ISSN 0104-7795 Versão Impressa
ISSN 2317-0190 Versão Online

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Número atual: Dezembro 2017 - Volume 24  - Número 4


ARTIGO DE REVISÃO

Correlação entre gravidade clínica e estado funcional com achados eletroneuromiograficos, em pacientes com síndrome do túnel do carpo: uma revisão sistemática

A correlation between clinical severity and functional state with nerve conduction studies findings in patients with carpal tunnel syndrome: a systematic review


Andressa Silvia Faé Nunes1; Lucas Martins de Exel Nunes1; Luciana Dotta2; Tae Mo Chung1; Linamara Rizzo Battistella3; Marcelo Riberto4

DOI: 10.5935/0104-7795.20170037

1. Physiatrist and Neurophysiologist, HCFMUSP Physical Medicine and Rehabilitation Institute
2. Physiatrist, Antonio Camargo Cancer Center
3. Physiatrist and Professor at the School of Medicine at USP
4. Physiatrist and Professor at the Ribeirão Preto Medical School at USP


RESUMO

A síndrome do Túnel do Carpo é a neuropatia compressiva mais frequente na população geral que pode levar a sintomas incapacitantes e significativa limitação funcional. Uma revisão sistemática foi realizada nas bases de dados Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS e SCIELO, sem delimitação de tempo ou idioma. Utilizou-se da estratégia PICO para a pesquisa, palavras-chave extraídas dos Descritores de Ciências da Saúde (Decs) e a qualidade dos estudos foi avaliada através da escala Agency for Healthcare Research and Quality (AHRQ). Identificaram-se 857 estudos dos quais, somente 10 obedeceram aos critérios de inclusão. Apesar dos bons resultados apresentados, verificou-se uma expressiva heterogeneidade existente entre os estudos incluídos, associado à discrepância metodológica, e um limitado tamanho amostral em alguns deles. São necessários estudos com melhor padrão metodológico, bem como avaliações mais homogêneas e precisas, a fim de melhorar o nível de evidência científica.

Palavras-chave: Síndrome do Túnel Carpal, Neuropatia Mediana, Eletromiografia, Eletrodiagnóstico, Condução Nervosa




INTRODUCTION

Carpal Tunnel Syndrome (CTS) is the most common compressive neuropathy, present in 3 to 16% of the general population, depending on the diagnostic method and used criteria.1-3 Thus, its correct diagnosis, treatment, and follow-up may offer significant health benefits to the population.3

According to the American Academy of Orthopedic Surgeons, CTS is a symptomatic compressive neuropathy of the median nerve in the carpal tunnel, characterized by an increased internal pressure in the carpal tunnel and neural dysfunction.4 It may present with other associated physiopathological factors such as mechanic compression and neural ischemia.5,6 It is more prevalent in women (3:1) between the ages of 45-65 years2,7 and is associated with a series of clinical conditions such as obesity, pregnancy, diabetes, rheumatoid arthritis, hypothyroidism,8 or occupational factors (repetitive movements, vibrations, and lasting positions in extension and ulnar deviation of the wrist).9

CTS diagnosis involves the association of clinical symptoms and signs as well as the use of nerve conduction studies (NCS) with a sensitivity of 84% and specificity of 95%.10-13 The most prevalent symptoms are pain and paresthesia, which can afflict the hand diffusely, as well as the specific innervation region of the median nerve.5,6,14

Also, patients may wake up at night due to their symptoms and show weakness and thenar atrophy as clinical signs.5,6 Conversely, patients with clinical criteria and negative findings in NCS may represent as much as 10% of the cases. Therefore, according to with the American Academy Neurology (AAN), the use of the ultrasound image can also contribute to the diagnosis of CTS, once it may show structural anomalies in the wrist.10 Pain in CTS is one of the most prominent symptoms and may have, as a physiopathological element, neuropathic mechanisms related to a neural lesion and have nociceptive mechanisms compatible with the subjacent musculoskeletal change.12,15

