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Impact of carpal tunnel syndrome on the expectant woman's life

Impact of carpal tunnel syndrome on the expectant woman's life Introduction: Carpal Tunnel Syndrome is known to be a common complication during pregnancy especially during the third trimester. Aim: This article focuses on its impact to the third trimester pregnant mothers with CTS. Methods: Third trimester pregnant mothers with no other known risk factors for CTS, were interviewed and examined for a clinical diagnosis of CTS. The severity of CTS was assessed by means of symptoms severity and functionality using the Boston Carpal Tunnel Questionnaire. Results: Out of 333 third trimester pregnant mothers, 82 (24.6%) were clinically diagnosed with CTS. Malay race was found to have significant correlation with the diagnosis of CTS (p = 0.024) and are two times more likely to get CTS during pregnancy (OR = 2.26) compare to the non-Malays. Bilateral CTS was two times higher (n = 58, 63.4%) than unilateral cases (n = 30, 36.6%), however no significant correlation between the two was found with severity (p = 0.284) or functional (p = 0.906). The commonest complaint was numbness/tingling during day time (n = 63, 76.8%). Majority of the CTS cases were mild (n = 66, 80.5%) and approximately one third (n = 28, 34.1%) had affected hand functions. All symptoms related to pain was found to have significant correlation with severity (p = 0.00, OR = 12.23) and function (p = 0.005, OR = 5.01), whereas numbness and tingling does not (Severity, p = 0.843, function, p = 0.632). Conclusion: This study shows that even though CTS in third trimester pregnancy is prevalent, generally it would be mild. However, function can still be affected especially if patients complain of pain. Keywords: Carpal Tunnel Syndrome, third trimester pregnancy, prevalence, impact, severity, functional Introduction symptoms”. Subsequent studies made and more theories CTS occurs when the median nerve is entrapped within of CTS in pregnancy were proposed. As more studies the Carpal Tunnel causing sensations of pain, numbness begin to address CTS in pregnancy, there was still no and tingling at the median nerve distribution in the equivocal estimate of how common it is in pregnancy hand and could extend up to the arms. Previous studies and how severe it could be. A study by Voitk et al. had found that CTS was more prevalent in the female found that 24.9% of pregnant mothers had hand symp- population. It was postulated because morphologically, toms in the median nerve distribution, where 51% found females are more prone to CTS compare to male [1]. the symptoms annoying, disturbed functions in 42%, 29% claimed that it interferes with sleep and 4% found CTS were first linked with pregnancy in 1957 by Wal- lace and Cook where they describe two cases of CTS in that it was intolerable [3]. Voitk et al. also recorded that pregnancy and did surgical decompression [2]. The only 49% mentioned the symptoms to their doctor in paper focuses on “pressure as the cause of such which only 16% were treated or given advice. Luckily many study found that the timing of the first pain of CTS occurs during pregnancy was the highest * Correspondence: contactbonedoctor@gmail.com Department of Orthopaedic, Faculty of Medicine, Universiti Kebangsaan during the third trimester [4,5] rather than facing the Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000 pain throughout the pregnancy. However there is not Cheras, Kuala Lumpur, Malaysia © 2012 Rozali et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 2 of 6 http://www.apfmj.com/content/11/1/1 much literature to assess how much CTS actually affects are enough to suggest CTS and they will be asked to their daily life as pregnant mothers particularly during map the site of the symptoms. in that third trimester. CTS might be the least of pro- (c) Underreported CTS. The pregnant mothers were blem that these woman had to face during pregnancy in also asked whether or not they had mentioned their which most of them experienced resolution[6,7] or symptoms to the doctors and whether treatment was improvements after delivery,[8] but the fact is, there are given for those who mentioned. no real data to address this problem. Therefore this The severity of CTS was evaluated using the Boston study focuses on how much CTS actually affects a Carpal Tunnel Questionnaire (BCTQ) [10]. The BCTQ consist of two measurements of disease’s severity, the mother’s life during the third trimester pregnancy. symptoms severity and functional status. The BCTQ is Methods also the main instrument used with the aim of studying Study Design the impact of CTS in pregnant mothers. This study is a prospective cross sectional study invol- ving 333 third trimester pregnant mothers from Statistical Analysis UKMMC Obstetric clinic. The data was analysed using the Statistical Package for Social Sciences (SPSS) 13. In order to estimate fre- Subjects and Settings quency (in percentage), standard descriptive statistical It was conducted from October 2010 till April 2011. methods were used on all variables except for the age Ethical approval by UKM Ethical Committee was which was a continuous data therefore expressed in obtained for this study. The pregnant mothers were mean and standard deviations. Relationships among selected at the UKMMC Obstetric Clinic during their categorical variables including the BCTQ symptoms antenatal follow up. Only pregnant mothers who were severity and functional severity were determined using in their third trimester were approached. After taking Chi-Square (X ) test. The BCTQ scores for symptoms consent, they were asked regarding exclusion criteria severity and functional status was also summed up into namely Gestational Diabetes Mellitus, Hypertension, group totals as proposed by Store et.al [11] as it was athropathies, thyroid disease, trauma at the hand or found to be the best way to present the data. The score wrist and pre-existing or history eclampsia or pre- totals used for symptoms severity was categorized into eclampsia, previous diagnosis of CTS and recurrent asymptomatic (11), mild (12-22), moderate (23-33), CTS. Clinical diagnosis of CTS was made from history severe (34-44) and very severe (45-55). Functions scores and physical examination. Pregnant mothers with nor- were grouped into asymptomatic (8), mild (9-16), mod- mal findings from physical examination and history erate (17-24), severe (25-32) and very severe (33-40) were grouped as non-CTS. For the CTS group, subjects [10]. For associations that were found to be significant, with onset of symptoms during first and second trime- odds ratio (OR) and 95% confidence interval was also ster were excluded. Subjects with distribution of symp- calculated. P value of less than 0.05 was considered as toms other than median nerve distribution, abnormal statistically significant. lumps or bumps at the hand or wrist, or positive for higher nerve compression were also excluded. This was Results done to ensure that the CTS group in our study is not In total, 333 third trimester pregnant mothers, with age because of other pathology in order to study the true ranged between 17-45 years old had agreed to partici- nature of CTS in pregnancy. pate in this study. There are multiracial involvement amongst the respondents consisting of the Malays (n = Instruments 263, 79%), and non Malays; Chinese (n = 54, 16.2%), The history taking was standardized using a question- Indians (n = 8, 2,4%) and other races (n = 8, 2.4%). The naire consisting or three main parts, National Statistics Department had revealed that Malay- (a) Demographic data, age, parity, registration number, sia had a population of 25.7 million of which 24 million and gestational weeks; Malaysians (93.4%) and 1.7 million were non-Malaysians (b) Diagnosis of CTS. The pregnant mothers were first (6.6%). Among the non-Malays, Indians made up 1.8 asked whether they had been diagnosed with CTS or million (7.5%), Chinese 6.1 million (25.4%), other races not. Six-item Carpal Tunnel SyndromeScale(CTS-6) 300,000 (1.3%) [12]. Therefore, the distribution of races questions were used for the diagnosis of CTS [9]. In in our study might not be exactly the same with the order to refined the scale, another item was added to racial distribution in Malaysia, however it is similar in the CTS 6 which was “shaking the hand relieves the which most of Malaysians are Malays followed by Chi- hand symptoms”. One or more symptoms in the CTS-6 nese, Indians and others. