Clinical management of carpal tunnel syndrome: a 12-year review of outcomes

Altered brain function and structure in carpal tunnel syndrome: a systematic review and meta-analysis of structural and functional brain imaging

This systematic review with a meta-analysis aimed to identify the altered brain structure and function in carpal tunnel syndrome (CTS) by summarizing the literature about magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and magnetoencephalography (MEG) outcomes compared to healthy controls (HC). CTS is the most common nerve entrapment in the arm associated with altered peripheral and central nociceptive system. PRISMA guidelines were used to report the outcomes. Six databases were searched for relevant literature (Web of Science, Scopus, PubMed, Sage, EBSCO host, and Cochrane). Eligible studies comparing MRI, fMRI, and MEG findings in people with CTS (present for at least 2 months) and HC through the following parameters: (1) interdigit cortical separation distance, (2) white and grey matter changes, (3) peak latency of M20 wave and recovery function of N20 from the somatosensory cortex (SI), and (4) surface area of activated digit cortical representation. The results from different studies were pooled and a meta-analysis was done. From 17 included, there was a significant reduction of interdigit cortical separation distance of index-middle and index-little fingers in the CTS (SMD = - 0.869, 95% CI (- 1.325, - 0.413), p-value = 0.000) and (SMD = - 0.79, 95% CI (- 1.217, - 0.364), p-value = 0.000), respectively. Middle-little fingers interdigit separation showed no difference (SMD = - 0.2, 95% CI (- 0.903, 1.309), p-value = 0.718). There is evidence supporting the altered brain structure and function in CTS as evidenced by reduction of interdigit cortical separation distance, and excessive blurring and disinhibition of SI, with low resting state functional connectivity. Thus, centrally directed therapeutic approaches might complement peripheral treatments.

Variation in Offer of Operative Treatment to Patients With Trapeziometacarpal Osteoarthritis

PURPOSE

Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment.

METHODS

We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms.

RESULTS

Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations.

CONCLUSIONS

The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations.

CLINICAL RELEVANCE

Surgeons' awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.

Carpal Tunnel Injections: A Novel Approach Based on Wrist Width

INTRODUCTION

Carpal tunnel steroid injections (CTIs) have the potential risk of damaging underlying critical structures, including the median nerve (MN), radial artery (RA), and ulnar neurovascular bundle (UB). The purpose of this study was to analyze the safety of a volar radial (VR) and volar ulnar (VU) CTI, using standardized anatomical "safe zones."

MATERIALS AND METHODS

This study was performed on 87 cadaveric arms using a percentage of the total wrist width as a guide for placement of a VR (30 and 33% of total wrist width) and VU (60 and 66% of total wrist width) injection.

RESULTS

Our results demonstrate a wide range of anatomic variations in the location of these critical neurovascular structures near the carpal canal, indicating that using superficial landmarks alone for CTIs may result in an increased risk of iatrogenic injury to these critical structures.

DISCUSSION

We propose a technique using a percentage of total wrist width as a guide for CTIs. Both VR (30% of wrist width) and VU (60% of wrist width) CTIs offer relatively safe and reliable CTI locations to the carpal canal.

LEVEL OF EVIDENCE

Not applicable/cadaveric study.

Effectiveness of low-level laser on carpal tunnel syndrome: A meta-analysis of previously reported randomized trials

BACKGROUND

Low-level laser therapy (LLLT) has been applied in the treatment of carpal tunnel syndrome (CTS) for an extended period of time without definitive consensus on its effectiveness. This meta-analysis was conducted to evaluate the effectiveness of low-level laser in the treatment of mild to moderate CTS using a Cochrane systematic review.

METHODS

We conducted electronic searches of PubMed (1966-2015.10), Medline (1966-2015.10), Embase (1980-2015.10), and ScienceDirect (1985-2015.10), using the terms "carpal tunnel syndrome" and "laser" according to the Cochrane Collaboration guidelines. Relevant journals or conference proceedings were searched manually to identify studies that might have been missed in the database search. Only randomized clinical trials were included, and the quality assessments were performed according to the Cochrane systematic review method. The data extraction and analyses from the included studies were conducted independently by 2 reviewers. The results were expressed as the mean difference (MD) with 95% confidence intervals (CI) for the continuous outcomes.

RESULTS

Seven randomized clinical trials met the inclusion criteria; there were 270 wrists in the laser group and 261 wrists in the control group. High heterogeneity existed when the analysis was conducted. Hand grip (at 12 weeks) was stronger in the LLLT group than in the control group (MD = 2.04; 95% CI: 0.08-3.99; P = 0.04; I = 62%), and there was better improvement in the visual analog scale (VAS) (at 12 weeks) in the LLLT group (MD = 0.97; 95% CI: 0.84-1.11; P < 0.01; I = 0%). The sensory nerve action potential (SNAP) (at 12 weeks) was better in the LLLT group (MD = 1.08; 95% CI: 0.44-1.73; P = 0.001; I = 0%). However, 1 included study was weighted at >95% in the calculation of these 3 parameters. There were no statistically significant differences in the other parameters between the 2 groups.

CONCLUSION

This study revealed that low-level laser improve hand grip, VAS, and SNAP after 3 months of follow-up for mild to moderate CTS. More high-quality studies using the same laser intervention protocol are needed to confirm the effects of low-level laser in the treatment of CTS.

Psychosocial aspects of hip disease in the young adult

The psychosocial impact of hip disease on the young adult has not been elucidated. This study aimed to identify the functional and psychosocial characteristics of a cohort of young patients (age less than 40 years) presenting to our tertiary care complex hip clinic. A postal questionnaire comprising of a Visual Analogue Scale (VAS) for Pain, the Oswestry Disability Index (ODI) and the Hospital Anxiety and Depression Scale (HADS) was posted to 63 patients. Forty-nine (n = 49) patients (79%) responded to the questionnaire. Mean age was 20 years (range 16-38) with a gender ratio of 2:1 (female: male). More than half of our patients had moderate to severe pain based on the VAS and at least moderate disability on the ODI. HADS showed that 32% and 49% of patients were classified as having borderline to abnormal levels of depression and anxiety respectively. Multiple regression showed ODI scores to be a significant predictor of anxiety and depression. Comparison with asymptomatic controls shows that these patients have significantly worse ODI and HADS scores compared to normal population. This study quantifies the degree of functional and psychosocial compromise present in young patients with hip problems.

