Prevalence and Awareness of Carpal Tunnel Syndrome Among Adults in Tabuk City of Saudi Arabia: A Cross-Sectional Study

Background Carpal Tunnel Syndrome (CTS) is a condition when the median nerve is entrapped and compressed within the wrist. It significantly affects the quality of life and work productivity of the affected individuals. Aim This study aimed to assess the prevalence of CTS and the risk factors associated with this condition among the general population in Tabuk City, Saudi Arabia, and to explore their knowledge of the causes, manifestations, and treatment options. Methods This cross-sectional study included male and female adult residents of Tabuk City aged 18 years and above who agreed to participate in the study. Data were collected using an online, self-administered questionnaire that was distributed to the public using different social media platforms. Results In this study, the prevalence of CTS was 3.4%. The presence of chronic diseases was a significant risk factor for the CTS (p = 0.003). Participants having chronic diseases were 6.370 times more likely to develop CTS (AOR: 6.370, 95% CI: 2.048 to 19.817). The participants had good levels of awareness about the causes (89.3%), clinical manifestations, and treatment of CTS (92.2%). There was a significant association between the level of knowledge about the causes of CTS and gender (p=0.014). Females (74.3%) showed a higher level of knowledge than males (25.7%). As well, the young (18-25) age group (67.9%) was more significantly aware of the causes of CTS in comparison to the other age groups (p=0.023). Conclusion The prevalence of carpal tunnel syndrome among the adult population in Tabuk City, Saudi Arabia, was 3.4%, and the significant underlying risk factors were chronic diseases such as diabetes mellitus, hypothyroidism, and rheumatoid arthritis. The level of awareness of CTS was satisfactory.


Introduction
Carpal Tunnel Syndrome (CTS) constitutes the most common compression mononeuropathy in the upper extremities [1].The condition is attributed to compression and traction of the short segment of the median nerve within the carpal tunnel.This might be complicated by ischemic injury of the nerve microcirculation.Consequently, a range of neurologic symptoms occurs along the palmar distribution of the median nerve in the hand [2,3].
Although most cases of CTS are idiopathic, certain risk factors have been identified, such as obesity, hormonal changes, pregnancy, trauma, wrist injuries, repetitive hand movements, and certain medical conditions such as diabetes mellitus, hypothyroidism, and rheumatoid arthritis.Aging, female gender, and genetic predisposition have also been implicated [4,5].
Diagnosis can be made clinically by a typical history of pain, numbness, and tingling as well as sensation loss along the thumb, index, middle finger, and radial side of the ring finger [6].With further progression of the

Eligibility criteria
The study included both male and female adult residents of Tabuk City aged 18 years and above.Individuals under the age of 18, non-residents of Tabuk City, who declined to participate in the study, or who were unable to understand the study's purpose and provide informed consent (e.g., those with cognitive impairments) were excluded.

Data collection
We collected data using an online, self-administered questionnaire.This electronic survey was created using Google Forms and was distributed to the public using different social media platforms.The questionnaire was developed based on a review of the previously published research articles on carpal tunnel syndrome, and it was reviewed by experts in the field to ensure the clarity and validity of the questions [9,10].Furthermore, the diagnosis of CTS was based on the American Academy of Orthopaedic Surgeons Guidelines [11].The researchers translated the questionnaire to Arabic and revised it, and it was pre-tested on a small sample to refine any ambiguous or problematic items.The questionnaire included three parts.The first part was about the sociodemographic data and included questions about age, gender, nationality, marital status, education level, and occupation, besides inquiries about their weight and height.The second part included questions regarding a previous diagnosis of carpal tunnel syndrome by a physician and the presence of one or more chronic diseases.The third part assessed the awareness of the participants about carpal tunnel syndrome and included queries about the causes, symptoms, and potential treatment of carpal tunnel syndrome.

Statistical analysis
All data were tabulated and analyzed using the statistical package for the social sciences software program, SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, NY).Awareness regarding causes, clinical manifestations, and potential treatments was classified into either "good" if the participants chose "yes" in at least one question or "poor" if they chose "no" in all questions.We presented qualitative data as frequencies and percentages and analyzed the possible associations between the sociodemographic variables and the prevalence as well as the awareness about CTS using Pearson's Chi-square or Fisher Exact tests as appropriate.A multivariable forward stepwise logistic regression analysis was performed to identify the risk factors of carpal tunnel syndrome.The variables that showed a p-value ≤ 0.1 in the univariate analysis were entered as candidate covariates in the multivariable analysis.Results were shown as adjusted odds ratio and confidence intervals.A p-value <0.05 was considered statistically significant.

