Carpal tunnel syndrome in pregnancy. A prospective study

Conduction blocks of the median nerve at the wrist in pregnancy and postpartum carpal tunnel syndromes

INTRODUCTION/AIMS

The aim in this study is to describe the clinical and electrophysiological patterns of pregnancy-related carpal tunnel syndrome (PRCTS) occurring during pregnancy or after delivery.

METHODS

Clinical, epidemiological, and electrodiagnostic (EDx) data were studied in 130 women with PRCTS onset during pregnancy (n = 80) or after delivery (n = 50). Twenty-six women with PRCTS underwent EDx analysis during pregnancy and 104 after delivery (83 within 6 months of delivery and 21 up to 24 months after pregnancy onset). PRCTS was compared with idiopathic CTS in a control group consisting of 57 age-matched women with 98 cases of CTS. Twenty-four women with PRCTS had clinical and electrophysiological follow-up after corticosteroid injection (CSI) at the wrist.

RESULTS

Clinical analysis showed a higher rate of bilateral and diurnal/permanent paraesthesia and more severe symptoms in PRCTS compared with idiopathic CTS. EDx analysis showed more severe abnormalities in classical tests and a higher rate of conduction block (CB) in PRCTS. Statistical analysis showed a strong negative correlation between the incidence and importance of CB and the time interval at which PRCTS women underwent EDx examination, between pregnancy onset and 24 months later. CSI resulted in significant clinical and EDx improvement in 22 of 24 PRCTS women, with disappearance of all motor and most sensory CBs.

DISCUSSION

The EDx pattern of PRCTS is an acute/subacute median nerve lesion at the wrist identified by many CBs. This occurs concurrently with hormonal changes, is responsible for more severe clinical symptoms and EDx data, and it explains why CSI is so effective.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery

Background  Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes  The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods  In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results  Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion  The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

Ultrasonography for carpal tunnel syndrome in pregnancy: a prospective cross-sectional study

Confirmation of carpal tunnel syndrome (CTS) diagnosis with sonographic measurement of the median nerve cross sectional area (MN-CSA) is increasing in popularity. We aimed to analyse the ultrasonography (USG) values of MN-CSA in pregnant women with and without CTS symptoms. MN-CSAs of third trimester pregnant women were measured with USG and they were asked about the presence of CTS symptoms. Symptomatic participants were assigned to the CTS group and remaining participants were assigned to the Control group. The groups were compared according to MN-CSA. Twenty-five participants were grouped in CTS group and the remaining 64 participants were grouped in Control group. The MN-CSA was higher in the CTS group (9.44 ± 2.68) than in the Control group (7.20 ± 1.99), p = .00004. Obstetricians can use USG measurement of MN-CSA to confirm CTS diagnosis and consequently can offer conservative management, which is the widely accepted treatment modality in this cohort.Impact statementWhat is already known on this subject? CTS is the most common mononeuropathy of pregnancy, with up to 62% prevalence rates. The American Association of Neuromuscular & Electrodiagnostic Medicine practice guideline for the diagnosis of CTS recommends sonographic measurement of median nerve swelling at the carpal tunnel inlet as an accurate diagnostic test (Level A).What do the results of this study add? We found that a simple sonographic measurement of median nerve cross sectional area (MN-CSA) at the wrist appears to be a convenient method to confirm clinical CTS diagnosis in pregnant women. This study offers to use USG to confirm clinical CTS diagnosis in third trimester pregnant women before delivery.What are the implications of these findings for clinical practice and/or further research? This study will help to raise awareness of obstetricians about CTS during pregnancy. USG can be an effective first-line confirmatory test for CTS diagnosis in the pregnant population, but further research is necessary to determine a clear cut-off value for MN-CSA. We advise obstetricians to use sonographic measurement of MN-CSA in pregnant women with typical CTS symptoms, which will increase uniformity for consensus development. Obstetricians can offer advice for conservative management of CTS during pregnancy, which is the widely accepted treatment in this cohort.

Carpal Tunnel Syndrome and Hand-Arm Vibration: A Swedish National Registry Case-Control Study

OBJECTIVE

To investigate the increased risk for carpal tunnel syndrome (CTS) in men and women with hand-arm vibration (HAV) exposure.

