Association between work-related biomechanical risk factors and the occurrence of carpal tunnel syndrome: an overview of systematic reviews and a meta-analysis of current research

Comparison of the Effects of Volar-Assisted and Elastic Wrist Splints on Edema, Pain, Grip Strength, and Functionality in Pregnant Women With Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a common musculoskeletal problem in pregnancy. The aim of this study is to compare the effects of rigid and elastic wrist splints on edema, pain levels, grip strength, and upper-extremity functionality in pregnant women with CTS.

METHODS

Forty-one pregnant women in the last trimester of pregnancy who were diagnosed with CTS were included in the study. The grip strength was evaluated with the Jamar hand dynamometer, functionality with the Quick Disabilities of the Arm, Shoulder, and Hand and Boston Carpal Tunnel Syndrome Questionnaire, pain with the Visual Analog Scale (VAS), and edema with the water overflow method.

RESULTS

The mean age of the participants was 31.71 ± 5.78 years, body mass index was 28.85 ± 3.63 kg/m2, duration of pain was 2.24 ± 0.79 months, and their pain intensity was 6.63 ± 1.69 according to the VAS. As a result of the study, reductions in pain (P = .001), increases in functionality values (P = .001), increases in grip strength (P = .001), and decreases in edema (P = .001) were observed in both groups after the treatment. However, there was no significant difference in pain, functionality, or grip strength values between the groups after the treatment (P > .05).

CONCLUSION

In this study comparing the effects of a wrist splint to those of an elastic splint, both treatment methods for pregnant women with CTS decreased pain and edema, increased grip strength, and improved upper-extremity functionality. Considering individual needs, characteristics, and living conditions, both splints can be recommended for pregnant women with CTS.

A Rapid Review on the Effectiveness and Use of Wearable Biofeedback Motion Capture Systems in Ergonomics to Mitigate Adverse Postures and Movements of the Upper Body

Work-related diseases and disorders remain a significant global health concern, necessitating multifaceted measures for mitigation. One potential measure is work technique training utilizing augmented feedback through wearable motion capture systems. However, there exists a research gap regarding its current effectiveness in both real work environments and controlled settings, as well as its ability to reduce postural exposure and retention effects over short, medium, and long durations. A rapid review was conducted, utilizing two databases and three previous literature reviews to identify relevant studies published within the last twenty years, including recent literature up to the end of 2023. Sixteen studies met the inclusion criteria, of which 14 were of high or moderate quality. These studies were summarized descriptively, and the strength of evidence was assessed. Among the included studies, six were rated as high quality, while eight were considered moderate quality. Notably, the reporting of participation rates, blinding of assessors, and a-priori power calculations were infrequently performed. Four studies were conducted in real work environments, while ten were conducted in controlled settings. Vibration feedback was the most common feedback type utilized (n = 9), followed by auditory (n = 7) and visual feedback (n = 1). All studies employed corrective feedback initiated by the system. In controlled environments, evidence regarding the effectiveness of augmented feedback from wearable motion capture systems to reduce postural exposure ranged from strong evidence to no evidence, depending on the time elapsed after feedback administration. Conversely, for studies conducted in real work environments, the evidence ranged from very limited evidence to no evidence. Future reach needs are identified and discussed.

Injection therapy for carpal tunnel syndrome: A systematic review and network meta-analysis of randomized controlled trials

Various injectants are available for the treatment of carpal tunnel syndrome. This systematic review and network meta-analysis was conducted to investigate the effectiveness of different injection therapies in alleviating the symptoms of carpal tunnel syndrome. Various databases were searched for relevant studies from inception until May 10, 2023. Eligible studies were identified using the patient (P), intervention (I), comparison (C), and outcomes (O) model, which involved (P) participants with carpal tunnel syndrome, (I) an intervention based on injection therapy, (C) the use of placebo or another injectant as a control treatment, and (O) the measurement of clinical and electrodiagnostic outcomes of interest. A total of 18 studies were included in the analysis. The network meta-analysis revealed that platelet-rich plasma is effective in the treatment of carpal tunnel syndrome in terms of symptom and pain relief and functional improvement in both the short and long term, whereas steroids are effective only in the short term. Additionally, injections of dextrose solution may offer long-term pain relief as well as short- and long-term symptom alleviation and functional improvement. The study findings suggest that platelet-rich plasma should be used as the first-line treatment for carpal tunnel syndrome, with dextrose and steroids serving as alternative treatment options.

