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Boston Carpal Tunnel Questionnaire: The

influence of diagnosis on patient-oriented
results

Article in Neurological Research · August 2005

DOI: 10.1179/016164105X17260 · Source: PubMed

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 Boston Carpal Tunnel Questionnaire: the
influence of diagnosis on patient-oriented
results

Luca Padua*,{, Roberto Padua{, Irene Aprile*,{, Pietro Caliandro* and

Pietro Tonali*
*Department of Neurosciences, Università Cattolica, Roma, Italy
{
Department of Orthopedics, Ospedale S. Giacomo, Roma, Italy
{
Fondazione Pro Iuventute Don C. Gnocchi, Roma, Italy
Objectives: To evaluate the influence of the patient–physician interaction and the instrumental
awareness of the assessment of patients’ answers to a carpal tunnel syndrome-specific
questionnaire.
Methods: We performed a prospective study of the results of a self-administered questionnaire
for carpal tunnel syndrome before and after electrodiagnosis. Thirty-two consecutive patients
were referred to our neurophysiological laboratory for suspected carpal tunnel syndrome. A
patient-oriented evaluation using the Italian version of the Boston Carpal Tunnel Questionnaire
(BCTQ), a widely used disease-specific questionnaire, was carried out before the clinical
interaction was performed. The assessment was performed by means of a neurophysiological
classification. After the communication of the result, the BCTQ was again administered.
Results: The comparison of the BCTQ results, obtained PRE and POST clinical interaction,
showed a significant reduction in the reported symptoms and hand function impairment not
related to the neurophysiological results.
Conclusions: The findings of the patient-oriented evaluation are significantly influenced by the
communication of the assessment results. In prospective studies, the baseline assessment by
means of a patient-oriented evaluation should consistently be performed in all patients at the
same stage of the clinical process. [Neurol Res 2005; 27: 522–524]

Keywords: Boston Carpal Tunnel Questionnaire; patient-oriented; physician-patient interaction;

administration methodology; outcome research

INTRODUCTION its use has provided very interesting results. We used

The increasing consensus regarding the centrality of this questionnaire in several studies and every time the
patients’ opinions in evaluating medical care outcomes study design clearly stated that the questionnaire should
has led to the development of standardized and always be administered before physician evaluation4–8.
validated patient-oriented measures, obtained usually Nevertheless, to our knowledge, no studies have
by means of self-administered questionnaires1. assessed the influence of the physician and the
A crucial aspect of these measurements is the diagnosis on the patients’ results.
administration methodology, which has been standar- To evaluate the influence of the physician’s point of
dized for different settings (self-administration in person view on the questionnaire result of a patient-oriented
or by mail, computer administration, administration by assessment, we administered the validated Italian
a trained interviewer in person or over the phone) in version9 of the BCTQ10 to a group of patients affected
order to minimize interaction bias in patients’ answers2. by carpal tunnel syndrome (CTS) before and after
It is clearly understood that, to obtain the ‘‘indepen- electrodiagnosis.
dent’’ (from physician) collection of data, the patient
must complete self-administered questionnaires before
any contact with the physician and that the data analysis MATERIALS AND METHODS
should be blinded3. We studied 32 consecutive patients (24 females, eight
The Boston Carpal Tunnel Questionnaire (BCTQ) is a males, mean age 50.1 years, range 17–76), who were
widely used disease-specific patient-oriented tool and referred to our neurophysiological laboratory for sus-
pected CTS. For each patient we studied only the most
symptomatic hand. We used the multi-parametric and
Correspondence and reprint requests to: Luca Padua, Department of
Neurosciences, Università Cattolica, L.go F. Vito 1, 00168 Rome,
multi-perspective protocol developed by the Italian CTS
Italy. [lpadua@rm.unicatt.it] Accepted for publication: November study group11.
2004. The protocol included the following steps.

522 Neurological Research, 2005, Volume 27, July # 2005 W. S. Maney & Son Ltd
10.1179/016164105X17260
 Quality of life research: Luca Padua et al.

