Prevalence, Awareness, and Management of Carpal Tunnel Syndrome Among Diabetic Patients

Background: Carpal tunnel syndrome (CTS) is a common condition that can significantly affect the quality of life for individuals, particularly those with diabetes. This study aims to examine the severity of CTS symptoms among diabetic patients and explore the associations between demographic factors, diabetic characteristics, knowledge, and management approaches. Methodology: A cross-sectional study was conducted among diabetic patients, and data were collected using standardized questionnaires. The incidence and severity of CTS were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ). Demographic information, diabetic characteristics, knowledge of CTS, and management approaches were also recorded. Descriptive statistics and inferential analysis were performed to analyze the data. Results: The study included 303 participants. The majority of the participants were aged 50 or older (44.9%) (N=136), followed by those aged 39-49 (24.4%) (N=74). In terms of gender, there were more female participants (61.4%) (N=186) than male participants (38.6%) (N=117). Older age groups exhibited higher mean BCTQ scores, suggesting increased severity. Females had significantly higher severity scores compared to males (mean BCTQ score of 17.52 vs 15.56). Regarding diabetic characteristics, complications in the eye and pain/numbness in the legs or feet were significantly associated with higher severity scores of CTS (P=0.0001). The study revealed a knowledge gap among diabetic patients about CTS, with inadequate knowledge about its causes, symptoms, consequences, and treatment options among 68.6% of the patients. The use of medical interventions such as splints, injections, and surgery was associated with higher severity scores. Conclusion: This study highlights the incidence and severity of CTS symptoms among diabetic patients and its associations with demographic factors, diabetic characteristics, knowledge, and management approaches. Older age, female gender, widowed, diabetic complications in the eye, and pain/numbness in the legs or feet were found to be related to increased severity of CTS. Additionally, inadequate knowledge about CTS was observed among diabetic patients.


Introduction
The carpal tunnel is formed by the carpal bones and the transverse ligament.The tendons of the flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus, as well as the median nerve, flow through the tunnel [1].Carpal tunnel syndrome (CTS) is caused by excessive wrist movement and entrapment of the median nerve within the canal.Nocturnal paresthesia and discomfort are caused by nerve compression.A physical examination will reveal grip weakness, a positive Tinel's sign, a positive Phalen's test, and, if severe, thenar atrophy.Night splinting, over-the-counter anti-inflammatory medicines, corticosteroid injections, and, as a last resort, surgery are all options for treatment [2,3].There is not a single cause of CTS; nevertheless, several variables contribute to the disease's development.Frequent and repetitive hand motions, such as typing or using a keyboard, are considered the main cause of CTS.Such people may have arthropathies such as arthritis, osteoarthritis, or rheumatoid arthritis.CTS can be caused by hormonal and metabolic disorders such as pregnancy, menopause, thyroid abnormalities, and diabetes mellitus (DM) [4].Obtaining an accurate history of the patient, performing a physical examination that includes sensory and motor evaluation, performing a nerve conduction study, and electromyography (EMG) in accordance with American Academy of Neurology/American Association of Neuromuscular and Electrodiagnostic Medicine/American Academy of Physical Medicine and Rehabilitation guidelines are all part of diagnosing carpal tunnel syndrome [5].CTS can be treated using both surgical and non-surgical methods.While surgical decompression is considered the final treatment for CTS, non-surgical therapies such as physical therapy, bracing, steroid injections, and alternative medicine can slow the development of CTS [6].Keeping all of this in mind, CTS is the most frequent entrapment neuropathy, affecting 3-6% of individuals globally [7].CTS is the most prevalent compression neuropathy in the general population and is common in persons with type 1 and type 2 diabetes.The reason(s) why a diabetic's peripheral nerve trunk is more vulnerable to nerve compression is unknown, although biochemical and structural changes in the peripheral nerve are most likely involved.Individuals with neuropathy are more prone to acquire peripheral nerve compression illnesses, such as diabetic neuropathy [8].CTS is more common among diabetics, especially those with concomitant diabetic polyneuropathy (DPN) and/or longer DM duration.It is unclear if it is more frequent in type 1 or type 2 diabetes.Although the precise origin is uncertain, it appears to be hyperglycemia-induced median nerve edema, increased susceptibility to external stress, nerve myelin ischemia, and axonal degeneration.Increased vascular endothelial growth factor (VEGF) and advanced glycation endproducts (AGEs) appear to have a role as well.Median nerve conduction testing, which is more sensitive than clinical examination, remains the cornerstone of CTS diagnosis in diabetes [9].The association between CTS and DM is not well understood.Therefore, this research aims to fill this gap by studying the prevalence, awareness, and management of CTS symptoms among diabetic patients.

