Sleep-related disorders in carpal tunnel syndrome

Carpal tunnel syndrome and sleep, a systematic review and meta-analysis

BACKGROUND

The most common symptom and reason patients seek treatment for carpal tunnel syndrome is lack of sleep. Our purpose was to determine how much sleep-related symptoms of carpal tunnel syndrome improve after carpal tunnel release using validated patient-reported outcome measures (PROMs) and objective sleep data as primary measures of interest.

METHODS

A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMed, Cochrane, and ClinicalTrials.gov. Only interventional clinical trials that examined primary outcome measures of interest were included. Patient-reported outcome measures underwent meta-analysis to determine how much scores improved following carpal tunnel release.

RESULTS

The Pittsburgh Sleep Quality Index improved significantly after carpal tunnel release, by 4.43 points and 6.02 points at 1-3 and 6-12 months postoperatively, respectively, and continued to improve up to 2 years. Improvement on the Insomnia Severity Index after carpal tunnel release was also significant, with improvement up to 1 year postoperatively, by 8.54 points and 9.05 points at 1-3 and 6-12 months, respectively. Insomnia Severity Index scores improved significantly after splinting as well.

CONCLUSIONS

The present meta-analysis determined to what extent patients can expect their sleep to improve after operative and non-operative intervention, as measured by various patient-reported outcome measures that assess sleep. The Pittsburgh Sleep Quality Index and Insomnia Severity Index correlated very well between studies and across hundreds of patients with carpal tunnel syndrome. Data are lacking to define the minimal clinically important difference and assess whether patients achieve a minimal clinically important difference for sleep questionnaires; more information on this topic is needed.

LEVEL OF EVIDENCE

III.

The Influence of Wound Closure Techniques after Surgical Decompression in Patients with Carpal Tunnel Syndrome on Sleep Disturbance and Life Quality: A Prospective Comparison of Surgical Techniques

BACKGROUND

The compression of the median nerve within the carpal tunnel is the cause of carpal tunnel syndrome (CTS). Surgical decompression is successful in improving sleep and quality of life, but the effect of tissue adhesives as a material for wound closure has not been investigated. The objective of the study was to evaluate sleep disorders and health-related life quality by comparing two methods for wound closure after carpal surgery in participants who were randomized to receive tissue adhesives or transcutaneous sutures.

METHODS

The subjects, aged 61.56 ± 12.03 years, were randomized to receive either tissue adhesives (n = 50) or suture-based wound closure (n = 50) using the Glubran Tiss 2® skin adhesive after subcutaneous running sutures. The outcomes were assessed during the 12-month postoperative follow-up. The Pittsburgh Sleep Quality Index (PQSI) and Insomnia Severity Scale (ISI) were used for the sleep disturbance assessment, and for the health-related quality of life assessment, the total SF-36 (36-Item Short Form Survey) was used.

RESULTS

The PQSI, ISI, and SF-36 were not statistically different between groups during the follow-up, except in the ISI score two weeks after surgery (9.40 ± 1.18 in the tissue adhesive group vs. 9.96 ± 1.09 in the suture-based group, p = 0.008). The PQSI, ISI, and SF-36 scores for all the subjects and groups were persistently improved at all the follow-up intervals after surgery. The total SF-36 score increased 12 months after surgery (49.84 ± 5.85 vs. 82.46 ± 5.68, p < 0.001).

CONCLUSIONS

Cyanoacrylate-based adhesion material can be used for wound closure after open CTS decompression as a standard transcutaneous suture, and both techniques equally lead to improved sleep and life quality. The possible advantages of tissue adhesives include a faster reduction in the ISI.

Outcomes of Patients with and without Nighttime Awakening Symptoms After Carpal Tunnel Release

