Structural validity of the Boston Carpal Tunnel Questionnaire and its short version, the 6-Item CTS symptoms scale: a Rasch analysis one year after surgery

Prospective evaluation of a novel device for ultrasound-guided percutaneous treatment of carpal tunnel and trigger finger disease. Efficacy and safety of sono-instruments®

PURPOSE

To evaluate the safety and effectiveness of percutaneous release procedures under sonography using Sono-Instruments® in the treatment of carpal tunnel syndrome (CTS) and trigger finger (TF).

METHODS

Prospective study involving 30 patients, divided into two groups (15 CTS, and 15 TF). The primary outcomes were surgical performance-related outcomes (visibility, ease of use, satisfaction, duration) using Sono-Instruments® and patient-related outcomes (pain, activity limitations, time to return to work, functional scores). Secondary outcomes included complications. Patients were followed for two months post-operatively.

RESULTS

In the CTS group, the average age of the patients was 58.7 years. The percutaneous release of the transverse carpal ligament was effectively completed in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 80% could perform activities of daily living, and 80% of those working had returned to their activities. At two months, all patients had resumed all activities. Pillar pain was still present in 53.3%. In the TF group, the patients had an average age of 57.9 years. The percutaneous release of the A1 annular pulley was successful in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 93.3% could do all activities of daily living, and 75% of those working were back to their professional activities. At two months, all patients were back to all activities of daily living and work. The DASH score was significantly improved at two months, compared to preoperative, for both groups (p < 0.001).

CONCLUSION

Percutaneous sono-guided release using Sono-Instruments® is safe and efficient, and associated with quick functional recovery.

LEVEL OF EVIDENCE

II.

Perceived stress, coping strategies, symptoms severity and function status among carpal tunnel syndrome patients: a nurse-led correlational Study

BACKGROUND

Carpal tunnel syndrome (CTS) is a prevalent condition characterized by hand pain, tingling, and numbness. The severity of symptoms and functional status in CTS patients may be influenced by perceived stress and how individuals cope with it. However, scarce knowledge exists about the role of coping strategies as moderators in this relationship. Unfolding the role of perceived stress and coping strategies for CTS management will help the nurse to provide comprehensive and tailored nursing care. This will ultimately improve patient comfort, functionality, and quality of life.

PURPOSES

This study aimed to examine the role of coping strategies (adaptive and maladaptive) in the relationship between perceived stress and both symptoms severity and function status among those patients.

METHOD

We employed a multisite, correlational study design with moderation analysis. The study included 215 patients with CTS from neurosurgery outpatient clinics at three hospitals in Egypt. After obtaining their consent to participate, eligible participants completed anonymous, self-reported measures of perceived stress, the brief COPE inventory, and the Boston Carpal Tunnel Questionnaire. Demographic and biomedical data were also collected. The questionnaire took about 20 min to be completed. The data was collected over six months, starting in February 2023.

RESULTS

The results showed that perceived stress, adaptive coping, and maladaptive coping were significant predictors of symptoms severity and functional status. Adaptive coping moderated the relationships between perceived stress and both symptoms severity and function status, while maladaptive coping did not. The interaction between perceived stress and adaptive coping explained a moderate effect on symptoms severity and function status after controlling for the main effects and the covariates.

CONCLUSION

This study explored the relationship between perceived stress, coping strategies, and outcomes in patients with CTS. The results indicate that nurses play a vital role in assessing and assisting patients to adopt effective coping strategies to manage perceived stress and alleviate symptoms and functional impairment. Moreover, the findings support the need for psychological interventions that address both perceived stress and coping strategies as a way to enhance the functioning status and quality of life of patients with CTS.

Rasch analysis of the carpal tunnel syndrome instrument

BACKGROUND

The carpal tunnel syndrome instrument (CTSI) is the most widely used patient-reported outcome measure (PROM) in carpal tunnel syndrome (CTS). However, CTSI is an ordinal-type questionnaire and might have caused misinterpretations of the PROM between surgical outcomes of CTS (Camitz and extra/open carpal tunnel release).

PURPOSE

This study aims to convert the CTSI to an interval scale using Rasch analysis (RA) and evaluate the outcome differences between the original and transformed scales.

