The Effect of Hand Dominance on Patient-Reported Outcomes of Carpal Tunnel Release in Patients with Bilateral Carpal Tunnel Syndrome

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1 Original Article The Journal of Hand Surgery (Asian-Pacific Volume) 17;22(3): DOI: /S The Effect of Hand Dominance on Patient-Reported Outcomes of Carpal Tunnel Release in Patients with Bilateral Carpal Tunnel Syndrome Qian Ying TANG*, Wei Hong LAI*, Shian Chao TAY *Yong Loo Lin School of Medicine, National University of Singapore, Department of Hand Surgery, Singapore General Hospital, Singapore J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. Background: There is a paucity of studies in published literature that examines the effect of hand dominance on the resolution of symptoms following a carpal tunnel release. The objective of this study is to examine the effect of hand dominance on the resolution of symptoms following surgical decompression in patients with severe and moderate carpal tunnel syndrome. Methods: Bilateral carpal tunnel release (total 90 open and 84 endoscopic) was performed on 87 patients (11 males, 76 females) presenting with bilateral severe or moderate carpal tunnel syndrome of equal severity. Patient-reported outcome of resolution of symptoms were recorded, with patients followed up until complete resolution of symptoms or last recorded consultation (mean follow-up duration 11.4 months, range 3.1 to 32.4 months). Results: In patients with bilateral severe carpal tunnel syndrome, a larger proportion of non-dominant hand (75.4%) achieved complete resolution compared to dominant hand (72.1%), and did so at a statistically shorter time (mean: 52.3 days) than the dominant hand (mean: 81.0 days). However, there was no statistically significant difference between proportion of patients and time taken before complete resolution of symptoms between dominant and non-dominant hand in patients with bilateral moderate carpal tunnel syndrome. Conclusions: Symptoms in the non-dominant hand resolved faster after carpal tunnel release in patients with severe carpal tunnel syndrome. We postulate that greater daily activity by the dominant hand compared to the non-dominant hand may be a contributing factor to its slower rate of symptoms resolution post-surgically in patients with bilateral severe carpal tunnel syndrome. This effect of hand dominance is not evident in post-surgical patients with moderate carpal tunnel syndrome. Keywords: Bilateral carpal tunnel syndrome, Severe, Hand dominance, Patient reported outcomes INTRODUCTION Literature about the relationship between hand dominance and carpal tunnel syndrome is scant. Whilst there Received: Apr. 14, 16; Revised: Jul. 28, 16; Accepted: Jul. 29, 16 Correspondence to: Shian Chao TAY Department of Hand Surgery, Singapore General Hospital, The Academia, College Road, Singapore Tel: , Fax: tay.shian.chao@sgh.com.sg have been published studies which examine the effect of hand dominance on the pathophysiology of carpal tunnel syndrome, 1) the effect of hand dominance on recovery of carpal tunnel syndrome remains unexplored. A 1981 paper by Reinstein 2) reported that carpal tunnel syndrome was found to occur significantly more frequently in the dominant hand and concluded that the increased daily activity of the dominant hand was a contributing factor in the development of carpal tunnel syndrome. Similarly, Wee and Abernathy 3) reviewed electrodiagnostic studies consistent with carpal tunnel syndrome

2 304 Qian Ying TANG, et al. Hand Dominance and Patient-Reported Outcomes in Bilateral Carpal Tunnel Syndrome J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. in 68 patients and reported that median compound sensory nerve action potential (CSNAP) abnormalities were relatively worse in the dominant hand among righthanders but not in left-handers. They postulated that left-handers might have a greater tendency to use either hand when performing certain manual tasks compared to right-handers, hence producing equal amount of repetitive stress on the median nerve in both wrists. By searching existing literature using Medline and PubMed (search terms used: carpal tunnel syndrome, hand dominance, handedness, recovery, surgery, carpal tunnel release, resolution of symptoms), we did not discover any studies pertaining to the role of hand dominance on the resolution of symptoms following carpal tunnel release. This study hence aims to address this gap in existing literature by examining the effect of hand dominance on the resolution of symptoms following surgical decompression in patients with severe