Background: A common symptom associated with carpal tunnel syndrome (CTS) is nighttime awakening (NTA), which typically resolves quickly following carpal tunnel release (CTR). The early improvement in those who do not wake-up at night is less clear. This study investigates outcomes following CTR in patients with preoperative NTA symptoms compared to those without at 6 weeks and 3 months. Methods: Patients diagnosed with CTS who proceeded with CTR and agreed to participate in a prospective study completed the Boston Carpal Tunnel Questionnaire (BCTQ) and Michigan Hand Outcome Questionnaire (MHQ) at their preoperative appointment and 6-week and 3-month follow-ups. We compared outcomes between time points for improvement. Results: Of 45 patients, 37 patients with NTA had BCTQ scores of 3.09, 1.86, and 1.50 at preoperative, 6-week, and 3-month follow-up, respectively, and MHQ scores of 56.68, 74.91, and 81.01. NTA patients had improvement of both BCTQ and MHQ at 6 weeks and 3 months. Nonawakening patients had BCTQ scores of 2.58, 2.15, and 1.86 and MHQ scores of 57.94, 62.71, and 72.16, respectively. This cohort did not have significant improvement of MHQ at 6 weeks, but did at 3 months. The BCTQ severity scores in the nonawakening patients had significant improvement at both 6 weeks and 3 months, but did not at either time point for the BCTQ functionality scores. At 6 weeks, 2/37 patients continued to have NTA and no patients had NTA at 3 months. Conclusion: Patients with CTS and NTA symptoms had significant improvements in BCTQ and MHQ at 6 weeks and 3 months. Patients who did not awaken at night did not have significant improvements when evaluating BCTQ functional results, although they did improve when analyzing for BCTQ for symptom severity and MHQ, but not to the same level as those that do awaken and improvement was slower based on MHQ scores.

Improvement of Sleep Quality after Surgical Decompression in Carpal Tunnel Syndrome

Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy which can cause severe sleep disturbance. Carpal tunnel release (CTR) is a choice for severe cases, which has shown to improve sleep quality, but the available evidence is limited. This study aimed to investigate the impact of CTR on sleep quality and hand symptoms and functions in patients with CTS.

Methods This was a prospective study in 2019–2020 on patients with CTS and poor sleep quality undergoing CTR. Patients were evaluated before and at 1, 3, and 12 months after CTR by the Pittsburgh sleep quality index (PSQI) and Boston carpal tunnel syndrome questionnaires.

Results There were 33 patients with 27 females (82%) and a median age of 51 years. The median time of CTS diagnosis and having sleep disorder before CTR were 12 and 6 months, respectively. The outcomes significantly improved after CTR, with the median PSQI and Boston symptom and function scores reduced from 12, 33, and 23 before CTR to 9, 14, and 11 at 1 month; 7, 13, and 9 at 3 months; and 1, 11, and 8 at 12 months postoperatively, respectively. The correlations between the PSQI and Boston symptom and function scores were > 0.6 at all time-points.

Conclusions Surgical decompression significantly improves sleep quality and the hand symptoms and functions in patients with CTS. Long-term evaluations are lacking and thus are required in future studies.

Association of Sleep and Hand Function in People With Carpal Tunnel Syndrome

This study examined whether sleep quality is associated with hand function above and beyond what can be explained by the effect of pain and carpal tunnel syndrome (CTS) severity on hand function in clients with CTS. The sample included 53 adults ages 30-86 yr. The Manual Ability Measure-20, Pittsburgh Sleep Quality Index, visual analog scale for pain, and electromyography for CTS diagnosis and severity level were used to measure outcomes. Sleep quality was significantly associated with manual ability after controlling for CTS severity and pain. In CTS care, attention to sleep is significant because it may promote hand function.

Relationship between electrodiagnostic findings and sleep disturbance in carpal tunnel syndrome: A controlled objective and subjective study

Objective

This controlled objective and subjective study aimed to evaluate the relationship between insomnia severity and electrodiagnostic findings in patients with carpal tunnel syndrome (CTS).

Methods

Twenty-one patients with an established clinical and electrodiagnostic diagnosis of CTS before surgery were included. Sleep characteristics were monitored objectively over 4 to 9 nights by means of actigraphy. On the following morning, participants completed a sleep log that conveyed their subjective impressions of how they had slept. All patients also completed the Insomnia Severity Index questionnaire. The correlation of these findings with patients’ motor latency and sensory latency was evaluated using Spearman correlation analysis.

Results

We found no correlation between sensory or motor latencies and all sleep measures.

Conclusion

Electrodiagnostic findings and sleep severity in patients with CTS appear to be independent measures, and they do not correlate with each other.

Physiological Nocturnal Hand Swelling: A Prospective Evaluation of Healthy Volunteers

PURPOSE

The goal of this study was to quantify the variation in daily volume that is expected in the normal hand. Our hypothesis is that hand swelling occurs overnight.