Physical and psychosocial work-related exposures and the incidence of carpal tunnel syndrome: A systematic review of prospective studies

This systematic review summarizes the evidence on associations between physical and psychosocial work-related exposures and the development of carpal tunnel syndrome (CTS). Relevant databases were searched up to January 2020 for cohort studies reporting associations between work-related physical or psychosocial risk factors and the incidence of CTS. Two independent reviewers selected eligible studies, extracted relevant data, and assessed risk of bias (RoB). We identified fourteen articles for inclusion which reported data from nine cohort studies. Eight reported associations between physical exposure and the incidence of CTS and five reported associations between psychosocial exposures and the incidence of CTS. Quality items were generally rated as unclear or low RoB. Work-related physical exposure factors including high levels of repetition, velocity, and a combination of multiple physical exposures were associated with an increased risk of developing CTS. No other consistent associations were observed for physical or psychosocial exposures at work and CTS incidence.

Natural evolution of idiopathic carpal tunnel syndrome with respect to wrist and hand anthropometry: A prospective cohort study

OBJECTIVE

A greater wrist depth/width ratio and wrist depth/palm length ratio are known risk factors for carpal tunnel syndrome. We hypothesized that these parameters might also predict progression in patients who were not surgically treated.

METHODS

Seventy-eight patients with moderately severe idiopathic carpal tunnel syndrome of at least 10 months duration at recruitment, who declined surgical treatment and steroid injection, underwent repeated neurophysiological assessments after 3 years. A > 10% increase in median SNAP latency was taken as evidence of significant deterioration.

RESULTS

Patients with a wrist ratio ≥ 0.72 showed a statistically significant deterioration in SNAP latency from 5.46 (SD 2.09) to 7.16 (SD 1.56) ms and in SNAP amplitude from 30.19 (SD 13.8) to 16.62 (SD 14.42) µv. For those with a wrist-to-palm ratio ≥ 0.42, SNAP latency deteriorated from 5.27 (SD 1.21) to 7.1 (SD 1.52) ms, and amplitude from 32.78 (SD 13.76) to 19.45 (SD 16.62) µv. Patients with lower ratios did not show significant changes in any neurophysiological parameter. The relative risk of significant deterioration in SNAP latency in patients with a wrist ratio ≥ 0.72 was 2.04 (95% CI 1.27-3.27).

CONCLUSION

In untreated idiopathic carpal tunnel syndrome, patients with larger wrist and wrist-to-palm ratios are more likely to show neurophysiological progression.

Musculoskeletal complaints, physical work demands, and functional capacity in individuals with a brachial plexus injury: An exploratory study

BACKGROUND

Musculoskeletal complaints (MSCs) may be more common in individuals with brachial plexus injury (BPI), whose physical work demands exceed their functional capacity (FC).

OBJECTIVES

(a) To assess the concurrent validity of five methods for measuring upper extremity work demands and the Dictionary of Occupational Titles (DOT). (b) To explore the relations between MSCs, physical work demands, and FC in individuals with BPI.

METHODS

This study had a descriptive correlational design. Physical work demands of 16 individuals with BPI (12 males, 6 one-handed workers) were assessed during work using five assessment methods and the DOT. Spearman correlation coefficients between work demand methods were determined. FC was assessed using the functional capacity evaluation one-handed (FCE-OH). A questionnaire was used to examine MSCs. The relationship between MSCs, physical work demands and FC was analyzed visually, using Spearman correlation coefficients, and by comparing FCE-OH results to FCE reference values.