[Minimally invasive surgery versus conventional surgery. A review of the scientific evidence]

The concept that small incisions lead to a better outcome in many procedures has extended into most surgical areas, orthopaedic surgery among them. However, in some cases there is not enough scientific evidence to recommend these procedures. This article attempts to provide an updated review of the works published with sufficient scientific evidence on the advantages of minimally invasive surgery (MIS) compared to conventional access approaches. The published articles, meta-analyses and systematic literature reviews with level I or II evidence are reviewed in topographic order. Wherever possible, the information available on the costs-benefits of this type of surgery is also reviewed.

Factors affecting return to work after carpal tunnel syndrome surgery in a large French cohort

OBJECTIVE

To evaluate occupational outcomes after surgical release of the median nerve in carpal tunnel syndrome (CTS).

DESIGN

Retrospective study 12 to 24 months after surgery.

SETTING

Hand centers (N=3) in 2 different areas.

PARTICIPANTS

Patients who had undergone surgical release of the median nerve in 2002 to 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Duration of sick leave after surgery and associated factors were analyzed by using bivariate (log rank) and multivariate analyses of survival (Cox model).

RESULTS

Questionnaires mailed in 2004 regarding medical condition (history and surgery), employment (occupational category codes in 1 digit), and compensation were returned (N=1248; 62%), with 253 men and 682 women stating they were employed at the time of surgery (N=935). Most were working at the time of the study (n=851; 91.0%). Median duration of sick leave before returning to work was 60 days. The main factors associated with adverse occupational outcome (long duration of sick leave) were simultaneous intervention for another upper-extremity musculoskeletal disorder, belief (by the patient) in an occupational cause, and "blue-collar worker" occupational category (the strongest determinant).

CONCLUSION

This study emphasizes the multifactorial nature of the occupational outcome of CTS after surgery, including occupational category. The probability of return to work for each risk factor provides a fair description of prognosis for physicians and patients.

Surgical techniques and return to work following carpal tunnel release: a systematic review and meta-analysis

INTRODUCTION

This systematic review was conducted to evaluate return to work (RTW) following minimally invasive carpal tunnel surgery versus open carpal tunnel release. This study also assesses how RTW as an outcome measure was examined in previous randomized controlled trials (RCTs).

METHODS

The bibliographic databases Medline, AMED and CINAHL were systematically searched. We found 15 relevant RCTs. Meta-analysis was possible only for four studies.

RESULTS

The result indicates that minimally invasive surgery offers earlier return to work compared to open carpal tunnel release (mean difference -7.2 days; 95% CI -10 to -4.4 days). There were remarkable inconsistencies in how return to work as an outcome measure was examined in different RCTs.

CONCLUSIONS

Calculating standardised mean difference in future RCTs would allow future reviews to be more inclusive of the evidence. The authors suggest more consistent approach for evaluating work-related features in future studies. We recommend that new fit note categories introduced by UK Department of Work and Pension (unfit for all work/return to modified work or work adaptations/return to normal work) would be used to identify different levels of return to work.

Cognitive-behavioral therapy for hand and arm pain

Cognitive-behavioral therapy (CBT) is a psychological treatment that emphasizes the interrelation among thoughts, behaviors, feelings, and sensations. CBT has been proved effective not only for treatment of psychological illness but also for teaching adaptive coping strategies in the context of chronic illnesses, including chronic pain. The present article provides general information on CBT, specific information on CBT for pain, as well as guidelines and strategies for using CBT for hand and arm pain patients, as part of multidisciplinary care models.

Carpal lock and the volar-supporting orthosis in mild and moderate carpal tunnel syndrome

OBJECTIVE

The carpal lock, which is a hand/wrist orthosis that supports the dorsal aspect of the hand, was used in patients with mild-moderate carpal tunnel syndrome, and its clinical and electrophysiological effectiveness was compared with that of a volar-supporting orthosis.

DESIGN

Nerve conduction study and clinical evaluation of 24 patients (41 hands) with mild or moderate carpal tunnel syndrome were performed before and 3 mos after the use of the carpal lock or the volar-supporting orthosis.

RESULTS

Significant improvement was observed in electrophysiological parameters and clinical outcomes after use of both orthoses. There was no statistically significant difference between the two groups. Patients in the carpal lock group used the orthosis 89.6% of the prescribed time, whereas those in the volar-supporting orthosis group used the orthosis 79.2% of the prescribed time (P < 0.05).

CONCLUSIONS

The carpal lock may be used as an alternative to the volar-supporting orthosis.

Work-related carpal tunnel syndrome in Washington State workers' compensation: utilization of surgery and the duration of lost work

BACKGROUND

Work-related carpal tunnel syndrome (CTS) is a leading cause of lengthy disability.

METHODS

This population-based retrospective cohort study used Washington State workers' compensation claims for CTS to characterize associations between utilization of CTS surgery and duration of lost work. The sample included all claims (n = 8,224) filed during 1990-1994 (followed through 2000) and receiving lost-work compensation.

RESULTS

Sixty-four percent of studied workers had CTS surgery. Among workers with >1 month of lost work, the total duration was much shorter when workers had surgery, versus those who did not (median 4.3 and 6.2 months, respectively; P < 0.001); there was no difference when disability extended >6 months. When workers had surgery, disability was less likely to end before 6 months if non-CTS conditions were present, surgery occurred >3 months after claim filing, or employment was in an industry with high incidence of CTS; disability was more likely to end if the diagnosing provider and operating surgeon had higher CTS claims volume. Physical and rehabilitation medicine services were associated with lower probability of returning to work, with or without surgery.

