BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1 / Name of the candidate
and Address / KAMLESH RAGWANI
SRINIVASCOLLEGE OF PHYSIOTHERAPY,
PANDESHWAR,
MANGALORE-575001.
2 /
Name of the Institute
/ SRINIVASCOLLEGE OF PHYSIOTHERAPY, MANGALORE.3 /
Course of study and
Subject / Master of Physiotherapy (MPT)2 years Degree Course.
“Physiotherapy in neurological and psychosomatic disorders”
4 /
Date of Admission
To course / 22.05.20075 /
Title of the Topic
/ “A STUDY TO EXAMINE THE RELATIONSHIP BETWEEN CARPAL TUNNEL SYNDROME QUESTIONNAIRE SCORE AND NERVE CONDUCTION STUDY FINDINGS IN LONG TERM KEYBOARD USERS ”6 /
Brief resume of the intended work:
6.1 Need for the study:Computer use is commonly increasing among working population and concern exist about possible adverse effects of computer use such as carpal tunnel syndrome.1
Carpal tunnel syndrome is defined as the symptom manifested when median nerve, the major sensory and motor nerve of the hand, becomes compressed as it travels from the forearm to the hand through carpal tunnel.
In a healthy tunnel, the synovial sheath surrounding the tendons of long flexors of wrist and finger act as a protective padding for the median nerve. When there is increase in demand of tendon activity2 such as in workplace3the repetitive motion of bending at wrist occurs which increases pressure in the carpal tunnel.4
At the same time rubbing of the tendon against the side of tunnel results in swelling of synovial sheath3 which further increases the pressure in carpal tunnel, there by compressing the median nerve and producing sensory and motor symptoms.4
Keystroke activation force, tactile and proprioceptive feedback, repetitiveness of the task,5a percentage of typing, typing speed and the unequal usage of fingers5b increases the risk of carpal tunnel syndrome in long term keyboard users.6
Carpal tunnel syndrome questionnaire is symptom based questionnaire which measure the severity of carpal Tunnel syndrome.7Itis simple and cost effective method to assess the severity of carpal tunnel syndrome.
Nerve conduction study is a gold standard technique used to measure the abnormality of nerve conduction entrapment.8, 9 But in our clinical setup this technique is in limited use and need skill to operate. Therefore it is not used by theclinicians very often.
So this study aims to provide a simple, cost effective and objective tool to the clinician, whereby severity of carpal tunnel syndrome can be assessed.
6.2 Review of Literature:
- Peter J. Keir et al. (2007) examined 37 healthy participants to develop work guidelines for wrist posture based on carpal tunnel pressure and concluded that wrist posture can also be used by ergonomists and clinician to identify tasks that may put the worker at the risk for developing or aggravating carpal tunnel syndrome. Sustained elevated pressure to median nerve in carpal tunnel is one of the risk factor for carpal tunnel syndrome4.
- Leif A. Havton et al. (2007) studied the correlation of median forearm conduction velocity with carpal tunnel syndrome severity and concluded that slowing of median motor nerve conduction velocity in the forearm is related to the severity of entrapment of median motor fibers at wrist. It signifies that slowed forearm median motor nerve conduction velocity can be a marker of motor nerve injury at wrist.10
- Roberta Bonfiglioli et al.(2006) conductedstudy to investigate the prevalence of carpal tunnel syndrome in a group of workers exposed to intensive use of hand and concluded that repetitive work was associated with high level of carpal tunnel syndrome and abnormal nerve conduction findings. These findings appeared to be reversible following a period of less repetitive work.11
- Alev LEVENTOGLU et al. (2006) did a study on 226 patient to assess the electromyography differences between groups with clinically mild and severe carpal tunnel syndrome and found that the electrophysiological investigations, being a highly sensitive procedure, reflects the pathology, independent of the severity of clinical involvement.12
- T Ogura et al. (2003) conducted a study on 37 patients to find out the relationship between nerve conduction study and clinical grading of carpal tunnel syndrome and concluded that, the amplitude of the sensory nerve action potential and motor nerve action potential reflects the state of axon and useful parameter for assessing clinical grading based on nerve conduction velocity13
- Robert A. Werner et al. (2001) did a study on 77 industrial asymptomatic workers to predict future symptoms suggestive of carpal tunnel syndrome and after 6 years concluded that there was an association between median neuropathy and future carpal tunnel syndrome symptoms in the workers.14
- Johan Hviid Anderson et al. (2000) conducted a study to estimate the prevalence and incidence of possible carpal tunnel syndrome and to evaluate the contribution of use of mouse device and keyboard to the risk of developing carpal tunnel syndrome and concluded that
- Katsuyuki Murata et al. (1996) assessed 27 female visual display terminal operators for presence of subclinlical carpal tunnel syndrome by using sensory nerve conduction velocity and found that wrist –finger /palm finger ratio was significantly higher in the operator group than in the control group so nerve conduction velocity can be a useful and reliable method for early detection of carpal tunnel syndrome due to repeated wrist hand and finger movements involved in work.16
- S.Rojviroj et al. (1990) examined 33 patients affected by carpal tunnel syndrome and 14 normal individuals to study carpal tunnel syndrome and found out that the pressure in carpal tunnel in patients was significantly higher than the normals.17
To correlate the carpal tunnel syndrome questionnaire severity score with nerve conduction study findings.