DESIGN

Case-control study of CTS where 4396 cases was obtained from National Outpatient Register between 2005 through 2016. Cases were matched to controls and exposure was estimated using a job exposure matrix.

RESULTS

Exposure to HAV increased the risk of CTS with an OR of 1.61 (95% CI 1.46-1.77). The risk was highest in men <30 years of age and among women <30 years no increased risk was observed. The risk increased with a mean year exposure above 2.5 m/s2 to OR 1.84 (95% CI 1.38-2.46).

CONCLUSIONS

HAV exposure increase the risk of CTS in both genders, with highest risk increase in younger men. This emphasize identification of HAV exposure in patients with CTS.

Neuromuscular disorders in pregnancy

Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

The Natural History of Carpal Tunnel Syndrome in Lactation

In a retrospective postal study of 27 women who have developed carpal tunnel syndrome (CTS) in the puerperium, the condition was found to affect predominantly elderly primiparous women (mean age 31.5 years). The condition was associated with breastfeeding in 24 women. The three who did not breastfeed had less severe symptoms which resolved within one month of onset. The symptoms developed a mean of 3.5 weeks following delivery, lasted 6.5 months and started to resolve within 14 days of weaning. Symptomatic treatments with either splint-age, diuretics, non-steroidal anti-inflammatory drugs or steroid injections provided some benefit. Two patients required surgical decompression. All patients were symptom-free by one year.

Carpal tunnel syndrome in pregnancy

During pregnancy, hormonal fluctuations, fluid shifts, and musculoskeletal changes predispose women to carpal tunnel syndrome. While the clinical presentation is similar to other patients, the history obtained must include information regarding the pregnancy itself. Currently, the indication for electrodiagnostic testing is not clearly defined. Given that symptoms often improve with conservative treatment and abate after delivery, EMG/NCV testing can often be avoided. However, if symptoms are severe or persist, carpal tunnel release is indicated and is considered a safe procedure for both mother and fetus.

Rheumatologic manifestations of pregnancy

Pregnancy, whether normal or complicated, induces change in nearly every system of the body. Because most rheumatologic disorders are multisystemic and often affect young women, it may be difficult to differentiate pregnancy-related change from new onset or exacerbation of rheumatic disease. Familiarity with common manifestations of pregnancy is important in evaluating young women of childbearing age,whether or not they have known rheumatologic disease. Presentation of new connective tissue disease during pregnancy is often associated with poorer prognosis, so it is especially important to distinguish between pregnancy-induced change and true autoimmune inflammation requiring prompt and aggressive therapy.

Prevalence and clinical features of arthralgia/arthritis in healthy pregnant women

The authors prospectively investigated 155 pregnant women, without a history of rheumatic disease who visited the Department of Obstetrics and Gynecology for routine antenatal care, to evaluate the prevalences and clinical features of arthralgia and arthritis in healthy pregnant women. Mean of the 155 subjects' ages was 31.8 +/- 3.8 (years, +/-SD). Arthralgia was found in 26 (16.7%) and arthritis in 15 (9.6%) pregnant women. Arthralgia or arthritis developed in the third trimester (28-40 weeks of gestation), except in one case (16 weeks of gestation). Most commonly involved joints were the proximal interphalangeal (n = 19, 12.2%). Rheumatoid factor and antinuclear antibody were negative in patients with arthritis. Ten women (6.8%) had persistent arthralgia for over 6 weeks, post-delivery. Four of them were followed up at Rheumatology Clinic and were diagnosed as having spondyloarthropathy (1), or unspecified arthralgia (3). In conclusion, arthralgia is common during pregnancy and most frequent in proximal interphalangeal joints.

Carpal tunnel syndrome

Carpal tunnel syndrome is the most common compressive neuropathy of the upper extremity. As a result of median nerve compression, the patient reports pain, weakness, and paresthesias in the hand and digits. The etiology of this condition is multifactorial; anatomic, systemic, and occupational factors have all been implicated. The diagnosis is based on the patient history and physical examination and is confirmed by electrodiagnostic testing. Treatment methods range from observation and splinting, to cortisone injection and splinting, to surgical intervention. Both nonsurgical and surgical management provide symptom relief in most patients. The results of open and endoscopic surgery essentially are equivalent at 3 months; the superiority of one technique over the other has yet to be established.

Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum

Gender-specific care of musculoskeletal impairments is increasingly important in women's health. This is most relevant and of paramount importance as it relates to identification and management of musculoskeletal and peripheral neurologic disorders of pregnancy, delivery, and postpartum. The specific anatomic and physiologic changes of pregnancy predispose to a specific set of diagnoses. Virtually all women experience some degree of musculoskeletal discomfort during pregnancy. This article provides an overview of the more common pregnancy-related musculoskeletal conditions and includes a discussion of epidemiology, risk factors, diagnosis, prognosis, and management.

Median nerve: neurophysiological parameters in third trimester of pregnancy

An examination of neurophysiologic features of median nerve in third trimester of regularly controlled normal risk pregnancies is performed at the Department of Neurophysiology of Primary Health Centre in Tuzla during January / April 2006. Examined group consisted of 40 young females in third trimester of pregnancy, and average age of 25,6 +/- 4,9 years. Control group consisted of young healthy females with average age of 31,1 +/- 4,4 years. Symptoms and signs of carpal tunnel sy. (CST) had 12 patients, but diagnosis is neurophysiologically confirmed in 9 (75%) patients. In group of pregnant females without symptoms 3 (10,7%) patients showed neurophysiologic evidence of CTS. Sensory velocity of right median nerve was significantly lower in pregnant group of patients (p=0,002), but area of sensory potentials on both sides were lower in pregnant group (p<0,0001). Area of CMAP of right median nerve was significantly lower in pregnant group (p=0,0003). Significant differences in CTS group compared with control group were in sensory velocities of median nerve (left median nerve p=0,0007, right p<0,0001), and area of SNAP of both sides (left p<0,0001, right p=0,0001), but area of CMAP right (p=0,0003). In CTS group 7 females had unilateral and 5 had bilateral neurophysiological changes. Our conclusion is that neurophysiological parameters of median nerve in third trimester of pregnancy are changed mainly due to high prevalence of CTS that might disturb quality of life and have psychological and physical implications on future mother. Hence, it is necessary to, continuously, pay enough attention in prevention or treatment of mentioned syndrome in this population group.

Prospective study of positive factors for improvement of carpal tunnel syndrome in pregnant women

The aims of this study were to evaluate differences between women with carpal tunnel syndrome (CTS) and symptom onset in pregnancy (pregnancy cohort) and women with idiopathic CTS (control cohort) and to report changes in symptoms assessed by the Levine Boston Questionnaire (BQ) administered by phone 3 years after diagnosis. Forty-five pregnant women with CTS (mean age 32 +/- 3.9 years) and 90 age-matched women with idiopathic CTS were consecutively enrolled. Diagnosis was based on clinical findings and abnormal transcarpal median nerve conduction. Univariate analysis showed that the pregnancy cohort had a shorter duration of symptoms, higher frequency of bilateral symptoms and non-blue-collar workers, and lower clinical and electrophysiological severity evaluated by ordinal scales and BQ scores. Multivariate analysis showed that the pregnancy cohort had a probability of improvement of symptoms 3-4 times greater than the control cohort. The need for further treatment depended on BQ functional score; 50% of pregnant women had tolerable CTS symptoms and 85% did not require further treatment 3 years after diagnosis, whereas 72% of women in the control cohort did not require long-term therapy. The probability of need for CTS treatment did not depend on the cohort, but only on the severity of hand disability.

Impact of physical activity during pregnancy and postpartum on chronic disease risk

Research over the past 20 years has focused on the safety of physical activity during pregnancy. Guidelines for health care providers and pregnant/postpartum women have been developed from the results of these studies. The overwhelming results of most studies have shown few negative effects on the pregnancy of a healthy gravida, but rather, be beneficial to the maternal-fetal unit. Recently, researchers have begun to consider the role of maternal physical activity in a more traditional chronic disease prevention model, for both mother and offspring. To address the key issues related to the role of physical activity during pregnancy and postpartum on chronic disease risk, the American College of Sports Medicine convened a Scientific Roundtable at Michigan State University in East Lansing, MI. Topics included preeclampsia, gestational diabetes, breastfeeding and weight loss, musculoskeletal disorders, mental health, and offspring health and development.

