Rajiv Gandhi University of Health Sciences s138

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and CHEMBON PRIYA RAJAN address (in block letters) Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY, VIDYA NAGAR, KULOOR, MANGALORE-575013

2. Name of the Institution Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY

3. Course of study and MASTER OF PHYSIOTHERAPY IN subject MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY.

4. Date of admission 2nd JULY 2012

5. Title of the Topic A STUDY TO ASSESS THE GRIP STRENGTH AND PREVALENCE OF CARPAL TUNNEL SYNDROME IN PIZZA DELIVERY BOYS.

6. Brief Resume of the Intended Work

6.1) Introduction and Need of the Study:

Carpal tunnel syndrome is the most well known nerve entrapment syndrome. Involving the median nerve it is often described as an occupational disease and also known as Occupational overuse syndrome (OOS) 1. The prevalence of this condition in general population is approximately 5%. A 1 in 20 incidence Carpal tunnel syndrome (CTS) is found in adult population with women outnumbering men 3:12. The physical factors implicated and extensively studied in relation to occupational CTS include repetition, force, posture, external pressure and vibration3.CTS is the most common form of repetitive trauma disorder (RTD) 4. Experimental studies have also shown a higher incidence of CTS in workers who are involved in high force and repetitive work compared to workers who are not5-8. Several studies examining Carpal tunnel pressure in healthy subjects indicate that the greatest increase in CTP occurs following wrist flexion and extension7-9. One such occupation that requires repetitive wrist flexion and extension is motorcycle riding. Motorcyclists subject themselves to high levels of vibration from road and use their wrist to control the motorcycle’s brakes, gas intake and gears via the handlebars. There are two mechanism that cause cumulative repetitive pressure and injury to the wrist and therefore the median nerve, when riding a motorcycle. First the handlebars receive an enormous amount of vibration from the engine and the irregular road surface. Second devices on the handlebars are controlled by the biker. The biker’s right hand control the throttle to increase or decrease the gas flow and the front brakes, and the left hand controls the clutch. All of these controls add to the repetitive pressures that are generated on the wrist joint3. In case of Pizza delivery boys, they work for almost 8-10 hours a day and have time constraints as they have to ensure they are at the delivery door within the promised time. While riding a motorcycle an excessive amount of vibration from the engine, road and hand controls (ie, throttle, brake and clutch) cause pressure on the wrist joint and the median nerve. This is a perfect scenario to cause a carpal tunnel syndrome. A commonly associated symptom of CTS is decreased grip strength. There are studies which prove that performance of highly repetitive task is associated with force dependent declines in Grip strength10-12.

Need of the study.

Pizza delivery boys subject themselves to high levels of vibration stress and repetitive wrist movements during acceleration and deceleration while riding a motorcycle. Vibration and repetitive movement of the wrist has proved to be major causes for carpal tunnel syndrome and one of the commonly associated symptoms of CTS is reduced grip strength. However there are lack of studies stating that grip strength is affected in this working population and hence the need arises to assess the grip strength and prevalence of CTS in Pizza delivery Boys.

Research Question: Will grip strength be affected in Pizza delivery boys and prevalence of CTS would be seen in this population?

Hypothesis:

Research Hypothesis: The grip strength will be affected and increased prevalence of Carpal tunnel syndrome would be observed in pizza delivery boys.

Null hypothesis: The grip strength would be normal and there will be no prevalence of Carpal tunnel syndrome in Pizza delivery boys.