CONCLUSIONS

There is a need to scrutinize the role of surgery and physical-rehabilitation medicine modalities in the management of CTS covered by workers' compensation. The findings suggest disability can be minimized by establishing the CTS diagnosis as early as possible and, if surgery is appropriate, conducting surgery without substantial delay and maximizing post-operative efforts to facilitate return to work. Use of surgery >6 months after filing should be considered with great caution.

Psychosocial aspects of disabling musculoskeletal pain

Psychosocial factors are important determinants of pain intensity and disability in patients with disabling musculoskeletal pain. The psychosocial aspects of disabling musculoskeletal pain include cognitive (e.g., beliefs, expectations, and coping style), affective (e.g., depression, pain anxiety, heightened concern about illness, and anger), behavioral (e.g., avoidance), social (e.g., secondary gain), and cultural factors. The effectiveness of cognitive behavioral therapy and other treatments that address the psychosocial aspects of disabling musculoskeletal pain has been confirmed in numerous high-quality studies.

LONG-TERM FOLLOW-UP OF DUAL-PORTAL ENDOSCOPIC RELEASE OF THE TRANSVERSE LIGAMENT IN CARPAL TUNNEL SYNDROME

OBJECTIVE

The long-term efficacy of dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is still being debated. In this study, the authors present 94 endoscopic carpal tunnel surgery cases with long-term follow-up data.

METHODS

The study includes 72 patients aged 17 to 86 years (mean age, 53.4 years); bilateral surgery was performed in 22 of these patients. Seventy-two hands of female patients and 22 hands of male patients were included. All procedures were performed with a dual-portal set according to the Chow technique. All patients were examined 2 to 3 months after surgery. The long-term follow-up evaluation was based on telephone interviews 5 to 12 years (mean, 8.2 years) after surgery.

RESULTS

From a cohort of 214 cases that were treated surgically between 1995 and 2002, 94 cases (44%) could be evaluated for long-term follow-up. Four of these patients had to be excluded from long-term follow-up because of a switch to an open technique and early open revision (3–6 months after the first surgery), owing to persistent symptoms. A good to optimal postoperative outcome with improvement of neurological signs and subjective patient satisfaction was observed in 84 (93.3%) of the remaining 90 cases. There were no recurrences.

CONCLUSION

The study shows that dual-portal endoscopic release of the transverse ligament in carpal tunnel syndrome is a valuable technique that produces very good long-term results and high patient satisfaction and does not result in a significant recurrence rate.

Effect of Er:YAG and CO2 lasers with and without sodium fluoride gel on dentinal tubules: a scanning electron microscope examination

OBJECTIVE

The aim of this pilot study was to evaluate the occluding effect of erbium:yttrium-aluminum-garnet (Er:YAG) and carbon dioxide (CO2) lasers as monotherapy and in combination with topical fluoride gel on human dentinal tubules by scanning electron microscopic (SEM) examination.

MATERIALS AND METHODS

Thirty-six dentine specimens with exposed dentinal tubule orifices were included in this study. The samples were divided into six groups. Group A served as controls, group B was treated with 2% sodium fluoride (NaF) gel alone, groups C and D were irradiated with Er:YAG (30 Hz, 60 mJ, for 10 sec) and CO2 (1 W, continuous-wave mode, for 10 sec) lasers, respectively, and groups E and F received NaF gel plus Er:YAG and CO2 laser irradiation, respectively.

RESULTS

Under SEM analysis, numerous exposed, normally-structured dentinal tubule orifices were seen in the control group. Some narrowing of the exposed tubule orifices was seen in group B. A melted, irregular surface structure with small peaks was observed in group C. The surface of group D also had a melted appearance, but a fibrillar deformation of the surface structure was seen on the specimens. However, the surface morphologies seen were remarkably different in groups E and F. While the tubule orifices were obviously occluded but depressed into craters in group E, the surface structure of group F primarily showed a smooth appearance. In terms of numbers and diameters of open dentinal tubules, there was no significant difference between the laser-alone and combination groups, whereas the difference was found to be significant when the control and NaF groups were compared with each other and the remaining laser-alone or combination groups.

CONCLUSION

The dentinal tubules in all laser groups were occluded after laser irradiation, but more marked occlusions were observed when laser and NaF gel were combined.

The effects of neural mobilization in addition to standard care in persons with carpal tunnel syndrome from a community hospital

The purpose of this study was to determine whether neural mobilization in addition to standard care is more effective than standard care alone in the treatment of Carpal Tunnel Syndrome (CTS). Sixty participants were randomly assigned to one of two groups. Group 1 received standard care, and Group 2 performed a neurodynamic mobilization exercise in addition to standard care. Outcomes were assessed at baseline and at one and six months using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Brigham and Woman's Hospital Carpal Tunnel Specific Questionnaire (CTSQ), and elbow extension range of motion during an upper limb median nerve tension test. There were no significant differences in the outcome measures between groups, except Group 1 had improved scores on the function status scale of the CTSQ compared to Group 2 at six months. The addition of neural mobilization to standard care did not result in improved outcomes in patients with CTS.

Management of work-relevant upper limb disorders: a review

BACKGROUND

Upper limb disorders (ULDs) are clinically challenging and responsible for considerable work loss. There is a need to determine effective approaches for their management.

AIM

To determine evidence-based management strategies for work-relevant ULDs and explore whether a biopsychosocial approach is appropriate.

METHODS

Literature review using a best evidence synthesis. Data from articles identified through systematic searching of electronic databases and citation tracking were extracted into evidence tables. The information was synthesized into high-level evidence statements, which were ordered into themes covering classification/diagnosis, epidemiology, associations/risks and management/treatment, focusing on return to work or work retention and taking account of distinctions between non-specific complaints and specific diagnoses.