Carpal tunnel syndrome during pregnancy

Carpal tunnel syndrome is common during pregnancy. The symptoms usually disappear after delivery, but how soon has not been established. Thirty pregnant women with the syndrome reported to us the degree of pain in their hands every week before, and daily after, delivery. Pain was graded on a scale from 0 (none) to 10 (worst imaginable). The prevalence of the syndrome during pregnancy was about 2%. The mean pain score was 5.6 (SD 2.0) at referral and this was reduced by 1.2 (SD 2.2) after wearing an orthosis for a week. After this, it stayed almost unchanged until delivery. The score fell by half during the first week after parturition and by half again during the next week. The reduction in score was strongly correlated with loss of the weight gained during pregnancy (r = 0.97; p <0.001). Although symptoms may persist for some weeks after delivery, the severity declines quickly.

Neuromuscular disorders in pregnancy

Many neuromuscular conditions occur more frequently during pregnancy and include carpal tunnel syndrome, Bell's palsy, lumbosacral radiculopathy, meralgia paresthetica, intercostal neuralgia, and other compression neuropathies. Preexisting or coincident neuromuscular diseases, including demyelinating polyneuropathies, inflammatory muscle disease, myasthenia gravis, and inherited nerve and muscle disease present specific problems during pregnancy. We review management of neuromuscular disorders during pregnancy, labor, delivery, and the early postpartum period.

Multicenter study on carpal tunnel syndrome and pregnancy incidence and natural course

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS and to assess the course of carpal tunnel syndrome after pregnancy.

METHODS

During 2000-2001, the Italian CTS study group in 7 Italian centers studied the occurrence of CTS in women during the last period of pregnancy. The group enrolled and followed-up (10-15 months) 63 women during and after pregnancy with multiple measurements of CTS. In addition to the physician-centered and neurophysiologic traditional evaluations, a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment was adopted.

RESULTS

CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Comparison of baseline and follow-up data showed a significant spontaneous improvement of patient-oriented and neurophysiologic measurements. Nevertheless, about half of women with CTS during pregnancy still complained of CTS symptoms one year after delivery.

CONCLUSIONS

Our observations confirmed the frequent occurrence of CTS in pregnancy. At follow-up we observed that most CTS cases improve spontaneously without treatment but only in half of women CTS symptoms disappeared one year after delivery.

Musculoskeletal aspects of pregnancy

Sex-specific care of musculoskeletal impairments is an increasingly important topic in women's health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.

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.

Gender differences in prevalence of upper extremity musculoskeletal disorders

A literature review was conducted on the current literature base to determine the strength of support for the hypothesis that women experience higher prevalences of upper extremity musculoskeletal disorders (UEMSDs) than men. Fifty-six articles were reviewed for data on gender differences in frequency, incidence or prevalence rates for musculoskeletal disorders specific to the upper extremities. These articles included both general and working populations. The majority of the studies showed that women had significantly higher incidences of various types of UEMSDs than men. This trend was consistently observed in studies based on self-report or plant/workers compensation records, with and without physical examination, and after adjusting for potential confounders such as age and physical work factors. With men as the referent, the odds ratio (OR) or prevalence ratio (PR) for UEMSDs ranged from 0.85 to 10.05 for self report. For self report combined with physical examination, the OR/PR ranged from 0.66 to 11.4. The OR/PR for carpal tunnel syndrome (CTS) ranged from 0.6 to 2.87 with confounder adjustment. These findings suggest that women do have significantly higher prevalences than men for many types of UEMSDs, even after controlling for the type of data source and confounders such as age or work factors.

Peripheral Neuropathy

This chapter focuses on peripheral neuropathy, which is the third or fourth most common neurologic disorder, even among the elderly. It begins with a description of the classification system for peripheral neuropathies. Because the underlying etiology or precipitating events of peripheral neuropathy are identifiable for the majority of affected individuals, epidemiologic research has largely focused on descriptive studies of disease frequency or on identifying the factors that modify the influence of the already existing risk factors. Three of the most common neuropathies are covered in detail: diabetic neuropathy, carpal tunnel syndrome, and Guillain–Barré syndrome. Each of these conditions is discussed in terms of distribution and risk factors, and is concluded with a discussion of future research directions to address unanswered questions. The chapter emphasizes methodologic approaches that that could be employed to improve the rigor of studies of these conditions.

