无相关性(P均＞0.05).结论 一半以上CTS患者夹板治疗短期内有效;临床评分与NCS相关性不大,两者共同评估夹板疗效更有意义;△DSL诊断CTS最敏感.