Evaluation of Boston questionnaire applied at late pos-operative period of carpal tunnel syndrome operated with the paine retinaculatome through palmar port

Abstracts

Entre os anos de 1995 e 1998, foram realizadas 112 cirurgias para tratamento da Síndrome do Túnel do Carpo (STC) pela técnica de incisão palmar e utilização do retináculo de Paine. Com o objetivo de avaliar os resultados em longo prazo, os pacientes foram convocados. Houve o retorno de 44 pacientes. Deste total, três pacientes, por terem doenças associadas, foram excluídos, resultando, um total de 53 mãos analisadas. Apresentaremos os resultados da avaliação subjetiva, obtidos através da aplicação de um teste de auto-avaliação chamado de questionário de Boston. Este questionário consiste em perguntas que avaliam a gravidade dos sintomas e o estado funcional no momento da aplicação do mesmo. Através da aplicação do referido questionário encontramos um escore de 1,41 ± 0,57 para gravidade dos sintomas e 1,59 ± 0,93 para o estado funcional. Como este questionário não foi aplicado no pré-operatório deste grupo de pacientes analisados, comparou-se a pontuação obtida com as encontradas na literatura pertinente. Os resultados obtidos demonstraram que as pontuações pós-operatórias são similares àquelas existentes na literatura, mesmo sendo referidas a tempos diferentes de seguimento pós-operatórios, concluindo que havendo uma melhora dos sintomas, o questionário de Boston é sensível a esta mudança clínica.

Questionários; Síndrome do túnel do carpo; Avaliação da deficiência

ORIGINAL ARTICLES

Evalution of the Boston questionnaire applied at late post-operative period of carpal tunnel syndrome operated with the paine retinaculatome trhough palmar port

Lia Miyamoto Meirelles^I; João Baptista Gomes dos Santos^II; Luciana Leonel dos Santos^III; Marco Aurelio Branco^III; Flavio Faloppa^IV; Vilnei Mattioli Leite^V; Carlos Henrique Fernandes^VI

^IPhysical Therapist, expert in hand therapy, Medical College, USP

^IIMaster, PhD, Head of the Discipline of Hand and Upper Limb Surgery, UNIFESP

^IIIResident Doctor of the Department of Orthopaedics and Traumatology, UNIFESP

^IVChairman of the Department of Orthopaedics and Traumatology, UNIFESP

^VFull Professor, Head of the Discipline of Hand and Upper Limb Surgery, UNIFESP

^VIMaster, PhD, Doctor of the Discipline of Hand and Upper Limb Surgery, UNIFESP

^{Correspondences to}

SUMMARY

Between the years of 1995 and 1998, 112 surgeries were performed for treating Carpal Tunnel Syndrome (CTS) using the technique of palmar incision employing the Paine retinaculum.

With the objective of analyzing results in the long-term, the patients were called for review. Forty four patients returned.

From these, three patients were excluded due to associated diseases, thus resulting in a total of 53 hands assessed.

Here we present the results of the subjective evaluation achieved by applying a self-assessment test called Boston questionnaire. This questionnaire consists of questions evaluating symptoms severity and functional status at the moment of its application.

By applying this questionnaire, we found a score of 1.41 ± 0.57 for symptoms severity and of 1.59 ± 0.93 for functional status. As this questionnaire was not applied at the pre-operative period for those patients assessed, its scores were thus compared to those found in pertinent literature.

The achieved results show that post-operative scores are similar to those described in literature, even when reported in different postoperative follow-up times, thereby concluding that when symptoms are improved, the Boston questionnaire is sensitive to that clinical change.

Keywords: Questionnaires; Carpal tunnel syndrome; Disability evaluation.

INTRODUCTION

Carpal tunnel is the anatomical region where flexor tendons of fingers and the median nerve are found. Tunnel’s roof is formed by flexors retinaculum, also called carpal transverse ligament. The retinaculum is a fibrous band, 2.5-3.5 mm thick and 3 – 4 cm large, immediately above the median nerve. The carpal tunnel syndrome (CTS) is characterized by median nerve compression on the area in which it crosses the carpal region. Compression may occur due to a reduction of tunnel’s inner diameter or due to an increased volume of the structures comprised in it. Anatomical studies show that the narrowest region of the tunnel is distal to the level of the hamate hamulus and that during wrist flexion, nerve compression occurs through the proximal margin of flexors retinaculum^(1,2).

Many publications about CTS surgical treatment report excellent results and low complication rates ^(3,4), while others report many kinds of complications, such as the recurrence of the carpal tunnel syndrome ^(5,6,7).

