|Year : 2021 | Volume
| Issue : 4 | Page : 245-249
Value of boston questionnaire in carpal tunnel syndrome
Ayse Caglar Sarilar, Duygu Kurt Gök
Department of Neurology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
|Date of Submission||29-Apr-2021|
|Date of Decision||14-Jul-2021|
|Date of Acceptance||05-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Duygu Kurt Gök
Department of Neurology, Faculty of Medicine, Erciyes University, Kayseri
Source of Support: None, Conflict of Interest: None
Objectives: The Boston Carpal Tunnel Questionnaire (BCTQ) is a patient-based outcome measure that has been developed for patients with Carpal tunnel syndrome (CTS). The purpose of this study was to investigate the association between BCTQ scores and electrophysiological findings in patients with CTS. Subjects and Methods: This study included 174 individuals (control group [n = 68] and patient group [n = 106]) admitted to Erciyes University Hospital Department of Neurology between August 2019 and November 2019 with complaints of pain, numbness, and paresthesia in the unilateral or bilateral median nerve trace and diagnosed with idiopathic CTS or normal after electrophysiological testing. The Turkish version of the BCTQ was applied to these patients. Results: The mean age of the participants was 46.6 (standard deviation ± 11.9). One hundred and fifty-seven (90.2%) of all the participants were female. Among patients, 29.9% (n = 52) had mild, 21.8% (n = 38) had moderate, and 9.2% (n = 16) had severe CTS. Both the Symptom Severity Scale (SSS) and functional status scale (FSS) scores were evaluated between the groups, and there was a significant difference between the groups (P < 0.001 and P = 0.001, respectively). Although there was a significant difference between the groups, the huge overlap in the distribution of the scores indicated that discrimination of an individual according to FSS/SSS scores is unrealistic in the clinical setting. Conclusion: The BCTQ will not be sufficient and objective in the diagnosis and management of CTS. Today, electrophysiological tests are still the gold standard for the diagnosis of CTS, and referring the patient to the electromyography EMG laboratory is necessary for early diagnosis and determining the effective treatment method.
Keywords: Boston questionnaire, carpal tunnel syndrome, electrophysiology
|How to cite this article:|
Sarilar AC, Gök DK. Value of boston questionnaire in carpal tunnel syndrome. Neurol Sci Neurophysiol 2021;38:245-9
| Introduction|| |
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy caused by compression of the median nerve at the wrist. The most common signs of CTS in affected individuals are numbness, tingling, pain, and weakness in the hand and wrist. Over the world, three times more women suffer from CTS than men. CTS occurs more frequently between the ages of 40 and 60, and an estimated 4% and 5% of people suffer from CTS worldwide.
The majority of the cases are idiopathic, and other causes include endocrinopathies, pregnancy, rheumatic diseases, amyloidosis, trauma, smoking, or space-occupying lesions of carpal tunnel.
Electrodiagnostic studies are currently the gold standard test for the evaluation of suspected CTS. Nevertheless, several assessments methods or questionnaires were developed to detect the presence or to assess the severity of CTS. Within these methods, the Boston CTS Questionnaire (BCTQ) is a patient-based outcome measure that has been developed specifically for patients with CTS. In our country, there are studies evaluating the correlation of BCTQ with electrophysiological grading,, but we did not find any study in which people with normal electrophysiological findings were included as a control group.
The purpose of this study is to investigate the association between BCTQ scores and electrophysiological findings and to demonstrate the utility of the BCTQ in Turkish patients with CTS and to specify whether BCTQ scores help in the staging of CTS patients.
| Subjects and Methods|| |
This study included 174 individuals admitted to the outpatient clinic of our University Hospital Department of Neurology between August 2019 and November 2019 with complaints of pain, numbness, and paresthesia in the unilateral or bilateral median nerve trace and diagnosed with idiopathic CTS after electrophysiological testing. Patients with a history suggesting diabetes mellitus, connective tissue disease, hypothyroidism, previous diagnosis of neuropathy, and familial hereditary neuropathy, malignancy, and those who received chemotherapy were excluded. Furthermore, patients with a previous history of CTS surgery were not included in the study. Informed consent from all the patients and local ethics committee approval was obtained.
Boston Carpal Tunnel Syndrome Questionnaire
The Turkish version of the BCTQ was applied to these patients. The questionnaire consists of two parts: the Symptom Severity Scale (SSS) consists of 11 items assessing pain, paresthesia, numbness, weakness, nocturnal symptoms, and difficulty of grasping and the Functional Status Scale (FSS) consists of 8 items, which assess functional deficits in the following domains: writing, buttoning clothes, holding a book while reading, gripping a telephone handle, opening jars, performing household chores, carrying grocery bags, bathing, and dressing. Answers for each question in the SSS are scored from 1 (lightest) to 5 (heaviest). The average of 11 questions in the SSS and 8 questions in FSS constitutes the total score. High scores in both parts indicate poor symptom grade and high functional disability.
