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ORIGINAL ARTICLE
Year : 2015  |  Volume : 42  |  Issue : 3  |  Page : 180-184

The prevalence of median neuropathy at wrist in systemic sclerosis patients at Srinagarind Hospital


1 Department of Rehabilitation, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
2 Department of Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand

Date of Web Publication16-Sep-2015

Correspondence Address:
Dr. Patpiya Sirasaporn
Department of Rehabilitation, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.165566

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  Abstract 

Objectives: To determine the prevalence and factor related with median neuropathy at wrist (MNW) in systemic sclerosis patients. Study Design: Cross-sectional study. Setting: Srinagarind Hospital, Khon Kaen, Thailand. Participants: Systemic sclerosis patients who attended the Scleroderma Clinic, Srinagarind Hospital. Materials and Methods: Seventyfive systemic sclerosis patients were prospectively evaluated by questionnaire, physical examination, and electrodiagnostic study. The questionnaire consisted of the symptoms, duration, and type of systemic sclerosis. The physical examination revealed skin score of systemic sclerosis, pinprick sensation of median nerve distribution of both hands, and weakness of both abductor pollicis brevis muscles. The provocative test which were Tinel's sign and Phalen's maneuver were also examined. Moreover, electrodiagnostic study of the bilateral median and ulnar nerves was conducted. Results: The prevalence of MNW in systemic sclerosis patients was 44% - percentage of mild, moderate, and severe were 28%, 9.3%, and 6.7%, respectively. The prevalence of asymptomatic MNW was 88%. There were no association between the presence of MNW and related factors of systemic sclerosis. Conclusions: MNW is one of the most common entrapment neuropathies in systemic sclerosis patients. Systemic sclerosis patients should be screened for early signs of MNW.

Keywords: Electrodiagnostic study, median neuropathy at wrist (MNW), systemic sclerosis


How to cite this article:
Nimitbancha T, Sirasaporn P, Wattanapan P, Foocharoen C. The prevalence of median neuropathy at wrist in systemic sclerosis patients at Srinagarind Hospital. J Sci Soc 2015;42:180-4

How to cite this URL:
Nimitbancha T, Sirasaporn P, Wattanapan P, Foocharoen C. The prevalence of median neuropathy at wrist in systemic sclerosis patients at Srinagarind Hospital. J Sci Soc [serial online] 2015 [cited 2020 Mar 28];42:180-4. Available from: http://www.jscisociety.com/text.asp?2015/42/3/180/165566


  Introduction Top


Median neuropathy at wrist (MNW) is the most common of the entrapment neuropathies. Prevalence of MNW seems high in work-related populations who have repetitive wrists movements such as cashiers, hairdressers, and knitters. This condition affects the capability of work performance and the quality of life. Moreover, there are many predisposing factors of MNW such as congenital bone disease, metabolic disease, degenerative disease, injury, and repetitive trauma. All of that are prone to entrap or compress the median nerve. The symptoms of MNW are paresthesia, pain, numbness along the distribution of the median nerve, and abductor pollicis brevis muscle weakness. At present, the diagnosis of MNW is composed of history, physical examination, and provocative test that are not specific to diagnose such disease. Besides, electrodiagnostic study is carried out using specific medical equipment to accurately diagnose MNW.

Systemic sclerosis is a disease of unknown causes that affects the multiorgan system. The pathology reveals that a lot of fibrosis tissues infiltrate into the skin layer and internal organs. These make skin and internal organs thicker and harder. Although the prevalence of this disease is low, the incidence of handicap is high. In addition, thickness of the skin layer directly induces risk for compression or entrapment to peripheral nerve and capillary vessel that increases the risk of MNW in systemic sclerosis patients. Furthermore, the most common entrapment neuropathy in such patients is MNW that occurs in about 3.2-25%. [1],[2],[3],[4],[5] MNW is one of factors affecting their routine activity. [6] In terms of literature review, there is no study of MNW in systemic sclerosis patients in Thailand. Moreover, the characteristics of Thai systemic sclerosis patients differ from the characteristics of the patients in Western countries. The type of systemic sclerosis in Thai patients is diffuse cutaneous systemic sclerosis, whereas the type of systemic sclerosis in patients in Western countries is limited cutaneous systemic sclerosis. [7] In this study, our objectives were to study the prevalence of MNW in systemic sclerosis patients, severity of symptoms, and predisposing factors.


  Materials and Methods Top


Participants

Systemic sclerosis patients attended the Scleroderma Clinic, Medicine Department, Srinagarind Hospital from October 2013 to August 2014. Inclusion criteria were age more than 18 years old and history of all types of systemic sclerosis. Exclusion criteria were renal failure, pregnancy, diabetes mellitus, hyperthyroidism or hypothyroidism, rheumatoid arthritis, wrist fracture or dislocation, and overlapping syndrome. This study was approved by the Khon Kaen University Ethics Committee for Human Research (HE 561299) and was supported by the Faculty of Medicine Research Fund, Khon Kaen University (I56334).