STUDY DESIGN

Prospective control study.

METHODS

Four hundred twenty-four patients with 567 CTSs had been interviewed for CTSI perioperatively and treated with either endoscopic/open carpal tunnel release or Camitz tendon transfer. Each CTSI was analyzed for dimensionality, fit statistics, and a transformation of the ordinal-to-interval scale by RA. We compared the two groups perioperative scores of three CTSI versions (original 11-item, modified 8-item, and transformed 8-item).

RESULTS

Based on the RA, the original CTSI was not unidimensional. We identified two dimensions. After removing misfit items, the perioperative course of each score by three versions of each dimension was compared (Repeated 2-factor analysis of variance). The transformed interval scales of CTSI provided different assessments of score changes from the ordinal scale of CTSI analyses.

CONCLUSIONS

Original CTSI consisted of ordinal scale items that yielded different conclusions than scores converted to interval scale by Rasch analysis. CTSI should convert into an interval scale after reclassifying dimensionality by Latent Factor Analysis and removing misfit items.

Occupational and non-occupational risk factors correlating with the severity of clinical manifestations of carpal tunnel syndrome and related work disability among workers who work with a computer

The contribution of certain occupational and personal factors to the development of carpal tunnel syndrome (CTS) is still uncertain. We investigated which specific occupational and non-occupational factors correlate with the level of clinical manifestations and work disability related to CTS. The study included 190 workers who work with a computer and have diagnosed CTS (100 men, 90 women, aged 20-65 years). Subjective experience of CTS-related impairments was assessed with the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) of the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The objective, neural impairments were tested with electrodiagnostics (EDX), whereas CTS-related work disability data were collected from medical records. We found a high inter-correlation between BCTQ, EDX, and work disability data. These also showed high correlations with certain occupational factors (duration of computer-working in months and hours spent daily in computer-working, certain ergonomic, microclimatic, and other occupational conditions) and non-occupational factors (demographic and lifestyle factors: nutritional status, diet, smoking, alcohol consumption, and physical activity). Despite its limitations, our study has identified occupational and non-occupational risk factors that can aggravate CTS and work disability, but which can also be improved with workplace and lifestyle preventive and corrective measures. More research is needed, though, to establish the possible causal relationships and the independent influence of each of those risk factors.

Diagnostic utility of anteroposterior measurements of the median nerve on sagittal ultrasonographic images and their correlation with clinical findings in carpal tunnel syndrome

PURPOSE

To investigate the efficacy of sagittal ultrasonography of the median nerve in diagnosing carpal tunnel syndrome (CTS).

METHODS

Seventy-six hands with idiopathic CTS and 80 hands of asymptomatic subjects were included. All patients with CTS underwent ultrasonographic examination, electrodiagnostic testing, and CTS-6 assessment. In the sagittal ultrasonographic examination, the maximum and minimum median nerve diameters (MNDs) were measured at the proximal and distal ends of the carpal tunnel, respectively. The median nerve stenosis rate (MNSR) was computed as (1 - minimum MND/maximum MND) × 100 (%). The cross-sectional area (CSA) of the median nerve at the level of the pisiform was measured.

RESULTS

In the sagittal ultrasonographic examination, the mean maximum MNDs were 0.252 cm and 0.202 cm, mean minimum MNDs were 0.145 cm and 0.165 cm, and mean MNSRs were 41.83% and 17.35% in the CTS and control groups, respectively; the mean maximum MND and MNSR were considerably larger in the CTS group. The maximum MND and MNSR were correlated with the electrodiagnostic testing results and CTS-6 score. The MNSR with a cut-off value of 34.0% had a higher sensitivity and specificity than the CSA in diagnosing CTS.

CONCLUSIONS

Sagittal ultrasonographic examination is useful in diagnosing CTS.

The effectiveness of neuromobilization exercises in carpal tunnel syndrome: Systematic review and meta-analysis

PURPOSE

To examine the effectiveness of Neuromobilization Exercises (NE) on pain, grip and pinch strength, two-point discrimination, motor and sensory distal latency, symptom severity, and functional status using the Boston Carpal Tunnel Questionnaire (BCTQ) in Carpal Tunnel Syndrome (CTS).