Serial studies of carpal tunnel syndrome during and after pregnancy

Carpal tunnel syndrome (CTS) is a frequent and underdiagnosed complication of pregnancy. Conservative therapies are common initial measures, but data on the course of improvement are limited. We report a case of pregnancy-associated CTS with unusually detailed serial electrophysiologic studies before and after wrist splinting. Physiologic measures reached a nadir and then rapidly improved following conservative therapy, paralleling clinical improvement. Responses took between 6 and 20 months postpartum to approach baseline values.

Medical history of carpal tunnel syndrome

The anatomical configuration of the carpal tunnel is that of an inelastic channel. Consequently, any increase in its volume or alteration in shape will usually result in a significant increase in interstitial pressure. At a pressure threshold of 20 mm Hg to 30 mm Hg, epineurial blood flow is compromised. When that pressure is sustained, the symptoms and physical findings associated with CTS appear. Typically, patients present with intermittent pain and paresthesias in all or part of the median nerve distribution of their hand(s). As weeks and months pass, symptoms progressively increase in frequency and severity. Eventually, thenar muscle weakness develops that initially manifests itself as "fatigue," or "tiredness." The progressive increase in symptoms and physical findings, usually accompanied by a progressive deterioration in electrodiagnostic studies, facilitates the classification of the condition into early, intermediate, and advanced stages. The increase in interstitial pressure in the carpal tunnel is in the vast majority of cases idiopathic (spontaneous). It can also be caused by a myriad of other conditions that can be classified into three other categories: intrinsic factors that increase the volume of the tunnel (outside and inside the nerve), extrinsic factors that alter the contour of the tunnel, and repetitive/overuse conditions. In addition, there is another category of neuropathic factors that affect the nerve without increasing interstitial pressure. In rare situations CTS can present as an acute problem. Far less common than the chronic form of the condition, it can follow acute wrist trauma, rheumatologic disorders, hemorrhagic problems, vascular disorders affecting a patent median artery, and high pressure injection injuries. Prompt recognition is important, followed in most cases by urgent surgical decompression of the median nerve.

Industrial medicine and acute musculoskeletal rehabilitation. 6. Occupational health for special populations

This self-directed learning module highlights work-related injuries in specific patient populations that the physiatrist may encounter. This chapter focuses on evaluating work-related injuries in the aging and disabled population. Specific problems encountered in pregnant working women and the dental profession are also summarized. Specific biologic and/or environmental factors as they relate to workers in the specific populations are reviewed. Strategies for evaluation, rehabilitation, and health care management of these workers are discussed.

OVERALL ARTICLE OBJECTIVES

(a) To be aware of specific needs and environmental factors for disabled, aging, pregnant, and dental workers and (b) to identify what may precipitate injury for disabled, aging, pregnant, and dental workers.

When exactly can carpal tunnel syndrome be considered work-related?

BACKGROUND

Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most frequently encountered peripheral entrapment neuropathy. Whilst rates of all other work-related conditions have declined, the number of work-related musculoskeletal disorders (which include CTS) has not changed for the past 9 years in the USA. Median days off work are also highest for CTS: 27 compared to 20 for fractures and 18 for amputations. This results in enormous Workers Compensation and other costs to the community. Awareness of CTS as a disorder associated with repeated trauma at work is now so widespread amongst workers that many have diagnosed themselves before being medically assessed, often by means of the Internet. Surprisingly, however, a definite causal relationship has not yet been established for most occupations. Although the quality of research in this area is generally poor, CTS research studies are being used as the basis for acceptance of Workers Compensation claims, substantial expensive ergonomic workplace change and even workplace closures. The fact that the incidence of work-related musculoskeletal disorders has not changed despite these latter measures would suggest that a causal relationship is not proven and that some resources are being misdirected in CTS prevention and treatment.

METHOD

A literature review of 64 articles on CTS was conducted. This included those articles most frequently cited as demonstrating the relationship between CTS and work.