and moderate carpal tunnel syndrome. METHODS Subjects With Institutional Review Board approval, a retrospective analysis of 174 hands in 87 consecutive patients (11 males and 76 females; mean age 54.5 years ± 12.0 years; range years) who had bilateral severe or moderate carpal tunnel syndrome and undergone bilateral carpal tunnel release (90 open and 84 endoscopic) between January 02 and December 12 was performed. All patients included in the study were diagnosed with carpal tunnel syndrome clinically, and had their pre-operative severity assessed by a nerve conduction study conducted by an independent neurologist, and severity was graded according to previously published neurophysiological classification system. 4) Patients were included in the study if clinical presentation and nerve conduction studies showed equal severity of carpal tunnel syndrome bilaterally. All patients reported bilateral numbness of equal severity. None of the carpal tunnel release operations were performed at the same seating. 22 patients who received endoscopic release in one hand and open release in the other hand were excluded from this study. 11 and 1 patient had concurrent trigger finger release and wrist ganglion removal performed at the same sitting as the carpal tunnel release respectively. There were no patients with inflammatory joint disease. Based on the results of nerve conduction studies and clinical presentation, there were 61 patients with severe carpal tunnel syndrome and 26 with moderate carpal tunnel syndrome (Table 2). Follow-Up Patients were followed up continuously until complete resolution of their symptoms was recorded or until their final follotw-up consultation. The minimum followup duration was 3 months. The mean follow-up duration was ± 6.3 months (range 3.1 to 32.4 months). Statistical Analysis Statistical analysis of the data collected was performed using IBM SPSS Statistics version. A p- value of <0.05 was considered statistically significant. Variables of interest were summarised using appropriate descriptive statistics. Table 1. CTS-6 Clinical Criterias 1. Numbness predominately or exclusively in the median nerve territory 2. Nocturnal numbness 3. Thenar weakness and/or atrophy 4. Positive Tinel sign 5. Positive Phalen Test 6. Loss of 2 point discrimination Table 2. Patient Demographics of Stratified Groups Demographic Severe Moderate Number of patients Number of hands Age Mean: 55.7 ± 11.6 years Range: years Mean: 51.8 ± 12.7years Range: years Gender Female: 53 (86.9%) Male: 8 (13.1%) Female: 23 (88.5%) Male: 3 (11.5%) Post-operative follow-up Mean 11.2 ± 6.3 months Mean 11.7 ± 6.4 months Type of carpal tunnel release performed Bilateral Open: 36 patients Bilateral Endoscopic: 25 patients Bilateral Open: 9 patients Bilateral Endoscopic: 17 patients

3 305 The Journal of Hand Surgery (Asian-Pacific Volume) Vol. 22, No. 3, 17 J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. RESULTS Overall Patient-reported outcome of resolution of numbness and its time taken was recorded and analysed. At the end of the 12-month follow-up, a larger proportion of non-dominant hand (n = 65, 74.7%) achieved complete resolution compared to dominant hand (n = 60, 69.0%). This proportion changed slightly with time, as 77.0% and 73.6% of non-dominant hands and dominant hands respectively achieved complete resolution of symptoms eventually at the time of final follow-up (Fig. 1). However, chi square analysis of this categorical data showed that this varying proportion was not statistically significant. In the 131 hands that achieved complete resolution of symptoms, the time taken was recorded and analysed. The mean time before complete resolution of symptoms for the dominant hand was 73.4 days, which was longer Number of hands with complete resolution of symp t oms weeks Comparison of hand dominance months Within 6 months Post-operative follow up Dominant hand Non dominant hand Within Eventual 12 months complete resolution of symptoms at time of final follow-op Fig. 1. Graph depicting the cumulative number of patients with carpal tunnel syndrome who had complete resolution of symptoms at followup duration of 3, 6 and 12 months. The blue line represents the dominant hands, while the red line represents the non-dominant hands. Table 3. Time Taken before Complete Resolution of Symptoms for Patients with Carpal Tunnel Syndrome Time Total (n = 131) Mean: 65.9 ± days Range: days Dominant Hand (n = 44) Mean: 73.4 ± days Range: days Non Dominant Hand (n = 46) Mean: 58.8 ± days Range days p-value than that of the non-dominant hand, at 58.8 days (Table 