Study design
This cross-sectional retrospective study aimed to assess the awareness of CTS symptoms among diabetic patients aged 18 years old and above in Riyadh, Saudi Arabia.

Study sample
The target population for this study was the diabetic general population in Riyadh.The estimated sample size was determined to be between 250 and 350 participants.Participants were included if they met the following criteria: (1) aged 18 or above, (2) diagnosed with diabetes (type 1 or type 2), and (3) residing in Riyadh.Participants were recruited through online surveys posted on various platforms and family medicine clinics in Imam Medical Centre.

Data collection
Data collection was conducted using a self-reported questionnaire consisting of four parts.Part one of the questionnaire collected demographic information, including age, gender, marital status, educational level, and nationality.Part two focused on diabetes-related factors, such as the type of diabetes, duration of diabetes, hemoglobin A1C levels to assess diabetes control (where hbA1c less than 7% is considered controlled [10]), type of medication, presence of kidney, eye, or neurological complications, and vitamin usage.
Part three of the questionnaire assessed participants' knowledge of CTS.It began with a question regarding whether participants had heard of CTS and the source of their knowledge.Subsequently, nine questions were included to evaluate participants' knowledge of CTS, with response options of "yes" (indicating a correct answer), "no" (indicating a wrong answer), or "I do not know" (also indicating a wrong answer).Each correct answer was assigned one point, resulting in a knowledge score ranging from 0 to 9. Participants scoring 5 or above were classified as having adequate knowledge.
Part four of the questionnaire aimed to assess the incidence, prevalence, and severity of CTS symptoms among the participants.The Boston Carpal Tunnel Syndrome Questionnaire (BCTS) was utilized, consisting of 10 questions.Each question was scored on a scale from 1 (indicating low incidence) to 5 (indicating high incidence), resulting in a total score ranging from 10 to 50.A higher score indicated a higher incidence and severity of CTS symptoms.

Data analysis
Microsoft Excel was used for data entry while the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY) was used for data analysis.Descriptive statistics were used to summarize the demographic characteristics of the participants.The knowledge scores and BCTS scores were analyzed to assess the awareness and prevalence of CTS symptoms among the diabetic population.Chi-square tests or t-tests were conducted to identify any associations between demographic factors and CTS awareness.

Ethical considerations
This study obtained ethical approval from the institutional review board of Al-Imam Mohammad Ibn Saud Islamic University (IMSIU) project number 432/2023.Participants were assured of the confidentiality and anonymity of their responses.Informed consent was obtained from all participants before their inclusion in the study.

TABLE 1: Demographic factors of the participants (N=303)
Table 2 presents information about the diabetic characteristics of the patients.The majority of participants had type 2 diabetes (60.1%) (N=182) and had been diagnosed for more than 20 years (16.8%)(N=51).Diabetic control was reported as uncontrolled for the majority of participants (63.4%) (N=192).The most common type of drug used for diabetes management was oral medications (63.4%) (N=192).Complications in kidney function were reported by 8.6% (N=26) of participants, complications in the eye by 30.4% (N=92), and complications like pain and numbness in the legs or feet by 31.7% (N=96).The frequency of vitamin supplementation varied, with 49.5% reporting occasional use.The majority of participants did not use any medical intervention for their wrist symptoms (89.1%) (N=270).Among patients depending on insulin, insulin aspart (NovoRapid®) was the most commonly used type of insulin reported by 58.2% (N=64) of patients, followed by insulin glargine (Lantus®) (33.6%) (N=37), and insulin glargine U-300 conc (Toujeo®) (20.9%) (N=23).

