PREDICTORS OF WRIST AND HAND SENSORIMOTOR FUNCTION AMONG DENTISTS WITH CARPAL

TUNNEL SYNDROME

1.0 INTRODUCTION

Physical burden of clinical work has been established as having a strong association with musculoskeletal
disorder (MSD) among dental health workers (Hayes, Cockrell & Smith, 2009). Carpal Tunnel Syndrome (CTS) is the
most common peripheral nerve entrapment in upper extremity among dental professional and also in the general working
population with repetitive wrist and hand movement (MacDermid & Wessel, 2004; Zafar Ali et al., 2012; Goodyear-
Smith & Arroll, 2004; Barcenilla, March, Chen & Sambrook, 2011; Hsu, Kuo, Chiu, Jou, & Su, 2013). A recent study by
Stomatologija, et al. (2007) stated that dental professional experiences high prevalence of hand and wrist pain specifically
CTS. Their practice requires high degree of concentration and precision with small hand movements.
CTS is usually caused by mechanical or dynamic compression of the median nerve (Lee, Kwon, Kim & Pyun,
2012). This leads to impairment in hand sensorimotor function that results to tingling, numbness and pain within the
median nerve distribution worsening at night (Hsu et al., 2013; Verdugo, Salinas, Castillo & Cea, 2008; Burke, Ellis,
McKenna & Bradley, 2003; Palmer, Harris & Coggon, 2006). Study shows that there are particularly high prevalence
rates and relative risks in a number of jobs that were believed to involve repetitive and forceful gripping (Palmer, Harris &
Coggon, 2011).
In the Philippines, licensed dentist perform almost all dental services for the clients unlike among other countries
which divided their services to the licensed dental professionals, dental hygienists, and dental assistances. These divisions
of services are just starting to increase its popularity in the Philippines.
Several systematic reviews or meta-analysis (Lee et al., 2012; Haase, 2007; Atroshi et al., 1999) discusses the risk
factors of the general population. However, there are few studies that determines the relationship of the intrinsic or
extrinsic factors that may contribute to the CTS among dentist. Thus, the purpose of this study was to determine the
person, occupation, and environment factors that may lead or contribute to carpal tunnel syndrome among dental
professional.