METHODS

Hand volume measurements of 36 healthy volunteers with no hand pathology were taken daily at 8 am, 2 pm, and 8 pm over a 3-day period. Participants were blinded to the objective of the study. Statistical analysis was performed to determine if any of the time points or patient demographics were associated with an increased change in hand volume.

RESULTS

Thirty-six healthy volunteers with mean age of 40.9 years and mean body mass index of 24.2 kg/m² were enrolled. Twenty-one volunteers were men and 15 were women. Three of the volunteers were left-handed. The key finding from this study was that the change in hand volume overnight (8 pm-8 am) is significantly different than the change in hand volume from 8 am to 2 pm and from 2 pm to 8 pm. Although there was a significant reduction in hand volume from 8 am to 2 pm, the further reduction in hand volume from 2 pm to 8 pm was not significant after correcting for the number of post hoc comparisons. In addition, demographic variables such as age, body mass index, and sex did not influence changes in hand volume.

CONCLUSIONS

Physiological hand swelling occurs overnight in individuals without active or prior hand pathology. Hand volume then decreases over the course of the day in these same individuals.

CLINICAL RELEVANCE

By investigating the changes in hand volume that occur overnight and throughout the day, we gain a better understanding of the temporal relationship between hand swelling and symptoms of chronic hand disease.

The effectiveness of splinting and surgery on sleep disturbance in carpal tunnel syndrome

This controlled prospective study assessed the effectiveness of night splinting compared with non-splinting and surgery for severity of insomnia in patients with carpal tunnel syndrome. Sleep characteristics were observed for several days without a brace, with a brace and after surgery. The sleep measurements included the use of an actigraph worn on the wrist during night, a 'sleep log' that conveyed subjective impressions as to how the patient had slept and a short insomnia instrument, the Insomnia Severity Index. The Insomnia Severity Index scores showed that a night splint significantly improved insomnia symptoms compared with no splinting, and surgery significantly improved insomnia symptoms compared with splinting. The sleep log scores showed that the sleep quality and the number of awakenings when a splint was not worn were significantly different from the scores with the splint and the scores after surgery but showed no differences between splint and surgery. The actigraph did not show any significant differences between the treatment methods.

LEVEL OF EVIDENCE

III.

Prospective Evaluation of Sleep Improvement Following Carpal Tunnel Release Surgery

PURPOSE

Sleep disturbance due to nighttime awakening is a well-documented symptom of carpal tunnel syndrome. While relief of nighttime waking following carpal tunnel release (CTR) has been demonstrated, the effect of CTR on overall sleep quality has not been fully investigated. We hypothesized that CTR would result in significant improvement in overall sleep quality as well as patients' overall satisfaction with their sleep habits.

METHODS

Cases of carpal tunnel syndrome with positive nerve studies, and treated with CTR, were prospectively enrolled. Demographic data, electromyography (EMG) severity, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and Insomnia Severity Index (ISI) scale data were collected.

RESULTS

A total of 398 patients were enrolled, with 99% available at 2 weeks and 64% available at 3-month final follow-up. At final follow-up, average Quick Disabilities of the Arm, Shoulder, and Hand score improved significantly from the preoperative value. Average ISI score on all 7 sleep categories on the survey improved significantly from before surgery to the first postoperative visit. However, the total ISI score did not further improve significantly between the 2-week and the 3-month postoperative visits. The ISI score improvements did not correlate with EMG severity.

CONCLUSIONS

Patients undergoing CTR demonstrated significant improvement in mean scores for 7 aspects of sleep quality. Sleep improvement was unrelated to preoperative EMG severity and was experienced within 2 weeks of surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Clinical manual assessment of the wrist

Although hand therapists often evaluate patients with wrist pain, novice and experienced clinicians alike would benefit from a systematic assessment to efficiently identify the source of dysfunction and initiate an appropriate treatment plan. This article proposes a systematic approach for clinical evaluation of the wrist by describing the basic clinical examination (BCE) process and interpreting the findings in terms of common pathology. The BCE will enable the hand therapist to identify conditions that are contraindicated for conservative care and require further physician intervention, determine a working diagnosis for most musculoskeletal problems, and determine the appropriate extra tests to confirm the working diagnosis and/or rule out differential diagnoses. By combining findings from the patient's history, BCE, and special testing, hand therapists can efficiently determine the underlying pathology and provide appropriate treatment that can optimize clinical outcomes.