RESULTS

Spearman correlation coefficients for the DOT and four out of five assessment methods for determining work demands on upper extremities were significant and moderate (four combinations: r = 0.65-0.79) to strong (five combinations: r = 0.81-0.94). Correlations of the fifth method with the other methods were weak to fair. No significant relationships were found between MSCs, physical work demands and FCE-OH results.

CONCLUSION

The relationships between MSCs, physical work demands, and FC are evidently complex and require further investigation. In this small sample the concurrent validity of the DOT and four methods for determining work demands on upper extremities was moderate to good.

Occupational and non-occupational risk factors correlating with the severity of clinical manifestations of carpal tunnel syndrome and related work disability among workers who work with a computer

The contribution of certain occupational and personal factors to the development of carpal tunnel syndrome (CTS) is still uncertain. We investigated which specific occupational and non-occupational factors correlate with the level of clinical manifestations and work disability related to CTS. The study included 190 workers who work with a computer and have diagnosed CTS (100 men, 90 women, aged 20-65 years). Subjective experience of CTS-related impairments was assessed with the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) of the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The objective, neural impairments were tested with electrodiagnostics (EDX), whereas CTS-related work disability data were collected from medical records. We found a high inter-correlation between BCTQ, EDX, and work disability data. These also showed high correlations with certain occupational factors (duration of computer-working in months and hours spent daily in computer-working, certain ergonomic, microclimatic, and other occupational conditions) and non-occupational factors (demographic and lifestyle factors: nutritional status, diet, smoking, alcohol consumption, and physical activity). Despite its limitations, our study has identified occupational and non-occupational risk factors that can aggravate CTS and work disability, but which can also be improved with workplace and lifestyle preventive and corrective measures. More research is needed, though, to establish the possible causal relationships and the independent influence of each of those risk factors.

Development and validation of a work-related risk score for upper-extremity musculoskeletal disorders in a French working population

OBJECTIVES

The aim was to develop an easy-to-use risk score based on occupational factors and to validate its performance to identify workers either having (diagnostic setting) or developing (prognostic setting) upper-extremity musculoskeletal disorders (UEMSD).

METHODS

This study relied on data from the Cosali prospective cohort conducted in a French working population. Diagnostic status for six UEMSD at inclusion and at follow-up was assessed by a standardized clinical examination. Data on occupational factors were collected through a self-administered questionnaire completed before the clinical examination at inclusion. The risk score was derived from a prediction model developed on data of 2,468 workers included in 2002-2003, and the validation sample is composed of 1,051 workers included later in 2004-2005. The prognostic performance of the risk score was assessed in workers without UEMSD at baseline.

RESULTS

A total of 13% and 12% of workers had a UEMSD at inclusion in the development and validation sample. The developed risk score includes physical, organizational and psychosocial factors at work. In the validation sample, this score had acceptable performance for identifying workers having or not UEMSD at baseline (AUC: 0.60 [95% CI 0.57 to 0.63]), in particular the negative predictive value was high (89%-90%). The baseline risk score showed similar performance for predicting incident UEMSD at follow-up examination.

CONCLUSION

This score can be useful as a first-line risk assessment tool, especially for excluding the low-risk work situations from further intervention by an ergonomist. Further validation studies are needed to determine its performance among various working populations.

The Mini-Incision Technique Versus Conventional Open Approach for Carpal Tunnel Release: A Retrospective, Comparative Cohort Study

