CHARACTERISTIC OF CARPAL TUNNEL SYNDROME IN BATIK

WORKERS AT KULONPROGO, YOGYAKARTA

ABSTRACT
Background : Batik is an Indonesian cultural heritage, particularly in Javanese society. Batik
still made traditionally involving hand skills, thus, it takes a long duration to make its pattern.
Due to this extended periods, batik workers are work with repetitive hand movement in a
static position. This discomfort condition may be a risk factor for carpal tunnel syndrome
(CTS). CTS is a musculoskeletal disorder that occurs in the upper extremities caused by
compression of the median nerve in the carpal tunnel, and experienced by approximately 3%
worldwide adulthood. The prevalence of work-related CTS in Indonesia is still unclearly due
to lack of work-related diagnoses reports. The main purpose of this study is to know the
characteristic of CTS in batik workers at Kulon Progo, Yogyakarta.
Method: Descriptive analysis research using primary data of batik workers at Lendah, Kulon
Progo district. This study was conducted in January until March 2020 and used purposive
technique sampling.
Results: We found 75% batik workers at Lendah, Kulon Progo regency suffered CTS after
checked by ENMG where the highest cases are at age group more than 40 and mostly affects
female (75%). CTS most commonly affects canting group (67,5%) with a length of work >4
years (65%). In terms of subjective complaints, parasthesia (46%) was the most common
complaint. On physical examination, 72,5% positive in phalen test and 25% positive in tinnel
test. The ENMG result showed 47,5% unilateral CTS and 27,5% bilateral CTS.

Key words : Carpal Tunnel Syndrome, ENMG, Pembatik, Yogyakarta

INTRODUCTION

Batik is an important Indonesian traditional inheritance which has a high value as a

cultural symbol, noticed as a masterpiece heritage from Java island that found at Malabar in

1516 and 1518.1 It spread in Indonesia quickly and also highlighted by the other country.

Batik declared as one of worldwide heritages by The United Nations Educational, Scientific

and Cultural Organization (UNESCO) on October 2nd, 2009.2 Yogyakarta had settled as a

worldwide batik city by World Craft Council (WCC) in 2014.3

 The batik industry is a place for batik workers dedicating creativity through the step

of batik process including canting worker whose job is applying wax and dye to cloth. Batik

industries spread in many cities and districts in Yogyakarta. Kulonprogo regency in

Yogyakarta has its own batik pattern, yet still doesn’t known by society due to lack of

information.4 One of activity that is using hands for a long duration is paint a batik. Most of

batik workers are using wrist for creating designs and colouring. 5 Thus, repetitive wrist

movements (extension-flexion), maintain uncomfort hand-upper body posture for extended

periods may be a risk factor for Carpal Tunnel Syndrome (CTS). CTS is most common form

work-related peripheral neuropathy. 6

Carpal Tunnel Syndrome is entrapment neuropathy and common upper-extremity

musculoskeletal disorder caused by increased carpal tunnel pressure and subsequent

compression the median nerve as it travels through the wrist’s carpal tunnel. CTS

experienced by approximately 3% worldwide adulthood . CTS classical symtpoms are

tingling, pain, and numbness in the median nerve distribution involving the thumb, index

finger, middle finger, and the radial half of the ring finger. Some patients may feel extreme

pain from the wrist spreading to the shoulder, with a tingling in the hand and fingers which is

defined as brachialgia paresthetica nocturna.7 CTS work-related prevalence in Indonesia is

still unknown due to lack of work-related injuries reports. The finding of previous study

reported CTS as a high-risk of work-related wrist injury approximately 5,6% - 14,8 %.8