Other conditions are possible causes of the similar CTS symptoms such as plexopathies, polyneuropathies, radiculopathies, osteoarticular injuries, cortical lesions, and compressions of the median nerve itself in other places, and these must be considered in a differential diagnosis.5,6 Thus clinical features are not entirely reliable and require the importance of NCS as a confirmatory resource.5,6,16 Besides, clinical characteristics of CTS are quite variable and difficult to interpret, being associated with psychosocial factors which may promote divergences between the clinical and electrophysiological diagnoses, as well as therapeutic inefficacy.17-22

Although the current literature recommends the combined use of clinical and NCS to establish CTS diagnosis, there are still conflicting results about the relationship between the severity of the electrophysiological findings and the clinical manifestations shown in CTS.23-29 Structured questionnaires to assess functioning and pain in multidimensional approaches have been used with progressive frequency to describe the impact of this condition on people's lives, however they also seem to be poorly related to NCS severity. Therefore, to study the diagnostic methods it is essential to understand its symptomatology better and to implement the right therapy.14,15,30


OBJECTIVE

The aim of this text is to systematically review the scientific evidence on the correlation between the clinic-functional aspects with the electrophysiological severity in patients with CTS.


METHOD

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) recommendations for systematic reviews.31

Inclusion criteria for the studies

The inclusion and exclusion criteria are defined below, based on the question that guides the review, considering that there were no limitations on the period or language of the publications.

Types of studies

This review analyzed published studies of controlled randomized clinical trials, quasi-randomized controlled clinical trials, controlled clinical trials, diagnostic studies of accuracy, cohort studies, case-control studies, descriptive studies, case series, and case studies.

Characteristics of the population

The participants were adults aged between 18 and 65 years, with a clinical and electrophysiological diagnosis of CTS, with no previous surgical intervention.

Types of interventions

To be included this review, subjects should undergo at least to two stages of evaluation carried out by different blinded investigators.


• First stage: NCS performed or supervised by a medical specialist. Both upper limbs had to be examined and median nerve conduction tests confirmed CTS following the recommendation of the American Association of Electrodiagnostic Medicine (AAEM).13 Padua's electrophysiological classification32 or numerical variables (following the values for latency and amplitude in the NCS defined the electrophysiological severity of CTS.

• Second stage: clinical evaluation guided by the American Academy of Neurology criteria for CTS, followed by the application of questionnaires and various tests to estimate the clinical severity and functional state.


Outcome

The studies should correlate the clinical severity and functional state with the electrophysiological grades in patients with CTS.

Method and search strategy to identify the studies and eligibility

The following databases were used to identify likely eligible studies in October of 2013, without restriction on publication period or language, in the:


• Pubmed / Medline

• Embase

• Cochrane

• CINAHL

• LILACS

• SCIELO

• Thesis and Dissertations from the Universidade de São Paulo (USP) and the Universidade Federal de São Paulo (UNIFESP).


The search strategy was based on questions structured in the P.I.C.O. format ("Patient", "Intervention", "Control", "Outcome") using as descriptors: Carpal tunnel syndrome (Carpal Tunnel Syndromes OR Syndrome, Carpal Tunnel OR Syndromes, Carpal Tunnel OR Median Neuropathy, Carpal Tunnel OR Compression Neuropathy, Carpal Tunnel OR Entrapment Neuropathy, Carpal Tunnel) AND (nerve conduction OR Neural Conduction OR electrodiagnosis) AND signs and symptoms (neuropathic pain OR Neuralgia).

Two investigators performed the search in the databases independently rigorously following the search strategy and inclusion and exclusion criteria. Any disagreements occurring between the two investigators were solved by consensus and by the analysis of a senior investigator. First, a triage of the studies was carried out, evaluating the titles and abstracts identified in the search. When the title and abstract were not sufficiently clarifying, the article was thoroughly read to prevent the loss of any critical studies to the review.