Background and objective Open carpal tunnel release (OCTR) is the gold standard technique for treating carpal tunnel syndrome (CTS). While mini-incision carpal tunnel release (MCTR) has been introduced as an alternative approach, there have been some concerns over its effectiveness and risks. In light of this, the aim of the study was to compare the long-standing clinical outcomes after MCTR with those following OCTR. Methods We employed a retrospective cohort design for this study. Patients were classified into two surgery groups, followed up for two years, and compared in terms of the following variables: duration of symptoms; pinch strength; grip strength; 2-point discrimination; visual analog scale (VAS) score; Levine symptom score; Levine function score; quick disabilities of the arm, shoulder, and hand (QuickDASH) score; wound pain; and pillar pain. Results The study included data regarding 120 patients, 71.66% of whom were females. The MCTR and OCTR groups were similar in terms of age, sex, duration of symptoms, and certain other aspects at baseline. The operation duration (15.15 ±2.20 vs. 25.01 ±2.15 minutes, p<0.01) and incision length (11.425 ±1.56 vs. 20.35 ±2.43 mm, p<0.01) were significantly shorter in the MCTR group compared to the OCTR group. Wound pain and pillar pain were not documented in the MCTR group at three and six months. The OCTR group had pillar pain in 25% of the patients till two years postoperatively. Conclusion Based on our findings, we propose that MCTR is superior to OCTR. The mini-incision technique has the advantages of small incision and scar, low pain, and faster recovery. Moreover, the technique was also found to be safe with no major complications or recurrence of symptoms. Further randomized control trials may help to re-evaluate the technique and validate our findings.

Impact of Occupations and Hobbies on the Severity of Carpal Tunnel Syndrome: An Electrodiagnostic Perspective

OBJECTIVE

This study describes the clinical and electrodiagnostic (EDX) findings as well as occupations and hobbies in 613 patients diagnosed with carpal tunnel syndrome (CTS).

METHODS

Patients with moderate, moderately severe, or severe CTS based on EDX criteria were included.

RESULTS

The most common occupations included workers in offices, construction/maintenance, and assembly lines. The occupation severity scores were greatest in garment workers, musicians, and landscapers. Regardless of occupation, patient age and occupation duration were significantly correlated ( P < 0.001). Gardeners had the highest average severity score of the hobbies, followed by painters, those who sew, and individuals who perform house chores.

CONCLUSIONS

Physicians should be aware of particular occupations and hobbies associated with a greater risk of severe CTS and offer modifications to their patients' work duties and hobbies to minimize the likelihood of developing severe CTS.

Relative motion between the flexor digitorum superficialis tendon and subsynovial connective tissue is time dependent

The subsynovial connective tissue is an integral component of flexor tendon gliding in the carpal tunnel, which is strained during longitudinal tendon displacement. We tested the effects of repetition frequency and finger load on flexor tendon function throughout active finger movement. Eleven participants performed metacarpophalangeal joint flexion/extension of the long finger cyclically at three repetition frequencies (0.75, 1.00, 1.25 Hz) and two finger loads (3.5, 7 N). Relative displacement between the flexor digitorum superficialis tendon and subsynovial connective tissue was assessed as the shear-strain index with color ultrasound throughout the entire time history of finger flexion and extension. In addition, long finger joint angles were measured with electrogoniometry while flexor digitorum superficialis and extensor digitorum muscle activities were measured with fine-wire electromyography to characterize the finger movements. The shear-strain index increased with greater finger flexion (p = 0.001), representing higher relative displacement between tendon and subsynovial connective tissue; however, no changes were observed throughout finger extension. The shear-strain index also increased with higher repetition frequencies (p = 0.013) and finger loads (p = 0.029), further modulating time-dependent effects during finger flexion versus extension. Using ultrasound, we characterized the time-dependent response of the shear-strain index, in vivo, providing valuable data on flexor tendon function during active finger movement. Our results infer greater subsynovial connective tissue strain and shear during repetitive and forceful finger movements. Future research characterizing time-dependent effects in carpal tunnel syndrome patients may further elucidate the relations between subsynovial connective tissue function, damage, and carpal tunnel syndrome.