Although the diagnosis of CTS could be confirmed by history and initial medical

tests such as tinnel’s sign and phalen’s manuever, there is still a chance of misdiagnosed due

to the similar clinically presentation with ulnar neuropathy, and other peripheral

neuropathies.2 To establish the diagnosis of CTS, electromyoneurography (EMNG) testing is

necessary as a gold standard for it has more than 90% of sensitivity and more than 95% of

specificity.9 The severity and duration of nerve compression produce various degrees of
demyelination and some cases induce axonal degeneration, it also known that demyelination

have a good prognose than axonal degeneration.10 The ENMG result of demyelination shows

prolonged distal latency, slowed nerve conduction velocity, and reduced amplitude in

Compound Muscle Action Potential (CMAP). Axonal degeneration have prolonged distal

latency, mild slowed nerve conduction velocity, and lower amplitude in Sensory Nerve

Action Potential (SNAP) than CMAP.11,12

Batik workers is a job prone to suffer from CTS. However, the prevalence about

CTS in batik workers still very minimalist. The previous research about prevalence CTS just

found in garment factory in Jakarta (2004), the worker in Unites States of America (2013),

general female population in Iran (2012) and the population in Swedia (1999). Whereas the

research about prevalence batik worker just found on research Wibaweni et al.13 This study

aimed to investigated the characteristics CTS in batik workers in Kulonprogo, Yogyakarta.

After, find out the characteristic CTS, hopefully we can anticipate to relieve the morbidity

and the result can increased the productivity daily work.

MATERIAL AND METHODS

A cross sectional study design with descriptive analysis that use primary data and it takes by

one time. The study population is batik workers in Lendah, Kulon Progo, Yogyakarta and

held since January 2020 – March 2020. Population target of this study is a batik works in

Lendah, Kulon Progo distric. The sample was taken by purposive sampling, that the sample

had to fulfil inclusion and exclusion criteria. Inclusion criteria of this study was determined

as follows jobholder in one of batik centered, work used hand with a long period such as

(“pencanting”, “pembatik” and “pengecap”) and the respondent approved to follow this

research with signing the formal consent. All of respondent in this study was answer the

questioner directly, then do physical examination tested include tinnel and phalen test. After
that, the respondent of this study was taken follow up examination by

electroneuromyography (ENMG) to confirm the diagnosis of CTS. Furthermore, all of data

were combined, analyzed, and interpreted by SPSS.

RESULT

Based on this research had been performed toward 40 respondents, shown a majority

of batik worker were female (75%) and a middle age (41 – 50 years old) (24,5%). The

majority of carpal tunnel syndrome suffers in batik workers was found in the canting’s group

(67,5%). Mainly respondent of carpal tunnel syndrome from this study has working as a batik

workers during 4 years (65%). The most subjective clinically symptom is parasthesia or

tingling sensation of the hands (46%), other clinically symptoms are wrist pain (34%) and

radiating pain from arm to shoulder (16%). Physical examination carried out in this study

were Phalen and Thinel test, phalen examination was found positive in 29 respondents

(72,5%) while 10 respondent (25%) got positive on tinel test (Table 1).

Based on the follow up examination that is ENMG test was performed on the sample

got result 13 respondent (32.5%) with CTS unilateral and 11 respondent with CTS bilateral

(27.5%). In addition, patient with Non CTS unilateral wes found 6 patient (15%) and non

CTS bilateral was found 2 patient (5%). Also, normal result of ENMG found in 8 patient

(20%). The result of ENMG test can be seen at Table 2

.
Table 1. Respondents Characteristics
Parameters Number (percentage)
Sex
a. Male 8 (26,7%)
b. Female 22 (73,3%)
Age
a. 30-40 years old 11 (27,5%)
b. 41-50 years old 17 (42,5%)
c. 50-60 years old 10 (25%)
d. >60 years old 2 (5%)
Type of works
a. Canting’s group 20 (66,7%)
b. Colouring Group 6 (20%)
c. Stamp’s group 4 (13,3%)
Work Duration
a. ≤ 4 years
b. > 4 years 10 (33,3%)
Symptoms 20 (66,7%)
a.Parasthesia in the hand
23 (46%)
b. Wrist pain
17 (34%)
c.Radiating pain from arm to shoulder
8 (16%)
d. Wrist pain at night
0 (0%)
e.Numbness at wrist
2 (4%)
f. Motor Disorder
0 (0%)
Physical Examination
a.Phallen test
- Positive 29 (72,5%)
- Negative 11 (27,5%)
b. Tinnel test
- Positive 10 (25%)
- Negative 30 (75%)