RESULTS

Primary risk factors in the development of CTS are: being a woman of menopausal age, obesity or lack of fitness, diabetes or having a family history of diabetes, osteoarthritis of the carpometacarpal joint of the thumb, smoking, and lifetime alcohol intake. In most cases, work acts as the 'last straw' in CTS causation.

CONCLUSION

Except in the case of work that involves very cold temperatures (possibly in conjunction with load and repetition) such as butchery, work is less likely than demographic and disease-related variables to cause CTS. To label other types of work as having caused CTS, therefore, would result in inappropriate allocation of resources. It would also relieve individuals of the responsibility of addressing correctable lifestyle factors and treatable illnesses such as obesity, diabetes, smoking and increased alcohol intake which may have contributed to their CTS more that their work. This results in both avoidable long-term health effects and ongoing costs to the community.

Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises

OBJECTIVE

To assess the effect of nerve and tendon gliding exercises in carpal tunnel syndrome.

DESIGN

The study was a prospective, randomized, before-and-after treatment trial. A total of 28 patients with the diagnosis of carpal tunnel syndrome in 36 hands were randomly assigned to two groups. A custom made neutral volar wrist splint was given to group 1 and group 2. The patients were instructed to wear the splints all night and during the day as much as possible for 4 wk. The patients in group 2 were also instructed to perform series of nerve and tendon gliding exercises in addition to the splint treatment. Patients were evaluated with clinical parameters, a functional status scale, and a symptom severity scale.

RESULTS

At the end of treatment, statistically significant improvement was obtained in all parameters in both groups. The improvement in group 2 was slightly greater, but the difference between the groups was not significant, except for the lateral pinch strength value. Patient satisfaction was investigated during the follow-up period, ranging from 5 to 11 mo, with a mean of 8 mo. A total of 72% of the patients in group 1 and 93% of the patients in group 2 reported good or excellent results. The difference between the two groups was not statistically significant.

CONCLUSION

Although the results in group 2 were better than group 1, the difference was not statistically significant. Further investigations are required to establish the role of nerve and tendon gliding exercises in the treatment of carpal tunnel syndrome.

Symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS.

METHODS

During 2000, the Italian CTS study group focussed on the occurrence of CTS in women during the final stages of pregnancy, enrolled in 7 Italian centers. In addition to the physician-centered and neurophysiologic traditional evaluations, we used a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment.

RESULTS

In our study, CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Our study provides evidence, reported here for the first time, of a correlation between edema and neurophysiological picture. Similarly, our study provides a correlation between validated patient-oriented measurement and edema. Moreover, a significant correlation between a negative trend (subjectively assessed) and smoking and alcohol consumption was observed.

CONCLUSIONS

Our observations confirm that the edema of the tissues in the carpal tunnel could induce a mechanical compression of the nerve. Moreover, our data suggest that smoking and alcohol consumption have a negative role in the evolution of the syndrome probably due to impairment of the microcirculation.

The effects of pregnancy on the musculoskeletal system

During pregnancy the female body undergoes many hormonal and anatomic changes that affect the musculoskeletal system. These changes may cause various musculoskeletal complaints, predispose to injury, or alter the course of preexisting conditions. The changes of pregnancy should be taken into account when counseling women who wish to exercise through their pregnancy. Treatment of musculoskeletal complaints during pregnancy must include the potential effects on mother and fetus.

Histological appearances in post-partum de Quervain's disease

Six patients who developed de Quervain's disease during pregnancy or within 12 months of childbirth were treated surgically. Histopathological examination of the tendon sheaths using alcian blue stain showed that myxoid degeneration was responsible for the thickening observed in the sheath. Characteristic intramural deposits of mucopolysaccharides were present, predominantly in the subsynovial region. Acute or chronic inflammatory changes were not seen. These findings were the same as those described in patients with de Quervain's disease unrelated to pregnancy or childbirth.