6.2) REVIEW OF LITERATURE: Harvey R. Manes did a study on prevalence of carpal tunnel syndrome in Motorcyclists as they subject themselves to high levels of vibration from the road and use their wrists to control the motorcycle’s brakes, gas intake and gears via the handlebars under these conditions, the author hypothesized that an increased prevalence of carpal tunnel syndrome would be observed in this population.2

Gunilla Wieslander, D. Norback, C.J Gothe et al. did a case referent study on Carpal tunnel syndrome (CTS) and its exposure to vibration, repetitive wrist movements, and heavy manual work and concluded that CTS was significantly correlated with exposure to vibration from handheld tools and to repetitive wrist movements but showed a weaker correlation with work producing a heavy load on the wrist.13

Atroshi I, Gummensson C and Johnsson R did an epidemiologic study on Prevalence of Carpal tunnel syndrome in a General Population and concluded that a there was a strong association between overweight and the presence of CTS. Women outnumbered men by 4:1 with older women showing highest age- specific prevalence for confirmed CTS.3

Akuthota V, Plastaras C, Linberg K, et al. did nerve conduction study on Effect of Long Distance bicycling on ulnar and median nerves after a long distance multi -day cycling event. They concluded that physiological changes occurred in deep branch of ulnar nerve and the symptoms of CTS could be exacerbated or even develop.14

Keith T. Palmer, E. Clare Harris and David Coggon conducted a systematic literature review on Carpal Tunnel Syndrome and its relation to occupation. They found evidence stating that regular and prolonged use of hand –held vibratory tools increases the risk of CTS by more than 2 fold and found substantial evidence for similar or even higher risks from prolonged and highly repetitive flexion and extension of the wrist, especially when allied with a forceful grip.15

Ibrahim Amayyreh, Naheyah Almutaseb did a study on Grip strength as a Predictor for the severity of CTS in female patients and concluded that weak grip strength was associated with CTS severity.11

Silverstein BA, Fine LJ, Armstrong TJ did a prevalence study on Occupational Factors and Carpal tunnel syndrome among workers in a job which required specific hand force and repetitiveness and concluded that workers with high repetitive job were at greater risk than job requiring high force.4 Chiang HC, Chen.S, Yu HS. Did a study on the occurrence of Carpal tunnel Syndrome in Frozen food factory employees and concluded that workers with high degree of repetitive movement in combination with exposure to cold had a higher risk to develop CTS.5

Viikari – Juntura E, Silverstein B. did a study on Role of Physical load factors in CTS. In this study they reviewed epidemiologic and experimental studies to assess the role of postural factors, hand grip and pinch forces, repetitive hand and wrist movements, external pressure and vibration in the occurrence of CTS and thereby concluded that reducing the duration, frequency or intensity of exposure to forceful repetitive work, extreme wrist postures and vibration is likely to reduce the incidence of CTS in working population.6

Werner. R, Armstrong TJ, Bir C, et al did a study on intracarpal canal pressures: The role of finger, hand and forearm position and concluded that the wrist and forearm should be maintained in a neutral position during activities in an effort to minimize pressure within the carpal tunnel and thereby reduce the risk of developing CTS.8

Nicola M Massy-Westropp, Tiffany K Gill, Anne W Taylor, et al. did a study on Hand Grip Strength: age and gender stratified normative data a population- based study. The aim of this study was to describe normative data for hand grip strength in a community-based Australian population. Secondary aims were to investigate the relationship between body mass index (BMI) and hand grip strength, and to compare Australian data with international hand grip strength norms. They concluded that the population demonstrated higher BMI and lower grip strength in younger participants than much of the international published, population data and also the age and gender grip strength values were lower in younger adults than those reported in international literature.16

David W. Levine. M.d., Mph. Barry P. Simmons. et al. developed A Self- Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome and concluded that the scales for the measurement of severity of symptoms and functional status were reproducible, internally consistent, and responsive to clinical change, and that they measured dimensions of outcomes not captured by traditional measurements of impairment of the median nerve. Hence these scales would enhance standardization of measurement of outcomes in studies of treatment for carpal tunnel syndrome.17

6.3) OBJECTIVE OF STUDY:

1) To assess the grip strength in pizza delivery boys. 2) To determine the prevalence of Carpal tunnel syndrome in pizza delivery boys.