Prevalence of Carpal Tunnel Syndrome Symptoms Among Young Dentists

Objectives Although age is a risk factor, carpal tunnel syndrome (CTS) can also affect younger individuals, particularly those involved in activities or occupations that require repetitive hand movements, forceful gripping, or prolonged wrist flexion/extension. This case-control study aimed to examine the prevalence of CTS symptoms and frequent object dropping among a group of young dentists who are exposed to CTS risk factors. Additionally, other reported risk factors for CTS, such as sex, obesity, and square wrist sign, were also investigated. Methods A total of 74 dentists (48 women, mean age 28.5 years), who are working at Istanbul Faculty of Dentistry, the largest dental school in Istanbul, which is the biggest city in Turkey, were included in the study. Additionally, 61 age- and sex-matched controls (38 women, mean age 27.9 years) were also recruited. The Edinburgh Hand Preference Questionnaire, Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), a questionnaire for object dropping and occupational hand usage, anthropometric measurements of the hands, clinical neurologic examination, and electromyography intended for the detection of CTS were performed. Results The dentists had a higher total weekly hand usage duration compared to the controls (66.3 vs 44.8 hours, p<0.001). BCTQ scores and the frequency of object dropping were also significantly higher in dentists compared to controls (respective p values: 0.011, 0.003). Positive correlations were found between BCTQ scores, hand usage durations, and object dropping (respective p values: 0.001, <0.001). BCTQ scores were higher in women than in men (p=0.027). Electrophysiologic evidence of CTS was found in one dentist. Conclusions Symptoms of CTS may manifest in individuals at a younger age than predicted, primarily influenced by their occupation and the duration of hand usage. Dentists, in particular, report a higher incidence of complaints related to object dropping, which can be attributed to their frequent use of specialized tools and engagement in delicate tasks, resulting in heightened awareness. However, it can also potentially serve as an indicator of CTS.

Pathophysiology of Work-Related Neuropathies

Work-related injuries are common. The cost of these injuries is around USD 176 billion to USD 350 billion a year. A significant number of work-related injuries involve nerve damage or dysfunction. Injuries may heal with full recovery of function, but those involving nerve damage may result in significant loss of function or very prolonged recovery. While many factors can predispose a person to suffer nerve damage, in most cases, it is a multifactorial issue that involves both intrinsic and extrinsic factors. This makes preventing work-related injuries hard. To date, no evidence-based guidelines are available to clinicians to evaluate work-related nerve dysfunction. While the symptoms range from poor endurance to cramping to clear loss of motor and sensory functions, not all nerves are equally vulnerable. The common risk factors for nerve damage are a superficial location, a long course, an acute change in trajectory along the course, and coursing through tight spaces. The pathophysiology of acute nerve injury is well known, but that of chronic nerve injury is much less well understood. The two most common mechanisms of nerve injury are stretching and compression. Chronic mild to moderate compression is the most common mechanism of nerve injury and it elicits a characteristic response from Schwann cells, which is different from the one when nerve is acutely injured. It is important to gain a better understanding of work-related nerve dysfunction, both from health and from regulatory standpoints. Currently, management depends upon etiology of nerve damage, recovery is often poor if nerves are badly damaged or treatment is not instituted early. This article reviews the current pathophysiology of chronic nerve injury. Chronic nerve injury animal models have contributed a lot to our understanding but it is still not complete. Better understanding of chronic nerve injury pathology will result in identification of novel and more effective targets for pharmacological interventions.

Wearable Motion Capture Devices for the Prevention of Work-Related Musculoskeletal Disorders in Ergonomics-An Overview of Current Applications, Challenges, and Future Opportunities

Work-related musculoskeletal disorders (WMSDs) are a major contributor to disability worldwide and substantial societal costs. The use of wearable motion capture instruments has a role in preventing WMSDs by contributing to improvements in exposure and risk assessment and potentially improved effectiveness in work technique training. Given the versatile potential for wearables, this article aims to provide an overview of their application related to the prevention of WMSDs of the trunk and upper limbs and discusses challenges for the technology to support prevention measures and future opportunities, including future research needs. The relevant literature was identified from a screening of recent systematic literature reviews and overviews, and more recent studies were identified by a literature search using the Web of Science platform. Wearable technology enables continuous measurements of multiple body segments of superior accuracy and precision compared to observational tools. The technology also enables real-time visualization of exposures, automatic analyses, and real-time feedback to the user. While miniaturization and improved usability and wearability can expand the use also to more occupational settings and increase use among occupational safety and health practitioners, several fundamental challenges remain to be resolved. The future opportunities of increased usage of wearable motion capture devices for the prevention of work-related musculoskeletal disorders may require more international collaborations for creating common standards for measurements, analyses, and exposure metrics, which can be related to epidemiologically based risk categories for work-related musculoskeletal disorders.