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 3 of 6 http://www.apfmj.com/content/11/1/1 82 pregnant mothers (24.6%) were clinically diagnosed (n = 59, 72%), relief by shaking (n = 43, 52.4%), waking to have CTS where 72 (87%) of them were Malays, and up due to numbness (n = 27, 32.9%), pain during day 10 (12%) were non-Malay which comprise of Chinese (n and night time (both n = 20, 24.4%), and the least com- = 9, 11%) and Indians (n = 1, 2.4%). The correlation of mon symptom was waking up due to pain (n = 14, the Malay race with CTS in this study was found to be 17.1%). Similarly, the most common complaint from the significant (p = 0.024) and the risk for Malay pregnant BCTQ symptom severity scale (Figure 1) was also mothers to get CTS was twice higher than the non- numbness (n = 76, 92.7%), where 45 (54.9%) had mild malays (OR = 2.26). Other variables such as gravida, numbness, 27 (32.9%) moderate numbness and 4 (4.9%) had severe numbness. The other two common com- parity, and age have no significant correlation with CTS. The cases of bilateral CTS in pregnancy (n = 58, plaints were tingling sensation (n = 62, 75%) and numb- 63.4%) were almost two times more than the unilateral ness at night (n = 53, 64.6%). Even though pain was the cases (n = 30, 36.6%). However, whether it is bilateral or least common complaint for CTS in pregnancy it was unilateral CTS, there was no significant correlation with found that complains of any symptoms related to pain the severity of CTS (p = 0.284) or functional (p = have significant correlation with severity (p = 0.00, OR 0.906). From the physical examination, 11% had affected = 12.23) and function (p = 0.005, OR = 5.01), whereas 2 point discrimination and8.5%had weakness of the numbness and tingling did not (Severity, p = 0.843, func- abductor pollicis brevis muscle. tion, p = 0.632). Among those who complained of pain, The most common presenting symptom from the numbness or tingling at night, 13 (15.9%) woke up because CTS-6 was numbness and tingling during daytime (n = of pain and 27 (32.9%) woke up because of numbness or 63, 76.8%), followed by numbness and tingling at night, tingling sensation. However, both complaint of waking up Figure 1 Symptoms severity by each complaints. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 4 of 6 http://www.apfmj.com/content/11/1/1 due to pain or waking up due to numbness had significant community, not even to the high risk group of pregnant correlation with impaired function (p = 0.001, p = 0.000 mothers. respectively). As a whole, summation of BCTQ-Symptoms severity Discussion scale (Figure 2) revealed that, most of the CTS cases in Recognizing the prevalence of CTS in pregnancy gives third trimester pregnancy was mild (n = 13, 80.5%), 7 an overview on how common and important it is in the (17.1%) had moderate CTS and only 1 respondent community. The prevalence of CTS in pregnancy varies (2.4%) had the severe form of CTS. Whereas, the from the previous researches. Padua et.al and Pazzaglia BCTQ-Functional scores (Figure 2) found that 28 [13] et.al recorded more than 50% incidence of CTS in (34.1%) of symptomatic pregnant mothers had func- pregnancy, Voitk et al. recorded that it was 34% while tional difficulties, where 21 (25.6%) had mild and 7 Stolp et al. found that it was less than 1%. In our study, (8.5%) had moderate functional difficulties. There were theprevalencewas 24.6%or onefourthofuncompli- no respondents’ scores higher than moderate functional cated third trimester pregnancy. We choose to study score. The function from the BCTQ-functional score specifically the woman in the third trimester as previous according to task is shown in Figure 3. The task that study found that most CTS during pregnancy occur rd was commonly affected were carrying grocery bag (n = during the 3 trimester [4,5]. Compared to other stu- 18, 23%), followed by doing household chores (n = 17, dies, this study also excludes CTS in Diabetic patients in 20.7%), gripping telephone (n = 15, 18.3%) and writing which was a known risk factor for CTS. Other diseases (n = 15, 18.3%), holding a book (n = 13, 15.9%), opening which are common in pregnancy, (thyroidism and a jar (n = 12, 14.6%), buttoning clothes (n = 9, 14.6%) hypertension) and higher nerve compression were also and bathing and dressing (n = 7, 9%). excluded. Therefore, it can be concluded that the small Despite all this, only 21 (25.6%) of the symptomatic number of CTS patients was because the respondents pregnant mothers mentioned their problems to the doc- selected were only those who had pure idiopathic CTS tor in which only 2 (9.5%) receive treatments, such as during pregnancy. This is an important criterion as only vitamins, painkillers, calcium supplements and advice to the pure idiopathic CTS in pregnancy respondents were drink plenty of milk. There was a significant correlation indentified. This allows us to get the appreciation of the between the number of pregnant mothers who mention true nature of idiopathic CTS in pregnancy. Previously their symptoms to the doctors with the severity (p = there was no study that found CTS had significant cor- 0.013, OR = 4.08) and function (p = 0.041, OR = 2.84). relation with ethnicity. Therefore, the finding that CTS In addition to that, it was also observed that none of the was twice as common in the Malay is an important find- pregnant mothers knew about CTS except for those ing for the Malaysian population. The pathology and who work in the clinical health setting such as doctors reasons however, was unknown as this was the first and nurses. However no objective data were taken to finding documented in literature. support this. But this fact further strengthens the The incidence for unilateral and bilateral CTS in preg- impression that CTS is still not well known to the nancy was almost the same, with bilateral cases being higher than unilateral cases. Whether the CTS were uni- lateral or bilateral, it has no significant correlations with increasing of severity or impairment of function. This was the same with one of the studies by Padua et.al on CTS in general population where bilateral cases was also higher but no significant correlation with severity [8]. In this study BCTQ was used, as it is a standardised, patient-based outcome measure of symptom severity and functional status in patients with carpal tunnel syndrome. The use of BCTQ in this study was also preferred as it was found to be valid, reliable, responsive and it is an acceptable instrument to assess CTS according to a review on BCTQ [14]. In the present study, 80.5% of pregnant mothers were found to have mild symptoms of CTS and smaller number was found to have moderate CTS. Therefore even though CTS in pregnancy could occur in one fourth of pregnant mothers with no other Figure 2 Frequency of symptoms and functional severity risk factor for CTS, the severity will not extend beyond according to group totals. moderate. However, considering that pregnant mothers Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 5 of 6 http://www.apfmj.com/content/11/1/1 Figure 3 Functional severity by each task. would also experienced other difficulties such as back complain of pain also have 12 times higher risk getting pain, abdominal pain, or leg swelling, such disturbances moderate to severe CTS. Compare to respondents who could be a significant stressor to the mother. complains of numbness only, not many had functional The result in Figure 1 shows that the nature of CTS in difficulty unless it was severe enough to wake them up at night. Another way to interpret this is that both wak- third trimester pregnant mothers revolves more on ing up at night because of the symptoms, whether its numbness and tingling. Numbness or paraesthesia was also found to be the most common symptoms of CTS pain or numbness, have significant correlation with in pregnancy and CTS in general [15]. On the other functionality. Therefore, mothers with sleep difficulty hand, even though numbness and tingling was more find CTS more disturbing during the day than those common than all the other complaint, it was not as whose sleep not affected. This can be a good indicator troubling as pain. Voitk et.al documented that pain was for future studies on impact of CTS particularly during a prominent feature in 67% of symptomatic pregnant pregnancy. mothers. In the present study, all of the symptoms in Even though more than 80% of CTS cases in preg- CTS-6 regarding pain did not have any significant corre- nancy were found to be mild, one third of the pregnant lation to the symptoms severity, but it was found to mothers with CTS had some degree of functional diffi- have a significant correlation with impairment of func- culties. The most affected task involves doing heavy tion. Whereas for numbness, only waking up due to work such as carrying grocery bag and household numbness had significant correlation with impairment chores. Since some pregnant mothers who are in their of function. This signifies that once a patient complains third trimester usually avoid hard work, the functional of pain, regardless of severity, the function would difficulties may not be so prominent. This could also be usually become impaired. Pregnant mothers who thereasonwhy thenumberofpregnantmothers that Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 6 of 6 http://www.apfmj.com/content/11/1/1 Head of Obstetrics and Gynaecology Department, for giving us the mention their symptoms to their doctors was only 26%. permission to run this study, Prof Shamsul for his help with the statisctics, However what would be more of a concern was that and not