METHODS

Major electronic databases were searched from inception up to September 2021 for randomized trials comparing the effects of NE with or without other interventions against no treatment, surgery, or other interventions in patients with CTS. Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the GRADE approach.

RESULTS

Twenty-five articles were included and sixteen of them demonstrated high methodological quality. NE was superior to no treatment on pain (very low-quality evidence; SMD = -2.36, 95% CI -4.31 to -0.41). NE was superior to no treatment on the functional scale of the BCTQ (low-quality evidence; SMD = -1.27 95% CI -1.60 to -0.94). Most importantly, NE did not demonstrate evidence of clinical effectiveness.

CONCLUSION

Low to very low-quality evidence suggests that there are no clinical benefits of NE in patients with mild to moderate CTS.

Reducing Opioid Exposure Following Common Ambulatory Hand Surgery: A Systematic Review

BACKGROUND

The opioid epidemic is a health crisis in the United States. Physicians contribute to this problem by overprescribing opioids. Ambulatory hand surgery (AHS) is common in the United States and associated with overprescribing of opioids. Education and guidance regarding the effectiveness of nonopioid compared with opioid interventions for pain management following ambulatory hand procedures are lacking. We assessed the current literature to suggest evidence-based protocols for postoperative analgesia.

METHODS

A systematic review was performed using PubMed, Web of Science, and Cochrane Library. Studies comparing nonopioid with opioid treatments for pain management following AHS were identified. Studies investigating opioid-sparing strategies after AHS were also identified. Evidence was examined to determine efficacy of nonopioid interventions and to provide recommendations for optimal nonopioid protocols and opioid-sparing strategies.

RESULTS

A total of 510 studies were identified in the search with 18 meeting inclusion criteria. High-level evidence demonstrated efficacy of nonopioid interventions for pain management following AHS (levels I and II evidence). Results provided evidence-based guidelines for recommendations of nonopioid treatment protocols and opioid-sparing strategies (levels I and II evidence).

CONCLUSIONS

Our review demonstrated nonopioid interventions are adequate in multiple aspects of pain management compared with opioid treatments. Recommendations were established for two nonopioid treatment protocols, and for an opioid-sparing intervention (levels I and II evidence). The evidence provided in this review should be strongly considered for pain management guidance following AHS and provides a means to decrease opioid overprescribing in the United States.

Early Postoperative Recovery after Modified Ultra-Minimally Invasive Sonography-Guided Thread Carpal Tunnel Release

Thread carpal tunnel release (TCTR) has been reported to be safe and effective for the treatment of carpal tunnel syndrome. The aim of this study is to evaluate the modified TCTR for safety, efficacy, and postoperative recovery. Seventy-six extremities in 67 patients undergoing TCTR were analyzed pre- and postoperatively using clinical parameters and patient-reported outcome measures. Twenty-nine men and 38 women with a mean age of 59.9 ± 18.9 years underwent TCTR. The mean postoperative time to resume activities of daily living was 5.5 ± 5.5 days, analgesia was completed after 3.7 ± 4.6 days, and return to work was achieved after a mean of 32.6 ± 15.6 days for blue-collar workers and 4.6 ± 4.3 days for white-collar workers. The Boston Carpal Tunnel Questionnaire (BCTQ) and Disability of Arm, Shoulder, and Hand (DASH) scores were comparable with previous studies. Overall, two persistent compressions and one recurrence required open reoperation (3.9%). All three had been operated in the initial phase, and none required reoperation after an additional safety step was introduced. No other complications occurred. TCTR surgery appears to be a safe and reliable technique with almost no wound and scarring and a potentially faster recovery time than open techniques. Although our technical modifications may reduce the risk of incomplete release, TCTR requires both ultrasound and surgical skills and has a considerable learning curve.

Splinting for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.

OBJECTIVES

To assess the effects (benefits and harms) of splinting for people with CTS.

SEARCH METHODS

On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies.

SELECTION CRITERIA

Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.

MAIN RESULTS

We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence).  We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence).  None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants).  There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.