RESULTS

Neither biomedical treatment nor ergonomic workplace interventions alone offer an optimal solution; rather, multimodal interventions show considerable promise, particularly for occupational outcomes. Early return to work, or work retention, is an important goal for most cases and may be facilitated, where necessary, by transitional work arrangements. The emergent evidence indicates that successful management strategies require all the players to be on side and acting in a coordinated fashion; this requires engaging employers and workers to participate.

CONCLUSIONS

The biopsychosocial model applies: biological considerations should not be ignored, but psychosocial factors are more influential for occupational outcomes. Implementation of interventions that address the full range of psychosocial issues will require a cultural shift in the way the relationship between upper limb complaints and work is conceived and handled. Dissemination of evidence-based messages can contribute to the needed cultural shift.

The effect of a job placement and support program for workers with musculoskeletal injuries: a randomized control trial (RCT) study

BACKGROUND

This is a randomized clinical trial (RCT) to investigate the efficacy of a job placement and support program designed for workers with musculoskeletal injuries and having difficulties in resuming the work role. The program was planned to help injured workers to successfully return to work (RTW) by overcoming the difficulties and problems during the process of job seeking and sustaining a job using a case management approach.

METHODOLOGY

A total of 66 injured workers were recruited and randomly assigned into the job placement and support group (PS group) or the self-placement group (SP group). A three-week job placement and support program was given to subjects in the PS group while subjects in the control group (SP group) were only given advice on job placement at a workers' health center. The PS program was comprised of an individual interview, vocational counseling, job preparation training, and assisted placement using the case management approach. The Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), the Chinese State Trait and Anxiety Inventory (C-STAI), and the SF-36 were the outcome measures for the two groups before and after the training program to observe the changes in subjects' work readiness status, emotional status and their health related quality of life pre- and post-training program. The rate of return to work was measured for both groups of subjects after the training program.

RESULTS

The results indicated that the rate of success in RTW (73%) was significantly higher in the job placement (PS) group than that of the self-placement (SP) group (51.6%) with P < 0.05. Significant differences were also found in C-STAI (P < 0.05), SF-36 (P < 0.05) and C-LASER scores on action (P < 0.05) between the two groups.

CONCLUSION

The job placement (PS) program appeared to have enhanced the employability of injured workers. Workers who participated in the program also showed higher levels of work readiness and emotional status in coping with their work injuries.

Impact of compensation on work outcome of carpal tunnel syndrome

BACKGROUND

Work-related carpal tunnel syndrome (CTS) is a complex and costly condition. There is some evidence that the employment outcome may be worse in cases of CTS where the condition is being considered for compensation.

AIM

To examine whether workers' compensation status is an important determinant of outcome of CTS.

METHODS

Cases, with a Workers' Compensation Board (WCB) claim, and referents, in work but without a WCB claim, were identified from the practice of a single specialist physician. Data on history prior to and at the time of diagnosis, and events since diagnosis, were collected from clinical records and by a telephone-administered questionnaire. Prior events, severity, treatment and outcome associated with a WCB claim were assessed by logistic regression.

RESULTS

Interviews were successfully completed for 46 cases and 50 referents. In the model adjusted only for age and gender, claimants had a worse outcome in terms of changing job or stopping work with time loss from work due to CTS [odds ratio (OR) 5.1, 95% confidence interval (CI) 1.9-13.3]. The OR was much influenced by the inclusion of treatment in the model (OR = 9.6, 95% CI 1.6-58.6) with WCB cases more likely to have surgical and physiotherapy treatments. Cases with a WCB claim cost more to treat and reported greater loss in income than those not seeking compensation.

CONCLUSIONS

Although these data are limited, the results are suggestive of poorer outcome among WCB claimants despite greater use of treatment and comparable severity of disease.

Differential diagnosis of atypical focal peripheral neuropathy: case report

Carpal tunnel syndrome (CTS) is the most frequent form of focal peripheral neuropathy but is commonly misdiagnosed. The aim of this case report was to describe the differential diagnosis of CTS and atypical focal peripheral neuropathy in a 34-year-old female. Although the patient's medical diagnosis was CTS, she did not report night pain, did not exhibit hand atrophy, had no sensory loss, did not meet the five criteria of the clinical prediction rule for CTS, and demonstrated symptoms associated with radial and median nerve pain. The patient's concordant symptoms were associated with wrist passive accessory stiffness and functional activities that required repetitive end range movements. Interventions included treatment of two priority impairments: 1) pain and 2) wrist accessory stiffness. After five treatments, the patient no longer reported pain with activities and was able to return to work with no restrictions. Although the patient in this case report exhibited isolated features consistent with CTS, compelling cumulative evidence suggested a distinct diagnosis. Limited evidence exists to support the use of mobilization, strengthening, and pain reduction-based modalities for the treatment of focal peripheral neuropathy; subsequently, treatments must be individually effective when targeted toward the patient's priority impairments. The diagnosis of CTS is challenging because there are a variety of possible clinical presentations. Using evidence-based indices, such as the clinical prediction rule for CTS and other comparative history and physical measures, should improve the likelihood of accurate diagnosis and treatment.

A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

OBJECTIVE

The purpose of this study was to determine the clinical efficacy of manual therapy interventions for relieving the signs and symptoms of carpal tunnel syndrome (CTS) by comparing 2 forms of manual therapy techniques: Graston Instrument-assisted soft tissue mobilization (GISTM) and STM administered with the clinician hands.

METHODS

The study was a prospective comparative research design in the setting of a research laboratory. Volunteers were recruited with symptoms suggestive of CTS based upon a phone interview and confirmed by electrodiagnostic study findings, symptom characteristics, and physical examination findings during an initial screening visit. Eligible patients with CTS were randomly allocated to receive either GISTM or STM. Interventions were, on average, twice a week for 4 weeks and once a week for 2 additional weeks. Outcome measures included (1) sensory and motor nerve conduction evaluations of the median nerve; (2) subjective pain evaluations of the hand using visual analog scales and Katz hand diagrams; (3) self-reported ratings of symptom severity and functional status; and (4) clinical assessments of sensory and motor functions of the hand via physical examination procedures. Parametric and nonparametric statistics compared treated CTS hand and control hand and between the treatment interventions, across time (baseline, immediate post, and at 3 months' follow-up).