The diagnosis of CTS was made according to the history, physical examination, and electrophysiological evaluation. Nerve conduction studies were performed at room temperature, using the electromyography (EMG) device (Medelec Synergy EMG machine; Medelec, Oxford, England), and the skin temperature was 32°C.
Conduction studies for both upper extremity median and ulnar nerves were performed in accordance with general standards. Motor conduction studies were performed using superficial disc electrodes and orthodromic method, and sensory conduction studies were performed using ring electrodes and antidromic method. Conduction velocity and amplitudes were recorded as well as motor and sensory latencies of the median and ulnar nerves.
For motor nerve conduction studies, superficial disc electrodes were used with supramaximal stimulation. Active electrode was placed on abductor pollicis brevis muscle and reference electrode 3 cm distal to the tendon of the muscle. The stimulation was applied at the wrist, 8 cm proximal to the active electrode and the elbow. For sensory nerve conduction studies recording, active electrode was placed on the middle finger and the reference electrode was positioned at the distal interphalangeal flexion crease of the index finger so that a distance of at least 3 cm was mentioned between the active and reference electrodes. The stimulation at the wrist was not <10 cm but no more than 14-cm distance proximal to the active electrode. Mixed nerve conduction studies were performed by stimulating the mid-palm with the cathode placed proximally and recording over the median nerve at the proximal wrist crease.
The findings in the electrophysiological evaluation were graded as follows:
- Normal: Normal electrophysiology
- Mild CTS: Prolonged (relative or absolute) sensory or mixed nerve action potential (NAP) distal latency (orthodromic, antidromic, or palmar) ± sensory NAP (SNAP) amplitude below the lower limit of normal, and fourth finger sensory median-ulnar nerve latency difference was 0.5 msec and above
- Moderate CTS: Abnormal median sensory latencies as above, and (relative or absolute) prolongation of median motor distal latency
- Severe CTS: Prolonged median motor and sensory distal latencies, with either an absent SNAP or mixed NAP, or low amplitude or absent thenar compound muscle action potential. Needle examination often reveals fibrillations, reduced recruitment, and motor unit potential changes.
According to the electrophysiological findings, the participants were assigned to four groups with electrophysiologically normal individuals constituting the control group.
Categorical variables were shown as percentages and continuous variables as mean ± standard deviation (SD) or median (range).
As the Kolmogorov–Smirnov test showed a nonnormal distribution, the BCTQ and its subscores (SSS and FSS) of the groups were compared using the Kruskal–Wallis test. Tamhane's T2 test was used to determine the source of the difference detected in the variance analysis. Correlation between the BCTQ, SSS, and FSS scores and CTS stages was evaluated with Spearman analysis. P < 0.05 level was considered statistically significant. Analyses were performed using IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA).
| Results|| |
The mean age of the included 174 participants (control group [n = 68] and patient group [n = 106]) was 46.6 (SD ± 11.9). One hundred and fifty-seven (90.2%) of all the participants were female. Participants with CTS were significantly older than the controls (50.4 [SD ± 10.6] vs. 40.7 [SD ± 11.9], P = 0.001); no significant difference between the groups regarding sex was detected (P = 0.099).
According to the electrophysiological grading system, 29.9% (n = 52) of the patients had mild, 21.8% (n = 38) had moderate, and 9.2% (n = 16) had severe CTS.
Both the SSS and FSS scores were evaluated according to electrophysiological staging between the groups, and there was a significant difference between the groups (P < 0.001 and P = 0.001, respectively). The reason of this difference between the groups was examined. The group with severe CTS was found to have significantly higher SSS scores compared to the normal, mild, and moderate CTS groups (P < 0.001). When the groups were evaluated according to FSS scores, significantly higher results were obtained in the group with severe CTS compared to the normal group (P = 0.020). The results of the group comparison regarding the BCTQ subscores are given in [Table 1].
|Table 1: Evaluation of the Symptom Severity Scale and Functional Disability Scale scores according to the electrophysiological grading between groups|
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Patients with severe CTS differed significantly compared to normal regarding the FSS scores. Likewise, SSS scores showed a significant deviation in the severe CTS group as opposed to the normal, moderate, and severe groups. Although there was a significant difference between the severe group and the normal group with regard to FSS and SSS scores, the huge overlap in the distribution of the scores indicated that discrimination of an individual according to FSS/SSS scores is unrealistic in the clinical setting [Figure 1]a. When the Boston questionnaire score was examined as subgroups, it was observed that there was a moderate positive correlation between the SSS score and the FSS score (r = 0.652, P < 0.001) [Figure 1]b.