Evaluation of Factors Associated with Night Pain in Women Undergoing Carpal Tunnel Release

BACKGROUND

Night pain has important diagnostic and prognostic values in patients with carpal tunnel syndrome (CTS). We aimed to determine whether night pain is associated with certain patient characteristics in female patients undergoing carpal tunnel release.

METHODS

We recruited 75 women with the mean age of 54 years who were scheduled for carpal tunnel release. Diagnosis of CTS was made based on both the clinical symptoms and the results of electrophysiologic studies. Patient characteristics investigated as factors potentially associated with night pain were: age, body mass index (BMI), symptom duration, comorbidities such as diabetes mellitus (DM) and thyroid disease, electrophysiologic severity of CTS, and sleep position. We conducted a logistic regression analysis to examine the relationships between the presence of night pain and the different patients' demographic and clinical variables.

RESULTS

Absence of night pain was associated with increased age (odds ratio (OR), 0.918, 95% confidence interval (CI), 0.851 to 0.99) and presence of DM (OR, 0.196; 95% CI, 0.046 to 0.835). The other variables assessed were not found to be associated with presence or absence of night pain.

CONCLUSIONS

This study found that in women undergoing carpal tunnel release, older patients or those having DM are slightly less likely to have night pain. As night pain is an important prognostic factor for CTS, further studies are warranted to determine whether the absence of night pain could affect outcome assessment of CTS in the elderly or patients with DM.

The negative effect of carpal tunnel syndrome on sleep quality

Objective. Sleep disturbances are common in patients with carpal tunnel syndrome (CTS). This study investigates the impact of CTS on sleep quality and clarifies the magnitude of this relationship. Methods. This is a prospective investigation of patients with CTS. Patients responded to the Levine-Katz Carpal Tunnel and the Pittsburgh Sleep Quality Index (PSQI) questionnaires to assess symptom severity and quality, respectively. Descriptive and bivariate analyses summarized the findings and assessed the correlations between CTS severity and sleep quality parameters. Results. 66 patients (53F, 13M) were enrolled. Patients reported a sleep latency of 30.0 (±22.5) minutes, with a total sleep time of 5.5 (±1.8) hours nightly. Global PSQI score was 9.0 (±3.8); 80% of patients demonstrated a significant reduction in sleep quality (global PSQI score >5). Increased CTS symptom and functional severity both resulted in a significant reduction in quality and time asleep. Both significantly correlated with subjective sleep latency, sleep disturbance, use of sleep promoting medications, daytime dysfunction, and overall global PSQI score. Conclusions. The findings confirm the correlation of sleep disturbances to CTS, that is, significant reduction of sleep duration and a correlation to sleep quality. Patients sleep 2.5 hours less than recommended and are at risk for comorbid conditions.

Pain-related diseases and sleep disorders

Pain and sleep share mutual relations under the influence of cognitive and neuroendocrine changes. Sleep is an important homeostatic feature and, when impaired, contributes to the development or worsening of pain-related diseases. The aim of the present review is to provide a panoramic view for the generalist physician on sleep disorders that occur in pain-related diseases within the field of Internal Medicine, such as rheumatic diseases, acute coronary syndrome, digestive diseases, cancer, and headache.

Concomitant presentation of carpal tunnel syndrome and trigger finger

Background

Carpal tunnel syndrome (CTS) and trigger finger (TF) are common conditions that may occur in the same patient. The etiology of most cases is unknown. The purpose of this study was to evaluate the rate of concomitant occurrence of these two conditions at presentation and to compare the concomitant occurrence in normal and diabetic patients.

Methods

One-hundred and eight consecutive subjects presenting to our hand clinic with CTS and/or TF were evaluated. The existence of both of these conditions was documented through a standard history and physical examination. The definition of trigger finger was determined by tenderness over the A1 pulley, catching, clicking or locking. CTS was defined in the presence of at least two of the following: numbness and tingling in a median nerve distribution, motor and sensory nerve loss (median nerve), a positive Tinel's or Phalen's test and positive electrophysiologic studies.

Results

The average age of the participants was 62.2 ± 13.6 years. Sixty-seven patients presented with symptoms and signs of CTS (62%), 41 (38%) subjects with signs and symptoms of TF. Following further evaluation, 66 patients (61%) had evidence of concomitant CTS and TF. Fifty-seven patients (53% of all study patients) had diabetes. The rate of subjects with diabetes was similar among the groups (p = 0.8, Chi-square test).

