Association of Wrist Ratio, Body Mass Index, and Hand Grip Strength with Boston Carpal Tunnel Questionnaire Scores among Online Motorcycle Drivers

• Rulan Adnindya
• Syarinta Adenina
• Tri Suciati

Vol. 7 No. 2 (2026) | Pages: 75–80

DOI: 10.47679/makein.2026300   Reader: 82 times PDF Download: 33 times

---

Abstract

INTRODUCTION

Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies associated with occupational activities and is characterized by pain, numbness, and paresthesia in the median nerve distribution due to compression within the carpal tunnel (Chairunnisa et al., 2021; Genova et al., 2020). CTS predominantly affects workers exposed to repetitive wrist movements, sustained gripping, vibration, and prolonged non-neutral wrist postures, making it a significant occupational health concern worldwide (Sari & Novendy, 2022; Utamy et al., 2020). The rapid expansion of online motorcycle transportation services has introduced distinct ergonomic challenges. Online motorcycle drivers are required to perform repetitive hand and wrist movements, including continuous gripping of handlebars, throttle control, and braking, often for extended working hours. These repetitive and sustained activities may increase intracarpal pressure and mechanical stress on the median nerve, thereby predisposing drivers to the development of CTS (Chairunnisa et al., 2021; Nurdasari & Rr. Arum Ariasih, 2021).

Previous studies have suggested that individual anatomical and anthropometric factors may influence CTS risk. Increased body mass index (BMI) has been associated with elevated hydrostatic pressure and adipose tissue accumulation within the carpal tunnel, potentially leading to median nerve compression (Amalia et al., 2023; Raissi et al., 2025). Wrist ratio has also been proposed as an anatomical indicator reflecting carpal tunnel morphology and susceptibility to CTS, although evidence regarding its predictive value remains inconsistent across populations (Han et al., 2022). In addition, hand grip strength has been evaluated both as a functional consequence of CTS and as a potential risk marker; however, reported associations vary, particularly in populations with mild or early-stage symptoms (Baker et al., 2013; Sasaki et al., 2020; Singh & Srivastava, 2020).

Despite extensive research on CTS risk factors, studies examining the combined role of wrist ratio, BMI, and hand grip strength among online motorcycle drivers remain limited, especially in the Indonesian population. Moreover, objective anthropometric data specific to this occupational group are still scarce, limiting the development of evidence-based ergonomic and preventive interventions.

Therefore, this study aimed to analyze the association between wrist ratio, body mass index, and hand grip strength with CTS symptoms assessed using the Boston Carpal Tunnel Questionnaire. The findings are expected to contribute to a more comprehensive understanding of CTS risk profiles among online motorcycle drivers and to inform future ergonomic and occupational health strategies. It was hypothesized that higher wrist ratio and body mass index (BMI) would be positively associated with CTS symptom severity. In contrast, greater hand grip strength would be inversely associated with CTS symptoms.

METHOD

Participant Characteristics and Research Design

This study employed an observational analytic design with a cross-sectional approach. The study was conducted in Palembang, Indonesia, from June to October 2023. The study population consisted of male online motorcycle drivers aged 18–50 years who were actively working at the time of data collection, reflecting the dominant demographic profile of online motorcycle drivers in the study area. Only male participants were included to reduce biological variability related to body composition. Participants were required to provide written informed consent before enrollment. Key characteristics assessed in this study included age, body mass index, wrist ratio, hand grip strength, and the severity of carpal tunnel syndrome (CTS) symptoms.