In the last few years, an increasing use of endoscopic methods for carpal tunnel release is noticed, intending to reduce morbidity and hasten the return to work ^(8,9). Because there are many treatments and surgical techniques, it was required to develop studies evaluating those results. Among the several instruments proposed, the Boston questionnaire was developed, designed to be applied in patients with carpal tunnel syndrome, with the purpose of evaluating the severity of symptoms and the degree of manual skill⁽¹⁰⁾.

This evaluation instrument was recognized as reproducible, valid, with internal consistency and able to respond to clinical changes, with a transcultural adaptation being performed and validated in our country by means of a study conducted at UNIFESP in 2003 ⁽¹¹⁾.

The objective is to evaluate Boston questionnaire applied at the late postoperative period of carpal tunnel syndrome operated by means of Paine’s retinaculatome through palmar port.

MATERIALS AND METHODS

The present material comprehends 44 patients, totaling 57 hands submitted to surgical release of the carpal tunnel through palmar port and Paine^® retinaculatome, with follow up of at least 5 years postoperatively.

Regarding related diseases, it was observed that 3 (5.2%) patients had other diseases such as stroke, AR and scleroderma, which were excluded in order to not to cause bias in the results, therefore, with 41 patients and 53 hands being analyzed.

Time elapsed from surgery to evaluations ranged from 80 to 117 months, with an average of 97 months.

In Table 1, data concerning those 41 patients are described and chronologically listed from surgery day, according to the order number, age in years, gender, dominant side, affected side, operated side, surgery date and current follow-up time in months. The evaluation routine consisted of calling patients by telegram or phone. Reaching to the infirmary, the patient was re-evaluated by the doctor.

The Boston questionnaire, ^{Annex 1}, properly translated and validated into Portuguese, was applied to all patients returning for evaluation.

The Boston questionnaire is self-applied and evaluates the severity of symptoms and the functional status of patients with carpal tunnel syndrome. The symptoms severity scale (SSS) evaluates symptoms regarding severity, frequency, time and kind. The functional status scale (FSS) evaluates how the syndrome affects daily life.

Questions concerning symptoms severity scale are composed of 11 questions addressing: pain intensity during daytime and nighttime, time of pain during the day, dormancy, weakness, tingling sensation at night, frequency of that night tingling sensation, and skill. Each question has five answers numbered from 1 to 5, arranged in an increasing order of symptoms severity. Therefore, 1 means no symptoms, 2 mild symptoms, 3 moderate symptoms, 4 intense symptoms, and 5 severe symptoms.

Questions concerning functional status are composed of 8 questions, where each one corresponds to a functional activity (writing, buttoning clothes, holding a book while reading, holding a telephone hang, housekeeping, opening a glass vial cap, carrying market bags, bathing and dressing). Each activity has five difficulty degrees, labeled according to a table shown at the end of the question, where degree 1 corresponds to no difficulty, degree 2 little difficulty, degree 3 moderate difficulty, degree 4 intense difficulty, and degree 5 cannot perform the activity at all due to hands and wrists symptoms.

All answers should be concerned to the symptoms within a typical period of 24 hours, for the last two weeks.

For the self-appraisal, patients were guided into a room, where they received a copy of the questionnaire. After a brief explanation of what the questions were about and how to answer those questions, patients were left on their own to answer the questionnaire.

The patients should answer to the 11 first questions choosing only one alternative. Regarding the last eight questions, they should select the degree of difficulty felt in each activity described, according to the label on the questionnaire itself.

In case a patient had both hands operated, two questionnaires should be applied, one for each hand. From answers, two scores were calculated. The symptoms severity score (SSS) refers to the first 11 questions.

The functional status score (FSS) refers to the last 8 questions. This calculation is the sum of answers divided by the number of questions. Unanswered questions were excluded from calculation.

Answers were listed and analyzed (Table 2).

An average of the answers for each question was calculated, aiming a careful analysis of results for each question (Table 3).

RESULTS

By applying the Boston questionnaire, we found a symptoms severity score (SSS) of 1.41 ± 0.57 and a functional status score (FSS) of 1.59 ± 0.93. In the analysis by question, the highest averages were found for symptoms severity in questions number 4, 5 and 7 (S4, S5, and S7), and, for functional status, in questions number 5, 6, and 7 (F5, F6 and F7). (Table 3, Graphs 1 and 2).

DISCUSSION

By analyzing the age group affected, we see that the mean age ranges from 44 years old ⁽¹²⁾, 46 years old⁽¹³⁾, 56 years old⁽¹⁴⁾ and 57 years old⁽¹⁰⁾. In this study group, ages ranged from 45 to 70 years old, with an average of 57. In our study, the incidence of females is higher, as reported in other studies ^(12,14).

The condition affected bilaterally 47 (88.67%) patients, followed by 6 (11.32%) on the right hand, and 0 on the left hand. This order is consistent to findings of other authors^(15,16).