Methodology

The participants were assessed by questionnaire, physical examination, and electrodiagnostic study.

  • Baseline characteristics: Age, sex, hand dominance, weight, height, and underlying disease
  • Systemic sclerosis associated data: Duration, type, symptoms, and modified Rodnan skin score of dorsum of both hands [8],[9]
  • MNW associated data: Symptoms, Boston questionnaire, [10],[11],[12] sensation of both hands, weakness of both the abductor pollicis brevis muscles, Tinel's sign, and Phalen's maneuver
  • Electrodiagnostic study: Nerve conduction study of both median and ulnar nerves and electromyography of the abductor pollicis brevis muscle


Electrodiagnostic study

  1. Sensory nerve conduction study: Antidromic technique recording distal sensory latency (DSL) and nerve conduction velocity:

    1.1. Median sensory nerve conduction study:

    • E1 active: Ring electrode at proximal interphalangeal joint (PIP) joint of the middle finger.
    • E2 reference: Ring electrode at 4 cm distal to E1.
    • Stimulation site: At wrist (about 14 cm proximal to the active electrode at E1) and elbow region.


    1.2. Ulnar sensory nerve conduction study:
    • E1 active: Ring electrode at PIP joint of the little finger.
    • E2 reference: Ring electrode at 4 cm distal to E1.
    • Stimulation site: At wrist (about 14 cm proximal to the active electrode at E1) and elbow region.
  2. Motor nerve conduction study: Orthodromic technique recording distal motor latency (DML) and nerve conduction velocity:

    2.1. Median motor nerve conduction study.

    • E1 active: Surface electrode attach at motor point of abductor pollicis brevis muscle.
    • E2 reference: Surface electrode at 4 cm distal to E1.
    • Stimulation site: At wrist (about 8 cm proximal to the active electrode at E1) and elbow region.


    2.2. Ulnar motor nerve conduction study:
    • E1 active: Surface electrode attach at motor point of abductor digiti minimi muscle.
    • E2 reference: Surface electrode at 4 cm distal to E1.
    • Stimulation site: At wrist (about 8 cm proximal to the active electrode at E1) and elbow region
  3. Electromyography:

    3.1. Needle examination: Examining the abductor pollicis brevis muscle MNW was classified in three levels.
    • Mild: Only prolonged DSL (more than 3.48 ms).
    • Moderate: Prolonged DSL (more than 3.48 ms) and prolonged DML (more than 4.2 ms).
    • Severe: Absent or prolonged DSL (more than 3.48 ms) or DML (more than 4.2 ms) and decreased compound muscle action potential (CMAP) or abnormality in electromyography.


Statistical analysis

Using SPSS 19.0 (IBM SPSS statistics Version 19), the continuous data were presented as mean and standard deviation (SD). The ordinal data were shown as frequency and percentage. Prevalence of MNW was presented in percentage and 95% confidence interval (CI). Correlation between systemic sclerosis associated factor and MNW was analyzed by chi-square test (significant P-value < 0.05).


  Result Top


The number of participants was 75 out of whom 57 (76%) were females. The average age of the participants was 51 ± 11 years (range 21-75 years). Most of body mass index was 18.50-22.99 kg/m 2 . Duration of systemic sclerosis disease was 6.9 ± 4.8 years. Diffuse cutaneous type of systemic sclerosis is the most common type (72%). The Boston questionnaire showed that most of the participants presented with mild degree of MNW (72%) and difficulty in hand functioning (48%) [Table 1].
Table 1: Baseline characteristics


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According to electrodiagnostic study, the prevalence of MNW was around 44% (32.77-55.23%). The percentages of mild, moderate, and severe MNW were 28%, 9.3%, and 6.7%, respectively. The percentage of symptomatic MNW, with symptoms such as abductor pollicis brevis weakness and/or numbness along the median nerve distribution, was 12% and that of asymptomatic MNW was 88% [Table 2].
Table 2: Electrodiagnostic study


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The correlation between factors and MNW showed that age more than 51 years old and female were associated with such disease. However, no correlation between systemic sclerosis factors and MNW was detected [Table 3].
Table 3: Correlation between factors and MNW