7. MATERIALS AND METHODS:

7.1) STUDY DESIGN:

Quasi experimental.

7.2 I DEFINITION OF THE STUDY SUBJECTS :

Pizza delivery boys in the age group of 18 to 30 years will be recruited for the study.

7.2 II INCLUSION AND EXCLUSION CRITERIA:

Inclusion Criteria:

. Only male workers

. Age group 18 to 30

. Duration - 3months

. Have been working for a minimum period of 1year.

. Have been working minimum 2-3hrs a day.

Exclusion Criteria:

. Previous Fractures of wrist .

. Alcoholism18

. Smoking18

. Kidney disease19

. Hypothyroidism20,21 7.2 III STUDY SAMPLE DESIGN, METHOD, SIZE:

Sample design and method :

Purposive sampling technique.

Sample size:

120 subjects will be selected.

7.2 IV FOLLOW UP:

Not applicable (one time study).

7.2 V PARAMETERS USE FOR COMPARISION AND STATISTICAL TESTS :

Collective data will be analyzed with paired‘t’ test.

7.2 VI DURATION OF STUDY:

Duration of the study will be 12 months.

7.2 VII METHODOLOGY:

120 male pizza delivery boys in the age group of 18 -30 years will be recruited for the study. Subjects will be screened for inclusion and exclusion criteria. Prior to participation subjects are oriented to the study and taken informed consent.

The subjects will be then divided into 2 groups, Group A will be consisting of 60 pizza delivery boys and Group B will be the control group of 60 subjects riding a motorcycle for a minimum period of 12 months.

They will be tested for grip strength using a hand held dynamometer. The participant will be in a sitting position, arms at their side, not touching their body. Elbow bent slightly. The participant will be asked to squeeze the dynamometer with as much force as possible, being careful to squeeze only once for each measurement. Three trials will be made with a pause of about 10-20 seconds between each trial to avoid the effects of muscle fatigue. The highest recorded measurement will be noted and the results will be compared to published age and sex-specific norms.22, 23

The prevalence of Carpal tunnel syndrome will be assessed using a Carpal tunnel syndrome questionnaire (CTSQ).24 Parameters from the outcome measures will be recorded and analysed by statistical procedures. 7.3) Does the study require any investigations to be conducted on patients or other human or animal if so please describe briefly? 8. Yes, Hand held dynamometer and Carpal tunnel syndrome questionnaire.

7.4) Has ethical clearance been obtained from your institution in case of 7.3.

List of References:

1.Stephanie Y.Kao, Carpal Tunnel Syndrome as an occupational disease

2. Harvey R .Manes, MD. Prevalence of carpal tunnel syndrome in Motorcyclists. 3.Atroshi I, Gummesson C, Johnson R, Ornstein E, Ranstam J, Rosen I. 1999. Prevalence of carpal tunnel syndrome in a general population. JAMA: The Journal of the American Medical Association 282: 153-158

4. Silverstein BA, Fine LJ, Armstrong TJ. Occupational factors and carpal tunnel syndrome. Am J Ind Med. 1987; 11(3):343–58. 5. Chiang HC, Chen SS, Yu HS, Ko YC. The occurrence of carpal tunnel syndrome in frozen food factory employees. Gaoxiong Yi Xue Ke Xue Za Zhi. 1990; 6(2):73–80. 6. Viikari-Juntura E, Silverstein B. Role of physical load factors in carpal tunnel syndrome. Scand J Work Environ Health. 1999;25(3):163–85 7. Stetson DS, Silverstein BA, Keyserling WM, Wolfe WA, Albers JW. Hypothesis relating cumulative trauma to the median nerve with sub-clinical nerve conduction deficits. Am J Ind Med.1995; 27(2):309–10. 8. Werner R, Armstrong TJ, Bir C, Aylard MK. Intracarpal canal pressures: the role of finger, hand, wrist and forearm position. Clin Biomech (Bristol, Avon) 1997; 12(1):44– 51. 9. Ham SJ, Kolkman WF, Heeres J, den Boer JA. Changes in the carpal tunnel due to action of the flexor tendons: visualization with magnetic resonance imaging. J Hand Surg [Am] 1996; 21(6):997–1003.

