Rheumatol Int (2002) 22: 68–70

DOI 10.1007/s00296-002-0192-0

O R I GI N A L A R T IC L E

Sercan Sarmer Æ Güneş Yavuzer

Ayşe Küçükdeveci Æ Süreyya Ergin

Prevalence of carpal tunnel syndrome in patients with fibromyalgia

Received: 22 October 2001 / Accepted: 5 February 2002 / Published online: 16 March 2002
Ó Springer-Verlag 2002

Abstract This study was planned to investigate the

prevalence of carpal tunnel syndrome (CTS) in patients
Introduction
with fibromyalgia (FM) and the normal population.
Fibromyalgia (FM) is a noninflammatory rheumatic
Paresthesia in the hands, sensory and motor deficits, and
syndrome characterized by widespread musculoskeletal
atrophy of the thenar muscles of 50 patients with FM
pain with palpable tender points, muscle stiffness, fa-
and 50 matched control subjects were evaluated. Tinel’s
tigue, and sleep disturbance [1]. The most common as-
and Phalen’s signs and bilateral electrophysiological
sociated conditions are paresthesias, headaches, irritable
studies of the median nerves were performed. The dif-
bowel syndrome, Raynaud’s-like syndrome, depression,
ferences between the groups in terms of paresthesia (13
and anxiety [2, 3]. Previous studies of FM have reported
FM patients, two control subjects, P<0.01) and sensory
paresthesia in 26% to 84% of FM patients [4, 5, 6].
deficits (four FM patients, 0 control subjects, P<0.05)
Carpal tunnel syndrome (CTS) is the most common
were statistically significant. In the FM and the control
entrapment neuropathy. Typically, patients complain of
groups, a total of five (10%) and two (4%) cases of CTS
paresthesias such as burning, pins-and-needles sensa-
were documented electrophysiologically, respectively.
tion, numbness, and tingling in the hand [7]. It has been
However, the difference between the groups in CTS
found that, compared with those with other rheumatic
prevalence was not statistically significant (P>0.05). In
disorders, patients with FM are more likely to have a
conclusion, paresthesias are a common symptom and
history of lifetime surgical interventions, including car-
associated condition of FM patients. Together with
pal tunnel surgery [8]. Simms et al. found that although
sensory deficits in the hands, they should remind the
84% of their 161 patients with FM complained of
physician of the possibility of undiagnosed CTS.
numbness and tingling, only three (2%) had CTS on
Keywords Fibromyalgia Æ Carpal tunnel electrophysiological studies [4]. They warned physicians
syndrome Æ Paresthesias Æ Electrophysiology ‘‘to be alert to the diagnosis of FM and be judicious in
the use of expensive and/or invasive neurodiagnostic
testing.’’ However, Perez et al. reported a high rate
(16%) of underdiagnosed CTS in women with FM
S. Sarmer having paresthesia in the fingers for years [9]. Cimmino
Ankara Üniversitesi Tıp Fakültesi, found the prevalence of the association between FM and
Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, CTS to be 9.7% [10]. These studies, which assessed the
Samanpazarı, 06100 Ankara, Turkey
association between FM and CTS, lacked either elec-
G. Yavuzer (&) trophysiological studies [10] or a matched normal con-
Ankara University Medical School,
Department of Physical Medicine and Rehabilitation, trol group [4, 9]. The present study was designed to
Mustafa Kemal Mah Barış sitesi investigate the prevalence of CTS in patients with FM
87.sokak No:24 06530 Ankara, Turkey and to compare it with the condition of normal control
E-mail: gunesyavuzer@hotmail.com subjects.
Tel.: +90-312-2842199
Fax: +90-312-5620116
A. Küçükdeveci Æ S. Ergin
Ankara University Medical School, Subjects and method
Department of Physical Medicine and Rehabilitation,
Ankara Üniversitesi Tıp Fakültesi, From the outpatient clinic of Ankara University Medical School’s
Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, Department of Physical Medicine and Rehabilitation, 50 patients
Samanpazarı, 06100 Ankara, Turkey (44 female, six male) with FM satisfying American College of
 69

