Awareness of Carpal Tunnel Syndrome Among the Adult Population in Northern Saudi Arabia

Background Carpal tunnel syndrome (CTS) is the most prevalent entrapment neuropathy affecting the upper limb. It is recognized as a complex condition that is attributed to both non-medical and medical risk factors. Lack of awareness leads to delays in seeking advice, diagnosis, and treatment. Objective To determine the awareness of CTS, its associated symptoms, signs, and risk factors among the adult population. Subjects and methods A cross-sectional study design was carried out among the adult population in Arar city, Northern Saudi Arabia. Results In total, 338 respondents participated in this study. More than one-third (40.8%) mentioned that median nerve entrapment is a cause of CTS. The most commonly cited risk factor by the respondents was engaging in physical tasks such as using a computer (53%). Additionally, 60% of participants agreed that symptoms of CTS include tingling and numbness in the thumb, index, and middle fingers. Conclusion The findings of the study indicated a lack of adequate community awareness about CTS among the studied population.


Introduction
Carpal tunnel syndrome (CTS) is a medical condition that is indeed caused by the compression of the median nerve as it passes through the carpal tunnel, a narrow passageway located in the wrist [1].In Saudi Arabia, the prevalence of CTS varied from 14% to 30.5%, but for individuals with diabetes, it reached 10%-56.1% [2,3].It is particularly prevalent in people with certain medical conditions or those in predisposed professions [4].There are numerous causes of CTS, including rheumatoid arthritis, diabetes mellitus, obesity, work requiring manual tasks [5], and repetitive motions of the hands and wrists [6].CTS leads to dysfunctions as a result of compression [7].The symptoms of CTS include pain, paresthesia, weakness and numbness in the thumb's opposition and abduction, and difficulties gripping objects [8].It interferes with tasks that are necessary for daily living, like cooking, cleaning teeth, and holding objects with one hand [9].Pain, numbness, paresthesia, weakness, and temperature fluctuations in the affected limb are the most common symptoms of CTS.Many individuals have stated that their symptoms worsen at night or are brought on by specific activities [10,11].Additionally, it has been noted that 73% of CTS cases exhibit bilateral symptoms, typically affecting the dominant hand first, even when the manifestations do not occur simultaneously [12].CTS affects the quality of life and impairs hand function, mainly when patients express pain [8].According to a study conducted in Hail, Saudi Arabia, CTS can interfere with daily tasks and lower one's quality of life [5].Albaker AB et al. (Saudi Arabia) reported that 55.9% of people were aware of CTS, with 38.3% being aware of its associated pain.Among the participants, 37.3% reported experiencing tingling or numbness in their thumbs, 27.8% believed that CTS could cause thumb weakness, and 35.2% observed decreased hand grip strength [13].In a Brazilian study, participants mentioned experiencing pain and difficulties with tasks requiring delicate hand motions.This affected activities at home, in the workplace, and during leisure time [14].Few studies have been conducted in Saudi Arabia to assess the awareness of CTS, its symptoms, signs, and risk factors.To our knowledge, no studies have been specifically conducted in the northern region.The current study aims to determine the awareness of CTS and its associated symptoms, signs, and risk factors among the adult population in Arar city, Northern Saudi Arabia.

Study design and setting
A cross-sectional study design was carried out from March 1 to September 30, 2023, among an adult population in Arar city, Northern Saudi Arabia.

Inclusion and exclusion criteria
Subjects who were willing to participate and were older than 18 were included in the study; those who declined to participate or were younger than 18 were not.

Research ethics
The Local Committee of Bioethics at Northern Border University approved the research (HAP-09-A-043) with a decision no.35-44-H, dated March 29, 2023.With informed consent, participation was voluntary.Confidentiality was ensured, and we kept the collected data safe.

Methodology
A structured questionnaire was developed by searching pertinent literature and revised by two physicians (family and orthopedic).In order to resolve any ambiguities, the questionnaire was piloted on 20 subjects (their results were not included in the analysis) before it was actually administered.The questionnaire included questions related to socio-demographic backgrounds, risk factors, symptoms, protective factors, and the effects of CTS.
The sample size was calculated by using the following formula: N = Z2(p)x(1-p)/d2, where N = sample size, Z = confidence level (1.96), P = the expected prevalence of awareness (30%) from the previous study [15], and d = precision (0.05).The expected sample size was 323, and we completed the sample at 338.Following ethical permission, a survey was carried out via social media platforms (WhatsApp, Telegram).After discussing the research objective, consent was obtained from the willing participants for enrollment in the study.

Statistical analysis
The collected data was analyzed using SPSS version 22. Frequency and percentage were used to present qualitative data, and mean and SD were used to present quantitative data.

Results
In total, 338 respondents participated in this study; their mean age was 29.5±9.8, with slightly more women than men (52.4%), around 50% were married, 50% had a university degree, and more than one-third unemployed (37%) (Table 1).