2.0 REVIEW OF LITERATURE

Carpal tunnel is a U-shaped structure that is composed of a bony canal that consists of carpal bones as its base and
the flexor retinaculum as its roof. It contains nine flexor tendons and median nerve which enters the tunnel in the midline
or slightly radial to it (Ibrahim, Khan & Smitham, 2012). The median nerve is a mixed nerve comprised of sensory and
motor axons innervating most of the extrinsic hand flexor muscle and some intrinsic muscles, and relay sensory
information from the palms aspect of thumb, index, middle and lateral half of the ring finger. CTS can also affect motor
fibers thus leading to force deficits in the thumb that results to loss of manual dexterity (Zhang, Johnston, Ross, Sanniec,
Gleason, Dueck & Santello, 2013).
According to demographics, CTS occurs in 5.8% of women and 0.6% of men (Lee et al., 2012) and usually affects
3.8% of the general population (Atroshi et al., 1999). From literature studies it is concluded that CTS is most common in
age group 30-60 years. A family history is found among 20% of “proven” CTS patients especially if they have bilateral
symptomology (Haase, 2007).
The pathomechanic of nerve entrapment disorders are multifaceted. Moore (1992) discussed two theories for the
symptoms associated with CTS: ischemic responses resulting from microvascular insufficiency and mechanical
compression of the median nerve. Microascular insufficiency, or ischemia, is believed to be responsible for intermittent
syndromes (paresthesia and pain) and reversible nerve conduction dysfunction. While, the mechanical compression and
entrapment of the median nerve results from hypertrophy of the flexor tendon, or tenosynovial changes due to
compression of the flexor tendon sheaths. This mechanical compression is transmitted directly to the myelin sheaths of the
nerve axons which results in a shearing of the myelin lamellae in response to the mechanical pressure (Lowe & Freivalds,
1999). The external compression can be applied in several ways including: (a) a low force present for a long period; (b) an
acute focal application of a large external force; (c) repetitive application of brief large forces (Werner & Andary, 2002).
Patients’ condition is characterized as numbness, tingling, wrist, hand and arm pain and muscle dysfunction. The
disorder is not restricted by age, gender, ethnicity, or occupation and is associated with or caused by systemic disease and
local mechanical and disease factors (AAOS, 2006). In severe cases, it may cause motor deficits particularly in the thumb
(Zhang et al., 2012).
Conservative management has a place in the early management of mild to moderate CTS and may reduce the
number of patients undergoing surgical intervention. There is strong evidence that local corticosteroid injections and to a
lesser extent oral corticosteroids, give short-term relief for CTS suffers. There is insufficient evidence to evaluate whether
yoga, nerve and tendon gliding exercises, or laser-acupuncture are effective modalities. The evidence on wrist splinting
showed that splinting at night was not as effective as full-time splinting day and night (Goodyear-Smith, 2004).
Patients with mild symptoms should be offered conservative treatment. Surgical referral should be considered in
patients with symptoms that are causing persistent sleep disturbance, interfering with their ability to work, or otherwise
adversely affecting their lifestyle (Goodyear-Smith, 2004).
CTS most often occur after the age of 30 years or a mean age of 51±12.25 years (Zafar Ali et al., 2012), with
women affected more than men by a factor of 3 to 1 (Goodyear-Smith as cited from Stevens, Suns, & Beard, 1988). The
female gender is an independent risk factor that is related to fluid retention due to previous pregnancy or hormonal factors
(Zafar Ali et al., 2012).
The potential increase CTS risk among older individuals is due to the loss of axonal development of the nerve
conduction and vascular abnormalities due to aging (Komurcu et al., 2013). Elderly patients have severe nerve conduction
with relatively fewer symptoms. It is suggested that there is reduced pain sensitivity with age, which is possibly sue to a
reduction of the nerve membrane excitability as an age-related factor (Zafar Ali et al., 2012).
BMI is “a number calculated from a person’s weight and height. BMI provides a reliable indicator of body fatness
for most people and is used to screen for weight categories that may lead to health problems” (Centers for Disease Control
and Prevention, 2013).
 The National Center for Health Statistics classified weight by dividing the weight from the normal score of the
BMI for slender men and women BMI is <20; for normal men 20-27.79 and for normal women 20-27.29; overweight men
27.8-31 and for overweight women 27.3-32.29; and for obese men ≥31.1 and for obese women ≥32.3 (Nordstrom et al.,
1997).
BMI increases CTS severity by the increase of fat deposit in the carpal canal and increased hydrostatic pressure in
the carpal tunnel of the obese individuals (Werner et al, 1994).
A study by Zhang et al (2012) found that patients with CTS exhibited significantly larger force grip. The result
was due to the compensatory strategy to prevent object slip in response to the inability to form accurate sensorimotor
memories from previous manipulations.
A cross-sectional study by Silverstein et al, found strong positive association (odds ratio = 15; p < 0.001) between
high repetition/high grip and the prevalence of CTS among 652 workers (Kao, 2003).
Wrist posture is one of the factors considered in estimating risk for developing distal upper extremity disorders in
workplace studies. Non neutral wrist posture may be a risk for hand and wrist symptoms, tendon-related disorders, and
carpal tunnel syndrome (Keir, Bach, Hudes & Rempel, 2007).
Patients with CTS typically have carpal tunnel pressure above 30 mmHg whereas healthy individuals have may
have carpal tunnel pressure under 10 mmHg. To prevent mean carpal tunnel pressure from exceeding 30 mmHg, wrist
extension should not exceed 32.7°, flexion should not exceed 48.6°, and ulnar and radial deviation should not exceed
14.5° and 21.8°, respectively (Keir et al., 2007).
A study by Moore and Garg, used videotaped observations of workers in a pork processing factory to accurately
measure and verify ergonomic physical factors and reviewed employees’ medical records to obtain full details regarding
upper extremity disorders (including CTS). They concluded that the association between CTS and ergonomic factors was
not statistically significant (RR = 2.8, P = 0.44) (Kao, 2003).
A study by Rempel et al (2008) conducted a study twenty healthy subjects participated in a laboratory study to
investigate the effects of typing at different wrist postured on carpal tunnel pressure of the right hand. The findings of the
study revealed that carpal tunnel pressure at 30° wrist extension configuration was significantly greater than the pressure
at the 15° flexion and 0° extension configuration. The carpal tunnel pressure at the 45° extension configuration was higher
than all other configurations.
A systematic literature review by Palmer et al. (2006) found that repeated extension and flexion of the wrist
doubled the risk of physician-confirmed CTS.
2.2.2 Repetition