3). However, this difference was not statistically significant. Severe Carpal Tunnel Syndrome In our subset analysis of those with bilateral severe carpal tunnel syndrome, a larger proportion of nondominant hand (75.4%) achieved complete resolution compared to dominant hand (72.1%). A graphical representation of the recovery during a 12-month follow up period is shown in Fig. 2. The difference in proportions was not statistically significant. The mean time before complete resolution of symptoms for the dominant hand was 81.0 days compared to the shorter mean time of 52.3 days in the non-dominant hand (Table 4). This difference in time taken before resolution of symptom was statistically significant (p = 0.034). Number of hands with complete resolution of symp t oms weeks Table 4. Time Taken before Complete Resolution of Symptoms for Patients with Severe Carpal Tunnel Syndrome Time Total (n = 90) Mean: 66.3 ± days Range: days Dominant Hand (n = 44) Mean: 81.0 ± days Range: days Non Dominant Hand (n = 46) Mean: 52.3± 86.7 days Range days p-value 0.040* *Statistically significant. Hand dominance & resolution of symptoms (severe CTS) months Within 6 months Post-operative follow up Dominant hand Non dominant hand Within Eventual 12 months complete resolution of symptoms at time of final follow-op Fig. 2. Graph depicting the cumulative number of patients with severe carpal tunnel syndrome who had complete resolution of symptoms at follow-up duration of 3, 6 and 12 months. The blue line represents the dominant hands, while the red line represents the non-dominant hands.

4 306 Qian Ying TANG, et al. Hand Dominance and Patient-Reported Outcomes in Bilateral Carpal Tunnel Syndrome J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. Number of hands with complete resolution of sym p toms weeks Hand dominance & resolution of symptoms (moderate CTS) months Within 6 months Post-operative follow up Dominant hand Non dominant hand Within Eventual 12 months complete resolution of symptoms at time of final follow-op Fig. 3. Graph depicting the cumulative number of patients with moderate carpal tunnel syndrome who had complete resolution of symptoms at follow-up duration of 3, 6 and 12 months. The blue line represents the dominant hands, while the red line represents the non-dominant hands. Moderate Carpal Tunnel Syndrome At the end of 12 months erative follow-up, 76.9% achieved complete resolution of symptoms, with remaining 23.1% reporting that whilst there was still residual numbness, surgery had improved their symptoms. The proportion of complete resolution of symptoms was the same (n = ) for both dominant and non-dominant hand. Throughout the follow-up period, this proportion remained largely the same, but 1 more non-dominant hand eventually recovered fully as compared to the dominant hand. At the end of the follow-up period, 78.8% of cases with moderate carpal tunnel syndrome had complete resolution of symptoms. A graphical representation of the recovery during a 12-month follow up period is shown in Fig. 3. The mean time before complete resolution of symptoms for the dominant hand was 56.8 days, as compared to the longer mean time of 73.0 days in the non-dominant hand. This difference was not statistically significant (Table 5). Patients with Trigger Fingers As previous studies have expounded an association between trigger finger and carpal tunnel syndrome, 5) a subset analysis of 11 patients with concomitant trigger fingers was carried out to examine the influence of trigger finger on the outcomes of carpal tunnel release. We found no statistically significant difference (p = 0.616) in time taken before resolution of symptoms in patients Table 5. Time Taken before Complete Resolution of Symptoms for Patients with Moderate Carpal Tunnel Syndrome with concurrent trigger fingers. DISCUSSION Time Total (n = 41) Mean: 65.1 ± days Range: days Dominant Hand (n = ) Mean: 56.8 ± 98.2 days Range: days Non Dominant Hand (n = 21) Mean: 73.0 ± days Range days p-value Carpal Tunnel Syndrome (CTS) is one of the most common pathologies of the upper limbs, with an estimated incidence of 1 to 5 per 1,000 person-years depending on study location and metholodology employed. 6,7) While treatment options for CTS include splinting, 8) oral glucocorticoids 9) and local steroid injections, 10) surgical decompression remains the definitive treatment for CTS. 11) Published literature has revealed a plethora of factors that influence the outcome of carpal tunnel release, amongst which include age, 12) gender, 13) severity of CTS 14) and presence of medical comorbidities. 