Individuals were excluded if they had a history of chronic kidney disease, diabetes mellitus, thyroid disorders, rheumatoid arthritis, lupus, or other systemic conditions known to be associated with CTS. Participants with a history of wrist trauma or those undergoing hemodialysis were also excluded. These criteria were applied to minimize potential confounding factors that could independently influence median nerve function and the development of CTS, thereby enhancing the internal validity of the study. CTS symptoms were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), a validated patient-reported outcome instrument that evaluates symptom severity and functional status, although this study does not provide a clinical or electrodiagnostic diagnosis. The study protocol was reviewed and approved by the Health Research Ethics Committee of the Faculty of Medicine, Universitas Sriwijaya (Protocol No: 200-2023)

Sample Size and Sampling Procedures

Participants were recruited using a consecutive sampling method, in which all eligible drivers encountered during the data collection period were invited to participate until the required sample size was achieved.

Sample size was determined using the single-proportion formula, assuming a 95% confidence level (Z = 1.96), an expected proportion of 0.82 derived from prior studies (Utami et al., 2023), and a margin of error of 10%. The minimum required sample size was calculated to be 56 participants.

Variables

Wrist ratio was calculated as the ratio of wrist depth to width, measured with a standardized measuring tool. Measurements were taken for both the dominant and non-dominant hands. BMI was calculated as weight (kg) divided by height squared (m²) and categorized according to standard BMI classifications based on the WHO criteria (Novosad et al., 2013). Pain intensity was assessed using a visual analog scale (VAS) reflecting wrist-related pain experienced during daily activities over the past two weeks. Hand grip strength was measured using a hand dynamometer Camry EH101 Digital Hand Dynamometer Grip Strength Meter. Measurements were performed for both hands, and values were categorized into weak, normal, or strong based on the device-specific reference ranges provided in the manufacturer’s manual (Camry, n.d.). CTS symptoms were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), which consists of two subscales evaluating symptom severity and functional status. Each item is scored on a 5-point Likert scale, with higher scores indicating greater symptom severity. Participants were classified as having CTS symptoms when the BCTQ score was greater than 11. This study was conducted as part of a joint research project, and a more detailed description of the BCTQ has been reported by Islamia et al. (Islamia et al., 2024).

Data Analysis

Data were collected through structured interviews, questionnaire administration, and direct physical measurements. All data collectors received standardized training prior to data collection to ensure measurement consistency. Data were processed and analyzed using Statistical Package for the Social Sciences (SPSS). Univariate analysis was conducted to describe participant characteristics and variable distributions. Bivariate analysis was performed to assess associations between wrist ratio, BMI, hand grip strength, and CTS symptoms using the chi-square test or Fisher’s exact test, as appropriate. A p-value of <0.05 was considered statistically significant. All analyses were prespecified based on the study objectives.

RESULTS OF STUDY

Descriptive Statistics

A total of 80 online motorcycle drivers were included in the final analysis. The mean age of participants was 38.7 ± 11.1 years. The average wrist ratio was 0.69 ± 0.14 for the right hand and 0.68 ± 0.13 for the left hand. Mean hand grip strength was 31.5 ± 9.5 kg for the right hand and 30.8 ± 9.4 kg for the left hand. Nearly half of the participants (48.8%) exhibited CTS symptoms based on the Boston Carpal Tunnel Questionnaire (BCTQ). A substantial proportion of participants were classified as overweight or obese (approximately 44%), indicating a high prevalence of elevated body mass index within the study population. The distribution of body mass index, CTS symptom severity, functional status, and pain intensity is summarized in Table 2. Notably, a pattern of noticeable symptoms with minimal functional impairment was observed, as most participants reported symptoms on the BCTQ Symptom Severity Scale while remaining functionally asymptomatic. This pattern suggests early-stage or mild manifestations of CTS, or possibly non-specific symptoms related to repetitive occupational exposure rather than clinically significant neuropathy. Pain intensity was generally low, with most participants reporting no or mild pain. This finding may explain the discrepancy between the presence of BCTQ-reported symptoms and the relatively preserved functional status, suggesting that symptoms were mild and not yet associated with significant pain or disability.