Stretson et al. tested employees from a range of occupations. Industrial workers with exposure to repetitive hand
exertion were found to have significantly smaller sensory amplitudes (p < 0.05) and longer motor and sensory latencies (p
< 0.001) in tests of nerve conduction (Kao, 2003).
There is strong evidence of a positive association between exposure to a combination of risk factors (such as force
and repetition) and CTS. Evidence is reported of a positive association of CTS and highly repetitive work alone or in
combination with other factors and forceful work and with work involving hand and wrist vibration (Palmer et al., 2006;
Barcenilla et al., 2011).
Three studies point out that wrist flexion or extension for at least half the working day as carrying a particularly
high risk (Palmer et al., 2006). Risks were elevated 5- to 8-fold when the self-reported time spent in activities with the
wrist flexed or extended was ≥ 20 hours per week, while in the study of Nordstrom et al. showed that CTS was more than
doubled for those estimating that they bent/twisted their wrists for > 3.5 hours per day versus 0 hours per day.
Over relatively wide temperature ranges, motor and sensory nerve conduction velocities have a positive linear
relationship with body temperature. With cooling, motor and sensory amplitudes increase and conduction values decrease.
The normal temperature of the upper extremity that will provide efficient function should be the range of 32 to 36°C.

2.4 Theoretical/Conceptual Framework

The model was founded by Law et al (1996) that describes the theory and clinical application between the person,
the environment and the occupation. The model is a framework that guides clinical reasoning in analysis and
understanding of the interdependent interaction and therefore can form a foundation for application in practice.
The optimal function or occupational performance results from a good fit between the three components.
Maximum fit relates to optimal occupational performance, whereas minimum fit relates to minimum occupational
performance, hence dysfunction. Disability can be associated with a minimum or poor-environment fit rather than the
impairment itself.
Work-related musculoskeletal disorders (WMSDs) are associated with different factors including work postures
and movements, repetitiveness and pace of work, force of movements, vibration, temperature, lack of influence or control
over one’s job, increase pressure, and monotonous tasks.

3.0 METHODOLOGY

3.1 Research Design

This study used a quantitative, non-experimental, correlational research design to determine the predictors of
wrist and hand sensorimotor function.

3.2 Research Locale

This study was conducted on selected dental clinics in the vicinity of the Second District of Caloocan City.

3.3 Population and Sampling

Fifteen Licensed Dentists who are registered in the Caloocan Business Registry within the vicinity of the 2nd
District of Caloocan were selected for the study. This sample size is based on a prevalence and incidence rate of CTS
among the dental professional of 56.5% (Simmer-Beck & Branson, 2010). A 95% confidence interval plus a 10%
expected attrition rate was calculated based on the Epi-Info formula (CDC, 2013).

A non-probability purposive sampling was utilized following a set of inclusion and exclusion criteria to specify
the characteristics of the people in the population in order to be included or excluded in the study. The respondents of the
study possesses at least two of the following: (1) pain and paresthesia within the distribution of the median nerve; (2)
increases in pain and paresthesia at night; (3) sensory symptoms in any one of their first four fingers (thumb = 1) or in any
combination thereof; (4) self-perceived hand strength deficits; and (5) a positive Tinel’s or Phalen’s sign (Mattos,
Domenech, Borges & Santos, 2012).

3.4 Data Collection

The study utilized the following software forms to gather data: Basic Information Sheet (Appendix D), Visual
Analog Scale (VAS) (Appendix D), Rapid Upper Limb Assessment (RULA) (Appendix E), Boston Carpal Tunnel
Questionnaire Tool (BCTQ) (Appendix F), and Katz Hand Diagram (Appendix G). Handheld dynamometer was used to
measure the grip strength of the respondents and a performance based assessment (Tinel’s and Phalen’s Test) was used to
confirm the symptoms of the respondents.