|Figure 1: (a) The “box plot” diagram of the BCTQ subscores in patients with CTS. (b) The correlation between FSS and SSS scores|
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In multiple logistic regression analysis, the increase in age was evaluated as a risk factor for the development of CTS. No significant relationship was found between FSS score, SSS score, and CTS risk [Table 2].
|Table 2: Logistic regression analysis of age, BCTQ scores, and CTS development risk|
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| Discussion|| |
According to the data in our study, it was seen that the scores obtained from the FSS and SSS were not sufficient to distinguish the severity of CTS, and electrophysiological examinations were required.
In our study, individuals were divided into four groups according to the electrophysiological grading system. The BCTQ-SSS scores were found to be significantly higher in those with severe CTS compared to both the normal group and those with mild and moderate CTS. FSS scores were also significantly higher in patients with severe CTS compared to the normal group. We observed that the BCTQ, SSS, and FSS subgroups were higher in those with severe CTS, but with correlation analysis, the possibility of making a clear distinction between the groups was low.
BCTQ and many similar questionnaires are used in CTS patients. These questionnaires do not have superiority over each other, and the results may also vary according to the cultures. In a recently published systematic meta-analysis, 34 studies using the BCTQ and the other questionnaires about carpal tunnel were evaluated and found that the BCTQ was found to be more sensitive and reliable than other questionnaires. In a study from Turkey, 100 idiopathic CTS patients were evaluated without including a control group and they have identified a significant correlation between the BCTQ scores and electrophysiological staging. In our study, it was observed that the BCTQ and EMG result correlation was not sufficient. In a similar study, 50 patients with CTS were grouped as mild, moderate, and severe. No significant difference was found between the CTS subgroups in regard to the symptom severity, and functional status impairment were found in the severe CTS group than in the other two groups. In a study by De la Llave-Rincon et al., 72 female patients and 19 age- and gender-matched control groups were compared and no correlation was found with FSS score, SSS score, and electrophysiological findings. In the same study, the pain was also evaluated, and no significant difference was found between the intensity of pain and electrophysiological findings between the groups.
Studies have reported that the BCTQ could be useful in clinical follow-up, especially in the postoperative period of CTS patients. It is emphasized that BCTQ is effective and reliable in the follow-up of symptoms both in the early and in the late postoperation period and it is sensitive to clinical changes.,
Age seems to be the most important risk factor in the development of CTS. The fact that age was significantly higher in the CTS group compared to the control group in our study supports the literature. In a systematic meta-analysis, in addition to older age, female gender and high body mass index were reported as major risk factors for the development of CTS. In our study, higher FSS and SSS scores have not been identified as risk factors for the presence of CTS. As a result, neither higher FSS scores nor higher SSS scores were found to be a marker for the presence of CTS.
In our study group, 157 female and 17 male patients were included. Although the female/male ratio is higher than the general population rates, in many studies that evaluated the BCTQ in terms of both validity, reliability and response rates, it was seen that the majority of the participants of these studies were female, similar to our study.,
The mean age of the CTS group was 50.4 years, and this was similar to the previous studies. The most common age group for CTS in the general population was 40–60 years.
The most important limitation of our study is that we did not design a prospective study in which we applied the questionnaire before conducting the electrophysiological studies.
Moreover, we did not apply additional tests for emotional states to the participants. Because psychological disturbance and emotional distress could influence the presentation of CTS symptoms. In addition, the fact that the education and socioeconomic levels of the patients were not questioned may also have affected the reliability of the BCTQ results. However, there are conflicting results according to the studies. In a study, the subjective symptoms in CTS were found to be correlated with psychological factors rather than electrophysiological findings. In other studies, mood and education levels do not directly affect the results in the evaluation of the Boston questionnaire, and it can be safely applied to illiterate patients.
As a result, although the BCTQ was defined as an auxiliary assessment test in the diagnosis of CTS, it seems to have a low predictive value in diagnosis and staging CTS. Moreover, BCTQ's applicability has been proven in the postoperative follow-up of the disease, but alone it will not be sufficient and objective in the preoperative process, treatment management, and follow-up.
| Conclusion|| |
The gold standard test in the diagnosis of CTS is nerve conduction studies or electrodiagnostic methods, and referring the patient to the EMG laboratory is necessary for early diagnosis and determining the effective treatment method.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]