Results
This

FIGURE 1: Frequency of chronic diseases among the study participants
The prevalence of CTS diagnosis by a physician among the study participants was 3.4% (13/384) (Figure 2).The possible associations between CTS and some sociodemographic and medical factors were analyzed.
There was a significant association between the presence of chronic diseases and having CTS (p<0.001).Six (46.2%) out of the 13 subjects diagnosed with CTS had chronic diseases.The presence of diabetes mellitus alone did not show a significant relationship with CTS (p=0.077).On the other hand, there were no significant associations between gender, age, practicing office or professional work, or obesity and the CTS (all p values >0.05) (Table 2).A multivariable forward stepwise logistic regression analysis revealed that the presence of chronic diseases was a significant risk factor for the CTS (p = 0.003).Participants with chronic diseases were 6.370 times more likely to develop CTS (AOR: 6.370, 95%CI: 2.048 to 19.817).Other candidate variables, including age, type of work (office or professional work), or the presence of diabetes mellitus alone were not significant risk factors (Table 3).

Discussion
Carpal tunnel syndrome is a musculoskeletal disorder caused mainly by strain and repetitive hand movement.The associated work absence and healthcare costs constitute a great socioeconomic burden.Adequate knowledge of the CTS is essential for early diagnosis and proper treatment [12].The purpose of this study was to assess the prevalence, risk factors, and level of awareness and knowledge about CTS among the general population in Tabuk City, Saudi Arabia.
This study revealed a CTS prevalence of 3.4% (3/384) which was based on a previous diagnosis by a physician.The detected prevalence aligns with the reported global prevalence of CTS (4-5%) [5].In comparison to previous studies in Saudi Arabia, the identified prevalence is higher than that reported by Tawakul et al. [10] in the Western region (2%), while it is much lower than the previously reported in Al-Majmaah City (14%) [9].Furthermore, Altraifi et al. [13], in Hail City, reported a CTS prevalence of 24.1%.This high rate was based on the prevalence of self-reported symptoms by the participants as well as a previously confirmed diagnosis of CTS.
The observed differences in the prevalence of CTS among different regions of Saudi Arabia might be attributed to variances in the age and gender distribution among the studied population, besides work practices that require repetitive hand and wrist movements [14].Genetic predisposition, which modifies the mechanical properties of tendons and other connective tissue structures within the carpal tunnel might also have a role [15].
Analysis of risk factors for CTS revealed a significant association between the presence of chronic diseases such as diabetes mellitus and hypothyroidism and having CTS.A significantly high percentage of individuals who developed CTS (46.2%) reported having chronic diseases.Logistic regression analysis documented a significant contribution of chronic diseases to the development of CTS, with 6.370 times increased risk of developing the disorder.However, the relationship between diabetes mellitus alone and developing CTS failed to reach a significant result.Most of the corresponding studies in Saudi Arabia [9,10,13] revealed similar findings.Alternatively, one study included a general population from different regions in Saudi Arabia that did not find an association between CTS and chronic disease despite the high frequency of diabetes as a comorbidity [16].An earlier study in Boston, United States of America demonstrated diabetes mellitus and untreated hypothyroidism as common non-occupational risk factors for CTS [17].Another casecontrol study in China revealed a significant association between chronic diseases such as diabetes and hypothyroidism and showed diabetes as a significant predictor of moderate and severe CTS [18].It has been shown that diabetes can cause local microcirculatory disorders in the median nerve, followed by chronic peripheral neuropathy [19].Further, a study reported a higher tendency to develop CTS among diabetic patients (30%) compared to non-diabetics (14%) [20].The relationship between other chronic diseases like rheumatoid arthritis and CTS has been demonstrated by Devi et al. [21].
The participants of this study showed sufficient levels of overall awareness of CTS.High percentages displayed good levels of awareness about the causes (89.3%), clinical manifestations, and potential treatments (92.2%),where they have a piece of knowledge about the causes, suggestive clinical manifestations, and potential treatment of the disease.Regarding the causes of CTS, more than two-thirds (67.7%) identified repeated physical activity, and more than half identified trauma (55.7%), arthritis (53.9%), and wrist fractures (53.1%).Moreover, the diagnostic features of CTS, including wrist pain (73.7%), decreased overall hand grip (71.6%), wasting in the hand (70.8%), and tingling and numbness in the thumb, index, and middle fingers were identified.Concerning treatment of CTS, high percentages recognized surgery (75.5%) and steroid injection (60.9%) as options for treatment.
The detected sufficient levels of awareness among the study participants reflect their easy access to information via different sources such as online tools.Maintenance and improvement of public awareness about CTS is essential.This requires the collaboration of healthcare providers with community leaders and organizations.Ensuring awareness of the general population helps early appropriate treatment, prevents further nerve damage, and thereby, better outcomes and quality of life [22].
Previous studies in different regions of Saudi Arabia revealed contradictory results.Tawakul et al. [10] reported that residents in the Western region had inadequate knowledge about the causes (52.5%), clinical features (54.4%), and treatment (56%) of CTS.Public awareness of CTS in the Al-Jouf region was predominantly poor (74.8%) [23].Whereas Alyousef et al. [9] reported sufficient awareness in Al-Majmaah City, Saudi Arabia about causes, features, and treatment.Also, Albaker et al. [16] reported that Saudis from different regions in Saudi Arabia were aware of CTS clinical symptoms.Another study found poor awareness of both Indian and Malaysian dentists about the link between chronic diseases and CTS, possible treatment by steroid injection, and preventive measures [21].
The present study also revealed that females (74.3%) were significantly more knowledgeable about the causes of CTS than males (74.3%).Also, the young (18-25 years) age group (67.9%) was more significantly aware of the causes of CTS in comparison to the other age groups.Otherwise, no significant relationships were found between the levels of awareness and the gender, age, education, or type of participants' work.Similar findings have been reported by previous studies in Saudi Arabia [9,10,16,23].Furthermore, Raman et al. found a significant association between the level of awareness of CTS and female gender in Kuwait [24].