10. Samir M. Abdelmagid, Ann E. Barr, et al. Performance of Repetitive Tasks Induces Decreased Grip Strength and Increased Fibrogenic Proteins in Skeletal Muscle: Role of Force and Inflammation.

11. Ibrahim Amayyreh, Naheyah Almutaseb. Grip strength as a Predictor for the Severity of Carpal Tunnel Syndrome in Female Patients. 12. Mirta Wildia and Siti Zawaiah Md Dawal. Investigation on Upper Limb Muscle Activity and Grip Strength During Drilling Task.

13 Gunilla Wieslander, D Norback, C-J Gothe, Juhlin. Carpal tunnel syndrome (CTS) and exposure to vibration, repetitive wrist movements, and heavy manual work: a case- referent study. From the Department of Occupational Medicine, Southern Hospital, S-100 64 Stockholm, and Clinic of Hand Surgery, Sabbatsberg Hospital, S-113 82 Stockholm, Sweden.

14. Akuthota V, Plastaras C, Lindberg K, et al. The effect of long-distance bicycling on ulnar and median nerves. an electrophysiologic evaluation of cyclist palsy. Am J Sports Med 2005; 33:1224–30

15. Keith T. Palmer, E. Clare Harris and David Coggon. Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occupational Medicine 2007; 57:57–66. 16. Nicola M Massy-Westropp, Tiffany K Gill, and Anne W Taylor, et al. Hand Grip Strength: age and gender stratified normative data in a population-based study. Massy- Westropp et al. BMC Research Notes 2011, 4:127. 17. David W. Levine. M.D., m.p.h., Barry P. Simmons, et al. A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome. The Journal of Bone and Joint Surgery. Incorporated, Vol 75.A, NO. 11. November 1993.

18. Nathan, Peter A. MD; Keniston, Richard C. MD; Lockwood ,et al. Tobacco, Caffeine, Alcohol, and Carpal Tunnel Syndrome in American Industry: A Cross-Sectional Study of 1464 Workers. Journal of Occupational & Environmental Medicine: March 1996 - Volume 38 - Issue 3 - pp 290-298.

19. Gousheh, Jamal M.D.; Iranpour, Afshin M.D. Association between Carpel Tunnel Syndrome and Arteriovenous Fistula in Hemodialysis Patients.

20. Joseph C. Chishoim, Jr, MD, FACP Washington, DC. Hypothyroidism: A rare cause of the bilateral carpal tunnel syndrome-a case report and a review of the literature. Journal of the national medical association, Vol. 73, NO. 11, 1981.

21. V. Reid, A. S. M. Jawad and J. D. Perry. Hypothyroidism presenting as recurrence of previously surgically decompressed carpal tunnel syndrome. Grand Rounds Vol 5 pages 26–27 Speciality: Endocrinology, General surgery Article Type: Case Report .DOI: 10.1102/1470- 5206.2005.

22. Tufts, Brown, Johns Hopkins. Hand Grip Strength Protocol. Tufts University Nutrition Collaborative, Revised 09/03.

23. HeatherJ. Dynamometer Grip Strength Testing. Article reviewed by Sharon Last updated on: Jan 18, 2011. 24. Levine DW, Simmons HP, Koris MJ, et al. A self-administered questionnaire for the assessment severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg 1993; 75A:1585-1592. 25. Stetson DS, Silverstein BA, Keyserling WM, Wolfe WA, Albers JW. Hypothesis relating cumulative trauma to the median nerve with sub-clinical nerve conduction deficits. Am J Ind Med. 1995; 27(2):309–10.