Finally, the evaluator extracted data from each study with a standardized form for the following paramenters: age and gender of the subjects, number of subjects included in the study, the electrophysiological and clinical diagnostic criteria used for CTS, types of interventions (classifications of electrophysiological and clinical severity), types of results measured, and the authors' conclusions about the outcomes of the interventions.

Evaluation of the methodological quality

The two reviewers used the scale for observational studies from the Agency for Healthcare Research and Quality (AHRQ), modified and validated by West et al.33 to define methodological quality, and any discrepancies were examined by a third reviewer and by consensus. This instrument assess: study goal (2), population studied (8), comparability of the subjects (22), exposure or intervention (11), measurements of the results (20), statistical analysis (19), results (8), discussion (5), and support or sponsorship (5), totaling 100 points. Only articles with a score greater than 50 (scale of 0-100) were accepted.


RESULTS

The initial search identified 857 articles, 24 of which were excluded due to duplication, and 780 that were excluded during the analysis of titles and abstracts. Of the 53 remaining studies, only 10 studies23,34,35,36-42 met the inclusion criteria of the present review, after being thoroughly read, resulting in three case-control studies and seven cross-sectional observational studies. During the full reading, 43 studies were excluded: two of them scored less than 50 after the methodological quality analysis using the AHRQ scale, 38 studies analyzed the diagnostic correlation between the variables rather than the correlation of severity (object of this review), one study made a neurophysiological analysis with different electrophysiological studies (NCS and evoked potential associated), and two articles studied patients who had previously undergone surgery (Figure 1).


Figure 1. Study selection flowchart



Despite the concern in selecting more homogeneous studies in relation to the type of severity measurements, the studies showed significant heterogeneity and methodological discrepancies (Chart 1).




Overall, the studies included 1184 subjects in the specified age range, the two case-control studies recruited 39 subject without CTS. Six articles included men and women in their studies,23,36,38,40-42 and four included only women.34,35,37,39 All 10 studies used categorical scales based on electrophysiological findings: four studies used the electrophysiological classification by Pádua32 with five levels,36,37,40,41 five studies used a categorical classification with three levels (light, moderate, and severe),23,34,35,38,39 and one study used a categorical classification with six levels.42

In four studies, the evaluation of clinical and functional severity used the Boston Carpal Tunnel Questionnaire (BCTQ), the visual analogue scale (VAS), and a detailed physical exam with specific tests, including the fine motor ability test, the thumb abduction strength, the pinch grip strength, and the degree of thenar atrophy,34,35,40,41 while in four other articles, only the BCTQ and VAS were used;23,36-38 in the remaining studies, the researchers used their own clinical and functional questionnaires.39,42

Methodological limitations included the absence of controlled and randomized clinical trials, quasi-randomized or controlled trials, as well as the fact that three of the 10 articles contained less than 100 subjects.


DISCUSSION

Despite the broad search strategies used in this review, the final number of articles selected was small. Even with the vast literature covering the diagnostic correlation between CTS identified using clinical signs and NCS findings, few studies tried to correlate the severity of clinical parameters with the electrophysiological severity, even though there were controversial results and limitations concerning this issue.

Of the 53 studies initially selected, only 10 could be included according to the inclusion criteria and methodological evaluation. The most frequent methodological limitation concerned the lack of reasoning for small samples. In various studies, blinding the investigators during the application of the assessment tools was not reported. Another limiting aspect is that few studies cared to control psychosocial factors such as depression and catastrophizing, once these factors may introduce divergences between the clinical and electrophysiological findings, as well as therapeutic inefficacy.17-22

Four out of 10 studies correlated clinical and electrophysiological severity, using the following clinical scales: the Boston Carpal Tunnel Questionnaire (BCTQ), the Visual Analogue Scale for pain (VAS) and a detailed physical examination, with specific tests, evaluating pinch grip strength, thumb abduction, fine motor ability, and sensitivity.34,35,40,41 Of those four studies, two did not show any correlation between the electrophysiological34,35 severity and the scores of the subjective complaints presented by the patients. As a counterpart, the other two articles showed a positive correlation40,41 with objective measurements during the physical examination.