In comparative studies, postoperative follow-up time using the Boston questionnaire as an evaluation instrument was 1 – 6 months in a study ⁽¹⁴⁾ and 3 – 6 months in another study⁽¹²⁾.

Patients’ follow-up ranged from 80 to 117 months, with an average of 97 months. No long-term follow-up studies were found.

Many instruments are used to evaluate the results of carpal tunnel treatment. Among them, the nervous conduction study, symptom inspection, sensitivity test, tweezing and prehension strength measurement, complication rates, pain and skill degree evaluation, return to work and functional ability⁽¹⁷⁾.

Studies on carpal tunnel release usually get to outcomes where patients report symptoms relief and functional improvement⁽¹⁸⁾, but, until not so long ago, subjective results were not standardized or properly measured. Quality of life measurement instruments were developed, based on patient’s opinion, in order to scientifically evaluate subjective results in a surgical intervention. Initially, generic questionnaires were developed, such as, for example, the SF-36 (short form 36), which consists of 36 questions comprehending physical, mental and social aspects as well as a person’s welfare as a whole, with few specific questions. Over time, the need for specific questionnaires became evident. In 1995, a questionnaire was developed to measure upper limb results – DASH (Disabilities of the arm, shoulder, and hand). It consists of 30 items measuring function, symptoms, and quality of life relative to pathologies of the upper limb ⁽¹⁹⁾. Among others, we can also find the PRWE (patient-rated wrist evaluation), which consists of 15 questions evaluating pain and functional disability, where the patient evaluates his/ her own ability and degree of domain in personal care, work, housekeeping and leisure.

Some authors demonstrated that those scientific measurements of a patient’s opinion are more sensitive to clinical changes after treatment than data provided by physical examination performed by the surgeon him/herself ^{(17,20,21,23).}

The Boston questionnaire was employed, which also provided a standardization of those subjective outcomes, due to its reproducibility, coherence, validity and sensitiveness to clinical changes.

We noticed that there are scarce studies in literature making a long-term postoperative evaluation employing the Boston questionnaire. In one of the comparative studies, the Boston questionnaire was used to compare electrophysiological results in a carpal tunnel syndrome postoperative follow-up⁽¹⁴⁾. A similar study was published in 2002 by another author ⁽¹²⁾. Both could not find any correlation between nervous sensitive conduction speed and the Boston questionnaire.

One hundred fourteen patients were assessed, by comparing the Katz-Stirrat⁽²⁵⁾ hand diagram, in which the patient him/ herself marks the areas of symptoms distribution on a diagram, classifying the disease into Classic or Probable, possible and unlikely, with the results of the Boston questionnaire. Patients categorized as Classic or Probable achieved a symptoms severity score higher than the scores for possible and unlikely categories⁽²⁴⁾

We conducted a comparative study on scores found in other studies, including the results by Levine, regarding postoperative follow-up periods, using the Boston questionnaire (Table 4). Only three studies meeting the requirements for such comparison were found ^(10,12,14). When a careful analysis of the questionnaire was performed, we saw that questions concerning the major CTS symptoms such as tingling sensation, nighttime pain, dormancy and skills had lower scores.

When the averages for each question were calculated, we found the highest scores concerning symptoms severity for questions related to pain (pain frequency during the day S4, time of pain episodes during the day S5) and muscle weakness (presence of muscular weakness S7), and, concerning the functional status, activities related to strength (housekeeping F5, open a glass vial cap F6, and carry market bags F7). Anyway, scores were overall low, indicating a non-severe picture.

During questionnaire application, we observed that the patients were in doubt to answer questions especially regarding pain, because, in the majority of the cases, they experienced other kinds of pain, such as arthrosis, trigger or tendonitis, which could confuse answers.

In our study, a lot of difficulty was seen on understanding the labels of the functional status evaluation, requiring the investigator to repeat the explanation many times. Another important difficulty seen was in the moment of evaluating the degree of difficulty for item ‘writing’, because, when the dominant hand was not to be evaluated, it was impossible to answer, with two patients leaving the answer in blank and the others giving random answers.

In this last question concerning functional status, the questionnaire originally describes the label above each number, while at validation, the label was exhibited at the end of the question, which, in our opinion, made its comprehension difficult (^{Annex 2}).

CONCLUSION

Patients operated through palmar port technique using the Paine retinaculatome remain happy with their surgical outcomes, even after a long follow-up time, according to the results of the Boston questionnaire. The last portion of the questionnaire was shown to be confused and difficult to understand in what concerns to functional status.

REFERENCES

Received in: 07/25/05; approved in:09/29/05

Study conducted at the Department of Orthopaedics and Traumatology, Federal University of São Paulo – UNIFESP.

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Annex 1

Annex 2

Publication Dates

• Publication in this collection
  31 Aug 2006
• Date of issue
  2006

History

• Accepted
  29 Sept 2005
• Received
  25 July 2005