15) Hitherto, we do not know of any study in existing published literature that examines the effect of hand dominance on the outcome of carpal tunnel release. In cognizance of the above potentially confounding variables, this study examined the effects of hand dominance in patients with bilateral carpal tunnel syndrome of equal severity to allow for patients to serve as their own internal control. In addition, in the light of much heterogeneity in published literature regarding the outcomes of endoscopic vis-à-vis open carpal tunnel release, 16-18) only patients who had received either both open or both endoscopic carpal tunnel release were studied in order to reduce the effect of the type of release on the outcome of the surgery. Surgical decompression is commonly carried in moderate and severe carpal tunnel syndrome and preoperative electrophysiological tests are common practices. 19) Yet, existing studies have shown that electrophysiological studies may not always return to normal following surgical decompression, especially in patients with advanced pathologies.,21) This has given rise to debates over the effectiveness of carpal tunnel release in resolving symptoms amongst patients with severe patholo-

5 307 The Journal of Hand Surgery (Asian-Pacific Volume) Vol. 22, No. 3, 17 J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. gies. 22) By examining the effects of hand dominance on patient-reported outcomes following surgical decompression in moderate and severe carpal tunnel syndrome, we hope to contribute to existing literature in that aspect. Given that most patients present with numbness during their first consultation, we believe that it would be worthy to examine postoperative numbness following carpal tunnel release to assess the role of hand dominance in influencing the efficacy of surgery in resolving symptoms in patients presenting with bilateral carpal tunnel syndrome of equal severity. The results of this study showed that the non-dominant hand took a statistically significant (p < 0.05) shorter duration of time before achieving complete resolution of symptoms in patients with bilateral severe carpal tunnel syndrome. However, in patients with bilateral moderate carpal tunnel syndrome, there was no statistically significant difference in time taken before complete resolution of symptoms between the dominant and nondominant hand. In view of current literature which highlights a positive correlation between the stage of disease and intraneural microvascular dysfunction and nerve fibre injury, 23) it is conceivable that at advanced stages of nerve compression, axonal regeneration may be more sensitive to the amount of stress exerted on the median nerve at the wrist. With increased daily activity by the dominant hand, this could lead to a slower rate of recovery which is only pronounced in patients with bilateral severe carpal tunnel syndrome. Nonetheless, our results of shorter duration of time before complete resolution of symptoms in non-dominant hand for severe CTS illustrates the need for further research in this area to better understand the recovery process following carpal tunnel release. There are several limitations to this study. Firstly, this is a single centre series of 87 patients. A larger pool of patients would increase the power of analysis on the effect of hand dominance on the resolution of numbness after carpal tunnel release. Secondly, as the results of erative electrophysiological tests were not collected, it was unclear whether there was pathophysiological improvement after the surgical decompression and a nerve conduction study eratively with its correlation to resolution of symptoms would be helpful. The primary strength of this study lies in its novelty in addressing the clinically relevant question of the effect of hand dominance on the resolution of numbness in patients with bilateral severe and moderate carpal tunnel syndrome. This information may have some value when it comes to preoperative counselling in patients who are undergoing bilateral carpal tunnel release. In addition, it may provide future research directions on erative rehabilitation following carpal tunnel surgery. This study showed that there was statistically significant difference between the time taken before complete resolution of symptoms between the dominant and nondominant hand in patients with bilateral severe carpal tunnel syndrome but not in patients with bilateral moderate carpal tunnel syndrome. The results of this study showed that the time taken before complete resolution of symptoms was shorter in the non-dominant