JMM
pISSN: 2288-6478, eISSN: 2288-6761 http://dx.doi.org/10.6118/jmm.2016.22.2.80 Journal of Menopausal Medicine 2016;22:80-86
Original Article
Correlation between Female Sex Hormones and Electrodiagnostic Parameters and Clinical Function in Post-menopausal Women with Idiopathic Carpal Tunnel Syndrome Azam Mohammadi1, Mahshid Naseri2, Hamid Namazi3, Mohammad Javad Ashraf4, Alireza Ashraf5 1 Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, 2Department of Physical Medicine and Rehabilitation, Shiraz Geriatric Research Center, Shiraz University of Medical Sciences, Shiraz, 3Bone and Joint Research Center, Shiraz University of Medical Sciences, Shiraz, 4Department of Pathology, Shiraz University of Medical Sciences, Shiraz, 5Department of Physical Medicine and Rehabilitation, Shiraz Burn Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Objectives: To investigate the role of sex-hormonal changes in idiopathic carpal tunnel syndrome (CTS) among post-menopausal women through measuring estrogen receptor (ER) expression in their transverse carpal ligament (TCL) and serum estrogen level, as well as determine the correlation between these factors and electrodiagnostic parameters and Boston score. Methods: Biopsy samples of TCL were collected from 12 postmenopausal women who had undergone surgery for severe idiopathic CTS; control specimens were collected from 10 postmenopausal women without CTS who had undergone surgery for the other hand pathologies. To determine the distributions of ER in TCL, histological and immunohistochemical examinations were performed. Serum estrogen level was also measured. Electrodiagnosis and Boston questionnaire were used for CTS severity and determination of the patients’ function. Results: ER expression in TCL and serum estrogen level were not significantly different in the case group compared to the control group (P = 0.79 and P = 0.88, respectively). Also, there was no correlation between ER expression or serum estrogen level and electrodiagnostic parameters or Boston score. Conclusions: Sex hormones cannot still be considered as the etiology of idiopathic CTS in postmenopausal women. The role of other factors such as wrist ratio and narrower outlet in females compared to the males should be considered along with hormonal changes. (J Menopausal Med 2016;22:80-86)
Key Words: Carpal tunnel syndrome · Electrodiagnosis · Estrogen · Receptors
Introduction
outnumbers all other types. It often occurs in middleaged women without other known pathologies. Because
Carpal tunnel syndrome (CTS), a median nerve
of the higher CTS incidence in women particularly around
compressive lesion at the wrist, is the most common
menopause, the role of specific risk factors for females
1,2
entrapment neuropathy and a common disorder in women.
and hormonal changes related to menopause has been
Although there is a long list of causes leading to increased
proposed.2 In a study by Kim et al.3, increased expressions
pressure on the median nerve at the wrist, idiopathic CTS
of estrogen receptor alpha and beta (ERαand ERβ ) in the
Received: April 10, 2016 Revised: June 24, 2016 Accepted: July 19, 2016 Address for Correspondence: Alireza Ashraf, Department of Physical Medicine and Rehabilitation, Shiraz Burn Research Center, Shiraz University of Medical Sciences, Karimkhan Zand Street, Shiraz 71348-44119, Iran Tel: +98-71-3231-9040, Fax: +98-71-3231-9040, E-mail: [email protected] Copyright © 2016 by The Korean Society of Menopause This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).
80
Azam Mohammadi, et al. CTS in Post-menopausal Women
tenosynovial tissues of postmenopausal women with CTS 3
4
therapy, chemotherapy or radiotherapy, and patients with
was found. Although Toesca et al. found expression of
a history of alcohol consumption were excluded from both
ERαin both transverse carpal ligaments (TCL) and synovial
case and control groups. These conditions were diagnosed
tissues and progesterone receptor (PR) in TCL samples from
by reviewing medical history and physical examination of
CTS patients, no statistically significant difference between
subjects and performing laboratory investigations, including
male and female groups in the number of ER- and PR-
complete blood count, erythrocyte sedimentation rate,
positive cells within TCL or synovial tissue of CTS patients
C-reactive protein, rheumatoid factor, fasting blood sugar
was seen with the exception of the 50 to 70 year age
(FBS), thyroid function tests, blood urea nitrogen (BUN),
group. Despite these findings, the effect of sex hormones
and creatinine. Finally, 12 postmenopausal women with
on CTS independent of other risk factors which may be
idiopathic CTS who decided to undergo surgery as the case
different among men and women such as hand and wrist
group and 10 postmenopausal women without findings of
anthropometrics (higher wrist ratio, higher shape index, and
CTS admitted for surgery due to other hand pathologies
5~7
narrower outlet in women) is not clear.