Table 2. ENMG characteristics

Result CTS Non CTS
Frequency Percentage (%) Frequency Percentage (%)
Bilateral 11 27.5 2 5
Unilateral 19 47.5 6 15
Frequency Percentage (%)

Normal 2 5
DISCUSSION

Result of this study show the prevalence and characteristic carpal tunnel syndrome on

Batik’s workers at Lendah, Kulon Progo regency in Yogyakarta. Based on subjective

symptom and physical examination in patient with CTS mostly female with 30 patient (75%).

That result associated with the previous study Feng B et al (2021) wherever the hights

prevalence CTS in China’s worker dominated by female.14 A several study show the

prevalence of CTS was highest in female than male. 15 This can be caused by carpal space in

female more tighter than male.16 Also, hormonal changes factor during pregnancy and used

contraceptive pills can be risk CTS in female.17

Our result about the characteristic of age, shows the highest number in range age 41

– 50 years old with 17 respondents (42,5%). It is the same with the previous study conducted

by Paramitha et al (2020) show that CTS found in the age range above 40 years. 18 This study

associated with research by Komurchu et al (2014) there is a relationship between age and

severity CTS.19 The case of carpal tunnel syndrome with age, related with biological

responses in nerve when the people getting older. Nerve degeneration, delayed nerve

regeneration occurs at an older age.20 Aging process can lead to axon loss, nerve conduction

disorder and vascular abnormalities.19

In terms of type of work, the canting’s worker group have suffer carpal tunnel

syndrome more than the other group of workers, which is 67,5% (27 respondents) while the

colouring’s group just 7 people (17,5%) and stamp’s group just 6 people (15%). Based on

workplace observation, working position of canting’s group like writing but slightly bent

compared to writing position in general. It can be assumed, this is related between work

posture and the incidence of CTS. It is same with the previous study, show that there is a
relationship between work posture and the incidence with CTS where is the wrist position is

too extended or flexed.21

Long exposure in the workplace also have an effect on carpal tunnel syndrome. In

this study, show there are 26 respondents that work with more than 4 years work period have

the most complain related with CTS. It is related with the prevoius study performed by

Suherman et al (2012), had found the respondent with work period more than 4 years have a

positively correlation with incidence of CTS.22 This is due to caused by work with the same

hand gesture or position while working or can be called repetitive motion and followed using

hand strength when worked.14,15,16 Repetitive hand movement can lead inflammation of

synovial tendon so be able cause pressure on the median nerve.23

Based on subjective clinical symptom, there are 23 respondent (46%) had

parasthesia or tingling sensation of the hands. This result in line with the research by

Paramitha et al (2020), the result obtained the most CTS cases come with parasthesia. 18 This

can be caused by repetitive hand movement while working thus can be lead physical injury or

reccurent stress the the tissue around median nerve got swelling and increased

intracompartment within the median nerve. Due to this condition cause symptom of pain,

tingling, numbness in the hand and fingers except pinkie finger.24,25

The result from physical examination that occurred with batik workers, got a result

29 respondent (72,5%) with phalen test positive and 10 sample with positive tinnel test. In

previous studies, mentioned that phalen test is an examination to assist the diagnosis of

CTS.26 This examination can be done by flexing 90⁰ the wrist hand for one minute and the

result will be positive when the patient feel parasthesia. Meanwhile, the tinnel test can be

done by percussion in medianus nerve with reflex hammer. The result will be positive when
radiating pain is found.27 The study before, show sensitivity from phalen and tinnel test is