6.4 Hypotheses:
Experimental hypothesis:
There will be significant correlation between carpal tunnel syndrome questionnaire score and nerve conduction study findings.
Null hypothesis:
There will be no correlation between carpal tunnel syndrome questionnaire and nerve conduction study findings.
7 / Material and Methods:
7.1 Source of data:
Various corporate offices in and around Mangalore.
7.2 Method of collection of data:
100 healthy subjects will be taken for the study.
Sampling:
Purposive sampling.
Measurement procedure:
Written consent will be taken from subjects from various corporate offices who will fulfill the inclusion and exclusion criteria.
Carpal tunnel syndrome questionnaire will be distributed and scores will be obtained from the subjects. The selected subjects will undergo nerve conduction study.
Median sensory and motor nerve conduction study finding will be taken from the affected hand.
Subject position- sitting on back rest chair with pillow in lap,
Supporting the forearm of the subject.
The skin will be cleaned with spirit to reduce the skin resistance.
Sensory nerve conduction study will be taken. Short segment transcarpal NCV (palm to wrist conduction) of the median nerve will be taken.
The stimulation will be given on the palm in the distribution area of median nerve (between of 2nd & 3rd meta carpal) and recording will be taken on wrist at a distance of 8 cm from point of stimulation.18
Distal sensory latency of palm, sensory nerve action potential of palm and sensory nerve conduction velocity(SNCV) will be calculated.
SNCV = D/L
D – distance(mm)
L - latency(ms)
In Motor nerve conduction study (MNCV) the recording electrode will be placed closer to the motor point of ABDUCTOR POLLICIS BREVIS and reference electrode 3 cm distal at the IST METACARPAL-PHALENGEAL JOINT. The stimulation will be given at two points.
- At wrist – 3 cm proximal to distal wrist crease
- At elbow – medial to brachial artery
D - distance
PL – proximal latency
DL – distal latency
Materials to be used:
- Electromyography machine(Neurocare –2000 computerized E.M.G. with N.C.V. and evoked potentials,manufactureBiotech.India.)
- Electrodes
- Surface
- Bar
- Ring
- Conducting gel
- Spirit
- Adhesive tape
- Cotton
- Inch tape
- Carpal tunnel syndrome questionnaire
- Kidney tray
- Chair
- Pillow
- Scissors
- Pen
- pencil
Inclusion Criteria:
- Keyboard users who are using keyboard > 20 hours/week since 2 years
- 18 years and above age subjects
- Both male and female
- Subjects with cervical radiculopathy and cervical spondylosis.
- Subjects with diabetic history.
- Pregnant and lactating females.
- Subjects with reflex sympathetic dystrophy.
- Subjects with distal Forearm bone fracture.
7.4 Statistical Analysis:
Study design: Correlation study.Test:The collected data will be analyzed by Karl Pearson correlation coefficient and t – Test.
7.4Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
YES.
I intend to do the study on keyboard users.
7.5 Has ethical clearance been obtained from your institution in case of 7.4?
YES.
Consent has been taken from the college.