N Patient-oriented evaluation before clinical interaction

(in the waiting room) by means of the Italian version
of the BCTQ9. This is a validated questionnaire with
two scales: symptoms (SYMP) and function (FUNC).
The scores range from 1 to 5 points, with 1 indicating
best health and 5 representing worst health.
N Clinical examination.
N Neurophysiological assessment by means of a neuro-
physiological classification12.
During each phase of the neurological visit and the
electrodiagnosis we explained our investigation and the
usefulness of the tests to the patients, although we did
not provide any data about our observations or offer any Figure 1: Variation (POST FUNCT value – PRE FUNCT value): a
opinion on the severity of the disease. negative value indicates that after neurophysiological assessment
At the end of the neurophysiological tests we the patient’s score had diminished (i.e. his perception of his own
health status was better than before physician contact). Note that
provided the results of the electrodiagnostic evaluation patients with high levels of impairment at PRE evaluation have
according to the neurophysiological classification of better function after neurophysiological diagnosis, and vice versa
CTS. Note that the classification utilizes clear definitions
of severity of CTS: ‘‘negative’’, ‘‘minimal’’, ‘‘mild’’, RESULTS
‘‘moderate’’, ‘‘severe’’ and ‘‘extreme’’. The neurophy-
siologist clearly stated that the diagnosis and the Patient group
quantification of the severity of CTS were based only The mean duration of the clinical and neurophysio-
on the results of the electrodiagnostic test, which logical examination was 24¡4 minutes, and the time
reflects nerve function. No other explanation and between the PRE and POST questionnaire administra-
opinion were given to the patients. tion was 41¡7 minutes.
After communication of the neurophysiological test The comparison of the PRE and POST BCTQ results
results, the BCTQ was administered again in the waiting showed a significant reduction of the reported symp-
room. The second version of the questionnaire differed toms (SYMPT) and hand function impairment (FUNCT)
from the first only in the order of the questions. The two on administration of the questionnaire after diagnosis
versions were administered to the patients in random (see Table 1).
sequence. The duration of the neurophysiological From the analysis of correlation between the patient-
examination and the time between the two question- oriented variation and PRE BCTQ scores, we observed a
naires being administered were recorded. significant relationship (p,0.005, R 0.496) only in the
In addition to this patient sample, we also studied a FUNCT parameter (see Figure 1): patients with severe
control sample of patients who were referred to our impairment at the initial evaluation reported less
neurophysiological laboratory with suspected CTS. In discomfort after neurophysiological diagnosis. No other
this latter sample, re-submission of the questionnaire significant correlation was observed. In particular, no
was carried out 40 minutes after the first submission, but correlation between the patient-oriented variation and
before the neurophysiological evaluation. The control the neurophysiological diagnosis was detected.
group included 26 patients (23 females, three males, The CTS patients with a tangible ‘improvement’,
mean age 49.5 years, range 22–76). ‘worsening’ or those remaining ‘stationary’ were,
We compared the results of both the patient and respectively, SYMPT 10, 1, 21 and FUNCT 6, 2, 24.
control questionnaires using a non-parametric-paired
statistical test, the Wilcoxon matched pairs test. For Control group
correlation analysis the Spearman R-test was used. The comparison between the initial patient-oriented
To evaluate the percentage of hands (with CTS) with results of the control and the patient groups did not
a tangible ‘‘improvement’’, ‘‘worsening’’ or those show any significant difference.
remaining ‘‘stationary’’, we considered meaningful The comparison of the PRE and POST BCTQ results in
worsening or improvement of a patient-oriented the control group did not show any significant
measurement (SYMPT or FUNCT) between the first difference in the reported symptoms (SYMPT) and
and second questionnaire administration in which the hand function impairment (FUNCT): SYMPT at first
score was increased or decreased by 0.5 points or more
(for example, a case is considered symptomatically Table 1: The mean BCTQ data before and after the electrodiagnosis
worse if the SYMPT score was 2.7 at T0 and 3.6 at T1). and statistical results of the comparison between BCTQ scores
In order to limit the risk of an arbitrary decision, we pre- and post-diagnosis in the patient group
calculated previously9 that this threshold corresponds to
an effect size (delta/SD) of y0.75 (a medium effect size Pre-diagnosis Post-diagnosis p
in Cohen’s classification), clearly above the limit Symptoms score (SD) 3.1 (0.9) 3.0 (0.9) ,0.02
reported by the authors in the original paper on the Functional status score (SD) 2.7 (1.1) 2.5 (0.9) ,0.02
BCTQ10.

Neurological Research, 2005, Volume 27, July 523

 Quality of life research: Luca Padua et al.

administration was 3.3 (SD 0.9); SYMPT at second CONCLUSION

administration was 3.4 (SD 0.9); FUNCT at first These results confirm that a crucial aspect of the patient-
administration was 2.8 (SD 1.0); FUNCT at second oriented evaluation is the timing of the administration.
administration was 2.7 (SD 0.9). In order to obtain standardized results, patient-oriented
The CTS patients with a tangible ‘improvement’, assessment should be consistently performed in all
‘worsening’ or those remaining ‘stationary’ were, patients at the same stage of the clinical process, and
respectively, SYMPT 1, 1, 30 and FUNCT 0, 1, 31. preferably before any kind of clinical assessment has
been performed. Our data in fact show that the findings
DISCUSSION of the patient-oriented evaluation are significantly
As patient-oriented measures become a standard in influenced by the communication of the results of the
evaluating medical care outcome, more data are needed clinical assessment.
with regard to possible factors that might influence these
measurements, thereby introducing bias in our study.
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