Diabetic characteristics of the patients N %
What type of diabetes do you have?

TABLE 2: Diabetic characteristics of the patients
In Figure 1, 60.4% (N=183) of participants reported having heard of CTS (Figure 1).Among those who were aware of it, the main source of knowledge was social media (44.3%) (Figure 2).

TABLE 4: The relation between knowledge and demographic factors of the patients
In general, the mean BCTQ score among diabetic patients was 16.76 (SD=7.53).The severity of CTS was found to be significantly associated with various demographic factors and diabetic characteristics.The analysis revealed that age had a significant relationship with severity (p = 0.001*), with participants aged 39-49 and 50 or older showing higher mean BCTQ scores (17.95 and 17.89, respectively) compared to younger age groups.Gender also had a significant association (p = 0.027*), with females (mean BCTQ score of 17.52) exhibiting higher severity scores than males (mean BCTQ score of 15.56).Marital status showed a significant relationship with severity (p = 0.004*), with widowed individuals having the highest mean BCTQ score (22.35).Among diabetic characteristics, complications in the eye (p = 0.001*) and pain/numbness in the legs or feet (p = 0.000*) were significantly associated with higher severity scores.Participants who had heard of CTS (p = 0.000*) and had adequate knowledge about it (p = 0.000*) also showed higher severity scores.In terms of management, the use of medical interventions such as splints (mean BCTQ score of 19.29), injections around the wrist (mean BCTQ score of 25.90), and carpal tunnel release surgery (mean BCTQ score of 31.17) were associated with higher severity scores.In addition, there is no difference in BCTQ score between taking a specific type of insulin and not using it in all insulin types except for RYZODEG (mixedinsulin), in which using this type is associated significantly with a higher BCTQ score.Moreover, no significant difference was found between different types of insulin in the score of BCTQ (P=0.167)(Table 5).