Discussion
In the current study, slightly more than 40% of participants believed that CTS was caused by median nerve compression.Comparable research in the Al-Jouf region of Saudi Arabia, conducted by Alqunai MS in 2021, revealed that slightly more than 25% of participants had heard of CTS and understood that it is caused by median nerve entrapment [16].Similarly, a study by Kandhan T et al. in India found that 28.6% of participants were aware of CTS [17].Additionally, a majority of respondents in a nationwide study conducted in Rome recognized that CTS is caused by compression of the median nerve [18].
Regarding the participants' awareness of Carpal Tunnel Syndrome (CTS) risk factors, repetitive motions of the hands and wrists were cited most frequently (53%), while diabetes mellitus was stated less frequently (25.4%).This is in line with a comparable study conducted in Saudi Arabia [19], where 52.7% of the respondents reported repetitive hand and wrist motions, 37.3% cited wrist fracture or dislocation, 56.3% arthritis, and 41.6% bone tumors as risk factors for CTS.Additionally, Alqunai MS (2021) in Saudi Arabia discovered that about 30% of participants stated that engaging in repetitive hand and wrist activity could increase the chance of acquiring CTS [16].
Alyousef YM et al. in Saudi Arabia reported that one-third (33.8%) of their study participants believe that trauma is a primary cause of CTS, while 29.1% mentioned that repetitive physical activities such as computer use and typing are the reason.Additionally, 21.4% indicated wrist fracture or dislocation, 9.5% arthritis, and 6.2% bone tumors as contributing factors [15].
According to case-control studies conducted in Saudi Arabia [20] and China [21], using a mobile phone with repetitive hand movements was found to increase the chance of acquiring CTS.
On the other hand, Scalise V et al. in Rome, Italy, discovered that a significant portion of participants (88.2%, or 448 out of 508) accurately identified diabetes mellitus as a risk factor for CTS.Additionally, 11.6% (59 out of 508) cited hormonal factors, and 58.7% considered the use of computers as contributing to the risk of developing CTS [18].
In terms of awareness of protective factors for CTS, the study shows that keeping a straight wrist at rest is most frequent, followed by avoiding falls, keeping the wrist and hand warm, and using a splint while sleeping.On the other hand, the comparable study conducted in western Saudi Arabia revealed different percentages of participants mentioning protective factors like avoiding direct trauma (25.6%), keeping wrists straight at rest (23.3%), using splints while sleeping (14.3%), and staying warm [22].
Regarding symptom awareness among the study sample, 60% agreed that numbness and tingling in the middle, index, and thumb fingers are symptoms of CTS.Slightly less than 60% mentioned wrist pain, just below half stated weakness of the thumb muscles, and more than half cited changes in pain intensity as indicators of CTS.
In a similar Italian study, Scalise V et al. found that 81.7% of participants correctly identified the characteristic symptoms of CTS as tingling and numbness in the first three fingers of the hand.Additionally, 2.6% proposed that joint limitation due to a loss of hypothenar muscular power was a symptom.A correct response regarding the hypotrophy of the thenar eminence was demonstrated by 74.8% of participants [18].
The current study reveals that over 50% of respondents agree that CTS can lead to a reduction in hand grip strength, typically beginning slowly overnight.Additionally, just under one-third of the participants concur that CTS can manifest in both hands.This is in line with a similar survey in Saudi Arabia, where more than half of the respondents (57%) mentioned a decrease in hand grip strength, and 40% noted that the condition often starts at night [19].In the Alqunai MS study, also conducted in Saudi Arabia, 23.3% of participants reported that CTS manifests in both hands, 32% reported hand weakness, and one-fifth mentioned that CTS starts slowly overnight [16].
According to the survey results, slightly more than half of the respondents believe that Carpal Tunnel Syndrome (CTS) influences a patient's ability to perform their job effectively.Just under half of the participants mentioned that CTS affects the quality of a patient's sleep, while approximately 40% agreed that it impacts a patient's social life.In a similar study conducted in Saudi Arabia, 51.1% of respondents thought that CTS could affect work performance, 28.4% believed it influenced sleep, and 20.5% recognized its impact on social life [22].

TABLE 2 : Participants' awareness of CTS risk factors.
CTS: Carpal Tunnel Syndrome.

Table 3
illustrates the participants' awareness of protective factors for CTS.Slightly fewer than forty percent mentioned that preventing CTS involves keeping the wrist straight while at rest.More than one-third (37%) stated that avoiding falls is important, followed by 34.3% who emphasized keeping warm.Additionally, onethird of the participants (33.1%) reported that wearing a splint while sleeping is beneficial. ItemNo.

Table 4
displays the participants' awareness of the symptoms of CTS.Sixty percent of participants agreed that tingling and numbness in the thumb, index, and middle fingers are symptoms of CTS.More than half (56.4%) concurred that CTS causes pain in the wrist.Slightly below half (48%) agreed that CTS leads to weakening in the thumb muscles, and somewhat less than 60% believed that the intensity of pain changes with wrist movement. ItemNo.

Table 5
shows that more than half of the participants agreed that CTS reduces hand grip strength (50.5%) and that it typically starts slowly and lasts throughout the night (51.8%).Slightly less than half of the respondents agreed that CTS causes wasting of the hand muscles (46.4%) and that CTS sufferers experience discomfort at night and in the morning (47.6%).Additionally, just below one-third agreed that CTS can occur in both hands. ItemNo.

Table 6
shows the participants' awareness of the effects of CTS.A little over half of them (53.8%) agreed that CTS impacts patients' ability to perform their jobs, while slightly under half (48.2%) agreed that it affects patients' sleep.Around 40% concurred that the disease affects social life.A total of 12.4% of the participants believed that they had CTS.Less than 30% stated that the disease can be treated using steroids (29%), oral analgesics (26.9%), and splints (26.6%).ItemNo.

TABLE 6 : Participants' knowledge of the effects of CTS.
CTS: Carpal Tunnel Syndrome.