Conclusions
The findings of the present study disclosed a 3.4% prevalence of carpal tunnel syndrome among the adult population in Tabuk City, Saudi Arabia.Chronic diseases such as diabetes mellitus, hypothyroidism, and rheumatoid arthritis contributed significantly to the development of CTS; also the female gender shows a higher risk for developing CTS.Furthermore, there was a sufficient level of awareness of the causes, clinical features, and treatment of CTS.Still, there is a continuous need for awareness-raising campaigns about CTS and its symptoms.This will help people seek health care early, with better outcomes and quality of life.
Nevertheless, the reliance on a self-administered questionnaire, which is more prone to subjectivity, the dominance of females with a University degree, and the study being conducted in a single city limited our results.therefore, the current data cannot be generalized to the whole country.

Figure 3
Figure3shows that participants had good levels of awareness about the causes (89.3%), clinical manifestations, and treatment of CTS (92.2%).

FIGURE 3 :
FIGURE 3: Levels of awareness about causes, clinical manifestations, and treatment of carpal tunnel syndrome.

TABLE 2 : Factors associated with carpal tunnel syndrome
*Significant at p<0.05

TABLE 3 : A multivariable forward stepwise logistic regression model for identifying risk factors of carpal tunnel syndrome
AOR: adjusted odds ratio, CI: confidence interval, *Significant at p<0.05.

Table 4
displays the knowledge of the study participants about CTS.Regarding the causes of CTS, 260 (67.7%) respondents recognized repeated physical activity.The second-most identified cause was trauma (55.7%), followed by arthritis (53.9%).Additionally, 204 (53.1%) and 159 (41.4%) participants identified wrist fractures/dislocations and tumors of the bone as potential causes of CTS.Inquiries about awareness of the clinical features of CTS revealed that wrist pain (73.7%), decreased overall hand grip (71.6%), and wasting in the hand (70.8%) were the most identified clinical manifestations of CTS.Additionally, 263 (68.5%) reported weakness of the thumb muscle, and 259 (67.4%) recognized tingling and numbness in the thumb, index, and middle fingers as clinical features of CTS.Furthermore, surgery and steroid injection were the most identified treatments for CTS (75.5% and 60.9%, respectively).Non-steroidal anti-inflammatory drugs were reported as potential treatment options by 222 (57.8%) respondents.Splinting (40.9%) was also identified as a potential treatment.

TABLE 4 : Knowledge of the study participants about the causes, clinical symptoms, and potential treatments of carpal tunnel syndrome
N: number

Table 5
demonstrates a significant association between the level of knowledge about the causes of CTS and gender (p=0.014).Females (74.3%) showed a higher level of knowledge than males (25.7%).As well, the young (18 -25) age group (67.9%) was more significantly aware of the causes of CTS in comparison to the other age groups (p=0.023).Otherwise, there were no significant associations between the levels of awareness and the gender, age, education, or type of work of the participants.

TABLE 5 : Associations between levels of awareness and some sociodemographic characteristics
*Significant at p <0.05