RESULTS

After both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion. The improvements detected by our subjective evaluations of the signs and symptoms of CTS and patient satisfaction with the treatment outcomes provided additional evidence for the clinical efficacy of these 2 manual therapies for CTS. The improvements were maintained at 3 months for both treatment interventions. Data from the control hand did not change across measurement time points.

CONCLUSIONS

Although the clinical improvements were not different between the 2 manual therapy techniques, which were compared prospectively, the data substantiated the clinical efficacy of conservative treatment options for mild to moderate CTS.

The effect of a "training on work readiness" program for workers with musculoskeletal injuries: a randomized control trial (RCT) study

BACKGROUND

This is a clinical randomized trail (RCT) to investigate the effects of a three-week training program on work readiness designed for musculoskeletal injured workers with long-term sick leave who had difficulties resuming their work role. The program was planned to help injured workers overcome the psychological and psychosocial problems and to facilitate their Work Readiness on Return to Work (RTW) based on the Employment readiness model.

METHODOLOGY

A total of 64 injured workers were recruited and randomly assigned into the training (T) and control (C) groups. Observations were blinded between service providers and evaluators. A three-week intensive training on work readiness program was given to the T group while subjects in the C group were given advice on job placement by social workers in a community work health center. The training program was comprised of individual vocational counseling and group therapy using cognitive behavioral approach to alleviate symptoms of stress, pain and anxiety. The Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), the Chinese State Trait and Anxiety Inventory (C-STAI) and the Short form of Health Survey (SF-36) were used to evaluate all subjects' psychological health status and behavioral changes on job readiness before and after the intervention.

RESULTS

Subjects in the T group showed significant improvement in their work readiness (p < 0.05), level of anxiety (p < 0.05) and their self perception of health status measured by SF-36 (p < 0.02) when compared with subjects in the C group. Control of chronic pain, negative motivation, and anxiety level were some of the key behavioral changes found from the study.

CONCLUSION

The TWR program appeared to improve injured workers' motivation and employment readiness. Further study on the employment outcomes of subjects is recommended.

Photobiomodulation of Pain in Carpal Tunnel Syndrome: Review of Seven Laser Therapy Studies

In this review, seven studies using photoradiation to treat carpal tunnel syndrome (CTS) are discussed: two controlled studies that observed real laser to have a better effect than sham laser, to treat CTS; three openprotocol studies that observed real laser to have a beneficial effect to treat CTS; and two studies that did not observe real laser to have a better effect than a control condition, to treat CTS. In the five studies that observed beneficial effect from real laser, higher laser dosages (9 Joules, 12-30 Joules, 32 J/cm(2), 225 J/cm(2)) were used at the primary treatment sites (median nerve at the wrist, or cervical neck area), than dosages in the two studies where real laser was not observed to have a better effect than a control condition (1.8 Joules or 6 J/cm(2)). The average success rate across the first five studies was 84% (SD, 8.9; total hands = 171). The average pain duration prior to successful photoradiation was 2 years. Photoradiation is a promising new, conservative treatment for mild/moderate CTS cases (motor latency < 7 msec; needle EMG, normal). It is cost-effective compared to current treatments.

The role of job strain on return to work after carpal tunnel surgery

AIMS

To examine the impact of job strain (that is, high psychological job demands and low job control) on return to work and work role functioning at two months, six months, or both, following carpal tunnel release surgery.

METHODS

A community based cohort of carpal tunnel syndrome (CTS) patients from physician practices was recruited between April 1997 and October 1998 throughout Maine (USA). 128 patients at two months and 122 at six months completed all relevant questions. A three level outcome variable indicated whether patients had: (1) returned to work functioning successfully, (2) returned to work functioning with limitations, or (3) not returned to work for health reasons. Two job strain measures were created: one, by combining psychological job demands and job control; and two, by dividing demands by control. Ordinal logistic regression was used to identify predictors of the three level work outcome variable.

RESULTS

After adjustment, workers with high demands and high control (active work) were less likely to successfully return to work (OR = 0.22; p = 0.014) at two months. Having a job with higher demands than job control (high strain) predicted not returning to work or returning to work but not successfully meeting job demands (OR = 0.14; p = 0.001), at six months.

CONCLUSIONS

The findings underscore the role of psychosocial work conditions, as defined by the Karasek demand-control model, in explaining a worker's return to work. Clinicians, researchers, and employers should consider a multidimensional and integrative model of successful work role functioning upon return to work. Moreover, since the evidence of the effects of work process changes on the reduction of CTS is very scarce, these findings point to the opportunity for collaborative workplace interventions to facilitate successful return to work.

Work-related carpal tunnel syndrome in Washington State workers' compensation: temporal trends, clinical practices, and disability

BACKGROUND

Work-related carpal tunnel syndrome (CTS) is a leading cause of disability. There is a need for information about temporal trends, clinical practices, and treatment outcomes.

METHODS

A population based, retrospective cohort study of Washington State workers' compensation claims for CTS was initiated focusing on claims filed during 1990-1994, followed through 2000 (n = 16,710).

RESULTS

Half of the claims were filed for conditions other than CTS, but were eventually identified to be or include CTS. The first CTS diagnosis occurred more than 3 months after claim filing in 20% of claims. The longer that the CTS diagnosis occurred after claim filing, the more likely that CTS was accompanied by other problems, and disability tended to be longer.

CONCLUSIONS

Making an accurate diagnosis of CTS and initiating appropriate actions earlier than might otherwise occur could reduce the disability and costs in a large fraction of claims that are ultimately determined to involve CTS.

Effectiveness of exercise therapy: a best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinson's disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Determinants of work absence following surgery for carpal tunnel syndrome

BACKGROUND

The objective was to identify factors across multiple domains associated with return to work in a community-based cohort of workers with carpal tunnel syndrome.