Patient-Reported Outcomes and Provocative Testing in Peripheral Nerve Injury and Recovery

Background  Peripheral nerve function is often difficult to assess given the highly variable presentation and subjective patient experience of nerve injury. If nerve assessment is incomplete or inaccurate, inappropriate diagnosis and subsequent treatment may result in permanent dysfunction. Objective  As our understanding of nerve repair and generation evolves, so have tools for evaluating peripheral nerve function, recovery, and nerve-related impact on the quality of life. Provocative testing is often used in the clinic to identify peripheral nerve dysfunction. Patient-reported outcome forms provide insights regarding the effect of nerve dysfunction on daily activities and quality of life. Methods  We performed a review of the literature using a comprehensive combination of keywords and search algorithms to determine the clinical utility of different provocative tests and patient-reported outcomes measures in a variety of contexts, both pre- and postoperatively. Results  This review may serve as a valuable resource for surgeons determining the appropriate provocative testing tools and patient-reported outcomes forms to monitor nerve function both pre- and postoperatively. Conclusion  As treatments for peripheral nerve injury and dysfunction continue to improve, identifying the most appropriate measures of success may ultimately lead to improved patient outcomes.

A prospective cohort study: platelet-rich plasma combined with carpal tunnel release treating carpal tunnel syndrome

Background

PRP injection was proved to promote the health condition of individuals with mild to moderate Carpal Tunnel Syndrome (CTS). However, carpal tunnel release (CTR) was still a necessary treatment for individuals with moderate and severe CTS.

Methods

To explore whether adjuvant PRP treatment would improve the prognosis while using CTR, we included 82 patients in this study. Preoperative and postoperative visual analog scale (VAS), Boston carpal tunnel syndrome questionnaire-symptom severity scale (BCTQ-SSS), Boston carpal tunnel syndrome questionnaire-functional status scale (BCTQ-FSS), and grip strength were used to examine the patient's symptoms and function.

Results

CTR combined with PRP treatment improved the VAS (1.9 ± 0.5 versus 1.4 ± 0.4, P < .05), BCTQ-SSS (1.8 ± 0.4versus 1.5 ± 0.3, P < .05) and BCTQ-FSS (1.8 ± 0.5 versus 1.4 ± 0.6, P < .05) in patients with moderate symptoms within one month after surgery. At the same time, it does not show any advantages in treating individuals with severe carpal tunnel syndrome.

Conclusions

PRP does not affect long-term prognosis while increasing the surgery cost. To conclude, PRP as an adjuvant treatment of CTR has limited effect. Considering the additional financial burden on patients, CTR combined with PRP should be cautious in CTS treatment.

The Effectiveness of Plasma Rich in Growth Factors (PRGF) in the Treatment of Nerve Compression Syndromes of the Upper Extremity: A Retrospective Observational Clinical Study

Background: Nerve compression syndromes of the upper extremity are a common cause of neuropathic pain and functional impairment. Recently, platelet-rich plasma (PRP) infiltrations have emerged as an effective biological approach to the treatment of this type of injury. The objectives of this retrospective observational study were to assess clinical improvement in patients with median and ulnar nerve entrapment syndrome after undergoing biologically-assisted nerve release surgery with plasma-rich-in-growth-factors (PRGF) technology. Methods: Participants (n = 39) with moderate-to-severe nerve compression syndrome of the upper limb diagnosed by both electromyography and clinical examination, and who were treated with PRGF, were identified from the center’s medical records. The evaluation was based on patient-reported outcomes. Pre- and post-treatment differences in the Visual analog scale (VAS), the Boston carpal tunnel questionnaire (BCTQ), and the Quick-DASH score were assessed. Results: Three study groups were conducted: patients with carpal tunnel syndrome (n = 16), with recurrent carpal tunnel syndrome (n = 8), and with ulnar nerve entrapment (n = 15). The median follow-up was 12 months (interquartile range (IQR), 9−16). In comparison to pre-treatment values, all three study groups obtained statistically significant improvements for the three analyzed scales at the end of the follow-up, with p < 0.001 for all scales in the carpal tunnel syndrome and ulnar nerve entrapment groups and p < 0.01 for all scales in the recurrent carpal tunnel syndrome group. There were no serious adverse effects in the analyzed patients. Conclusion: PRGF-assisted open surgical nerve release treatment (intraneural and perineural liquid PRGF infiltrations and nerve wrapping with PRGF membrane) exerts long-term beneficial effects on pain reduction and functional improvement in the nerve and nerve−muscle unit in patients with upper extremity compression syndromes.