Tactile hypoesthesia and reduced strength to abduct the thumb positively correlate with reduced neuroconducion velocities. Also, hands with a distribution of the symptoms in the median nerve territory showed greater electrophysiological severity and more severe objective alterations in the physical examinations, when compared to the two other groups with a non-classic symptom distribution (1 – stocking and gloving distribution, 2 – distribution of the ulnar nerve).40

When the motor conduction of the median nerve was analyzed, the lack of manual dexterity correlated with the electrophysiological severity.41 There was also a strong correlation between the intensity of motor symptoms and the intensity of pain, suggesting a possible contribution of the pain to the occurrence of weakness and lack of manual dexterity in CTS patients,34,41 favoring the hypothesis that this altered motor control could be a consequence of pain.34,41,48 This could induce a reorganization of the motor strategies in the central nervous system either by diminishing the agonist activity of the muscle order limiting the velocity and force used during the action.34,41,48 Motor control deficits may perpetuate chronic pain, because fear or avoidance and are considered maladaptive processes that generate disabilities.34 Besides, it is know that small fibers, which are mainly disordered in early CTS, are not routinely studied in NCS, thus such association is less likely to be found in this stage of the disease.

However, NCS are still the gold standard for the diagnosis of this condition.Four other studies23,36-38 coherently failed to correlate the neurophysiological severity scales with subjective clinical scales (analog scale for pain and the BCTQ). However, when the analysis used quantitative measures of latency and amplitude in the NCS, one of the studies succeeded to show this association.38 In CTS patients who presented pain as their main symptom, the average motor latencies of the median nerve were prolonged.

A significant correlation was demonstrated between the frequency of pain and the increase in the severity of damage to the motor fascicle of the median nerve, regardless of any sensory involvement. This fact could be explained by irritation of the nervi nervorum, and by the structural and functional alterations present in the denervated muscles, once they may reduce muscle strength and overload the spared muscle fibers, leading to the genesis of myofascial trigger points, for example.38

The McGill Pain Questinnaire shows significant differences in the quality of pain in patients with light, moderate, and severe CTS. Pain is the most usual, repetitive, and disturbing symptom in women with severe CTS.37 Lack of correlation between electrophysiological findings and symptoms may be associated with alternative diagnoses like other neurological entrapments, myofascial pain syndrome and inflammatory conditions, which can mimic the clinical presentation of CTS.

Finally, two studies39,42 used clinical and eletrophysiological non validated scales, produced by the authors themselves, and showed a correlation between the clinical and neurophysiological severities. Reporting of the classic CTS story, the presence of primary symptoms (pain, paresthesia, and numbness), and sensory or motor deficits in the physical examination are more frequent and predominant when the electrophysiological severity is greater.42 It is noteworthy, however, that at the extreme level of neurophysiological severity (grade 6), the CTS patients may present a lower frequency of pain and paresthesia. This may be explained by the reduction in the number of sensory fibers surviving within the fibrotic nerve fascicle, which would result in fewer pain or paresthesia crises and a higher prevalence of sensory and motor alterations.42


CONCLUSION

Carpal Tunnel Syndrome is the most prevalent compressive neuropathy in the general population, and it can lead to disabling symptoms and functional limitations. It presents mixed physiopathological mechanisms that, when not identified properly, can lead to therapeutic inefficacy. The consequences of this may be disabilities, psychosocial problems, decrease in the quality of life, and a reduction in the capacity for work. This review could demonstrate that some clinical findings from physical examination or standardized questionnaires could be correlated with NCS severity, but the presence of studies which failed to demonstrate this correlation keep the issue still as an unsolved question. The large heterogeneity and methodological discrepancies in the selected studies call for larger and more controlled studies in the issue.


DECLARATION OF INTEREST

The authors report no conflicts of interest.


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