forgetting all the pregnant mothers who had participated. Our among those who mention the symptoms to their doc- study was supported by the UKMMC Medical Research and Industry Secretariat (FF-008-2011) tors, less than 10% were given treatment. Not only that, most of the treatment offered was not related to treating Authors’ contributions CTS such as giving vitamins, calcium supplements and ZIR, YKF, WNH, PKDC, and MFN have the same weightage of contributions in carrying out the study from the literature reviews, proposals, interviewing advice to drink milk. In one previous study, it shows the subjects, analyze the data, and preparing the manuscript. ZIR is the chief that CTS symptoms were being underreported by writer of this manuscript assisted by all the other authors above and MFN patients as only 46% of symptomatic patients complain coordinated the study in general. RS and JS supervise all the works, made big decisions for the study, provides assistance in areas of administrations about their hand symptoms to practitioners. Out of that, and give comments and ideas to improve the study in general. MFN assists only 35% were given treatment [3]. The lower incidence in the communication between the statistician and ethical committee and in the present study was probably because of a different participated during the interviews with the subjects. All the authors read and approve the final manuscript. country’s health role, also socioeconomic and education level factors in subjects. In contrast, this study had pro- Competing interests venthatCTS,eventhoughonlymildinseverity, could The authors declare that they have no competing interests. impairs a mother’s in the crucial last trimester and doc- Received: 19 August 2011 Accepted: 30 January 2012 tors should at least be able to acknowledge this fact to Published: 30 January 2012 offer some relief to the pregnant mothers. References 1. Pacek CA, Tang J, Goitz RJ, et al: Morphological analysis of the carpal Conclusions tunnel. Hand 2010, 5:77-81. 2. Wallace Cook AW: Carpal tunnel syndrome in pregnancy: a report of two CTS in pregnancy should be given more attention since cases. Am J Obstet Gynecol 1957, 73(6):1333-1336. it is common in the Malaysian population especially in 3. Voitk AJ, Mueller JC, Farlinger DE, Johnston RU: Carpal tunnel syndrome in the Malays. Though the extent of symptoms severity pregnancy. Can Med Assoc J 1983, 128:278-81. 4. Ferry S, Hannaford P, Warskyj M, et al: Carpal tunnel syndrome: A nested may not be worrisome to the doctors, it could impair case-control study of risk factors in women. Am J Epidemiol 2006, the daily functions of these pregnant mothers. The 15(6):566-74. symptoms of pain should be given a greater considera- 5. Stolp-Smith KA, Pascoe MK, Ogburn PL Jr: Carpal tunnel syndrome in pregnancy: Frequency, severity, and prognosis. Arch Phys Med Rehabil tion as it was found to commonly affect hand functions. 1998, 79:1285-7. Doctors should at least be able to identify, educate and 6. Turgut F, Cetinsahinahin M, Turgut M, Bolukbasi O: The management of offer conservative measures if needed, to mothers with carpal tunnel syndrome in pregnancy. J ClinNeurosc 2001, 8(4):332-4. 7. Baumann F, Karlikaya G, Yuksel G, et al: The subclinical incidence of CTS in CTS during pregnancy. pregnancy: Assessment of median nerve impairment in asymptomatic pregnant women. Neurol, Neurophysiol and Neurosc 2007, 3:1-9. 8. Padua L, Aprile I, Caliandro P, et al: Symptoms and neurophysiological Summary of Implications for GP picture of carpal tunnel syndrome in pregnancy. ClinNeurophysiol 2001, CTS is common in the third trimester pregnancy. Gen- 112:1946-51. eral practitioners should be on the lookout for CTS in 9. Atroshi I, Lyren PE, Gummesson C: The 6-item CTS symptoms scale: A brief outcome measure for CTS. Springer Sciences and Business Media 2009, pregnancy and ask the patient about it. Most commonly, 18:347-58. it is under reported as majority of the cases are mild 10. Levine DW, Simmons BP, Koris MJ, et al: A self-administered questionnaire and would not disturb functions. In the case of preg- for the assessment of severity of symtoms and functional status in carpal tunnel syndrome. J Bone Joint Surg 1993, 75-A:1585-92. nancy, the classical presentation of nocturnal paraesthe- 11. Storey PA, Fakis A, Hilliam R, Bradley MJ, Lindau T, Burke FD: Levine-Katz sia is still the hallmark of CTS, however, the symptoms (Boston) Questionnaire analysis: means, medians or grouped totals? J of pain may more likely to affect the mother’s daily life Hand Surg Eur Vol 2009, 34(6):810-2. 12. Department of Statistics, Malaysia. [http://www.statistics.gov.my/]. routines. Proper education and reassurance should be 13. Pazzaglia C, Caliandro P, Aprile I, Mondelli M, Foschini M, Tonali P, Luca given to the patient and referral should be given in case Padua and Italian CTS and others entrapment Study Group: Multicenter of severe CTS. study on carpal tunnel syndrome and pregnancy incidence and natural course. Acta Neurochirurgica Supplementum 2005, 97, Part I:35-39. 14. De Carvalho Leite JC, Jerosch-Herold C, Song F: A systematic review of the psychometric properties of the Boston Carpal Tunnel Questionnaire. List of Abbreviations BMC Musculoskeletal Disorders 2006, 7:78. CTS: Carpal Tunnel Syndrome; UKM: Universiti Kebangsaan Malaysia; UKMMC: 15. Somaiah A, Roy AJS: Review: Carpal tunnel syndrome. Ulster Med J 2008, Universiti Kebangsaan Malaysia Medical Centre; CTS-6: Six item Carpal Tunnel 2 77(1):6-1. Syndrome [atroshi]; BCTQ: Boston’s Carpal Tunnel Questionnaire; X = Chi Square; OR: Odds ratio doi:10.1186/1447-056X-11-1 Cite this article as: Rozali et al.: Impact of carpal tunnel syndrome on Acknowledgements the expectant woman’s life. Asia Pacific Family Medicine 2012 11:1. We would like to thank the doctors and staffs under the hand team of Orthopaedic Department who had helped in the making of this research, Prof Dr. Ruszymah Bt. Hj Idrus as the coordinator of Special Study Module, and Assoc. Prof Dr. Srijit Das for his teachings. Special thanks to Prof Hashim, http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Impact of carpal tunnel syndrome on the expectant woman's life

Introduction: Carpal Tunnel Syndrome is known to be a common complication during pregnancy especially during the third trimester. Aim: This article focuses on its impact to the third trimester pregnant mothers with CTS. Methods: Third trimester pregnant mothers with no other known risk factors for CTS, were interviewed and examined for a clinical diagnosis of CTS. The severity of CTS was assessed by means of symptoms severity and functionality using the Boston Carpal Tunnel Questionnaire. Results: Out of 333 third trimester pregnant mothers, 82 (24.6%) were clinically diagnosed with CTS. Malay race was found to have significant correlation with the diagnosis of CTS (p = 0.024) and are two times more likely to get CTS during pregnancy (OR = 2.26) compare to the non-Malays. Bilateral CTS was two times higher (n = 58, 63.4%) than unilateral cases (n = 30, 36.6%), however no significant correlation between the two was found with severity (p = 0.284) or functional (p = 0.906). The commonest complaint was numbness/tingling during day time (n = 63, 76.8%). Majority of the CTS cases were mild (n = 66, 80.5%) and approximately one third (n = 28, 34.1%) had affected hand functions. All symptoms related to pain was found to have significant correlation with severity (p = 0.00, OR = 12.23) and function (p = 0.005, OR = 5.01), whereas numbness and tingling does not (Severity, p = 0.843, function, p = 0.632). Conclusion: This study shows that even though CTS in third trimester pregnancy is prevalent, generally it would be mild. However, function can still be affected especially if patients complain of pain. Keywords: Carpal Tunnel Syndrome, third trimester pregnancy, prevalence, impact, severity, functional Introduction symptoms”. Subsequent studies made and more theories CTS occurs when the median nerve is entrapped within of CTS in pregnancy were proposed. As more studies the Carpal Tunnel causing sensations of pain, numbness begin to address CTS in pregnancy, there was still no and tingling at the median nerve distribution in the equivocal estimate of how common it is in pregnancy hand and could extend up to the arms. Previous studies and how severe it could be. A study by Voitk et al. had found that CTS was more prevalent in the female found that 24.9% of pregnant mothers had hand symp- population. It was postulated because morphologically, toms in the median nerve distribution, where 51% found females are more prone to CTS compare to male [1]. the symptoms annoying, disturbed functions in 42%, 29% claimed that it interferes with sleep and 4% found CTS were first linked with pregnancy in 1957 by Wal- lace and Cook where they describe two cases of CTS in that it was intolerable [3]. Voitk et al. also recorded that pregnancy and did surgical decompression [2]. The only 49% mentioned the symptoms to their doctor in paper focuses on “pressure as the cause of such