Utility of carpal tunnel release and ulnar decompression in CMT1A and HNPP

INTRODUCTION/AIMS

Carpal and cubital tunnel syndrome (CTS, CuTS) are common among patients with hereditary neuropathy with liability to pressure-palsies (HNPP) and Charcot-Marie-Tooth-1A (CMT1A), and may impact quality of life. We aimed to evaluate the utility of nerve decompression surgeries in these patients.

METHODS

Medical records were reviewed for patients with PMP22 mutation confirmed in Mayo Clinic laboratories from January 1999 to December 2020, who had CTS and CuTS and underwent surgical decompression.

RESULTS

CTS occurred in 53.3% of HNPP and 11.5% of CMT1A, while CuTS was present in 43.3% of HNPP and 5.8% of CMT1A patients. CTS decompression occurred in 10-HNPP and 5-CMT1A patients, and CuTS decompression with/without transposition was performed in 5-HNPP and 1-CMT1A patients. In HNPP, electrodiagnostic studies identified median neuropathy at the wrist in 9/10 patients and ultrasound showed focal enlargements at carpal and cubital tunnels. In CMT1A, median and ulnar sensory responses were all absent, and the nerves were diffusely enlarged. After CTS surgery, pain, sensory loss, and strength improved in 4/5 CMT1A, and 6/10 HNPP patients. Of clinical, electrophysiologic and ultrasound findings, only activity-provoked features significantly correlated with CTS surgical benefit in HNPP patients (odds ratio=117.0:95% CI 1.94>999.99, p=0.01). One CMT1A and one HNPP patient improved with CuTS surgery while 2 HNPP patients worsened.

DISCUSSION

CTS symptom improvement post-surgery can be seen in CMT1A and (less frequent) in HNPP patients. CuTS surgery commonly worsened course in HNPP. Activity-provoked symptoms in HNPP best informed benefits from CTS surgery.

Use of Sonophoresis with Corticosteroids in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

Carpal tunnel syndrome is a neuropathic disease. It is one of the most frequent musculoskeletal pathologies affecting the upper limbs. One of most frequently used non-surgical treatments is corticosteorids. There are several alternatives for corticosteroids administration. One of them is phonophoresis, this being an effective and painless method of treatment. A systematic review and meta-analysis have been conducted over the use of phonophoresis with corticosteroids for the treatment of carpal tunnel syndrome compared to other non-surgical treatment methods. Keywords from Medical Subjects Headings (MeSH) were used in the following databases: Wos, Scopus, CINHAL, SciELO and PeDro. A total of 222 potentially relevant articles were retrieved. Eleven articles analysing the efficacy of phonophoresis with corticosteroids in reducing pain symptoms in individuals with carpal tunnel syndrome were included, 10 of which were used to conduct the meta-analysis. A conclusion could not be reached as to the application of phonophoresis with corticosteroids being better than other treatment methods, except for the perception of pain and an improved motor and sensory nerve conduction in cases of mild to moderate carpal tunnel syndrome.

Boston Carpal Tunnel Questionnaire and Severity of Carpal Tunnel Syndrome

OBJECTIVES

Carpal tunnel syndrome (CTS) is a common compressive neuropathy linked to disability in severe cases. Tools capable of distinguishing the severity spectrum median nerve entrapment in clinical practice are desirable.

METHODS

This cross-sectional study included 58 CTS patients assisted in a Brazilian neurologic clinic. Participants were naive of surgical interventions and answered to Boston Carpal Tunnel Questionnaire (BCTQ). CTS was classified as mild, moderate, and severe according to electrodiagnostic testing.

RESULTS

There was no significant difference in BCTQ scores across the severity spectrum of median nerve entrapment, not even comparing mild cases with the group moderate/severe. Mild cases were younger (mean ± SD: 46.5 ± 9.2 years) than severe ones (60.0 ± 13.5, P = 0.04) and the group moderate/severe (55.5 ± 14.5, P = 0.01).

CONCLUSIONS

Results suggest that BCTQ is not adequate to assess the interpatient severity of median nerve entrapment on clinical practice.