Table 1. Descriptive Statistics of Age, Wrist Ratio, Hand Grip Strength and CTS Symptom among Online Motorcycle Drivers

Variable	Mean	SD
Age (years)	38.7	11.1
Wrist ratio (right)	0.69	0.14
Wrist ratio (left)	0.68	0.13
Hand grip strength (right, kg)	31.5	9.5
Hand grip strength (left, kg)	30.8	9.4
BCTQ Symptom Severity Scale (SSS)	13.23	3.77
BCTQ Functional Status Scale (FSS)	8.10	0.376

Table 2. Distribution of Body Mass Index, CTS Symptoms, Functional Status, and Pain Intensity

Variable	Frequency (n)	Percentage (%)
Body Mass Index
Underweight	14	17.5
Normal	31	38.8
Overweight	24	30.0
Obesity class I	8	10.0
Obesity class II	0	0
Obesity class III	3	3.8
CTS Symptom Severity (BCTQ)
Asymptomatic	41	51.2
Mild	37	46.3
Moderate	2	2.5
Severe	0	0
Very severe	0	0
Functional Status (BCTQ)
Asymptomatic	74	92.5
Mild	6	7.5
Moderate–severe	0	0
Pain Intensity (VAS)
No pain	66	76.7
Mild pain	2	2.3
Moderate pain	12	14.0

Bivariate Analysis

The association between wrist ratio and CTS symptoms is shown in Table 3. No statistically significant association was observed for either the right or left wrist (p = 0.426). This similarity may be explained by the relatively symmetrical anthropometric characteristics of the participants. The association between body mass index and CTS symptoms is presented in Table 4. Statistical analysis showed no significant relationship between BMI categories and CTS symptoms (p = 0.480). The association between hand grip strength and CTS symptoms is summarized in Table 5. No significant relationship was identified for either hand (right hand p = 0.480; left hand p = 0.231).

Table 3. Association between Wrist Ratio and CTS Symptoms

Wrist Ratio	CTS Symptoms Absent n (%)	CTS Symptoms Present n (%)	p-value	OR (95% CI)
Right wrist
Normal (<0.75)	39 (48.7)	35 (43.8)	0.426	2.229 (0.384 – 12.923)
High (≥0.75)	2 (2.5)	4 (5.0)
Left wrist
Normal (<0.75)	39 (48.7)	35 (43.8)	0.426	2.229 (0.384 – 12.923)
High (≥0.75)	2 (2.5)	4 (5.0)

Table 4. Association between Body Mass Index and CTS Symptoms

BMI Category	CTS Symptoms Absent n (%)	CTS Symptoms Present n (%)	p-value	OR (95% CI)
Underweight, Normal	24 (30%)	21 (26.25%)	0.673	1.210 (0.500-2.931)
Overweight, Obesity Class I-III	17 (21.25%)	18 (22.5%)

Table 5. Association between Hand Grip Strength and CTS Symptoms

Hand Grip Strength	CTS Symptoms Absent n (%)	CTS Symptoms Present n (%)	p-value	OR (95% CI)
Right hand
Weak	29 (36.3)	24 (30.0)	0.480	1.510 (0.595-3.836)
Normal-Strong	12 (15.0)	15 (18.8)
Left hand
Weak	34 (42.5)	27 (33.8)	0.192	2.159 (0.748-6.233)
Normal-Strong	7 (8.8)	12 (15)

DISCUSSION

This study demonstrated a high prevalence of CTS symptoms among online motorcycle drivers, with nearly half of the participants reporting symptoms based on the BCTQ. This finding supports previous reports indicating that online motorcycle drivers represent a high-risk occupational group due to prolonged exposure to repetitive wrist movements and sustained gripping activities (Chairunnisa et al., 2021; Sari & Novendy, 2022).