METHODS

Workers scheduled for carpal tunnel release were recruited into this prospective study. Subjects completed questionnaires preoperatively and at 2, 6, and 12 months postoperatively. The questionnaires contained demographic, clinical, and psychosocial factors and physical and psychosocial workplace stressors. Predictors of work absence at 6 and 12 months were examined in bivariate and multivariate logistic regression analyses.

RESULTS

Six months following surgery of 181 subjects, 29 (19%) were out of work. Twelve months postoperatively 33 subjects (22%) were out of work. In bivariate analyses, the factors associated with work absence at 6 months, at P < or = 0.01, included preoperative physical functional status, change in self-efficacy between preoperative assessment and 2 months, lower income, workers' compensation, representation by an attorney, work exposure to force and repetition, higher psychological job demands and lower control, lower social support by coworkers, lower job security and more supportive organizational policies and practices. The factors associated with work absence at 12 months in bivariate analyses included preoperative physical functional status, lower self-efficacy at 2 months, workers' compensation, and less supportive organizational policies and practices. Multivariate analyses documented a multidimensional model, with predictors from multiple domains.

CONCLUSIONS

Clinical, demographic, economic, and workplace factors were associated with work absence. Strategies to reduce work absence following carpal tunnel release should address multiple dimensions of the worker and workplace.

Randomized clinical trial of surgery versus conservative therapy for carpal tunnel syndrome [ISRCTN84286481]

BACKGROUND

Conservative treatment remains the standard of care for treating mild to moderate carpal tunnel syndrome despite a small number of well-controlled studies and limited objective evidence to support current treatment options. There is an increasing interest in the usefulness of wrist magnetic resonance imaging could play in predicting who will benefit for various treatments.

METHOD AND DESIGN

Two hundred patients with mild to moderate symptoms will be recruited over 3 1/2 years from neurological surgery, primary care, electrodiagnostic clinics. We will exclude patients with clinical or electrodiagnostic evidence of denervation or thenar muscle atrophy. We will randomly assign patients to either a well-defined conservative care protocol or surgery. The conservative care treatment will include visits with a hand therapist, exercises, a self-care booklet, work modification/ activity restriction, B6 therapy, ultrasound and possible steroid injections. The surgical care would be left up to the surgeon (endoscopic vs. open) with usual and customary follow-up. All patients will receive a wrist MRI at baseline. Patients will be contacted at 3, 6, 9 and 12 months after randomization to complete the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ). In addition, we will compare disability (activity and work days lost) and general well being as measured by the SF-36 version II. We will control for demographics and use psychological measures (SCL-90 somatization and depression scales) as well as EDS and MRI predictors of outcomes.

DISCUSSION

We have designed a randomized controlled trial which will assess the effectiveness of surgery for patients with mild to moderate carpal tunnel syndrome. An important secondary goal is to study the ability of MRI to predict patient outcomes.

Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review

The purpose of this study was to determine the effectiveness of hand therapy interventions for carpal tunnel syndrome (CTS) based on the best available evidence. A qualitative systematic review was conducted. A literature search using 40 key terms was conducted from the earliest available date to January 2003 using seven databases. Articles were randomly assigned to two of five reviewers and evaluated according to predetermined criteria for inclusion at each of the title, abstract, and article levels. Included studies were independently scored by two reviewers using a structured effectiveness quality evaluation scale and also graded according to Sackett's Levels of Evidence. There were 2027 articles identified from the literature search, of which 345 met the inclusion criteria. Twenty-four studies were used to formulate 30 recommendations. Current evidence demonstrates a significant benefit (grade B recommendations) from splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with CTS.

Predictors of Successful Work Role Functioning After Carpal Tunnel Release Surgery

This study identified the clinical, individual, and workplace predictors of successful work role functioning (WRF) after carpal tunnel release surgery (CTRS). A community-based cohort (n = 197) was followed for 6 months post-CTRS. Predictors of successful WRF were analyzed prospectively using ordinal logistic regression. Baseline WRF predicted successful WRF at 2 months, whereas being depressed and a workers' compensation claimant predicted being out of work. Baseline WRF, improved self-efficacy, and a supportive organization predicted 6-month successful WRF. Supportive organizations have an impact on the effectiveness of medical interventions for CTS. The significance of improved self-efficacy at 6 months and depression at 2 months postsurgery highlights the importance of psychosocial management of musculoskeletal disorders.

What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management

BACKGROUND

We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS).

METHODS

Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS.

RESULTS

We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment.

CONCLUSIONS

For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.

A Systematic Review of Reviews Comparing the Effectiveness of Endoscopic and Open Carpal Tunnel Decompression

Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information on treatment effectiveness is a review of high-methodologic-quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Cochrane, MEDLINE, EMBASE, CINAHL, and HealthSTAR databases were searched using the key words "endoscopic carpal tunnel," with limits "review or overview" and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality concurred that there is no difference between the two techniques in symptom relief and that the evidence is conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these two techniques, particularly with regard to return to work and function.

Carpal tunnel syndrome: cross-sectional and outcome study in Ontario workers

PURPOSE

To carry out an analytic cross-sectional study of Ontario workers with carpal tunnel syndrome (CTS) and to assess workers' symptoms, functional disabilities, recreational difficulties, and work capability 4 years after treatment of their CTS.

METHODS

Data were obtained by review of Ontario Workers Safety and Insurance Board (WSIB) files and by completion of self-assessment questionnaires. Inclusion criteria included all workers registered with the Ontario WSIB who were off work with newly diagnosed carpal tunnel syndrome in 1996.