68% and 50% respectively, meanwhile the specivicity 73% and 83% in which each.28

The next area we’d like to focus on is electromyoneurography (ENMG) examination

characteristics of batik workers. Firstly, the results of this study showed 19 samples (47.5%)

confirmed unilateral CTS, and 11 samples (27.5%) bilateral CTS which the injury types were

demyelination till axonal degeneration. These results are similar to previous study from

Akbar et al (2021) that reported 28 samples (63.6%) bilateral CTS, and 16 samples (36.3%)

unilateral CTS.29 CTS is a common medical condition that remains one of the most frequently

reported forms of median nerve compression. The dominant hand was associated with CTS

because it’s more commonly the affected side, and it has more severe pain than non-

dominant.30 ENMG helps in establishing the origin of the problem, for example,

neuromuscular disorders or other peripheral neuropathies. ENMG is necessary as a gold

standard for it has more than 90% of sensitivity and more than 95% of specificity.9,31 It also

helpful if the problem is related to a demyelination of axonal degeneration. CTS is

entrapment neuropathy the median nerve at the wrist level, so it slowed the nerve conduction

velocity while prolonged distal latency on ENMG examination and it showed nerve

consumption disorder at the wrist.31,32

Moving on now to ENMG examination in non-CTS, we found 6 samples (15%)

unilateral and 2 samples (5%) bilateral non-CTS. The ENMG results on this study also

showed varying degrees of demyelination and axonal degeneration of the ulnar nerve. Ulnar

neuropathy is the second most common focal neuropathy in the upper extremity after carpal

tunnel syndrome. At the wrist, the ulnar nerve passes the Guyon’s canal and gives off deep

and superficial branches. The most commonly wrist’s compression of ulnar neuropathy is

deep branches of palmar. The confirmed ulnar neuropathy through ENMG examination on

this study is of ulnar neuropathy at the wrist level that have a similar clinically presentation to
CTS such as parasthesia and pain. In contrast to CTS, where pain is usually a prominent

clinical symptom, ulnar neuropathy at the wrist level tends to cause numbness and

paresthesias in the ring and small fingers, but pain is less prominent, even absent. Another

cilinical feature is numbness of the fingers coupled with pain in the elbow flexion, may

worsen at night.33,34

Let’s turn now to normal results on ENMG examination were 2 samples (5%).

ENMG examination detects A fibers nerve conduction velocity but it cannot detect C fibers

conduction velocity caused by the small diameter of its fibers. A normal ENMG results on

this study may caused by ENMG only detects demyelination process and/or axonal

degeneration in bigger myelinated nerve diameter, meanwhile CTS clinical symptoms are

respresentation myelinated nerve injury of small diameter and unmyelinated nerve which

cannot be detected on ENMG.35,36

This research showed that the prevalence of CTS in Batik Works is high. CTS is

one of nerve entrapment that affect the quality of life and productivity of the patients. The

education is very important to be done the workers. The understanding about ergonomic

position and the work duration has important role. This prevention and rehablitation will

decrease the prevalence of the CTS among batik workers.

CONCLUSION

If we can sum up the main points, we found 60% confirmed CTS in batik workers in

Kulonprogo regency at the Lendah district after examined by ENMG. The characteristics of

CTS in batik workers mostly affects female, age group of >40 years, and mostly affects group

of canting worker who work for >4 years. The most common clinically presentation is

parasthesia (tingling), and positive result most commonly in phalen than tinnel examination.

To establish the diagnosis of CTS, ENMG examination is necessary. This study have
limitations such as history clinically presentation which affected by patients subjectivity,

absence of patient’s past medical history, and no comparison with another employment due to

geographical problems. Further similar study is necessary to evaluate risk factors and divided

the severity degrees through ENMG examination. Through publishing this descriptive study,

we want to inform and describe the characteristic of CTS in batik workers which hopefully

can lead more researchers, or doctors to create other analytic studies particulary comparison

with another employment. Furthermore studies hopefully can know how to reduce or prevent

carpal tunnel syndrome along batik workers.37,38

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