Despite the substantial prevalence of CTS symptoms, no significant association was found between wrist ratio and CTS symptoms. Although wrist ratio has been proposed as an anatomical risk indicator reflecting carpal tunnel morphology (Han et al., 2022), the present findings suggest that wrist ratio alone may not sufficiently explain CTS occurrence in this population. CTS is widely recognized as a multifactorial condition influenced not only by anatomical factors but also by biomechanical load, work duration, and ergonomic exposure (Peshin et al., 2022; Utamy et al., 2020). The absence of significant associations between anthropometric and strength-related variables and BCTQ outcomes suggests that occupational ergonomic exposures, such as repetitive wrist motion, vibration, and sustained non-neutral wrist posture, may play a more dominant role in symptom development in this population (Genova et al., 2020; Lund et al., 2019; You et al., 2014)

Similarly, body mass index was not significantly associated with CTS symptoms in this study. While several studies have reported obesity as a risk factor for CTS due to increased hydrostatic pressure within the carpal tunnel (Amalia et al., 2023; Raissi et al., 2025), the absence of a significant relationship in this study may reflect population-specific factors, differences in fat distribution, or the predominance of occupational biomechanical stress over metabolic factors.

Hand grip strength was also not significantly associated with CTS symptoms. Although CTS may lead to reduced grip strength due to median nerve dysfunction (Baker et al., 2013; Sasaki et al., 2020), grip strength reduction is often more pronounced in advanced disease stages. Most participants in this study presented with mild symptoms and minimal functional impairment, which may explain the lack of detectable strength differences. These findings suggest that BCTQ may capture early subjective symptoms that are not yet reflected in objective functional impairment or pain intensity, highlighting the importance of early screening in occupational populations. This aligns with previous reports suggesting that grip strength may not be a sensitive indicator for early CTS detection (Singh & Srivastava, 2020).

Overall, the findings highlight that CTS among online motorcycle drivers is likely driven by a complex interaction of occupational exposure and individual factors rather than single anthropometric or strength parameters. These results underscore the importance of ergonomic interventions, work-rest cycle regulation, and early symptom screening rather than reliance on anthropometric screening alone. From an occupational health perspective, these findings highlight the importance of preventive strategies targeting ergonomic risk factors. Practical interventions may include education on maintaining neutral wrist positioning, implementing scheduled microbreaks during driving, promoting grip variation strategies, and minimizing sustained wrist flexion or extension.Several limitations of this study should be acknowledged. In this study, CTS was defined based on patient-reported symptoms assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), rather than clinical or electrodiagnostic confirmation. As BCTQ is not a gold-standard diagnostic tool, misclassification of CTS status may have occurred, which could have attenuated the observed associations. Occupational factors such as daily working hours, duration of employment, riding posture, and vibration exposure were not quantitatively assessed and may act as unmeasured confounders. These limitations may affect the generalizability and interpretation of the findings. Therefore, the non-significant findings in this study should not be interpreted as evidence of no association, but rather as inconclusive results that warrant further investigation with larger sample sizes and more robust diagnostic approaches.

CONCLUSIONS AND RECOMMENDATION

This study demonstrates that carpal tunnel syndrome (CTS) symptoms are prevalent among online motorcycle drivers. However, no statistically significant evidence of an association was found in this study between wrist ratio, body mass index, and hand grip strength with CTS symptoms assessed using the Boston Carpal Tunnel Questionnaire. These findings indicate that CTS in this occupational group is not adequately explained by isolated anthropometric or strength-related parameters. The study contributes novel evidence that challenges the utility of single-parameter physical screening for CTS risk among informal workers and reinforces the multifactorial nature of CTS, in which occupational and biomechanical exposures likely play a more dominant role. Future studies should employ longitudinal designs and integrate detailed ergonomic and occupational exposure assessments, including work duration, posture, and vibration exposure. The incorporation of objective diagnostic modalities alongside patient-reported outcomes is recommended to strengthen CTS risk stratification and support the development of targeted preventive interventions in occupational health.

DECLARATIONS

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

The authors declare that they have no conflicts of interest or competing interests related to this study.