Predicting CTS Diagnosis and Prognosis Based on Machine Learning Techniques

Carpal tunnel syndrome (CTS) is a clinical disease that occurs due to compression of the median nerve in the carpal tunnel. The determination of the severity of carpal tunnel syndrome is essential to provide appropriate therapeutic interventions. Machine learning (ML)-based modeling can be used to classify diseases, make decisions, and create new therapeutic interventions. It is also used in medical research to implement predictive models. However, despite the growth in medical research based on ML and Deep Learning (DL), CTS research is still relatively scarce. While a few studies have developed models to predict diagnosis of CTS, no ML model has been presented to classify the severity of CTS based on comprehensive clinical data. Therefore, this study developed new classification models for determining CTS severity using ML algorithms. This study included 80 patients with other diseases that have an overlap in symptoms with CTS, such as cervical radiculopathysasas, de quervian tendinopathy, and peripheral neuropathy, and 80 CTS patients who underwent ultrasonography (US)-guided median nerve hydrodissection. CTS severity was classified into mild, moderate, and severe grades. In our study, we aggregated the data from CTS patients and patients with other diseases that have an overlap in symptoms with CTS, such as cervical radiculopathysasas, de quervian tendinopathy, and peripheral neuropathy. The dataset was randomly split into training and test data, at 70% and 30%, respectively. The proposed model achieved promising results of 0.955%, 0.963%, and 0.919% in terms of classification accuracy, precision, and recall, respectively. In addition, we developed a machine learning model that predicts the probability of a patient improving after the hydro-dissection injection process based on the aggregated data after three different months (one, three, and six). The proposed model achieved accuracy after six months of 0.912%, after three months of 0.901%, and after one month 0.877%. The overall performance for predicting the prognosis after six months outperforms the prediction after one and three months. We utilized statistics tests (significance test, Spearman's correlation test, and two-way ANOVA test) to determine the effect of injection process in CTS treatment. Our data-driven decision support tools can be used to help determine which patients to operate on in order to avoid the associated risks and expenses of surgery.

The effectiveness of the median nerve neurodynamic mobilisation techniques in women with mild or moderate bilateral carpal tunnel syndrome: A single-blind clinical randomised trial

BACKGROUND

Carpal tunnel syndrome (CTS) is the most prevalent upper limb compression neuropathy. Surgical or nonsurgical treatment is recommended. Both mild and moderate CTS can be managed conservatively. Neurodynamic mobilisation techniques (NMTs) of the median nerve have not been widely studied, and conflicting findings exist.

METHODS/DESIGN

Sixty-two female patients with mild or moderate bilateral CTS were assigned one wrist to the treatment group (TG) and the other to the control group (CG). Both groups underwent carpal bone mobilisation. The TG underwent NMTs while the CG received a placebo elbow mobilisation not targeting the median nerve. The Numerical Rating Pain Scale, JAMAR Plus Digital Hand dynamometer and Functional Status Scale (FSS) were used to assess pain, grip strength and functional status.

DISCUSSION

Comparison of groups showed that NMTs at 5 weeks decreased pain intensity by 1.15 (p = 0.001) and by 2 (p ˂ 0.001) at 10 weeks. Difference in functional status was 0.45 at 5 weeks (p = 0.003) and 0.84 at 10 weeks (p = 0.003). The CG's grip strength improved by 0.59 (p = 0.05) after 5 weeks and 0.61 (p = 0.028) at 10 weeks. Both groups improved in all parameters over time.