RESULTS

There are 3 million workers covered by the WSIB in the province of Ontario. In 1996, 964 of them developed work-related CTS that required time off for treatment. Of these patients 53% were women and 75% had bilateral CTS. Eighty-one percent of the unilateral cases involved the dominant extremity. The average age at the time of claim was 41 years and workers were at the same job type for an average of 7.4 years (unilateral) and 8.5 years (bilateral), respectively. Thirty-nine percent of workers had a history of another tendonitis or epicondylitis. Seventy-five percent of workers had surgery and on average returned to work 3 months later. Four years after treatment, outcome was assessed by self-administered questionnaires, for which there was a 73% response rate. Forty-six percent of workers experienced moderate to severe pain, 47% had moderate to severe numbness, and 40% had difficulty grasping and using small objects. Only 14% were symptom free. Successful return to work was considered to be a return to the same job with or without modifications, and it occurred in 64% of cases. Better clinical outcome scores were found to occur with surgery and abnormal nerve conduction study results. Worse clinical outcome scores were present with repeat surgery and surgical complications. Concurrent diagnoses of either tendonitis or epicondylitis also resulted in worse clinical outcome scores and worse return-to-work outcomes. The average total cost in Canadian dollars to the WSIB exceeded $13,700 per worker for a total cost in excess of $13,200,000 per year. (In 1996, $1 Canadian = $1.365 US.)

CONCLUSIONS

These outcomes indicate that Canadian workers have a large amount of permanent pain and suffering, a large loss of work productivity, and incur a considerable financial cost as a result of work-related CTS.

Work-related carpal tunnel syndrome (WR-CTS) in Massachusetts, 1992-1997: source of WR-CTS, outcomes, and employer intervention practices

BACKGROUND

The Massachusetts Sentinel Event Notification System for Occupational Risks (MASS SENSOR) receives reports of work-related carpal tunnel syndrome (WR-CTS) cases from (1) workers' compensation (WC) disability claims for 5 or more lost work days; and (2) physician reports (PR).

METHODS

From 1992 through 1997, 1,330 WC cases and 571 PR cases completed follow-back surveys to provide information on industry, occupation, attributed source of WR-CTS, outcomes, and employer intervention practices.

RESULTS

Sixty-four percent of the respondents had bilateral CTS and 61% had surgery, both of which were proportionally more frequent among WC cases. Office and business machinery was the leading source of WR-CTS (42% of classifiable sources) in every economic sector except construction, followed by hand tools (20%). Managers and professional specialty workers were the most likely to report employers' interventions and were up to four times more likely to report equipment or work environment changes than higher risk groups.

CONCLUSIONS

State-based surveillance data on the source of WR-CTS provided valuable information on how and where to implement interventions. New occurrences of WR-CTS are likely, especially in the highest risk industries where very few cases reported primary prevention measures (e.g., changes to equipment or work environment) implemented by their employers.

Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome

Several studies have suggested that low-level laser therapy (LLLT) is effective in patients with carpal tunnel syndrome (CTS). In a double-blind randomized controlled trial of LLLT, 15 CTS patients, 34 to 67 years of age, were randomly assigned to either the control group (n = 8) or treatment group (n =7). Both groups were treated three times per week for 5 weeks. Those in the treatment group received 860 nm galium/aluminum/arsenide laser at a dosage of 6 J/cm2 over the carpal tunnel, whereas those in the control group were treated with sham laser. The primary outcome measure was the Levine Carpal Tunnel Syndrome Questionnaire, and the secondary outcome measures were electrophysiological data and the Purdue pegboard test. All patients completed the study without adverse effects. There was a significant symptomatic improvement in both the control (P = 0.034) and treatment (P =0.043) groups. However, there was no significant difference in any of the outcome measures between the two groups. Thus, LLLT is no more effective in the reduction of symptoms of CTS than is sham treatment.

Stress Management and Workplace Disability in the US, Europe and Japan

Although the health care costs and the number of disability cases across all medical illnesses have increased, disability management programs implementing stress management interventions have been found to improve physical and mental health, reduce costs to employers, and facilitate the reintegration of injured individuals into the work environment. Stress management programs limit the impact and chronicity of disabilities and can be used to reduce and control the cost of disability in the workplace. Providing the most efficacious behavioral interventions thereby allows employers, employees and health professionals to work cooperatively to achieve optimum health and cost effectiveness. This review presents a variety of group and individual interventions, which have been utilized to aid disabled employees in coping with work-related injuries and medical illness. The implementation of stress management interventions in the workplace is described in detail, with special emphasis on the use of cognitive behavioral stress management. Finally, this review outlines a team approach to the application of a workplace stress management intervention aimed at reducing the overall impact of disability.

Predicting the outcome of carpal tunnel release

PURPOSE

To test the hypothesis that the result of steroid injection in the carpal tunnel provides a better predictor of the outcome of later surgery. We also explored other possible factors that might predict the outcome directly or interact with the results of steroid injection to better predict the outcome.

METHOD

We performed a historical cohort study on 57 patients who had carpal tunnel release. Care was taken to avoid problems of statistical nonindependence caused by both hands being studied and confounding from previous surgeries.

RESULTS

We found a large and significant difference in the success rate of surgery for patients who had obtained some relief from injection (87%) versus those who had not (54%). No other significant predictor was found. We discovered factors that may interact with the results of injection in predicting the outcome of surgery (eg, Katz and Stirrat hand diagram assessment of the probability of carpal tunnel syndrome) although not significant in our study.

CONCLUSIONS

Some relief from steroid injection is the best predictor for success of surgery. Further study is warranted to identify factors that interact with this predictor.

Does carpal canal stenosis predict outcome in women with carpal tunnel syndrome?

OBJECTIVE

We investigated the role of carpal canal stenosis as a predictor of outcome in patients who underwent surgical treatment for carpal tunnel syndrome (CTS).

METHODS

We performed magnetic resonance imaging (MRI) of the wrist in 31 female patients with clinically and neurophysiologically confirmed CTS. With a computerized analyser we quantitatively calculated the focal narrowest point of the tunnel. Patient's assessment of CTS-related symptoms were obtained by using a visual analogue scale before, and 6 months after treatment.