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Health Research Ethics Committee of the Faculty of Medicine, Universitas Sriwijaya (Protocol No: 200-2023)

Consent for publication

Not applicable.

Availability of data and materials

Data are available upon request.

Availability of data and materials

Not applicable

Artificial Intelligence-Assisted Technology

The authors declare that no artificial intelligence–assisted technologies were used in the conception, data analysis, interpretation, or writing of this manuscript. (If applicable: AI-assisted tools were used solely for language editing purposes, and all scientific content was reviewed and approved by the authors.)

Authors' contributions:

Rulan Adnindya contributed to study conception and design, data collection, data analysis, and manuscript drafting.

Syarinta Adenina contributed to data collection and statistical analysis.

Tri Suciati contributed to supervision and critical revision of the manuscript. All authors read and approved the final manuscript.

ABOUT THE AUTHOR

Rulan Andnindya completed a Master of Biomedical Science in Faculty of Medicine Universitas Indonesia. She is a lecturer at Departement of Anatomy, Faculty of Medicine, Universitas Sriwijaya, Indonesia. She is a medical researcher with a strong interest in occupational health and musculoskeletal disorders. Her research focuses on work-related risk factors, and ergonomics. She has been involved in observational studies addressing occupational health issues among informal workers.

Syarinta Adenina is a lecturer at the Department of Pharmacology, Faculty of Medicine, Universitas Sriwijaya, Indonesia. Her academic interests include herbal medicine, cancer research, and biomedical study. She has authored and reviewed scientific articles published in national and international peer-reviewed medical journals.

Tri Suciati is a senior lecturer at the Faculty of Medicine, Universitas Sriwijaya, Indonesia. Her expertise includes occupational medicine, public health research, and clinical epidemiology. She has extensive experience supervising undergraduate and postgraduate research and actively publish on several medical and health science journals.