which only 16% were treated or given advice. Luckily many study found that the timing of the first pain of CTS occurs during pregnancy was the highest * Correspondence: contactbonedoctor@gmail.com Department of Orthopaedic, Faculty of Medicine, Universiti Kebangsaan during the third trimester [4,5] rather than facing the Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000 pain throughout the pregnancy. However there is not Cheras, Kuala Lumpur, Malaysia © 2012 Rozali et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 2 of 6 http://www.apfmj.com/content/11/1/1 much literature to assess how much CTS actually affects are enough to suggest CTS and they will be asked to their daily life as pregnant mothers particularly during map the site of the symptoms. in that third trimester. CTS might be the least of pro- (c) Underreported CTS. The pregnant mothers were blem that these woman had to face during pregnancy in also asked whether or not they had mentioned their which most of them experienced resolution[6,7] or symptoms to the doctors and whether treatment was improvements after delivery,[8] but the fact is, there are given for those who mentioned. no real data to address this problem. Therefore this The severity of CTS was evaluated using the Boston study focuses on how much CTS actually affects a Carpal Tunnel Questionnaire (BCTQ) [10]. The BCTQ consist of two measurements of disease’s severity, the mother’s life during the third trimester pregnancy. symptoms severity and functional status. The BCTQ is Methods also the main instrument used with the aim of studying Study Design the impact of CTS in pregnant mothers. This study is a prospective cross sectional study invol- ving 333 third trimester pregnant mothers from Statistical Analysis UKMMC Obstetric clinic. The data was analysed using the Statistical Package for Social Sciences (SPSS) 13. In order to estimate fre- Subjects and Settings quency (in percentage), standard descriptive statistical It was conducted from October 2010 till April 2011. methods were used on all variables except for the age Ethical approval by UKM Ethical Committee was which was a continuous data therefore expressed in obtained for this study. The pregnant mothers were mean and standard deviations. Relationships among selected at the UKMMC Obstetric Clinic during their categorical variables including the BCTQ symptoms antenatal follow up. Only pregnant mothers who were severity and functional severity were determined using in their third trimester were approached. After taking Chi-Square (X ) test. The BCTQ scores for symptoms consent, they were asked regarding exclusion criteria severity and functional status was also summed up into namely Gestational Diabetes Mellitus, Hypertension, group totals as proposed by Store et.al [11] as it was athropathies, thyroid disease, trauma at the hand or found to be the best way to present the data. The score wrist and pre-existing or history eclampsia or pre- totals used for symptoms severity was categorized into eclampsia, previous diagnosis of CTS and recurrent asymptomatic (11), mild (12-22), moderate (23-33), CTS. Clinical diagnosis of CTS was made from history severe (34-44) and very severe (45-55). Functions scores and physical examination. Pregnant mothers with nor- were grouped into asymptomatic (8), mild (9-16), mod- mal findings from physical examination and history erate (17-24), severe (25-32) and very severe (33-40) were grouped as non-CTS. For the CTS group, subjects [10]. For associations that were found to be significant, with onset of symptoms during first and second trime- odds ratio (OR) and 95% confidence interval was also ster were excluded. Subjects with distribution of symp- calculated. P value of less than 0.05 was considered as toms other than median nerve distribution, abnormal statistically significant. lumps or bumps at the hand or wrist, or positive for higher nerve compression were also excluded. This was Results done to ensure that the CTS group in our study is not In total, 333 third trimester pregnant mothers, with age because of other pathology in order to study the true ranged between 17-45 years old had agreed to partici- nature of CTS in pregnancy. pate in this study. There are multiracial involvement amongst the respondents consisting of the Malays (n = Instruments 263, 79%), and non Malays; Chinese (n = 54, 16.2%), The history taking was standardized using a question- Indians (n = 8, 2,4%) and other races (n = 8, 2.4%). The naire consisting or three main parts, National Statistics Department had revealed that Malay- (a) Demographic data, age, parity, registration number, sia had a population of 25.7 million of which 24 million and gestational weeks; Malaysians (93.4%) and 1.7 million were non-Malaysians (b) Diagnosis of CTS. The pregnant mothers were first (6.6%). Among the non-Malays, Indians made up 1.8 asked whether they had been diagnosed with CTS or million (7.5%), Chinese 6.1 million (25.4%), other races not. Six-item Carpal Tunnel SyndromeScale(CTS-6) 300,000 (1.3%) [12]. Therefore, the distribution of races questions were used for the diagnosis of CTS [9]. In in our study might not be exactly the same with the order to refined the scale, another item was added to racial distribution in Malaysia, however it is similar in the CTS 6 which was “shaking the hand relieves the which most of Malaysians are Malays followed by Chi- hand symptoms”. One or more symptoms in the CTS-6 nese, Indians and others. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 3 of 6 http://www.apfmj.com/content/11/1/1 82 pregnant mothers (24.6%) were clinically diagnosed (n = 59, 72%), relief by shaking (n = 43, 52.4%), waking to have CTS where 72 (87%) of them were Malays, and up due to numbness (n = 27, 32.9%), pain during day 10 (12%) were non-Malay which comprise of Chinese (n and night time (both n = 20, 24.4%), and the least com- = 9, 11%) and Indians (n = 1, 2.4%). The correlation of mon symptom was waking up due to pain (n = 14, the Malay race with CTS in this study was found to be 17.1%). Similarly, the most common complaint from the significant (p = 0.024) and the risk for Malay pregnant BCTQ symptom severity scale (Figure 1) was also mothers to get CTS was twice higher than the non- numbness (n = 76, 92.7%), where 45 (54.9%) had mild malays (OR = 2.26). Other variables such as gravida, numbness, 27 (32.9%) moderate numbness and 4 (4.9%) had severe numbness. The other two common com- parity, and age have no significant correlation with CTS. The cases of bilateral CTS in pregnancy (n = 58, plaints were tingling sensation (n = 62, 75%) and numb- 63.4%) were almost two times more than the unilateral ness at night (n = 53, 64.6%). Even though pain was the cases (n = 30, 36.6%). However, whether it is bilateral or least common complaint for CTS in pregnancy it was unilateral CTS, there was no significant correlation with found that complains of any symptoms related to pain the severity of CTS (p = 0.284) or functional (p = have significant correlation with severity (p = 0.00, OR 0.906). From the physical examination, 11% had affected = 12.23) and function (p = 0.005, OR = 5.01), whereas 2 point discrimination and8.5%had weakness of the numbness and tingling did not (Severity, p = 0.843, func- abductor pollicis brevis muscle. tion, p = 0.632). Among those who complained of pain, The most common presenting symptom from the numbness or tingling at night, 13 (15.9%) woke up because CTS-6 was numbness and tingling during daytime (n = of pain and 27 (32.9%) woke up because of numbness or 63, 76.8%), followed by numbness and tingling at night, tingling sensation. However, both complaint of waking up Figure 1 Symptoms severity by each complaints. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 4 of 6 http://www.apfmj.com/content/11/1/1 due to pain or waking up due to numbness had significant community, not even to the high risk group of pregnant correlation with impaired function (p = 0.001, p = 0.000 mothers. respectively). As a whole, summation of BCTQ-Symptoms severity Discussion scale (Figure 2) revealed that, most of the CTS cases in Recognizing the prevalence of CTS in pregnancy gives third trimester pregnancy was mild (n = 13, 80.5%), 7 an overview on how common and important it is in the (17.1%) had moderate CTS and only 1 respondent community. The prevalence of CTS in pregnancy varies (2.4%) had the severe form of CTS. Whereas, the from the previous researches. Padua et.al and Pazzaglia BCTQ-Functional scores (Figure 2) found that 28 [13] et.al recorded more than 50% incidence of CTS in (34.1%) of symptomatic pregnant mothers had func- pregnancy, Voitk et al. recorded that it was 34% while tional difficulties, where 21 (25.6%) had mild and 7 Stolp et al. found that it was less than 1%. In our study, (8.5%) had moderate functional difficulties. There were theprevalencewas 24.6%or onefourthofuncompli- no respondents’ scores higher than moderate functional cated third trimester pregnancy. We choose to study score. The function from the BCTQ-functional score specifically the woman in the third trimester as previous according to task is shown in Figure 3. The task that study found that most CTS during pregnancy occur rd was commonly affected were carrying grocery bag (n = during the 3 trimester [4,5]. Compared to other stu- 18, 23%), followed by doing household chores (n = 17, dies, this study also excludes CTS in Diabetic patients in 20.7%), gripping telephone (n = 15, 18.3%) and writing which was a known risk factor for CTS. Other diseases (n = 15, 18.3%), holding a book (n = 13, 15.9%), opening which are common in pregnancy, (thyroidism and a jar (n = 12, 14.6%), buttoning clothes (n = 9, 14.6%) hypertension) and higher nerve compression were also and bathing and dressing (n = 7, 9%). excluded. Therefore, it can be concluded that the small Despite all this, only 21 (25.6%) of the symptomatic number of CTS patients was because the respondents pregnant mothers mentioned their problems to the doc- selected were only those who had pure idiopathic CTS tor in which only 2 (9.5%) receive treatments, such as during pregnancy. This is an important criterion as only vitamins, painkillers, calcium supplements and advice to the pure idiopathic CTS in pregnancy respondents were drink plenty of milk. There was a significant correlation indentified. This allows us to get the appreciation of the between the number of pregnant mothers who mention true nature of idiopathic CTS in pregnancy. Previously their symptoms to the doctors with the severity (p = there was no study that found CTS had significant cor- 0.013, OR = 4.08) and function (p = 0.041, OR = 2.84). relation with ethnicity. Therefore, the finding that CTS In addition to that, it was also observed that none of the was twice as common in the Malay is an important find- pregnant mothers knew about CTS except for those ing for the Malaysian population. The pathology and who work in the clinical health setting such as doctors reasons however, was unknown as this was the first and nurses. However no objective data were taken to finding documented in literature. support this. But this fact further strengthens the The incidence for unilateral and bilateral CTS in preg- impression that CTS is still not well known to the nancy was almost the same, with bilateral cases being higher than unilateral cases. Whether the CTS were uni- lateral or bilateral, it has no significant correlations with increasing of severity or impairment of function. This was the same with one of the studies by Padua et.al on CTS in general population where bilateral cases was also higher but no significant correlation with severity [8]. In this study BCTQ was used, as it is a standardised, patient-based outcome measure of symptom severity and functional status in patients with carpal tunnel syndrome. The use of BCTQ in this study was also preferred as it was found to be valid, reliable, responsive and it is an acceptable instrument to assess CTS according to a review on BCTQ [14]. In the present study, 80.5% of pregnant mothers were found to have mild symptoms of CTS and smaller number was found to have moderate CTS. Therefore even though CTS in pregnancy could occur in one fourth of pregnant mothers with no other Figure 2 Frequency of symptoms and functional severity risk factor for CTS, the severity will not extend beyond according to group totals. moderate. However, considering that pregnant mothers Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 5 of 6 http://www.apfmj.com/content/11/1/1 Figure 3 Functional severity by each task. would also experienced other difficulties such as back complain of pain also have 12 times higher risk getting pain, abdominal pain, or leg swelling, such disturbances moderate to severe CTS. Compare to respondents who could be a significant stressor to the mother. complains of numbness only, not many had functional The result in Figure 1 shows that the nature of CTS in difficulty unless it was severe enough to wake them up at night. Another way to interpret this is that both wak- third trimester pregnant mothers revolves more on ing up at night because of the symptoms, whether its numbness and tingling. Numbness or paraesthesia was also found to be the most common symptoms of CTS pain or numbness, have significant correlation with in pregnancy and CTS in general [15]. On the other functionality. Therefore, mothers with sleep difficulty hand, even though numbness and tingling was more find CTS more disturbing during the day than those common than all the other complaint, it was not as whose sleep not affected. This can be a good indicator troubling as pain. Voitk et.al documented that pain was for future studies on impact of CTS particularly during a prominent feature in 67% of symptomatic pregnant pregnancy. mothers. In the present study, all of the symptoms in Even though more than 80% of CTS cases in preg- CTS-6 regarding pain did not have any significant corre- nancy were found to be mild, one third of the pregnant lation to the symptoms severity, but it was found to mothers with CTS had some degree of functional diffi- have a significant correlation with impairment of func- culties. The most affected task involves doing heavy tion. Whereas for numbness, only waking up due to work such as carrying grocery bag and household numbness had significant correlation with impairment chores. Since some pregnant mothers who are in their of function. This signifies that once a patient complains third trimester usually avoid hard work, the functional of pain, regardless of severity, the function would difficulties may not be so prominent. This could also be usually become impaired. Pregnant mothers who thereasonwhy thenumberofpregnantmothers that Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 6 of 6 http://www.apfmj.com/content/11/1/1 Head of Obstetrics and Gynaecology Department, for giving us the mention their symptoms to their doctors was only 26%. permission to run this study, Prof Shamsul for his help with the statisctics, However what would be more of a concern was that and not forgetting all the pregnant mothers who had participated. Our among those who mention the symptoms to their doc- study was supported by the UKMMC Medical Research and Industry Secretariat (FF-008-2011) tors, less than 10% were given treatment. Not only that, most of the treatment offered was not related to treating Authors’ contributions CTS such as giving vitamins, calcium supplements and ZIR, YKF, WNH, PKDC, and MFN have the same weightage of contributions in carrying out the study from the literature reviews, proposals, interviewing advice to drink milk. In one previous study, it shows the subjects, analyze the data, and preparing the manuscript. ZIR is the chief that CTS symptoms were being underreported by writer of this manuscript assisted by all the other authors above and MFN patients as only 46% of symptomatic patients complain coordinated the study in general. RS and JS supervise all the works, made big decisions for the study, provides assistance in areas of administrations about their hand symptoms to practitioners. Out of that, and give comments and ideas to improve the study in general. MFN assists only 35% were given treatment [3]. The lower incidence in the communication between the statistician and ethical committee and in the present study was probably because of a different participated during the interviews with the subjects. All the authors read and approve the final manuscript. country’s health role, also socioeconomic and education level factors in subjects. In contrast, this study had pro- Competing interests venthatCTS,eventhoughonlymildinseverity, could The authors declare that they have no competing interests. impairs a mother’s in the crucial last trimester and doc- Received: 19 August 2011 Accepted: 30 January 2012 tors should at least be able to acknowledge this fact to Published: 30 January 2012 offer some relief to the pregnant mothers. References 1. Pacek CA, Tang J, Goitz RJ, et al: Morphological analysis of the carpal Conclusions tunnel. Hand 2010, 5:77-81. 2. Wallace Cook AW: Carpal tunnel syndrome in pregnancy: a report of two CTS in pregnancy should be given more attention since cases. Am J Obstet Gynecol 1957, 73(6):1333-1336. it is common in the Malaysian population especially in 3. Voitk AJ, Mueller JC, Farlinger DE, Johnston RU: Carpal tunnel syndrome in the Malays. Though the extent of symptoms severity pregnancy. Can Med Assoc J 1983, 128:278-81. 4. Ferry S, Hannaford P, Warskyj M, et al: Carpal tunnel syndrome: A nested may not be worrisome to the doctors, it could impair case-control study of risk factors in women. Am J Epidemiol 2006, the daily functions of these pregnant mothers. The 15(6):566-74. symptoms of pain should be given a greater considera- 5. Stolp-Smith KA, Pascoe MK, Ogburn PL Jr: Carpal tunnel syndrome in pregnancy: Frequency, severity, and prognosis. Arch Phys Med Rehabil tion as it was found to commonly affect hand functions. 1998, 79:1285-7. Doctors should at least be able to identify, educate and 6. Turgut F, Cetinsahinahin M, Turgut M, Bolukbasi O: The management of offer conservative measures if needed, to mothers with carpal tunnel syndrome in pregnancy. J ClinNeurosc 2001, 8(4):332-4. 