Measuring symptoms severity in carpal tunnel syndrome: score agreement and responsiveness of the Atroshi-Lyrén 6-item symptoms scale and the Boston symptom severity scale

PURPOSE

To assess score agreement between the Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale and compare their responsiveness in patients with carpal tunnel syndrome before and after carpal tunnel release surgery.

METHODS

This prospective cohort study included 3 cohorts that completed the A-L and Boston scales (conventional score 1-5) on the same occasion: a preoperative and short-term postoperative cohort (212 patients), a mid-term postoperative cohort (101 patients), and a long-term postoperative cohort (124 patients). Agreement was assessed with Lin's concordance correlation coefficient and Passing-Bablok regression analysis. Analyses using item response theory were conducted on responses from the preoperative/short-term postoperative cohort including testing of item infit/outfit. Reliability was assessed with Cronbach alpha. Overall and sex-specific effect sizes were calculated using Cohen's d.

RESULTS

Lin's CCCs were high (0.81-0.91). Passing-Bablok analysis showed constant and proportional differences in all cohorts except preoperative to short-term postoperative change. Both scales showed high reliability (alpha, 0.88-0.93). The IRT-based analyses showed infit/outfit values within the desired range. With IRT-based scoring, the A-L scale had significantly higher responsiveness than the Boston scale, overall (d, 2.02 vs 1.59), in women (d, 2.22 vs 1.77) and in men (d, 1.74 vs 1.36).

CONCLUSION

The Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale show good agreement but are not equivalent in measuring CTS-related symptoms severity. When using IRT-based scoring, the Atroshi-Lyrén scale demonstrated significantly higher responsiveness.

Endoscopic Carpal Tunnel Release: Techniques, Controversies, and Comparison to Open Techniques

Endoscopic carpal tunnel release (ECTR) continues to rise in popularity as a treatment option for carpal tunnel syndrome. Numerous variations in technique and instrumentation currently exist, broadly classified into two-portal and single-portal techniques with antegrade and retrograde designs. ECTR is equally effective as open carpal tunnel release for alleviating symptoms of carpal tunnel syndrome with no differences in long-term outcomes. ECTR has an increased risk of transient nerve injury, whereas open carpal tunnel release has an increased risk of wound and scar complications. ECTR has higher direct costs but is associated with earlier return to work. ECTR is a safe and effective approach to carpal tunnel release in the hands of experienced surgeons.

Association between severity of COVID-19 symptoms and habitual food intake in adult outpatients

Objective

To evaluate the association between habitual frequency of food intake of certain food groups during the COVID-19 pandemic and manifestations of COVID-19 symptoms in adult outpatients with suspected SARS-CoV-2 infection.

Design

We included 236 patients who attended an outpatient clinic for suspected COVID-19 evaluation. Severity of symptoms, habitual food intake frequency, demographics and Bristol chart scores were obtained before diagnostic confirmation with real-time reverse transcriptase PCR using nasopharyngeal swab.

Results

The results of the COVID-19 diagnostic tests were positive for 103 patients (44%) and negative for 133 patients (56%). In the SARS-CoV-2-positive group, symptom severity scores had significant negative correlations with habitual intake frequency of specific food groups. Multivariate binary logistic regression analysis adjusted for age, sex and occupation confirmed that SARS-CoV-2-positive patients showed a significant negative association between having higher symptom severity and the habitual intake frequency of ‘legumes’ and ‘grains, bread and cereals’.

Conclusions

Increase in habitual frequency of intake of ‘legumes’, and ‘grains, bread and cereals’ food groups decreased overall symptom severity in patients with COVID-19. This study provides a framework for designing a protective diet during the COVID-19 pandemic and also establishes a hypothesis of using a diet-based intervention in the management of SARS-CoV-2 infection, which may be explored in future studies.

Magnetic Resonance Imaging–Measured Cross-Sectional Area of the Median Nerve

Purpose

The size of the median nerve may serve as a useful parameter to predict carpal tunnel syndrome (CTS) in a subset of patients. The purpose of this study was to evaluate magnetic resonance imaging–based measurements of median nerve cross-sectional area (CSA) to examine trends between patient subgroups and CSA that may assist in predicting the individuals who are most likely to develop CTS symptoms.