3.4.1 Basic Information Sheet

The basic information sheet consist of demographic data of the respondents that includes their age, sex, height,
weight, hand dominance, grip strength, years of clinical experience, clinic hours per week, duration of treatment per
patient and number of patients per day. These data helped identify the predictors of CTS which were based on a
systematic review and meta-analysis of Ibrahim et al. (2012), Barcenilla et al. (2011), and Palmer et al. (2006).

3.4.2 Hand grip strength tests (Dynamometer)

The Electronic Hand Dynamometer CAMRY® EH101 was the measuring tool for the respondents hand grip. The
specification of the dynamometer includes a maximum capacity of 90kg with a tolerance of ± 0.5kg.

3.4.3 Boston Carpal Tunnel Questionnaire (BCTQ)

The BCTQ also referred as Levine scale, Brigham and Women’s Carpal tunnel Questionnaire, Boston
Questionnaire (İlhan, Toker, Kilincioğlu & Gülcan, 2008) and Carpal Tunnel Instrument, is a widely used standardized
disease-specific patient-oriented tool for which there is good evidence on validity, reliability and responsiveness. The
BCTQ has shown good levels of acceptability with response rates of 90% and above and takes less than 10 minutes to
complete. It has two distinct scales, the Symptom Severity Scale (SSS) which has 11 questions and uses a five-point rating
scale and the Functional Status Scale (FSS) containing 8 items which have to be rated for degree of difficulty on a five-
point scale. Each generates a final score which ranges from 1 to 5, with a higher score indicating greater disability (Leite,
Jerosch-Herold & Song, 2006).
The internal consistency reveals a Cronbach alpha values ranged from α = 0.80 to 0.90 for the SSS and from α =
0.88 to 0.93 for the FSS. Levine et al assessed the reliability and showed Pearson’s correlation coefficients showed high
correlation between the scores of r = 0.91 and 0.93 for SSS and FSS, respectively (Leite et al., 2006). The minimal
clinically important difference (MCID) is 0.74 based from the maximum score of 5.

3.4.4 Katz Self-administered Hand Symptom Diagram

A standardized, widely used method for collecting patients’ symptom histories. This tool classify CTS from
classical, probable and unlikely by the use of analyzing the location symbols indicated in the legend which includes pain,
tingling, numbness and loss of sensation. Katz and Sirrat defined classical CTS as symptoms on at least 1-3 digits but has
no symptoms on the palm or dorsum of the hand; probable CTS is the same as classical but affectation of the palm is
included and unlikely if symptoms does not meet the above description or affectation of the ulnar side of the hand. Hand
diagram shows sensitivity of 80% and specificity in diagnosing CTS of 90%. Existing literature demonstrates greater
predictive ability of hand diagrams for clinical diagnosis of CTS and nerve conduction abnormalities in clinic-based
studies (Calfee et al., 2012).

3.4.5 Rapid Upper Limb Assessment (RULA)

A survey method developed for use in ergonomic investigations of workplaces where work related upper limb
disorders are reported. RULA is a screening tool that assesses biomechanical and postural loading on the whole body with
particular attention to the neck, trunk and upper limbs. Reliability studies have been conducted using RULA on groups of
VDU users and sewing machine operators. A RULA assessment requires little time to complete and the scoring generates
an action list which indicated the level of intervention required to reduce the risks of injury due to physical loading on the
operator (McAtamney & Corlett, 1993).
The computation of the result of RULA is from the postures of the arm/wrist with neck and trunk. The final score
magnitude of RULA is between 1 (lower risk) to 7 (higher risk for musculoskeletal disorder).