7. Baumann F, Karlikaya G, Yuksel G, et al: The subclinical incidence of CTS in CTS during pregnancy. pregnancy: Assessment of median nerve impairment in asymptomatic pregnant women. Neurol, Neurophysiol and Neurosc 2007, 3:1-9. 8. Padua L, Aprile I, Caliandro P, et al: Symptoms and neurophysiological Summary of Implications for GP picture of carpal tunnel syndrome in pregnancy. ClinNeurophysiol 2001, CTS is common in the third trimester pregnancy. Gen- 112:1946-51. eral practitioners should be on the lookout for CTS in 9. Atroshi I, Lyren PE, Gummesson C: The 6-item CTS symptoms scale: A brief outcome measure for CTS. Springer Sciences and Business Media 2009, pregnancy and ask the patient about it. Most commonly, 18:347-58. it is under reported as majority of the cases are mild 10. Levine DW, Simmons BP, Koris MJ, et al: A self-administered questionnaire and would not disturb functions. In the case of preg- for the assessment of severity of symtoms and functional status in carpal tunnel syndrome. J Bone Joint Surg 1993, 75-A:1585-92. nancy, the classical presentation of nocturnal paraesthe- 11. Storey PA, Fakis A, Hilliam R, Bradley MJ, Lindau T, Burke FD: Levine-Katz sia is still the hallmark of CTS, however, the symptoms (Boston) Questionnaire analysis: means, medians or grouped totals? J of pain may more likely to affect the mother’s daily life Hand Surg Eur Vol 2009, 34(6):810-2. 12. Department of Statistics, Malaysia. [http://www.statistics.gov.my/]. routines. Proper education and reassurance should be 13. Pazzaglia C, Caliandro P, Aprile I, Mondelli M, Foschini M, Tonali P, Luca given to the patient and referral should be given in case Padua and Italian CTS and others entrapment Study Group: Multicenter of severe CTS. study on carpal tunnel syndrome and pregnancy incidence and natural course. Acta Neurochirurgica Supplementum 2005, 97, Part I:35-39. 14. De Carvalho Leite JC, Jerosch-Herold C, Song F: A systematic review of the psychometric properties of the Boston Carpal Tunnel Questionnaire. List of Abbreviations BMC Musculoskeletal Disorders 2006, 7:78. CTS: Carpal Tunnel Syndrome; UKM: Universiti Kebangsaan Malaysia; UKMMC: 15. Somaiah A, Roy AJS: Review: Carpal tunnel syndrome. Ulster Med J 2008, Universiti Kebangsaan Malaysia Medical Centre; CTS-6: Six item Carpal Tunnel 2 77(1):6-1. Syndrome [atroshi]; BCTQ: Boston’s Carpal Tunnel Questionnaire; X = Chi Square; OR: Odds ratio doi:10.1186/1447-056X-11-1 Cite this article as: Rozali et al.: Impact of carpal tunnel syndrome on Acknowledgements the expectant woman’s life. Asia Pacific Family Medicine 2012 11:1. We would like to thank the doctors and staffs under the hand team of Orthopaedic Department who had helped in the making of this research, Prof Dr. Ruszymah Bt. Hj Idrus as the coordinator of Special Study Module, and Assoc. Prof Dr. Srijit Das for his teachings. Special thanks to Prof Hashim,
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Abstract

Introduction: Carpal Tunnel Syndrome is known to be a common complication during pregnancy especially during the third trimester. Aim: This article focuses on its impact to the third trimester pregnant mothers with CTS. Methods: Third trimester pregnant mothers with no other known risk factors for CTS, were interviewed and examined for a clinical diagnosis of CTS. The severity of CTS was assessed by means of symptoms severity and functionality using the Boston Carpal Tunnel Questionnaire. Results: Out of 333 third trimester pregnant mothers, 82 (24.6%) were clinically diagnosed with CTS. Malay race was found to have significant correlation with the diagnosis of CTS (p = 0.024) and are two times more likely to get CTS during pregnancy (OR = 2.26) compare to the non-Malays. Bilateral CTS was two times higher (n = 58, 63.4%) than unilateral cases (n = 30, 36.6%), however no significant correlation between the two was found with severity (p = 0.284) or functional (p = 0.906). The commonest complaint was numbness/tingling during day time (n = 63, 76.8%). Majority of the CTS cases were mild (n = 66, 80.5%) and approximately one third (n = 28, 34.1%) had affected hand functions. All symptoms related to pain was found to have significant correlation with severity (p = 0.00, OR = 12.23) and function (p = 0.005, OR = 5.01), whereas numbness and tingling does not (Severity, p = 0.843, function, p = 0.632). Conclusion: This study shows that even though CTS in third trimester pregnancy is prevalent, generally it would be mild. However, function can still be affected especially if patients complain of pain. Keywords: Carpal Tunnel Syndrome, third trimester pregnancy, prevalence, impact, severity, functional Introduction symptoms”. Subsequent studies made and more theories CTS occurs when the median nerve is entrapped within of CTS in pregnancy were proposed. As more studies the Carpal Tunnel causing sensations of pain, numbness begin to address CTS in pregnancy, there was still no and tingling at the median nerve distribution in the equivocal estimate of how common it is in pregnancy hand and could extend up to the arms. Previous studies and how severe it could be. A study by Voitk et al. had found that CTS was more prevalent in the female found that 24.9% of pregnant mothers had hand symp- population. It was postulated because morphologically, toms in the median nerve distribution, where 51% found females are more prone to CTS compare to male [1]. the symptoms annoying, disturbed functions in 42%, 29% claimed that it interferes with sleep and 4% found CTS were first linked with pregnancy in 1957 by Wal- lace and Cook where they describe two cases of CTS in that it was intolerable [3]. Voitk et al. also recorded that pregnancy and did surgical decompression [2]. The only 49% mentioned the symptoms to their doctor in paper focuses on “pressure as the cause of such which only 16% were treated or given advice. Luckily many study found that the timing of the first pain of CTS occurs during pregnancy was the highest * Correspondence: contactbonedoctor@gmail.com Department of Orthopaedic, Faculty of Medicine, Universiti Kebangsaan during the third trimester [4,5] rather than facing the Malaysia Medical Centre, Jalan Yaacob Latiff, Bandar Tun Razak, 56000 pain throughout the pregnancy. However there is not Cheras, Kuala Lumpur, Malaysia © 2012 Rozali et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 2 of 6 http://www.apfmj.com/content/11/1/1 much literature to assess how much CTS actually affects are enough to suggest CTS and they will be asked to their daily life as pregnant mothers particularly during map the site of the symptoms. in that third trimester. CTS might be the least of pro- (c) Underreported CTS. The pregnant mothers were blem that these woman had to face during pregnancy in also asked whether or not they had mentioned their which most of them experienced resolution[6,7] or symptoms to the doctors and whether treatment was improvements after delivery,[8] but the fact is, there are given for those who mentioned. no real data to address this problem. Therefore this The severity of CTS was evaluated using the Boston study focuses on how much CTS actually affects a Carpal Tunnel Questionnaire (BCTQ) [10]. The BCTQ consist of two measurements of disease’s severity, the mother’s life during the third trimester pregnancy. symptoms severity and functional status. The BCTQ is Methods also the main instrument used with the aim of studying Study Design the impact of CTS in pregnant mothers. This study is a prospective cross sectional study invol- ving 333 third trimester pregnant mothers from Statistical Analysis UKMMC Obstetric clinic. The data was analysed using the Statistical Package for Social Sciences (SPSS) 13. In order to estimate fre- Subjects and Settings quency (in percentage), standard descriptive statistical It was conducted from October 2010 till April 2011. methods were used on all variables except for the age Ethical approval by UKM Ethical Committee was which was a continuous data therefore expressed in obtained for this study. The pregnant mothers were mean and standard deviations. Relationships among selected at the UKMMC Obstetric Clinic during their categorical variables including the BCTQ symptoms antenatal follow up. Only pregnant mothers who were severity and functional severity were determined using in their third trimester were approached. After taking Chi-Square (X ) test. The BCTQ scores for symptoms consent, they were asked regarding exclusion criteria severity and functional status was also summed up into namely Gestational Diabetes Mellitus, Hypertension, group totals as proposed by Store et.al [11] as it was athropathies, thyroid disease, trauma at the hand or found to be the best way to present the data. The score wrist and pre-existing or history eclampsia or pre- totals used for symptoms severity was categorized into eclampsia, previous diagnosis of CTS and recurrent asymptomatic (11), mild (12-22), moderate (23-33), CTS. Clinical diagnosis of CTS was made from history severe (34-44) and very severe (45-55). Functions scores and physical examination. Pregnant mothers with nor- were grouped into asymptomatic (8), mild (9-16), mod- mal findings from physical examination and history erate (17-24), severe (25-32) and very severe (33-40) were grouped as non-CTS. For the CTS group, subjects [10]. For associations that were found to be significant, with onset of symptoms during first and second trime- odds ratio (OR) and 95% confidence interval was also ster were excluded. Subjects with distribution of symp- calculated. P value of less than 0.05 was considered as toms other than median nerve distribution, abnormal statistically significant. lumps or bumps at the hand or wrist, or positive for higher nerve compression were also excluded. This was Results done to ensure that the CTS group in our study is not In total, 333 third trimester pregnant mothers, with age because of other pathology in order to study the true ranged between 17-45 years old had agreed to partici- nature of CTS in pregnancy. pate in this study. There are multiracial involvement amongst the respondents consisting of the Malays (n = Instruments 263, 79%), and non Malays; Chinese (n = 54, 16.2%), The history taking was standardized using a question- Indians (n = 8, 2,4%) and other races (n = 8, 2.4%). The naire consisting or three main parts, National Statistics Department had revealed that Malay- (a) Demographic data, age, parity, registration number, sia had a population of 25.7 million of which 24 million and gestational weeks; Malaysians (93.4%) and 1.7 million were non-Malaysians (b) Diagnosis of CTS. The pregnant mothers were first (6.6%). Among the non-Malays, Indians made up 1.8 asked whether they had been diagnosed with CTS or million (7.5%), Chinese 6.1 million (25.4%), other races not. Six-item Carpal Tunnel SyndromeScale(CTS-6) 300,000 (1.3%) [12]. Therefore, the distribution of races questions were used for the diagnosis of CTS [9]. In in our study might not be exactly the same with the order to refined the scale, another item was added to racial distribution in Malaysia, however it is similar in the CTS 6 which was “shaking the hand relieves the which most of Malaysians are Malays followed by Chi- hand symptoms”. One or more symptoms in the CTS-6 nese, Indians and others. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 3 of 6 http://www.apfmj.com/content/11/1/1 82 pregnant mothers (24.6%) were clinically diagnosed (n = 59, 72%), relief by shaking (n = 43, 52.4%), waking to have CTS where 72 (87%) of them were Malays, and up due to numbness (n = 27, 32.9%), pain during day 10 (12%) were non-Malay which comprise of Chinese (n and night time (both n = 20, 24.4%), and the least com- = 9, 11%) and Indians (n = 1, 2.4%). The correlation of mon symptom was waking up due to pain (n = 14, the Malay race with CTS in this study was found to be 17.1%). Similarly, the most common complaint from the significant (p = 0.024) and the risk for Malay pregnant BCTQ symptom severity scale (Figure 1) was also mothers to get CTS was twice higher than the non- numbness (n = 76, 92.7%), where 45 (54.9%) had mild malays (OR = 2.26). Other variables such as gravida, numbness, 27 (32.9%) moderate numbness and 4 (4.9%) had severe numbness. The other two common com- parity, and age have no significant correlation with CTS. The cases of bilateral CTS in pregnancy (n = 58, plaints were tingling sensation (n = 62, 75%) and numb- 63.4%) were almost two times more than the unilateral ness at night (n = 53, 64.6%). Even though pain was the cases (n = 30, 36.6%). However, whether it is bilateral or least common complaint for CTS in pregnancy it was unilateral CTS, there was no significant correlation with found that complains of any symptoms related to pain the severity of CTS (p = 0.284) or functional (p = have significant correlation with severity (p = 0.00, OR 0.906). From the physical examination, 11% had affected = 12.23) and function (p = 0.005, OR = 5.01), whereas 2 point discrimination and8.5%had weakness of the numbness and tingling did not (Severity, p = 0.843, func- abductor pollicis brevis muscle. tion, p = 0.632). Among those who complained of pain, The most common presenting symptom from the numbness or tingling at night, 13 (15.9%) woke up because CTS-6 was numbness and tingling during daytime (n = of pain and 27 (32.9%) woke up because of numbness or 63, 76.8%), followed by numbness and tingling at night, tingling sensation. However, both complaint of waking up Figure 1 Symptoms severity by each complaints. Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 4 of 6 http://www.apfmj.com/content/11/1/1 due to pain or waking up due to numbness had significant community, not even to the high risk group of pregnant correlation with impaired function (p = 0.001, p = 0.000 mothers. respectively). As a whole, summation of BCTQ-Symptoms severity Discussion scale (Figure 2) revealed that, most of the CTS cases in Recognizing the prevalence of CTS in pregnancy gives third trimester pregnancy was mild (n = 13, 80.5%), 7 an overview on how common and important it is in the (17.1%) had moderate CTS and only 1 respondent community. The prevalence of CTS in pregnancy varies (2.4%) had the severe form of CTS. Whereas, the from the previous researches. Padua et.al and Pazzaglia BCTQ-Functional scores (Figure 2) found that 28 [13] et.al recorded more than 50% incidence of CTS in (34.1%) of symptomatic pregnant mothers had func- pregnancy, Voitk et al. recorded that it was 34% while tional difficulties, where 21 (25.6%) had mild and 7 Stolp et al. found that it was less than 1%. In our study, (8.5%) had moderate functional difficulties. There were theprevalencewas 24.6%or onefourthofuncompli- no respondents’ scores higher than moderate functional cated third trimester pregnancy. We choose to study score. The function from the BCTQ-functional score specifically the woman in the third trimester as previous according to task is shown in Figure 3. The task that study found that most CTS during pregnancy occur rd was commonly affected were carrying grocery bag (n = during the 3 trimester [4,5]. Compared to other stu- 18, 23%), followed by doing household chores (n = 17, dies, this study also excludes CTS in Diabetic patients in 20.7%), gripping telephone (n = 15, 18.3%) and writing which was a known risk factor for CTS. Other diseases (n = 15, 18.3%), holding a book (n = 13, 15.9%), opening which are common in pregnancy, (thyroidism and a jar (n = 12, 14.6%), buttoning clothes (n = 9, 14.6%) hypertension) and higher nerve compression were also and bathing and dressing (n = 7, 9%). excluded. Therefore, it can be concluded that the small Despite all this, only 21 (25.6%) of the symptomatic number of CTS patients was because the respondents pregnant mothers mentioned their problems to the doc- selected were only those who had pure idiopathic CTS tor in which only 2 (9.5%) receive treatments, such as during pregnancy. This is an important criterion as only vitamins, painkillers, calcium supplements and advice to the pure idiopathic CTS in pregnancy respondents were drink plenty of milk. There was a significant correlation indentified. This allows us to get the appreciation of the between the number of pregnant mothers who mention true nature of idiopathic CTS in pregnancy. Previously their symptoms to the doctors with the severity (p = there was no study that found CTS had significant cor- 0.013, OR = 4.08) and function (p = 0.041, OR = 2.84). relation with ethnicity. Therefore, the finding that CTS In addition to that, it was also observed that none of the was twice as common in the Malay is an important find- pregnant mothers knew about CTS except for those ing for the Malaysian population. The pathology and who work in the clinical health setting such as doctors reasons however, was unknown as this was the first and nurses. However no objective data were taken to finding documented in literature. support this. But this fact further strengthens the The incidence for unilateral and bilateral CTS in preg- impression that CTS is still not well known to the nancy was almost the same, with bilateral cases being higher than unilateral cases. Whether the CTS were uni- lateral or bilateral, it has no significant correlations with increasing of severity or impairment of function. This was the same with one of the studies by Padua et.al on CTS in general population where bilateral cases was also higher but no significant correlation with severity [8]. In this study BCTQ was used, as it is a standardised, patient-based outcome measure of symptom severity and functional status in patients with carpal tunnel syndrome. The use of BCTQ in this study was also preferred as it was found to be valid, reliable, responsive and it is an acceptable instrument to assess CTS according to a review on BCTQ [14]. In the present study, 80.5% of pregnant mothers were found to have mild symptoms of CTS and smaller number was found to have moderate CTS. Therefore even though