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Boston Carpal Tunnel Questionnaire: The

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Article in Neurological Research · August 2005

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

522 Neurological Research, 2005, Volume 27, July # 2005 W. S. Maney & Son Ltd
10.1179/016164105X17260

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
opinion on the severity of the disease.
At the end of the neurophysiological tests we
provided the results of the electrodiagnostic evaluation
according to the neurophysiological classification of
CTS. Note that the classification utilizes clear definitions
of severity of CTS: ‘‘negative’’, ‘‘minimal’’, ‘‘mild’’,
‘‘moderate’’, ‘‘severe’’ and ‘‘extreme’’. The neurophy-
siologist clearly stated that the diagnosis and the
quantification of the severity of CTS were based only
on the results of the electrodiagnostic test, which
reflects nerve function. No other explanation and
opinion were given to the patients.
After communication of the neurophysiological test
results, the BCTQ was administered again in the waiting
room. The second version of the questionnaire differed
from the first only in the order of the questions. The two
versions were administered to the patients in random
sequence. The duration of the neurophysiological
examination and the time between the two question-
naires being administered were recorded.
In addition to this patient sample, we also studied a
control sample of patients who were referred to our
neurophysiological laboratory with suspected CTS. In
this latter sample, re-submission of the questionnaire
was carried out 40 minutes after the first submission, but
before the neurophysiological evaluation. The control
group included 26 patients (23 females, three males,
mean age 49.5 years, range 22–76).
We compared the results of both the patient and
control questionnaires using a non-parametric-paired
statistical test, the Wilcoxon matched pairs test. For
correlation analysis the Spearman R-test was used.
To evaluate the percentage of hands (with CTS) with
a tangible ‘‘improvement’’, ‘‘worsening’’ or those
remaining ‘‘stationary’’, we considered meaningful
worsening or improvement of a patient-oriented
measurement (SYMPT or FUNCT) between the first
and second questionnaire administration in which the
score was increased or decreased by 0.5 points or more
(for example, a case is considered symptomatically
worse if the SYMPT score was 2.7 at T0 and 3.6 at T1).
In order to limit the risk of an arbitrary decision, we
calculated previously9 that this threshold corresponds to
an effect size (delta/SD) of y0.75 (a medium effect size
in Cohen’s classification), clearly above the limit
reported by the authors in the original paper on the
BCTQ10.
Quality of life research: Luca Padua et al.
Figure 1: Variation (POST FUNCT value – PRE FUNCT value): a
negative value indicates that after neurophysiological assessment
the patient’s score had diminished (i.e. his perception of his own
health status was better than before physician contact). Note that
patients with high levels of impairment at PRE evaluation have
better function after neurophysiological diagnosis, and vice versa
RESULTS
Patient group
The mean duration of the clinical and neurophysio-
logical examination was 24¡4 minutes, and the time
between the PRE and POST questionnaire administra-
tion was 41¡7 minutes.
The comparison of the PRE and POST BCTQ results
showed a significant reduction of the reported symp-
toms (SYMPT) and hand function impairment (FUNCT)
on administration of the questionnaire after diagnosis
(see Table 1).
From the analysis of correlation between the patient-
oriented variation and PRE BCTQ scores, we observed a
significant relationship (p,0.005, R 0.496) only in the
FUNCT parameter (see Figure 1): patients with severe
impairment at the initial evaluation reported less
discomfort after neurophysiological diagnosis. No other
significant correlation was observed. In particular, no
correlation between the patient-oriented variation and
the neurophysiological diagnosis was detected.
The CTS patients with a tangible ‘improvement’,
‘worsening’ or those remaining ‘stationary’ were,
respectively, SYMPT 10, 1, 21 and FUNCT 6, 2, 24.
Control group
The comparison between the initial patient-oriented
results of the control and the patient groups did not
show any significant difference.
The comparison of the PRE and POST BCTQ results in
the control group did not show any significant
difference in the reported symptoms (SYMPT) and
hand function impairment (FUNCT): SYMPT at first
Table 1: The mean BCTQ data before and after the electrodiagnosis
and statistical results of the comparison between BCTQ scores
pre- and post-diagnosis in the patient group
Pre-diagnosis Post-diagnosis p
Symptoms score (SD) 3.1 (0.9) 3.0 (0.9) ,0.02
Functional status score (SD) 2.7 (1.1) 2.5 (0.9) ,0.02
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
administration was 3.4 (SD 0.9); FUNCT at first
administration was 2.8 (SD 1.0); FUNCT at second
administration was 2.7 (SD 0.9).
The CTS patients with a tangible ‘improvement’,
‘worsening’ or those remaining ‘stationary’ were,
respectively, SYMPT 1, 1, 30 and FUNCT 0, 1, 31.
DISCUSSION
As patient-oriented measures become a standard in
evaluating medical care outcome, more data are needed
with regard to possible factors that might influence these
measurements, thereby introducing bias in our study.
Great attention has been given to the process of
development and validation of questionnaires, in order
to obtain standardized measures. Other aspects of the
study design, such as timing of the administration, have
not been sufficiently underlined.
Although it has been widely recognized that patients
should fill in the questionnaire before clinical interac-
tion with the health care providers3, no measure of the
effect of this interaction has been provided. To our
knowledge, no previous study has addressed the
relationship between the awareness of the clinical
assessment results and patient-oriented measures by
means of self-administered questionnaires.
The BCTQ is a very reliable patient-oriented tool,
which has provided interesting data on the patient-
perspective in CTS9–11 and has even been used in large
populations4,5,13.
A good physician–patient interaction is known to
positively influence a patient’s satisfaction with the
physician and the medical care received14. In a review
carried out in 199515, most of the studies showed a
correlation between effective physician–patient commu-
nication and improved the patient outcome. In our case,
a simple transfer of information played a predominant
role in the reassurance of the patient. Conversely, our
control group, which was not influenced either by an
acquaintance with the examiner or by an awareness of
the neurophysiological results, showed no differences
between the first and second BCTQ administration.
We believe that the variation in BCTQ scores that
were measured here reflects rather a change in the
patients’ perception of their own health status as a result
of the physician–patient interaction. This is probably
due to the new information obtained and/or to a
different perspective given to the presenting complaints.
After clinical assessment, the patients that showed a
higher degree of initial self-reported impairment seemed
to reconsider their functional limitation in a more
positive way, while less impaired patients seem to pay
more attention to their limitations.
524 Neurological Research, 2005, Volume 27, July
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CONCLUSION
These results confirm that a crucial aspect of the patient-
oriented evaluation is the timing of the administration.
In order to obtain standardized results, patient-oriented
assessment should be consistently performed in all
patients at the same stage of the clinical process, and
preferably before any kind of clinical assessment has
been performed. Our data in fact show that the findings
of the patient-oriented evaluation are significantly
influenced by the communication of the results of the
clinical assessment.
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