8 / List of references:
- Johan Hviid Anderson, Jane Froelund Thomsen, Erik Overgaard, Christina Funch Lassen, Lars Peter Andreas Brandt, Imogen Vilstrup et al. Computer use and carpal tunnel syndrome: A 1 Year follow- up study. Journal of American medical association 2003 Jun;289(22); 2963-69.
- Department of Rehabilitation Services, BRIGHAM & Women’s HOSPITAL, Standard of care Carpal tunnel syndrome (online).2005 (cited 2007 November 08). Available from: .org/Rehabilitation Services.
- Mark Sheehan. Avoiding Carpal Tunnel Syndrome; A guide for computer users 1990 July- August (cited 2007 November 10) From: office, com/content.php.
- Peter J.Keir, Joel M. Bach, Mark Hudes, David M. Rempel. Guidelines for Wrist Posture Based on Carpal Tunnel Pressure Thresholds. Human Factor 2007 Feb; 49(1):88-89.
- Mircea Fagarasanu, Shrawan Kumar. Work related carpal tunnel syndrome: Current Concepts 2003 May; 7(2):87-96.
- Coury HJCG, Kumar S, Rodgher S, Narayan Y. Measurement of shoulder adduction strength in different postures. Int J Ind Ergon 1998; 22:195-206.
- Amell TK, Kumar S. Cumulative trauma disorders and keyboarding work. Int J Ind Ergon 1999; 25:69-78.
- de Krom MC, Kester AD, Knipschild PG, Spaans F. Risk factors for carpal tunnel syndrome. Am J Epidemiol 1990 Dec; 132(6):1102-10.
- Atroshi L, Breidenbach WC, McCabe SJ. Assessment of carpal tunnel outcome instrument in patients with nerve compression symptoms. J Hand Surg 1997 Mar; 22(2):222-7.
- Robin Herbert, Fredric Gerr, Jonathan Dropkin. Clinical evaluation and management of work related carpal tunnel syndrome. American Journal of Industrial Medicine 2000; 37:62-74.
- Joao Aris Kouyoumdjian, Rogerio Gayer Machado de Araujo. Carpal tunnel syndrome and manual milking. Arq Neuropsiquiater 2006; 64(3-B):747-49.
- Leif A. Havton, John R. Hotson, Jan-Olof Kellerth. Correlation of median forearm conduction velocity with carpal tunnel syndrome severity. Clinical Neurophysiology 2007 Apr;118(4):781-85.
- Roberta Bonfiglioli, Stefano Mattioli, Maria Rosa Spagnolo, Francesco Saverio Violante. Course of symptoms and median nerve conduction values in performing repetitive jobs at risk for carpal tunnel syndrome. Occupational Medicine 2006; 56:115-121.
- Alev LEVENTOGLU, Reha KURUOGLU. Do electrophysiological findings differ according to the clinical severity of carpal tunnel syndrome? Journal of Neurological Sciences 2006; 23(4):272-78.
- T Ogura, N Akiyo, T Kubo, Y Kira, S Aramaki, F Nakanishi. The relationship between nerve conduction study and clinical grading of carpal tunnel syndrome. Journal of Orthopedic surgery 2003; 11(2):190-93.
- Robert A.Werner, Nancy Gell, Alfred Franzbalu, Thomas J. Armstrong. Prolonged median sensory latency as a predictor of future carpal tunnel syndrome. Muscle and Nerve 2001 Oct; 24(11):1462-67.
- Katsuyuki Murata, Shunichi Araki, Fumika Okajima, Yuko Saito. Subclinical impairement in the median nerve across the carpal tunnel among female visual display terminal operators. Occupational and Enviornmental Health 1996 Jan; 68(2):1246-1432.
- S. Rojviroj, W. Sirichativapee, W. Kowsuwon, J. Wongwiwattananon, N. Tamnanthong, P. Jeeravipoolvarn. A comparison between patients with carpal tunnel syndrome and subjects. J Bone Joint surg 1990; 72-B: 516-8.
- lew HL, Date ES,Pan SS, Wu P, Ware PF, Kingery WS. Sensitivity, specificity and variability of nerve conduction velocity measurements in carpal tunnel syndrome. Arch Phys Med Rehabil 2005; 86; 12-6.
9 /