Conclusion

CTS and TF commonly occur together at presentation though the symptoms of one condition will be more prominent. Our results support a common local mechanism that may be unrelated to the presence of diabetes. We recommend evaluation for both conditions at the time of presentation.

Diagnosing carpal tunnel syndrome—clinical criteria and ancillary tests

Damage to the median nerve within the carpal tunnel gives rise to carpal tunnel syndrome (CTS), which is associated with a wide spectrum of symptoms. The predominant classic symptoms are nocturnal pain of the hand, and sensory disturbances within the distribution of the median nerve, both of which are characteristically relieved by hand movements. Ancillary tests, including nerve conduction studies (NCS) and imaging techniques, are mainly indicated when the classic defining features are absent. NCS are less accurate in the early stages of CTS, and in younger patients. Imaging tests (ultrasound and MRI), while still having a lower diagnostic accuracy than NCS, are proving to be useful for explaining persistence of symptoms following surgical relief. Supplementary tests of small nerve fiber function and measurement of intracarpal pressure might, in the future, improve early recognition of CTS, especially in the absence of well-defined symptoms.

Ergonomic Pain--Part 2: Differential Diagnosis and Management Considerations

Work-related musculoskeletal disorders (MSDs) can produce ergonomic pain in several different regions of the body, including the shoulder, elbow, wrist and hand, lumbar spine, knee, and ankle/foot. Each family of disorders is distinctive in presentation and requires diagnosis-specific interventions. Because of the complex nature of these disorders, management approaches may not always eliminate symptoms and or completely restore patient function to a level found prior to symptom onset. As a consequence, ergonomic measures should be implemented to reduce the overload on tissue and contribute to patient recovery. However, functional limits may persist and the clinician must make further decisions regarding a person's functional status in the chronic stages of the patient's care.

Prevalence of sleep disturbance and its relationship to pain in adults with chronic pain

The study examined the prevalence and relationship between sleep disturbance and chronic pain. Research questions were: (1) What is the prevalence of sleep disturbance in adults with chronic pain, and how does this prevalence compare with healthy and insomniac adults? (2) What is the relationship between sleep disturbance and chronic pain? (3) What is the relationship of patient characteristics to sleep? This descriptive, correlational field study was done at an interdisciplinary pain clinic, sampling 99 adults, and using an 11-point pain scale and a visual analog sleep scale. For every disturbance item, more than 47% of subjects reported a score of 50 or higher, twice as high as those for healthy adults, indicating disrupted sleep. For every effectiveness item, more than 54% of subjects reported a score of 50 or less, significantly lower than for healthy adults, indicating poor sleep quality. For every supplementation item, more than 60% reported mean scores of 10 or less, indicating minimal napping, yet scores were higher than for healthy adults. For all three scales, scores were similar to the mean scores for insomniacs. Soundness of sleep showed a small but significant positive (r <.30) correlation with years of pain. Supplementation scale items were not correlated with either years of pain or pain intensity. Fragmentation was significant on the basis of gender, with men having higher scores than women. Age was a negative predictor of sleep latency. Education and age were negative predictors of the quality of sleep.

Ergonomic and psychosocial factors affect daily function in workers' compensation claimants with persistent upper extremity disorders

Pain and other symptoms associated with work-related upper extremity disorders (WRUEDs) can lead to significant distress, lost function, and disability. Identifying factors associated with decreased upper extremity function may lead to the development of more effective interventions. In this study, participants were 165 government employees (127 female, 38 male) with an accepted workers' compensation claim (< 90 days from claim filing) for a WRUED who were unable to perform their normal work. Participants completed baseline measures of upper extremity functional limitation, symptoms, general health status, problem solving orientation, pain coping, and workplace factors. After controlling for pain and gender in a multiple regression analysis, greater functional limitation was further explained by: (1) upper extremity symptoms other than pain (e.g., sleep disturbance, numbness and tingling), (2) symptoms in one or both hands, (3) feeling overwhelmed by pain, (4) low confidence in problem solving abilities, and (5) higher ergonomic risk factor exposures at work. The final model accounted for 47.4% of the variance in upper extremity function, F(7157) = 4.33, P < 0.05. Mental health status was related to functional limitation in univariate, but not multivariate analyses. These results suggest that improving function in this population may require: (1) pain coping techniques and active problem solving to overcome functional barriers, and (2) reduction of workplace ergonomic risk exposure.