(except hand tumor) as the control group were recruited.
Electrodiagnosis is the gold standard test for CTS
The study protocol was approved by our university Ethics
diagnosis and an appropriate tool for its severity
Committee and written informed consents were taken from
determination. Boston questionnaire is a valid and reliable
subjects before taking part in the survey.
tool for assessment of functional status and clinical severity 8,9
To confirm a diagnosis of severe CTS and rule out other
In this study, we aimed to consider
neuropathies, we performed a conventional electrodiagnostic
whether ER expression in TCL and serum estrogen level as
test by a Medelec synergy electromyography (EMG)
two sex hormone related factors are different between post-
instrument (VIASYS Healthcare UK, Surrey, UK) at a
menopausal women with idiopathic CTS who had undergone
room with constant temperature of 22oC to 24oC. The
carpal tunnel release and those operated due to hand
skin temperature during all the tests was 32oC. In mid-
pathologies other than CTS. Also, to investigate whether sex
palm antidromic test, active (E1) electrode (ring, clip or bar
hormones have any effect on clinical or electrophysiological
electrode) was placed on the midpoint of the 3rd digits and
severity of CTS, the relationship between these factors and
the reference (E2) electrode was attached 4 cm distal to
either electrodiagnostic parameters or functional status
the E1 electrode. Stimulating cathode with anode proximal
according to the Boston score in the group of women with
was placed 7 and 14 cm proximal to E1 at the mid-palm
CTS was assessed.
and wrist between tendons of the flexor carpi radialis and
in patients with CTS.
palmaris longus, respectively. A band pass of 20 Hz to 2 kHz, a sweep speed of 2 ms/div and a sensitivity of 20 μV/
Materials and Methods
div were used. For motor median nerve conduction study, the E1 electrode was placed on the most prominent eminence of
We selected and enrolled case and control subjects from
the thenar area halfway between the midpoint of the wrist
those 50 to 70 year old women admitted for hand surgery if
crease and the midpoint of the first metacarpophalangeal
they had severe CTS and experienced menopause for at least
joint in the volar aspect. The E2 electrode was attached on
one year.
the proximal phalanx of the thumb. Wrist stimulation was
Patients with a history of systemic diseases such as
applied 8 cm proximal to the E1 at the wrist, between the
obesity (body mass index [BMI] ≥ 30 kg/m ), diabetes
tendons of the flexor carpi radialis and palmaris longus.
mellitus, thyroid dysfunction, malignancy, rheumatoid
A band pass of 8 Hz to 8 kHz, a sweep speed of 10 ms/
disorders, renal dysfunction, neurological disease, previous
div and a sensitivity of 2 mv/div were used.8 Needle EMG
hand fracture, hand tumor, diagnosis of peripheral
was done for abductor pollicis longus muscle. Severe CTS
neuropathy or other neuropathies based on nerve
was considered for patients with any evidence of axon loss
conduction studies, those who received prior hormone
including absent or low amplitude sensory nerve action
2
http://dx.doi.org/10.6118/jmm.2016.22.2.80
81
JMM
Journal of Menopausal Medicine 2016;22:80-86
potential, low amplitude or absent compound motor action
using estradiol enzyme-linked immunosorbent assay (ELISA)
potential or a needle EMG with fibrillation potentials or
kit (IB78239; Immuno-Biological Laboratories, Minneapolis,
motor unit potential changes.10
MN, USA). Normal range of estradiol for postmenopausal
Demographic data including age, level of education and
women was considered < 13 pg /mL.
occupation as well as BMI, duration of menopause, age at
Data were analyzed using the SPSS for Windows version
menopause, and number of parity of both cases and controls
22 software (SPSS Inc., Chicago, IL, USA). Data were
were recorded. A Persian version of Boston questionnaire
reported as mean ± standard deviation (SD). Chi-square
the validity and reliability of which have been established by
test and independent samples t-test were used to compare
11
Rezazadeh et al. , was used for the assessment of severity
the group differences for qualitative and quantitative
and functional status in patients with CTS.
variables, respectively. Also, Spearman and Pearson
Case and control specimens of the TCL were collected
correlation coefficient tests were used for assessing the
from all patients operated for CTS or other hand pathologies.