hand compared to the dominant hand. We believe that greater daily activity load by the dominant hand may be a contributing factor to its slower rate of symptoms resolution postsurgically and this is only evident in severe carpal tunnel syndrome possibly due to greater extent of intraneural changes such as intrinsic fibrosis and axon loss. 23) CONFLICT OF INTERESTS All named authors hereby declare they have no conflicts of interest to disclose. FUNDING STATEMENT This research received no specific grant from any funding agency in the public, commercial, or not-for profit sectors. ETHICS APPROVAL DETAILS This research has been approved by SingHealth Centralised Institutional Review Board. REFERENCES 1. Shiri R, Varonen H, Heliövaara M, Viikari-Juntura E. Hand dominance in upper extremity musculoskeletal disorders. J Rheumatol. 07;34: Reinstein L. Hand dominance in carpal tunnel syndrome. Arch Phys Med Rehabil. 1981;62: Wee A, Abernathy S. PO31-FR-21 Carpal tunnel syndrome: correlation between hand dominance and median compound sensory nerve action potential abnormalities. J. Neurol. Sci. 09;285:S Padua L, LoMonaco M, Gregori B, Valente E, Padua R, Tonali P. Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand. 1997;96(4): Wessel L, Fufa D, Boyer M, Calfee R. Epidemiology of

6 308 Qian Ying TANG, et al. Hand Dominance and Patient-Reported Outcomes in Bilateral Carpal Tunnel Syndrome J Hand Surg Asian-Pac Vol 17.22: Downloaded from by on 03/05/18. For personal use only. Carpal Tunnel Syndrome in Patients With Single Versus Multiple Trigger Digits. J Hand Surg Am. 13;38(1): Gelfman R, Melton L, Yawn B, Wollan P, Amadio P, Stevens J. Long-term trends in carpal tunnel syndrome. Neurology. 09;72: Roh Y, Chung M, Baek G, Lee Y, Rhee S, Gong H. Incidence of Clinically Diagnosed and Surgically Treated Carpal Tunnel Syndrome in Korea. J Hand Surg Am. 10;35: Manente G, Torrieri F, Di Blasio F, Staniscia T, Romano F, Uncini A. An innovative hand brace for carpal tunnel syndrome: A randomized controlled trial. Muscle Nerve. 01;24: Chang M, Chiang H, Lee S, Ger L, Lo Y. Oral drug of choice in carpal tunnel syndrome. Neurology. 1998;51: Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford). 12;51: Roh Y, Lee B, Noh J, Oh J, Gong H, Baek G. Effects of Metabolic Syndrome on the Outcome of Carpal Tunnel Release: A Matched Case-Control Study. J Hand Surg Am. 15;40: Porter P, Venkateswaran B, Stephenson H, Wray C. The influence of age on outcome after operation for the carpal tunnel syndrome. J Bone Joint Surg Br. 02;84: Hobby J, Venkatesh R, Motkup P. The effect of age and gender upon symptoms and surgical outcomes in carpal tunnel syndrome. J Hand Surg Br. 05;30: Kronlage S, Menendez M. The Benefit of Carpal Tunnel Release in Patients With Electrophysiologically Moderate and Severe Disease. J Hand Surg Am. 15;40: e Cagle P, Reams M, Agel J, Bohn D. An Outcomes Protocol for Carpal Tunnel Release: A Comparison of Outcomes in Patients With and Without Medical Comorbidities. Hand Surg Am. 14;39: Michelotti B, Romanowsky D, Hauck R. Prospective, Randomized Evaluation of Endoscopic Versus Open Carpal Tunnel Release in Bilateral Carpal Tunnel Syndrome. Ann Plast Surg. 14;73:S Sayegh E, Strauch R. Open versus Endoscopic Carpal Tunnel Release: A Meta-analysis of Randomized Controlled Trials. Clin Orthop Relat Res. 14;473: Zuo D, Zhou Z, Wang H, Liao Y, Zheng L, Hua Y et al. Endoscopic versus open carpal tunnel release for idiopathic carpal tunnel syndrome: a meta-analysis of randomized controlled trials. J Orthop Surg Res 15;10: Bland J. Do nerve conduction studies predict the outcome of carpal tunnel decompression?. Muscle Nerve. 01;24: Kanatani T, Fujioka H, Kurosaka M, Nagura I, Sumi M. Delayed Electrophysiological Recovery After Carpal Tunnel Release for Advanced Carpal Tunnel Syndrome. J Clin Neurophysiol. 13;30: Rotman M, Enkvetchakul B, Megerian J, Gozani S. Time course and predictors of median nerve conduction after carpal tunnel release. J Hand Surg Am. 04;29: Leit M, Weiser R, Tomaino M. Patient-reported outcome after carpal tunnel release for advanced disease: a prospective and longitudinal assessment in patients older than age 70. J Hand Surg Am. 04;29: Tomaino MM, Weiser RW. Carpal tunnel release for advanced disease in patients 70 years and older: does outcome from the patient s perspective justify surgery? J Hand Surg Br. 01;26:481-3.

Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study

RESEARCH Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study B Povlsen 1 K Aggelakis 2 M Koutroumanidis 2 1 Department of Orthopaedics, Guy s, St