References

• Amalia, S., Setyaningsih, Y., & Suroto. (2023). Faktor Risiko Carpal Tunnel Syndrome Pada Pekerja. Syntax Literate : Jurnal Ilmiah Indonesia, 8(4), 2427–2441. https://doi.org/10.36418/syntax-literate.v8i4.11631
• Baker, N. A., Moehling, K. K., Desai, A. R., & Gustafson, N. P. (2013). Effect of carpal tunnel syndrome on grip and pinch strength compared with sex- and age-matched normative data. Arthritis Care and Research, 65(12), 2041–2045. https://doi.org/10.1002/acr.22089
• Camry. (n.d.). Electronic Hand Dynamometer EH101: Instruction Manual.
• Chairunnisa, S., Novianus, C., & Hidayati. (2021). Faktor-Faktor yang Berhubungan Dengan Gejala Carpal Tunnel Syndrome pada Komunitas Ojek Online Di Kota Tangerang Selatan Tahun 2021. (Online) Ifi-Bekasi.e-Journal.Id/Jfki Jurnal, 1(2), 2807–8020. https://doi.org/10.59946/jfki.2021.45
• Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal tunnel syndrome: a review of the literature. Cureus, 12(3), 1–6. https://doi.org/10.7759/cureus.7333
• Han, B. S., Kim, K. H., & Kim, K. J. (2022). The Radiographic Risk Factors Predicting Occurrence of Idiopathic Carpal Tunnel Syndrome in Simple Wrist X-ray. Journal of Clinical Medicine, 11(14). https://doi.org/10.3390/jcm11144031
• Islamia, M. P., Adnindya, M. R., Laeto, A. Bin, & Hasbi, A. (2024). Association Of Awkward Wrist Posture With Symptoms of Carpal Tunnel Syndrome In Online Motorcycle Taxi Drivers In Palembang. Syifa Medika, 15(September), 53–60. https://jurnal.um-palembang.ac.id/syifamedika/article/view/8031
• Lund, C. B., Mikkelsen, S., Thygesen, L. C., Hansson, G.-åke, & Thomsen, J. F. (2019). Movements of the wrist and the risk of carpal tunnel syndrome : a nationwide cohort study using objective exposure measurements. Occupational and Environmental Medicine, 76(8), 519–526. https://doi.org/10.1136/oemed-2018-105619
• Novosad, S., Khan, S., Wolfe, B., & Khan, A. (2013). Role of Obesity in Asthma Control , the Obesity-Asthma Phenotype. Journal of Allergy, 2013, 1–9. https://doi.org/10.1155/2013/538642
• Nurdasari, A., & Rr. Arum Ariasih. (2021). Faktor-Faktor yang Berhubungan dengan Potensial Kejadian Carpal Tunnel Syndrome (CTS) pada Pengendara Ojek Online di Kota Tangerang Selatan. Jurnal Semesta Sehat (J-Mestahat), 1(1), 10–17. https://doi.org/10.58185/j-mestahat.v1i1.68
• Peshin, S. E., Karakulova, Y. V., Nyashin, Y. I., & Nyashin, M. M. (2022). Carpal Tunnel Syndrome in Terms of Biomechanics. Literature Review. Russian Journal of Biomechanics, 26(2), 13–18. https://doi.org/10.15593/RZhBiomeh/2022.2.01
• Raissi, G., Ahadi, T., Esmailpour, J., & Khadembashiri, M. A. (2025). Correlation of body composition and anthropometric indices with electrodiagnostic and ultrasonographic findings in patients with carpal tunnel syndrome. BMC Musculoskeletal Disorders, 26(1–9). https://doi.org/10.1186/s12891-025-08972-7
• Sari, M. F., & Novendy. (2022). Hubungan durasi mengemudi dengan risiko suspect carpal tunnel syndrome pada ojek online. 4(1), 155-162. https://doi.org/10.24912/tmj.v4i2.18049
• Sasaki, T., Makino, K., Nimura, A., Suzuki, S., Kuroiwa, T., Koyama, T., Okawa, A., Terada, H., & Fujita, K. (2020). Assessment of grip-motion characteristics in carpal tunnel syndrome patients using a novel finger grip dynamometer system. Journal of Orthopaedic Surgery and Research, 15(1), 1–8. https://doi.org/10.1186/s13018-020-01773-9v
• Singh, G. K., & Srivastava, S. (2020). Grip strength of occupational workers in relation to carpal tunnel syndrome and individual factors. International Journal of Occupational Safety and Ergonomics, 26(2), 296–302. https://doi.org/10.1080/10803548.2018.1462915
• Utami, R. F., Segita, R., & Syah, I. (2023). Carpal Tunnel Syndrome Dipengaruhi Lama Kerja dan Postur Pergelangan Tangan pada Pengendara Ojek Online di Kota Bukittinggi. Jurnal Kesehatan Tambusai, 4(2), 2573–2578. https://doi.org/10.31004/jkt.v4i2.15465
• Utamy, R. T., Kurniawan, B., & Wahyuni, I. (2020). Literature Review : Faktor Risiko Kejadian Carpal Tunnel Syndrome ( Cts ) pada Pekerja. Jurnal Kesehatan Masyarakat (e-Journal), 8(5), 601–608. https://doi.org/10.14710/jkm.v8i5.27901
• You, D., Smith, A. H., & Rempel, D. (2014). Meta-Analysis : Association Between Wrist Posture and Carpal Tunnel Syndrome Among Workers. Safety and Health at Work, 5(1), 27–31. https://doi.org/10.1016/j.shaw.2014.01.003

Rights and permissions

© The Author(s) 2026
Open Access This article is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0), which permits others to share, adapt, and redistribute the material in any medium or format, even for commercial purposes, provided appropriate credit is given to the original author(s) and the source, a link to the license is provided, and any changes made are indicated. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. To view a copy of this license, visit https://creativecommons.org/licenses/by-sa/4.0/.