correlation between variables. In all statistical analysis, P
pISSN: 2288-6478, eISSN: 2288-6761 http://dx.doi.org/10.6118/jmm.2016.22.2.80 Journal of Menopausal Medicine 2016;22:80-86
Original Article
Correlation between Female Sex Hormones and Electrodiagnostic Parameters and Clinical Function in Post-menopausal Women with Idiopathic Carpal Tunnel Syndrome Azam Mohammadi1, Mahshid Naseri2, Hamid Namazi3, Mohammad Javad Ashraf4, Alireza Ashraf5 1 Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, 2Department of Physical Medicine and Rehabilitation, Shiraz Geriatric Research Center, Shiraz University of Medical Sciences, Shiraz, 3Bone and Joint Research Center, Shiraz University of Medical Sciences, Shiraz, 4Department of Pathology, Shiraz University of Medical Sciences, Shiraz, 5Department of Physical Medicine and Rehabilitation, Shiraz Burn Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Objectives: To investigate the role of sex-hormonal changes in idiopathic carpal tunnel syndrome (CTS) among post-menopausal women through measuring estrogen receptor (ER) expression in their transverse carpal ligament (TCL) and serum estrogen level, as well as determine the correlation between these factors and electrodiagnostic parameters and Boston score. Methods: Biopsy samples of TCL were collected from 12 postmenopausal women who had undergone surgery for severe idiopathic CTS; control specimens were collected from 10 postmenopausal women without CTS who had undergone surgery for the other hand pathologies. To determine the distributions of ER in TCL, histological and immunohistochemical examinations were performed. Serum estrogen level was also measured. Electrodiagnosis and Boston questionnaire were used for CTS severity and determination of the patients’ function. Results: ER expression in TCL and serum estrogen level were not significantly different in the case group compared to the control group (P = 0.79 and P = 0.88, respectively). Also, there was no correlation between ER expression or serum estrogen level and electrodiagnostic parameters or Boston score. Conclusions: Sex hormones cannot still be considered as the etiology of idiopathic CTS in postmenopausal women. The role of other factors such as wrist ratio and narrower outlet in females compared to the males should be considered along with hormonal changes. (J Menopausal Med 2016;22:80-86)
Key Words: Carpal tunnel syndrome · Electrodiagnosis · Estrogen · Receptors
Introduction
outnumbers all other types. It often occurs in middleaged women without other known pathologies. Because
Carpal tunnel syndrome (CTS), a median nerve
of the higher CTS incidence in women particularly around
compressive lesion at the wrist, is the most common
menopause, the role of specific risk factors for females
1,2
entrapment neuropathy and a common disorder in women.
and hormonal changes related to menopause has been
Although there is a long list of causes leading to increased
proposed.2 In a study by Kim et al.3, increased expressions
pressure on the median nerve at the wrist, idiopathic CTS
of estrogen receptor alpha and beta (ERαand ERβ ) in the
Received: April 10, 2016 Revised: June 24, 2016 Accepted: July 19, 2016 Address for Correspondence: Alireza Ashraf, Department of Physical Medicine and Rehabilitation, Shiraz Burn Research Center, Shiraz University of Medical Sciences, Karimkhan Zand Street, Shiraz 71348-44119, Iran Tel: +98-71-3231-9040, Fax: +98-71-3231-9040, E-mail: [email protected] Copyright © 2016 by The Korean Society of Menopause This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).
80
Azam Mohammadi, et al. CTS in Post-menopausal Women
tenosynovial tissues of postmenopausal women with CTS 3
4
therapy, chemotherapy or radiotherapy, and patients with
was found. Although Toesca et al. found expression of
a history of alcohol consumption were excluded from both
ERαin both transverse carpal ligaments (TCL) and synovial
case and control groups. These conditions were diagnosed
tissues and progesterone receptor (PR) in TCL samples from
by reviewing medical history and physical examination of
CTS patients, no statistically significant difference between
subjects and performing laboratory investigations, including
male and female groups in the number of ER- and PR-
complete blood count, erythrocyte sedimentation rate,
positive cells within TCL or synovial tissue of CTS patients
C-reactive protein, rheumatoid factor, fasting blood sugar
was seen with the exception of the 50 to 70 year age
(FBS), thyroid function tests, blood urea nitrogen (BUN),
group. Despite these findings, the effect of sex hormones
and creatinine. Finally, 12 postmenopausal women with
on CTS independent of other risk factors which may be
idiopathic CTS who decided to undergo surgery as the case
different among men and women such as hand and wrist
group and 10 postmenopausal women without findings of
anthropometrics (higher wrist ratio, higher shape index, and
CTS admitted for surgery due to other hand pathologies
5~7
narrower outlet in women) is not clear.