RESULTS

Seventeen (56%) patients improved in all symptoms after treatment. The focal narrowest point of the tunnel was identified at its distal third in all patients, at 8 mm from the outlet. The median area of the narrowest point in those who improved clinically (n=17) was 238.9 mm2 compared with 269.8 mm2 in others (n=14), P=0.046.

CONCLUSION

Identification of carpal canal stenosis may be important in selecting candidates for treatment in symptomatic CTS.

Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electric nerve stimulation: A controlled study

OBJECTIVE

To investigate whether real or sham low-level laser therapy (LLLT) plus microamperes transcutaneous electric nerve stimulation (TENS) applied to acupuncture points significantly reduces pain in carpal tunnel syndrome (CTS).

DESIGN

Randomized, double-blind, placebo-control, crossover trial. Patients and staff administered outcome measures blinded.

SETTING

Outpatient, university-affiliated Department of Veterans Affairs medical center.

PARTICIPANTS

Eleven mild to moderate CTS cases (nerve conduction study, clinical examination) who failed standard medical or surgical treatment for 3 to 30 months.

INTERVENTION

Patients received real and sham treatment series (each for 3-4wk), in a randomized order. Real treatments used red-beam laser (continuous wave, 15mW, 632.8nm) on shallow acupuncture points on the affected hand, infrared laser (pulsed, 9.4W, 904nm) on deeper points on upper extremity and cervical paraspinal areas, and microamps TENS on the affected wrist. Devices were painless, noninvasive, and produced no sensation whether they were real or sham. The hand was treated behind a hanging black curtain without the patient knowing if devices were on (real) or off (sham).

MAIN OUTCOME MEASURES

McGill Pain Questionnaire (MPQ) score, sensory and motor latencies, and Phalen and Tinel signs.

RESULTS

Significant decreases in MPQ score, median nerve sensory latency, and Phalen and Tinel signs after the real treatment series but not after the sham treatment series. Patients could perform their previous work (computer typist, handyman) and were stable for 1 to 3 years.

CONCLUSIONS

This new, conservative treatment was effective in treating CTS pain; larger studies are recommended.

Relationship between stress and pain in work-related upper extremity disorders: the hidden role of chronic multisymptom illnesses

BACKGROUND

Pain and fatigue are commonly associated with work-related upper extremity disorders. Occasionally these symptoms persist beyond a reasonable healing period. One potential explanation for prolonged symptom expression is the concurrent development of a stress-mediated illness or CMI (Chronic Multi-Symptom Illness). In such a scenario, the chronic regional pain and other symptoms that the individual is experiencing would be attributable to the CMI rather than to tissue damage or a biomechanical dysfunction of the upper-extremity.

METHODS

This article critically reviews the case definitions of the new class of CMI disorders and evaluates the existing evidence supporting centrally mediated physiological changes (e.g., sensory hypervigilance, dysautonomia) that manifest as symptoms of pain and fatigue in some individuals experiencing chronic stressors.

RESULTS

While explanations for prolonged pain and fatigue have historically focused on mechanisms involving peripheral pathology or psychiatric explanations, ample evidences support the role of altered Central Nervous System function in accounting for symptom manifestation in CMI.

CONCLUSIONS

A model is presented that unites seemingly disparate findings across numerous investigations and provides a framework for understanding how genetics, triggering events, stressors, and early life events can affect CNS activity. Resultant symptom expression (e.g., pain and fatigue) from central dysregulation would be expected to occur in a subset of individuals in the population, including a subset of individuals with work-related upper extremity disorders. Thus when symptoms such as pain and fatigue persist beyond a reasonable period, consideration of CMI and associated assessment and interventions focused on central mechanisms may be worthwhile.

Corticosteroid injection vs. nonsteroidal antiinflammatory drug and splinting in carpal tunnel syndrome

OBJECTIVE

To compare the efficacy of local corticosteroid injection to a nonsteroidal antiinflammatory drug and splinting for the treatment of carpal tunnel syndrome.

DESIGN

This study was a prospective, unblinded, randomized clinical trial with an 8-wk follow-up. Thirty-three hands of 23 patients were randomly treated with acemetacine and splinting (group A) or with corticosteroid injection (group B). Clinical (symptom severity scale, visual analog scale, Tinel and Phalen tests) and electromyographic evaluations were performed on initial visit and after 8 wk.

RESULTS

Clinical and electromyographic parameters, which were similar at baseline, were improved in both groups after treatment. Improvement was also similar when both groups were compared at 8 wk.

CONCLUSION

Both splinting combined with the use of a nonsteroidal antiinflammatory drug and steroid injection into the carpal tunnel resulted in significant improvement in carpal tunnel syndrome.

Test-retest reliability of the Upper Extremity Questionnaire among keyboard operators

BACKGROUND

Questionnaires are often used in research among workers although few have been tested in the working population. The Upper Extremity Questionnaire is a self-administered questionnaire designed for epidemiological studies and tested among workers. This study assessed reliability of the instrument.

METHODS

A two-part assessment was conducted among 138 keyboard operators as part of a large medical survey. Test-retest reliability was analyzed using the kappa statistic, paired t-test, and intraclass correlation coefficient (ICC). Logistic regression models were used to test the effect of demographic and work-related factors on reliability.

RESULTS

The average respondent was a white woman, age 35 years, with some college education, in permanent employment with tenure of 1.4 years. Overall, reports of symptoms were stable from Round 1 to 2. Most kappa values for symptom reports were between 0.60 and 0.89. Kappa values for right and left hand diagrams were 0.57 and 0.28, respectively. Among psychosocial items, Perceived Stress and Job Dissatisfaction Scales were most reliable (ICC = 0.88); co-worker support was least reliable (ICC = 0.44).

CONCLUSION

Reliability of items on the Upper Extremity Questionnaire were generally good to excellent. Reports of symptom severity and interference with work were less stable. Demographic and work-related factors were not statistically significant in modeling the variation in reliability. Repeated use of the questionnaire with similar results suggests findings are applicable to a larger working population.