CTS in pregnancy could occur in one fourth of pregnant mothers with no other Figure 2 Frequency of symptoms and functional severity risk factor for CTS, the severity will not extend beyond according to group totals. moderate. However, considering that pregnant mothers Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 5 of 6 http://www.apfmj.com/content/11/1/1 Figure 3 Functional severity by each task. would also experienced other difficulties such as back complain of pain also have 12 times higher risk getting pain, abdominal pain, or leg swelling, such disturbances moderate to severe CTS. Compare to respondents who could be a significant stressor to the mother. complains of numbness only, not many had functional The result in Figure 1 shows that the nature of CTS in difficulty unless it was severe enough to wake them up at night. Another way to interpret this is that both wak- third trimester pregnant mothers revolves more on ing up at night because of the symptoms, whether its numbness and tingling. Numbness or paraesthesia was also found to be the most common symptoms of CTS pain or numbness, have significant correlation with in pregnancy and CTS in general [15]. On the other functionality. Therefore, mothers with sleep difficulty hand, even though numbness and tingling was more find CTS more disturbing during the day than those common than all the other complaint, it was not as whose sleep not affected. This can be a good indicator troubling as pain. Voitk et.al documented that pain was for future studies on impact of CTS particularly during a prominent feature in 67% of symptomatic pregnant pregnancy. mothers. In the present study, all of the symptoms in Even though more than 80% of CTS cases in preg- CTS-6 regarding pain did not have any significant corre- nancy were found to be mild, one third of the pregnant lation to the symptoms severity, but it was found to mothers with CTS had some degree of functional diffi- have a significant correlation with impairment of func- culties. The most affected task involves doing heavy tion. Whereas for numbness, only waking up due to work such as carrying grocery bag and household numbness had significant correlation with impairment chores. Since some pregnant mothers who are in their of function. This signifies that once a patient complains third trimester usually avoid hard work, the functional of pain, regardless of severity, the function would difficulties may not be so prominent. This could also be usually become impaired. Pregnant mothers who thereasonwhy thenumberofpregnantmothers that Rozali et al. Asia Pacific Family Medicine 2012, 11:1 Page 6 of 6 http://www.apfmj.com/content/11/1/1 Head of Obstetrics and Gynaecology Department, for giving us the mention their symptoms to their doctors was only 26%. permission to run this study, Prof Shamsul for his help with the statisctics, However what would be more of a concern was that and not forgetting all the pregnant mothers who had participated. Our among those who mention the symptoms to their doc- study was supported by the UKMMC Medical Research and Industry Secretariat (FF-008-2011) tors, less than 10% were given treatment. Not only that, most of the treatment offered was not related to treating Authors’ contributions CTS such as giving vitamins, calcium supplements and ZIR, YKF, WNH, PKDC, and MFN have the same weightage of contributions in carrying out the study from the literature reviews, proposals, interviewing advice to drink milk. In one previous study, it shows the subjects, analyze the data, and preparing the manuscript. ZIR is the chief that CTS symptoms were being underreported by writer of this manuscript assisted by all the other authors above and MFN patients as only 46% of symptomatic patients complain coordinated the study in general. RS and JS supervise all the works, made big decisions for the study, provides assistance in areas of administrations about their hand symptoms to practitioners. Out of that, and give comments and ideas to improve the study in general. MFN assists only 35% were given treatment [3]. The lower incidence in the communication between the statistician and ethical committee and in the present study was probably because of a different participated during the interviews with the subjects. All the authors read and approve the final manuscript. country’s health role, also socioeconomic and education level factors in subjects. In contrast, this study had pro- Competing interests venthatCTS,eventhoughonlymildinseverity, could The authors declare that they have no competing interests. impairs a mother’s in the crucial last trimester and doc- Received: 19 August 2011 Accepted: 30 January 2012 tors should at least be able to acknowledge this fact to Published: 30 January 2012 offer some relief to the pregnant mothers. References 1. Pacek CA, Tang J, Goitz RJ, et al: Morphological analysis of the carpal Conclusions tunnel. Hand 2010, 5:77-81. 2. Wallace Cook AW: Carpal tunnel syndrome in pregnancy: a report of two CTS in pregnancy should be given more attention since cases. Am J Obstet Gynecol 1957, 73(6):1333-1336. it is common in the Malaysian population especially in 3. Voitk AJ, Mueller JC, Farlinger DE, Johnston RU: Carpal tunnel syndrome in the Malays. Though the extent of symptoms severity pregnancy. Can Med Assoc J 1983, 128:278-81. 4. Ferry S, Hannaford P, Warskyj M, et al: Carpal tunnel syndrome: A nested may not be worrisome to the doctors, it could impair case-control study of risk factors in women. Am J Epidemiol 2006, the daily functions of these pregnant mothers. The 15(6):566-74. symptoms of pain should be given a greater considera- 5. Stolp-Smith KA, Pascoe MK, Ogburn PL Jr: Carpal tunnel syndrome in pregnancy: Frequency, severity, and prognosis. Arch Phys Med Rehabil tion as it was found to commonly affect hand functions. 1998, 79:1285-7. Doctors should at least be able to identify, educate and 6. Turgut F, Cetinsahinahin M, Turgut M, Bolukbasi O: The management of offer conservative measures if needed, to mothers with carpal tunnel syndrome in pregnancy. J ClinNeurosc 2001, 8(4):332-4. 7. Baumann F, Karlikaya G, Yuksel G, et al: The subclinical incidence of CTS in CTS during pregnancy. pregnancy: Assessment of median nerve impairment in asymptomatic pregnant women. Neurol, Neurophysiol and Neurosc 2007, 3:1-9. 8. Padua L, Aprile I, Caliandro P, et al: Symptoms and neurophysiological Summary of Implications for GP picture of carpal tunnel syndrome in pregnancy. ClinNeurophysiol 2001, CTS is common in the third trimester pregnancy. Gen- 112:1946-51. eral practitioners should be on the lookout for CTS in 9. Atroshi I, Lyren PE, Gummesson C: The 6-item CTS symptoms scale: A brief outcome measure for CTS. Springer Sciences and Business Media 2009, pregnancy and ask the patient about it. Most commonly, 18:347-58. it is under reported as majority of the cases are mild 10. Levine DW, Simmons BP, Koris MJ, et al: A self-administered questionnaire and would not disturb functions. In the case of preg- for the assessment of severity of symtoms and functional status in carpal tunnel syndrome. J Bone Joint Surg 1993, 75-A:1585-92. nancy, the classical presentation of nocturnal paraesthe- 11. Storey PA, Fakis A, Hilliam R, Bradley MJ, Lindau T, Burke FD: Levine-Katz sia is still the hallmark of CTS, however, the symptoms (Boston) Questionnaire analysis: means, medians or grouped totals? J of pain may more likely to affect the mother’s daily life Hand Surg Eur Vol 2009, 34(6):810-2. 12. Department of Statistics, Malaysia. [http://www.statistics.gov.my/]. routines. Proper education and reassurance should be 13. Pazzaglia C, Caliandro P, Aprile I, Mondelli M, Foschini M, Tonali P, Luca given to the patient and referral should be given in case Padua and Italian CTS and others entrapment Study Group: Multicenter of severe CTS. study on carpal tunnel syndrome and pregnancy incidence and natural course. Acta Neurochirurgica Supplementum 2005, 97, Part I:35-39. 14. De Carvalho Leite JC, Jerosch-Herold C, Song F: A systematic review of the psychometric properties of the Boston Carpal Tunnel Questionnaire. List of Abbreviations BMC Musculoskeletal Disorders 2006, 7:78. CTS: Carpal Tunnel Syndrome; UKM: Universiti Kebangsaan Malaysia; UKMMC: 15. Somaiah A, Roy AJS: Review: Carpal tunnel syndrome. Ulster Med J 2008, Universiti Kebangsaan Malaysia Medical Centre; CTS-6: Six item Carpal Tunnel 2 77(1):6-1. Syndrome [atroshi]; BCTQ: Boston’s Carpal Tunnel Questionnaire; X = Chi Square; OR: Odds ratio doi:10.1186/1447-056X-11-1 Cite this article as: Rozali et al.: Impact of carpal tunnel syndrome on Acknowledgements the expectant woman’s life. Asia Pacific Family Medicine 2012 11:1. We would like to thank the doctors and staffs under the hand team of Orthopaedic Department who had helped in the making of this research, Prof Dr. Ruszymah Bt. Hj Idrus as the coordinator of Special Study Module, and Assoc. Prof Dr. Srijit Das for his teachings. Special thanks to Prof Hashim,

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Jan 30, 2012

References