(except hand tumor) as the control group were recruited.
Electrodiagnosis is the gold standard test for CTS
The study protocol was approved by our university Ethics
diagnosis and an appropriate tool for its severity
Committee and written informed consents were taken from
determination. Boston questionnaire is a valid and reliable
subjects before taking part in the survey.
tool for assessment of functional status and clinical severity 8,9
To confirm a diagnosis of severe CTS and rule out other
In this study, we aimed to consider
neuropathies, we performed a conventional electrodiagnostic
whether ER expression in TCL and serum estrogen level as
test by a Medelec synergy electromyography (EMG)
two sex hormone related factors are different between post-
instrument (VIASYS Healthcare UK, Surrey, UK) at a
menopausal women with idiopathic CTS who had undergone
room with constant temperature of 22oC to 24oC. The
carpal tunnel release and those operated due to hand
skin temperature during all the tests was 32oC. In mid-
pathologies other than CTS. Also, to investigate whether sex
palm antidromic test, active (E1) electrode (ring, clip or bar
hormones have any effect on clinical or electrophysiological
electrode) was placed on the midpoint of the 3rd digits and
severity of CTS, the relationship between these factors and
the reference (E2) electrode was attached 4 cm distal to
either electrodiagnostic parameters or functional status
the E1 electrode. Stimulating cathode with anode proximal
according to the Boston score in the group of women with
was placed 7 and 14 cm proximal to E1 at the mid-palm
CTS was assessed.
and wrist between tendons of the flexor carpi radialis and
in patients with CTS.
palmaris longus, respectively. A band pass of 20 Hz to 2 kHz, a sweep speed of 2 ms/div and a sensitivity of 20 μV/
Materials and Methods
div were used. For motor median nerve conduction study, the E1 electrode was placed on the most prominent eminence of
We selected and enrolled case and control subjects from
the thenar area halfway between the midpoint of the wrist
those 50 to 70 year old women admitted for hand surgery if
crease and the midpoint of the first metacarpophalangeal
they had severe CTS and experienced menopause for at least
joint in the volar aspect. The E2 electrode was attached on
one year.
the proximal phalanx of the thumb. Wrist stimulation was
Patients with a history of systemic diseases such as
applied 8 cm proximal to the E1 at the wrist, between the
obesity (body mass index [BMI] ≥ 30 kg/m ), diabetes
tendons of the flexor carpi radialis and palmaris longus.
mellitus, thyroid dysfunction, malignancy, rheumatoid
A band pass of 8 Hz to 8 kHz, a sweep speed of 10 ms/
disorders, renal dysfunction, neurological disease, previous
div and a sensitivity of 2 mv/div were used.8 Needle EMG
hand fracture, hand tumor, diagnosis of peripheral
was done for abductor pollicis longus muscle. Severe CTS
neuropathy or other neuropathies based on nerve
was considered for patients with any evidence of axon loss
conduction studies, those who received prior hormone
including absent or low amplitude sensory nerve action
2
http://dx.doi.org/10.6118/jmm.2016.22.2.80
81
JMM
Journal of Menopausal Medicine 2016;22:80-86
potential, low amplitude or absent compound motor action
using estradiol enzyme-linked immunosorbent assay (ELISA)
potential or a needle EMG with fibrillation potentials or
kit (IB78239; Immuno-Biological Laboratories, Minneapolis,
motor unit potential changes.10
MN, USA). Normal range of estradiol for postmenopausal
Demographic data including age, level of education and
women was considered < 13 pg /mL.
occupation as well as BMI, duration of menopause, age at
Data were analyzed using the SPSS for Windows version
menopause, and number of parity of both cases and controls
22 software (SPSS Inc., Chicago, IL, USA). Data were
were recorded. A Persian version of Boston questionnaire
reported as mean ± standard deviation (SD). Chi-square
the validity and reliability of which have been established by
test and independent samples t-test were used to compare
11
Rezazadeh et al. , was used for the assessment of severity
the group differences for qualitative and quantitative
and functional status in patients with CTS.
variables, respectively. Also, Spearman and Pearson
Case and control specimens of the TCL were collected
correlation coefficient tests were used for assessing the
from all patients operated for CTS or other hand pathologies.
correlation between variables. In all statistical analysis, P