3.4.6 Visual Analog Scale (VAS)

According to Wewers & Lowe (1990), visual analog scale (VAS) is a “straight line, the end anchors of which are
labeled as the extreme bounderies of the sensation, feeling ot response to be measure.” It has been described as simple,
highly sensitive, and reliable rating scales for subjective experiences. is straight horizontal line of fixed length, usually
100mm (Paul-Dauphin, Guillemin, Virion & Briancon, 1999) or 10cm (Hauser & Walsh, 2008; Bijur, Silver &&
Gallagher, 2001) with descriptors at the ends that may be defined as the extreme limits of the parameter to be measured
oriented from the left (worst) to the right (best). The score is measured as the distance of the mark from one end of the line.
A score of >30mm is equal to or greater than “moderate,” a score of >54 is equal to or greater than “severe.” Usually, the
line does not have markings, words, or numbers along it. This assessment tool was used to measure the light and
temperature of the environment.

3.4.7 Phalen’s Test

In Phalen’s test, the patient is asked to flex their wrist and keep it in that position for 60 seconds. A positive
response is if it leads to pain or paresthesia in the distribution of the median nerve. The sensitivity of Phalen’s test is in the
range of 67% to 83%, and specificity between 40% and 98% (Ibrahim, Khan, Goddard & Smitham, 2012).

3.4.8 Tinel’s Test

Tinel’s test is performed by tapping over the volar surface of the wrist. A positive response it if this causes
paresthesia in the fingers innervated by the median nerve: the thumb, index, middle finger and the radial side of the ring
finger. Tinel’s test has sensitivity in the range of 48% to 73% and specificity of 30% to 94% (Ibrahim et al, 2012).

3.5 Ethical Consideration

This research study ensured that all issues concerning ethicality were addressed. Informed consent form was
given to the respondents at the start of the study.
This study was intended to determine the factors that contribute on having carpal tunnel syndrome and ensuring
that all potential risk and harm was prevented or at least kept to a minimum. All respondents were given truthful and
accurate information at all times. Also, written informed consent form (Appendix B) states that they were given the
freedom to participate or withdraw from the study anytime they want.
Likewise, they were given just compensation due to harm or injury acquired in the study.

3.6 Procedure

A review of literature was conducted to serve as a background for the study. Licensed databases like PUBMED
and Google Scholar were searched using the key terms carpal tunnel syndrome, systematic review, prevalence, and
environmental factors. Articles of the year 2000 to 2014 were prioritized as a reference. A paper proposal was drafted and
revised by the professor’s feedback.
The pilot testing phase of the study included the Special Test such as Phalen’s and Tinel’s Test, and
Dynamometer to assess the raters Inter- and Intra-rater reliability. A letter to the Dean of the College of Dentistry of a
local university was sent for pilot testing of Phalen’s and Tinel’s test, and dynamometer. This step was used to determine
the reliability of the assessor.
To determine the understandability and clarity of demographic profile sheet, the same pilot test participants
answered and completed the demographic profile sheet. After which, they were asked for feedback/comment on the
demographic profile sheet. The demographic profile sheets were revised based on their feedback.
 Furthermore, the purpose of the pilot testing was also to determine whether the assessors were reliable in
administrating Phalen’s and Tinel’s Test, and Handheld Dynamometer. In order to determine the reliability of the study’s
assessors, two licensed physical therapists with a mean age of 24±3.54years were asked to administer the Phalen’s and
Tinel’s Test, and Handheld Dynamometer on five dentistry students with the same characteristics as the study’s
participants. The assessors conducted the Phalen’s and Tinel’s Test, and Handheld Dynamometer twice and randomly and
independently. The physical therapist with an ICC score of > 0.80 was selected as the study’s assessor.
A letter to the City Planning and Development Department of the Caloocan City Hall was sent for the list of
registered dental clinics within the vicinity of the 2nd District of Caloocan City. Informed consent forms together with the
PDS, BCTQ and Katz Hand Diagram were given to the dentists. Also, the grip strength, Phalen’s test and Tinel’s test was
assessed. All data gathered (Appendix A2) in the study were tabulated and sent to the statistician for analysis.

3.7 Statistical Analysis

Descriptive statistics (mean, median and mode) were used to describe the subject demographics and baseline
clinical characteristics. All data were expressed as Mean ± SD to compare the means of the parameters.
Spearman and Pearson was used to evaluate the relationship between the confounding variables and the BCTQ.
All statistical level of significance were set at p<0.005. Statistical Package for Statistical Science version 21 was utilized
to analyze the data (statistical package for Social Sciences Inc. Chicago, IL, USA).

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