CONCLUSION

When combined with carpal bone mobilisation, both NMTs and placebo elbow mobilisation seem to reduce pain intensity and improve grip strength and functional status. However, NMTs had better results in pain intensity and FSS.

CLINICAL IMPLICATIONS

Women with mild or moderate bilateral CTS may benefit from NMTs as a conservative treatment option.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR202201807752672, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=19340.

Work-relatedness of carpal tunnel syndrome: Systematic review including meta-analysis and GRADE

Background and Aims

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome with a high prevalence among workers. Insights on the physical work-related risk factors is necessary to develop appropriate preventative methods. The objective of this systematic review, including meta-analyses, is to assess which physical work-related risk factors are associated with carpal tunnel syndrome.

Methods

Systematic literature searches were carried out using PubMed and Embase until September 6, 2021. Studies were included if: (1) CTS was clinically assessed, (2) the studies were prospective cohort studies, and (3) the exposure was reported using terms of exposed/less or nonexposed. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results

In total, 9270 patients with CTS from a population of 1,051,707 workers were included from 17 studies. Meta-analyses revealed high-quality evidence for associations between CTS and high exposures to repetition (hazard ratio [HR] 1.87, 95% CI 1.42-2.46), force intensity (HR 1.84, 95%CI 1.22-2.79), exposures above hand activity level of ACGIH (HR 1.75, 95%CI 1.40-2.17), and the Strain Index >10 (HR 1.58, 95% CI 1.09-2.30). No significant associations were found for pinch gripping, hand-arm vibration or force duration. High computer-use exposure was significantly associated with a decreased rate of work-related CTS (HR 0.28, 95% CI 0.12-0.64).

Conclusion

This systematic review of prospective cohort studies found high certainty for an increased rate of CTS due to a high Strain Index, exposures exceeding the Activity Level of ACGIH, and high force intensity and high repetition. Workers performing tasks requiring both high force and high repetition even have a higher rate of developing CTS.

Is Smoking Associated with Carpal Tunnel Syndrome? A Meta-Analysis

To date, the role of smoking in carpal tunnel syndrome (CTS) is unclear. The aim of this systematic review and meta-analysis was to assess the association between smoking and CTS. The literature searches were conducted in PubMed, Embase, and Scopus, from inception until October 2021. Three reviewers screened the titles, abstracts, and full-text articles and evaluated the methodological quality of the included studies. A random-effects meta-analysis was used, and heterogeneity across studies was examined using I² statistic. A total of 31 (13 cross-sectional, 10 case-control, and 8 cohort) studies were qualified for meta-analysis. In a meta-analysis of cohort studies, the risk of CTS did not differ between current and never smokers (pooled hazard ratio (HR) 1.09, 95% CI 0.84–1.43), current and past/never smokers (HR 1.07, 95% CI 0.94–1.23), and past and never smokers (HR 1.12, 95% CI 0.83–1.49). Furthermore, a meta-analysis of case control studies found no difference in the risk of CTS between current and never smokers (pooled odds ratio (OR) 0.92, 95% CI 0.56–1.53), current and past/never smokers (OR 1.10, 95% CI 0.51–2.36), and past and never smokers (OR 0.91, 95% CI 0.59–1.39). However, a meta-analysis of cross-sectional studies showed the associations of ever (OR 1.36, 95% CI 1.08–1.72) and current smoking (OR 1.52, 95% CI 1.11–2.09) with CTS. However, the association between ever smoking and CTS disappeared after limiting the meta-analysis to higher quality studies or after adjusting for publication bias. The association between current smoking and CTS also attenuated after limiting the meta-analysis to studies that confirmed CTS by a nerve conduction study or studies with low attrition bias. This meta-analysis does not support an association between smoking and CTS. The association between smoking and CTS observed in cross-sectional studies could be due to biases and/or confounding factors.