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  Discussion Top


In this study, we found a high prevalence (3.2-25%) of MNW compared to the previous studies. [1],[2],[3],[4],[5] Among the participants in this study, the most common type systemic sclerosis was diffused cutaneous systemic sclerosis, whereas in other studies it was limited cutaneous systemic sclerosis. Although most of the MNW cases were of asymptomatic kind that did not directly affect the lifestyle of systemic sclerosis patients, a manifestation sign of increased vulnerability to the entrapment of the peripheral nerve may result from their underlying disease. This study showed that the prevalence of MNW in systemic sclerosis patients is higher than the prevalence of MNW in the general population that showed only 2.7%. [13]

The factors associated with MNW are as follows: Older age and female. It was accord with previous study which found in female [14] and the age of 40-60 years. [15] Nevertheless, there was no correlation between factors of systemic sclerosis and MNW. It may be caused by limitation of recognition onset time of systemic sclerosis disease and variation of systemic sclerosis sign and symptoms presentation. Moreover, there was no association between the Boston score and MNW because most participants had low score in both items of severity score and loss of hand function score. Systemic sclerosis patients presented with the limitation of hand function and hand deformities, so usage of the Boston questionnaire to evaluate MNW was not suitable.

Study limitation

In this study, the sample size was calculated for the prevalence study and was not suitable for the risk factor study. Therefore, statistical analysis revealed no systemic sclerosis factors associated with MNW. In the future, cohort study for long-term detection of MNW in systemic sclerosis patients will demonstrate more clearly.


  Conclusion Top


Asymptomatic MNW is one of the most common entrapment neuropathies in systemic sclerosis patients. Thereby, physicians who deal with these patients should recognize the occurrence of this disease in order to consider surveillance, early detection, and improve the quality of care for systemic sclerosis patients.

Financial support and sponsorship

Supported by Faculty of Medicine Research Fund, Khon Kaen University (I56334).

Conflicts of interest

No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

 
  References Top

1.
Machet L, Vaillant L, Machet MC, Esteve E, Muller C, Khallouf R, et al. Carpal tunnel syndrome and systemic sclerosis. Dermatology 1992;185: 101-3.   Back to cited text no. 1
    
2.
Amaral TN, Peres FA, Lapa AT, Marques-Neto JF, Appenzeller S. Neurologic involvement in scleroderma: A systematic review. Semin Arthritis Rheum 2013;43:335-47.  Back to cited text no. 2
    
3.
Mondelli M, Romano C, Della Porta PD, Rossi A. Electrophysiological evidence of "nerve entrapment syndromes" and subclinical peripheral neuropathy in progressive systemic sclerosis (scleroderma). J Neurol 1995;242:185-94.   Back to cited text no. 3
    
4.
Poncelet AN, Connolly MK. Peripheral neuropathy in scleroderma. Muscle Nerve 2003;28:330-5.   Back to cited text no. 4
    
5.
Lee P, Bruni J, Sukenik S. Neurological manifestations in systemic sclerosis (scleroderma). J Rheumatol 1984;11:480-3.   Back to cited text no. 5
    
6.
Casale R, Buonocore M, Matucci-Cerinic M. Systemic sclerosis (scleroderma): An integrated challenge in rehabilitation. Arch Phys Med Rehabil 1997;78:767-73.  Back to cited text no. 6
    
7.
Foocharoen C, Mahakkanukrauh A, Suwannaroj S, Nanagara R. Pattern of skin thickness progression and clinical correlation in Thai scleroderma patients. Int J Rheum Dis 2012;15:e90-5.  Back to cited text no. 7
    
8.
Furst DE. Outcome measures in rheumatologic clinical trials and systemic sclerosis. Rheumatology (Oxford) 2008;47(Suppl 5):v29-30.   Back to cited text no. 8
    
9.
Pope JE, Bellamy N. Outcome measurement in scleroderma clinical trials. Semin Arthritis Rheum 1993;23:22-33.  Back to cited text no. 9
    
10.
Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status incarpal tunnel syndrome. J Bone Joint Surg Am 1993;75:1585-92.  Back to cited text no. 10
    
11.
Upatham S, Kumnerddee W. Reliability of Thai version Boston questionnaire. J Med Assoc Thai 2008;91:1250-6.  Back to cited text no. 11
    
12.
Rao BH, Kutub M, Patil SD. Carpal tunnel syndrome: Assessment of correlation between clinical, neurophysiological and ultrasound characteristics. J Sci Soc 2012;39:124-9.  Back to cited text no. 12
  Medknow Journal  
13.
Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999;282:153-8.  Back to cited text no. 13
    
14.
Dumitru D, Zwarts M. Focal peripheral neuropathies. In: Dumitru D, Zwarts M, editors. Electrodiagnostic Medicine. 2 nd ed. Philadephia: Hanley and Belfus; 2002. p. 1043-126.  Back to cited text no. 14
    
15.
Spahn G, Wollny J, Hartmann B, Schiele R, Hofmann GO. Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part I. General factors. Z Orthop Unfall 2012;150:503-15.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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