Clinical evaluation and management of work-related carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a clinical entity characterized by pain, paresthesias, and numbness in the distribution of the median nerve with weakness and atrophy of the thenar muscles in advanced cases. It is universally accepted that CTS is the clinical concomitant of compression of the median nerve as it passes through the carpal canal. It is reported to be the most common of the entrapment neuropathies. Increasing evidence suggests that occupational factors, including forceful use of the hands, repetitive use of the hands, and hand-arm vibration, are etiologic for CTS. When occurring as a result of occupational exposures, the term "work-related carpal tunnel syndrome" is applied. Clinical approaches to the diagnosis and treatment of work-related CTS are described in this paper. Particular attention is paid to the clinical features and pathophysiology of CTS, the epidemiology of work-related CTS, ascertainment of work-relatedness in the clinical setting, treatment including both work and non-work interventions, and control of occupational ergonomic risk factors that may contribute to the illness.

Pregnancy-related carpal tunnel syndrome

Clinical and electrophysiological features were studied in 52 cases of carpal tunnel syndrome (CTS) associated with 30 pregnancies. The duration of symptoms was less than 3 months before electrodiagnosis was performed. This study revealed a higher incidence of persistent, painful diurnal symptoms in pregnancy-related CTS (PRCTS) than in idiopathic CTS. PRCTS usually occurs for the first time (de novo) (24/30 cases), in primigravidas (15 cases) as well as multigravidas. The onset of symptoms was in the first or second trimester in 11 women, the third trimester in 12 women, or the post-partum period in seven women. Nerve conduction studies demonstrated evidence of an acute median nerve lesion at the wrist with motor and/or sensory conduction blocks in 20/30 women and severe denervation signs in five women.

Complications in the treatment of carpal tunnel syndrome

Complications may result from every facet of the management of carpal tunnel syndrome. The authors review the common errors in diagnosis, nonoperative management, and operative treatment, with emphasis on prevention and resolution of complications. In general, surgeons can minimize complications by taking a thorough patient history, performing a comprehensive physical examination, and possessing a precise knowledge of the appropriate anatomy. Endoscopic techniques appear to offer some advantage over conventional open techniques with regard to the patient's postoperative incision pain, preservation of grip strength, and time to return to work; however, these advantages may be potentially negated by the risk of injury to neurovascular structures and tendons.

Carpal tunnel syndrome in pregnancy: indications for early surgery

The incidence of carpal tunnel syndrome is increased during pregnancy. The common conventional therapeutic approach is conservative, as symptoms usually abate after delivery. We describe our experience with 65 hands (50 patients), who were treated initially by a conservative approach and later, when required, surgically. We found that all patients who (i) had either started having CTS symptoms during the first two trimesters or had previous history of CTS symptoms; and (ii) had both a positive Phalen test within less than 30 seconds and abnormal two point discrimination at the finger tips ( > 6 mm), were eventually operated upon, either during or after pregnancy, as conservative measures failed. We therefore recommend consideration of an early surgical approach in patients fulfilling these criteria.

Splinting for symptoms of carpal tunnel syndrome during pregnancy

OBJECTIVE

To determine whether splints are effective in decreasing symptoms of carpal tunnel syndrome during pregnancy.

METHODS

Case series at a military hospital of 82 pregnant women who had symptoms of carpal tunnel syndrome (135 hands). The author compared the ratings of eight subjective symptoms (tingling, numbness, pain, weakness, wakes you up, drops things, swelling, and stiffness) and grip (Jamar) and pinch (two-point, three-jaw, and key) strengths at the time of referral and 1 week after splinting (polyform volar splint with the wrist in 10 to 15 degrees of extension). Forty-eight women (82 hands) returned 1 month postpartum for reassessment. Grip and pinch strengths of an additional 26 women who had not had problems with their hands during pregnancy were measured 1 month postpartum.

RESULTS

One week after splinting, there was an average increase of 5.4 pounds in grip strength and over 1 pound in each type of pinch strength (p < 0.0001). There was a decrease in each of the eight symptoms (range, -0.9 to -1.6; scale of 5). At 1 month postpartum, symptoms had resolved completely for 76% of the subjects (weakness had resolved for 76% and wakes you up for 93%). Strength was improved, but was not normal. However, the women who had not had hand problems during pregnancy did have normal strengths.

CONCLUSIONS

Splinting is a noninvasive method for helping to decrease the uncomfortable symptoms of carpal tunnel syndrome during pregnancy.