Methods

A retrospective chart review of 1,273 wrist magnetic resonance images was performed, and the images were analyzed to evaluate the median nerve CSA at the level of the pisiform and the hook of hamate. The age, sex, height, weight, and body mass index (BMI) of the patients were collected from their medical records.

Results

The median nerve size correlated with patient BMI. Additionally, patients with CTS had larger median nerves at the hook of hamate and pisiform than those without CTS. When subdividing patients on the basis of BMI, obese patients with CTS had larger median nerve CSA at the pisiform than those without CTS.

Conclusions

This study demonstrated that increased BMI is associated with increased median nerve CSA at the hook of hamate and pisiform in patients with or without CTS. Additionally, patients with CTS had larger median nerve CSA than those without CTS. Measurements at these locations may help predict individuals who are likely to experience median nerve impingement.

Type of study/level of evidence

Prognostic III.

Use of conservative therapy before and after surgery for carpal tunnel syndrome

Background

Conservative therapies are typically offered to individuals who experience mild or intermittent symptoms of carpal tunnel syndrome (CTS) or postoperatively to subjects who have undergone carpal tunnel release. Although long-term studies report mostly positive results for carpal tunnel release, knowledge on the need for conservative treatments following surgery is scarce. The aim of this retrospective cohort study was to examine the use of conservative therapies before and after carpal tunnel releasing surgery.

Methods

Of 528 patients who underwent carpal tunnel release surgery in the study hospital during the study period, 259 provided sufficiently completed questionnaires (response rate 49 %). The patients completed a questionnaire battery including a sociodemographic, medical history and symptom questionnaire, the Boston Carpal Tunnel Syndrome Questionnaire, 6-item CTS symptoms scale and EuroQoL 5D. Frequencies of conservative therapies pre- and postoperatively were calculated. Association between Pain VAS and satisfaction with treatment were examined in patient groups according to the use of conservative therapies.

Results

Of all patients, 41 (16 %) reported receiving only preoperative, 18 (7 %) reported receiving only postoperative, 157 (60 %) reported receiving both pre- and postoperative conservative therapies and 43 (17 %) did not receive any therapies. Preoperative use of conservative therapies was more common in females than males (82 % vs. 64 %; p = 0.002), but postoperatively no significant gender difference was observed. The patients who received conservative therapies were younger than non-users in both the preoperative (median age 59 vs. 66; p < 0.001) and postoperative (59 vs. 66; p = 0.04) phases. The patients reported high satisfaction with their treatment and simultaneous improvement in Pain VAS scores. Those receiving conservative therapies only preoperatively reported the highest satisfaction.

Conclusions

While the use of conservative therapies decreased after surgery, a large proportion of the patients received these adjunct interventions. Patients reported high satisfaction with their treatment one year post surgery. Pain outcome seems to be closely related to satisfaction with treatment.

Level of Evidence

Level III.

Measurement properties of the Boston Carpal Tunnel Questionnaire in subjects with neurophysiological confirmation of carpal tunnel syndrome: a Rasch analysis perspective

PURPOSE

To perform a comprehensive psychometric analysis of the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) by means of factor and Rasch analyses in subjects with neurophysiologic confirmation of carpal tunnel syndrome (CTS). Relationship between clinical severity assessed with the log-linear version of the BCTQ and neurophysiologic severity assessed with nerve conduction studies was further examined.

METHODS

Five hundred and twenty-eight individuals completed the questionnaire. Confirmatory and exploratory factor analyses were used to determine the latent structure of the BCTQ. Through Rasch methodology, a log-linear version was proposed given the latent structure of the questionnaire. Linear relationship between the proposed questionnaire and neurophysiologic findings was established.

RESULTS

The BCTQ underlying structure comprises, at least, three factors that may be represented by Functionality, Paresthesia and Pain domains. Two log-linear subscales may be proposed: subscale 1 comprised of the Functionality factor and subscale 2 which incorporates the Paresthesia and Pain factors under a bifactor solution. Neurophysiologic and clinical severity classification system displays a very weak linear correlation.

CONCLUSION

A log-linear version of the BCTQ, useful as an outcome tool in clinical and trial settings, is proposed. Neurophysiological data lack the ability to resemble changes in clinical status of individuals with CTS.