Discussion
The primary objective of the current research was to assess the extent of CTS in individuals with diabetes, while considering a range of demographic variables and diabetic attributes.The results of this study illuminate the correlations between these variables and the extent of CTS, offering significant contributions to the comprehension of the illness in relation to diabetes.
Age and gender, among other demographic variables, were discovered to be highly correlated with the severity of CTS.In comparison to younger age cohorts, older age groups, particularly those aged 39-49 and 50 or older, demonstrated higher average BCTQ scores.This finding is consistent with prior investigations that suggest CTS is more widespread and severe among the elderly [11][12][13] where the few previous population-based studies of CTS suggest a bimodal age distribution with a peak between ages 50 and 54 years, and a second peak between 75 and 84 years [11].Potential contributors to the elevated severity scores include age-related alterations in tissues and an elevated probability of comorbidities among the elderly [14].
Gender disparities were also noted, whereby females exhibited severity scores that were higher in comparison to males.This result aligns with other research that has documented an increased incidence and severity of CTS in females [15][16][17].One study showed that women had a five times higher risk for developing CTS than men [15].Hormonal influences, anatomical distinctions, and disparities in lifestyle and professional conditions might all play a role in this gender gap [18].Still, additional research is necessary in order to comprehensively comprehend the fundamental mechanisms.
A correlation was observed between marital status and the severity of CTS; people who were widowed demonstrated the highest average BCTQ scores.Diverse elements may exert an influence on this relationship.For example, individuals who are bereaved may encounter elevated levels of stress and reduced social support, both of which have the potential to adversely affect their general well-being and exacerbate the intensity of symptoms associated with CTS.Nevertheless, further investigation is required in order to clarify the precise mechanisms at play.
Diabetes is suggested to be associated with poorer outcomes after CTR [19][20][21][22][23].This may seem reasonable, given the high incidence of sensorimotor neuropathy in diabetic patients.Higher severity scores of CTS were substantially associated with problems in the eye and pain/numbness in the legs or feet when diabetic features were examined.Consistent with prior research emphasizing the influence of diabetes complications on the onset and severity of CTS [8,24,25], these results support this notion.Indicative of more advanced stages of diabetes, the existence of comorbidities such as retinopathy or peripheral neuropathy may exacerbate symptoms of CTS by causing nerve compression in the carpal tunnel [8,26].Effective management of these problems is of utmost importance in order to mitigate the impact of CTS in individuals with diabetes.
Additionally, participants' knowledge of CTS was assessed.The findings revealed a notable deficiency in knowledge, as the majority of respondents exhibited an insufficient understanding of CTS, encompassing its etiology, manifestations, repercussions, and therapeutic interventions.This emphasizes the necessity for focused educational campaigns aimed at enhancing diabetic patients' knowledge and comprehension of CTS.Acquiring more information can encourage the adoption of preventive measures, promote treatmentseeking behavior, and assist early identification.
Higher severity scores were connected with the utilization of medical procedures, including splints, injections around the wrist, and carpal tunnel release surgery, in terms of management options.This finding implies that those experiencing more severe symptoms of CTS are inclined to seek medical procedures in order to mitigate their pain and restore their ability to operate [27,28].Nevertheless, the determination to administer a medical intervention ought to be grounded in a thorough evaluation that considers various aspects, including the intensity of symptoms, functional constraints, and the patient's reaction to conservative therapies.
An additional contribution to the body of knowledge is made by the study, which emphasizes the correlation between the severity of CTS and diabetic problems.Healthcare specialists consider the presence of ocular problems and pain/numbness in the legs or feet to be significant clinical indications of CTS.These symptoms underscore the need for thorough diabetes control in order to reduce the risk and severity of the condition.
The insufficient understanding of CTS among diabetes patients underscores the necessity for educational programs.By acknowledging this area of limited understanding, medical professionals can enable individuals to identify initial indications, pursue suitable treatment, and implement preventive actions.It is imperative to prioritize the distribution of precise information via diverse channels, such as educational resources, healthcare practitioners, and social media platforms.
This study offers an important contribution to our knowledge of the frequency and relationships between diabetes and CTS in the context of medicine.It clarifies the complex interplay between diabetic characteristics, knowledge gaps, and management approaches, as well as the varied ways in which CTS manifests in people with diabetes.
A limitation of this study is that it does not provide an exhaustive analysis of the relationships between CTS and diabetes.Important next stages for research include examining these relationships in more detail, exploring additional factors beyond the scope of this study that may impact CTS in diabetics, and evaluating the effectiveness of focused therapies.This study does not investigate variables like the influence of various diabetes management strategies on CTS, lifestyle choices, or genetic predispositions, which warrant further investigation to gain a comprehensive understanding of the topic.

Conclusions
The consequences of this paper's findings hold significance for healthcare providers.They emphasize how addressing CTS in diabetic populations requires a thorough and interdisciplinary approach.Comprehending the complex connection between various variables influencing the severity of CTS in patients with diabetes requires an understanding of the diverse nature of these relationships in order to develop customized and appropriate treatment options.Finally, our research opens the door to a more sophisticated comprehension of the control and therapy of CTS in diabetic patients.In order to deliver better care, it highlights the necessity of an ongoing, in-depth investigation of these relationships.This could open up new directions for more successful, patient-centered interventions that could greatly enhance the quality of life for persons impacted by both disorders.

FIGURE 1 :FIGURE 2 :
FIGURE 1: Have you ever heard of carpel tunnel syndrome?

TABLE 3 : Knowledge of the participants toward CTS (Yes is the correct answer for all questions)
CTS: Carpal tunnel syndrome

Table 4
examines the relationship between knowledge and demographic factors of the patients.Significant differences were found in the knowledge of CTS based on gender (p = 0.001) and type of diabetes (p = 0.041).Females had a higher proportion of adequate knowledge compared to males, and participants with type 1 diabetes had a higher proportion of adequate knowledge compared to those with type 2 diabetes.

TABLE 5 : The relation between severity and management of CTS and demographic factors and diabetic characteristics
BCTQ: Boston Carpal Tunnel Syndrome Questionnaire, CTS: Carpal tunnel syndrome