Rheumatology 1990 criteria for the classification of fibromyalgia Data analysis was performed using the SPSS package. De-
[11] and 50 healthy control subjects were enrolled into the study. scriptive statistics of the FM patients and controls were calculated.
This followed preliminary evaluation consisting of detailed history, Student’s t-test and the chi-squared test were used when appro-
physical examination, and laboratory assessment. The control priate for comparisons between the groups.
group was selected among the volunteers from staff and the rela-
tives and/or caregivers of the patients without any musculoskeletal
symptoms or signs. Patients and controls with a history of any
malign or inflammatory disease were excluded. Two groups were Results
matched according to age and gender.
Neurological examinations of all patients and control subjects Demographic, clinical, and electrophysiological charac-
were performed. Numbness and tingling of the hands, sensory teristics of the FM patients and the controls are pre-
deficits in the median nerve dermatome, loss of strength in oppo-
sition of first and second fingers, and atrophy of the thenar muscles sented in Table 1. All FM patients and controls were
were recorded. Tinel’s and Phalen’s signs for the diagnosis of CTS right-handed. There were no statistically significant dif-
were performed. To test for Tinel’s sign, the wrist was held in ferences between the groups in age, gender, and occu-
extension, and percussion was performed over and just proximally pation (P>0.05). Twenty-six percent of the FM patients
to the transverse carpal ligament. The sign was recorded as positive
if the patient perceived paresthesia which radiated distally. Phalen’s reported numbness and tingling of their hands, whereas
sign was performed by having the patient hold the wrists in extreme only 4% of the controls had the same symptoms; the
but unforced flexion for 1 min. It was positive if paresthesia was difference was statistically significant (P<0.01). The
reported [7, 12]. difference between the groups in the number of patients
Electrophysiological studies of the bilateral median nerves were reporting sensory deficits (hypoesthesia) in the hands
performed with DISA Neuromatic 2000 C electroneuromyography
equipment. The upper extremities were placed in a relaxed and was statistically significant (P<0.05). However, there
comfortable position with the arm extended, palm up. The room was no difference between the groups in terms of motor
temperature was 26°C and the skin temperature ranged between deficits and atrophy of the thenar muscle (P>0.05).
31° and 34°. The skin was scraped. After applying electrode gel, Although the number of patients in the FM group
electrodes were affixed to the skin with adhesive tape. For motor
nerve conduction studies, the active recording electrode was placed whose Tinel’s and Phalen’s signs were positive and who
on the midportion of the belly of the thenar muscle (abductor were diagnosed with CTS using electroneuromyography
pollicis brevis), and the reference recording electrode on the tendon was higher than in the control group, but the difference
of the muscle at the thumb. The ground electrode was attached was not statistically significant (P>0.05).
between the stimulating and recording electrodes on the flexor
surface of the forearm. The first stimulation site was at the wrist,
5 cm proximally to the active electrode, between the two prominent
middle tendons or on the middle of the crease between the thenar Discussion
and hypothenar muscles. The second stimulation site was the ulnar
side of the pulsating brachial artery at the elbow. The latency was
measured in milliseconds from the stimulus onset to the beginning
The prevalence of CTS was found to be 4% in control
of the initial deflection of the compound muscle action potential subjects and 10% in FM patients. Previous studies re-
(CMAP). The amplitude was measured from peak to peak of the ported the prevalence of CTS in the general population
CMAP and expressed in millivolts. To calculate the conduction to be from 0.1% to 9.2% [14, 15]. There are many causes
velocity in m/sec, the length of the nerve was measured in milli- of CTS, such as: a narrow tunnel as an anatomical
meters between the proximal and distal sites of stimulation by
surface measurement using a measuring tape [13]. variation, space-occupying lesions, connective tissue
The antidromic method was used for the sensory nerve con-
duction study of the median nerve. The ground electrode was
placed at the palm, the recording electrode was on the index finger, Table 1. Demographic, clinical, and electrophysiological charac-
and the distance between the active and the reference electrodes teristics of the FM patients and controls (Age is presented in
was 3 cm. Stimulating electrodes were at the wrist between the two mean±SD, all other parameters are in number of cases)
prominent middle tendons (at the site marked during motor nerve
conduction study). The latency in milliseconds was measured from Characteristic Fibromyalgia Control
the onset of the stimulus to the initial positive peak or to the be-
ginning of the major negative deflection of the sensory compound Age 33.72±7.34 32.46±9.75*
nerve action potential (CNAP). The peak-to-peak amplitude of Gender Male 6 7
CNAP was measured in microvolts. The length of the nerve was Female 44 43*
measured in millimeters by surface measurement from the center of Occupation Housewife 40 39
the active stimulating electrode to the center of the active recording Teacher 4 5
electrode, and nerve conduction velocity was calculated in m/sec Secretary 6 6*
[13]. Paresthesias of the hand 13 2***
The amplitudes of the sensory CNAP, sensory, and motor distal Sensory deficits 4 0**
latencies and sensory nerve conduction velocities of all FM patients Motor deficits 1 0*
and normal control subjects were recorded for further analysis. Atrophy of the thenar muscle 3 0*
To establish the lower normal limit for sensory nerve conduc- Positive Tinel’s sign 5 2*
tion velocity, two times the standard deviation (2SD) was sub- Positive Phalen’s sign 4 2*
tracted from the mean sensory nerve conduction velocity of the Electrophysiologically 5 2*
normal control subjects. The upper normal limit for motor and diagnosed CTS
sensory nerve latencies was calculated by adding 2SD to the mean Number of cases 50 50
latencies of the normal control subjects. If the sensory nerve con-
duction velocity at the wrist segment, and the motor distal latencies *P>0.05
of FM patients or controls were beyond these normal values, CTS **P<0.05
was diagnosed. ***P<0.01