Screening for Cardiac Amyloidosis 5 to 15 Years After Surgery for Bilateral Carpal Tunnel Syndrome

BACKGROUND

Bilateral carpal tunnel syndrome (CTS) is a common extracardiac manifestation of amyloidosis and usually predates overt cardiac amyloidosis (CA) by several years. Screening studies on patients undergoing CTS surgery have shown a low yield of CA (2.0%), but high prevalence of amyloid in the carpal ligament. The proportion of patients with amyloid in the carpal ligament who later develop CA is unknown.

OBJECTIVES

The authors sought to investigate the prevalence of undiagnosed CA 5 to 15 years after surgery for bilateral CTS.

METHODS

Using national registries, the authors identified subjects aged 60 to 85 years with prior CTS surgery, where the first procedure on the second wrist was performed 5 to 15 years earlier. Invitations to participate in the study were sent by mail. Per international recommendations, the initial cardiac evaluation included echocardiography, ^99mtechnetium-pyrophosphate scintigraphy, and assessment of monoclonal proteins in serum and urine.

RESULTS

A total of 250 subjects (35.7% of those invited) participated in the study. The median age was 70.4 years, and 50% were female. CA was diagnosed in 12 patients (4.8%; 95% CI: 2.5%-8.2%), and all cases were wild-type transthyretin amyloidosis (ATTRwt). The prevalence of ATTRwt in men was 8.8% (95% CI: 4.5%-15.2%; n = 11), and 21.2% (95% CI: 11.1%-34.7%) in male subjects ≥70 years with a BMI <30 kg/m². All but 2 patients diagnosed with ATTRwt were in the lowest disease severity score (Mayo score).

CONCLUSIONS

Screening for CA in patients with prior surgery for bilateral CTS finds approximately 5% with early-stage transthyretin CA. The clinical yield was higher (>1 in 5) when focusing on nonobese men ≥70 years, showing potential for systematic screening.

Long-Term Outcome of Electrodiagnostic Values and Symptom Improvement After Carpal Tunnel Release: A Retrospective Cohort Study

PURPOSE

The aim of this study was to evaluate electrodiagnostic studies and clinical outcomes after carpal tunnel release surgery in moderate and severe cases of carpal tunnel syndrome (CTS).

METHODS

Seventy-two patients with moderate or severe CTS who underwent carpal tunnel release surgery (46 unilateral; 26 bilateral; total, 98 surgeries) between 2009 and 2014 were included in the study. The cases were divided into 2 groups according to electrodiagnostic results: those with moderate CTS and those with severe CTS. Michigan Hand Outcomes Questionnaire scores and electrodiagnostic data (sensory nerve action potentials and compound muscle action potentials) were recorded before surgery and in postoperative follow-up studies obtained at 3 months, 1 year, and 5 years.

RESULTS

There were 56 surgeries in the moderate CTS group and 42 surgeries in the severe CTS group. Sensory nerve action potentials and compound muscle action potentials were significantly lower in the severe CTS group when compared to the moderate CTS group at all follow-up times. There was a significant difference in Michigan Hand Outcomes Questionnaire scores between the groups before surgery, but no significant differences at the final follow-up. It was found that the values of all parameters (sensory nerve action potentials, compound muscle action potentials, and Michigan Hand Outcomes Questionnaire score) demonstrated significant improvements with time in both the severe and the moderate CTS groups.

CONCLUSIONS

Carpal tunnel release surgery improves symptoms, regardless of the preoperative severity. Postoperative electrodiagnostic study results of patients with moderate CTS improve to a greater degree than those of patients with severe CTS, but all remain abnormal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IIb.

Evaluation of the Transverse Carpal Ligament in Carpal Tunnel Syndrome by Shear Wave Elastography: A Non-Invasive Approach of Diagnosis and Management

Objectives

The goal of this work is to determine the clinical value of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS) for guiding subsequent treatment.

Methods

This study analyzed patients who underwent median nerve (MN) ultrasound (US) examination of the wrist from April 2020 to April 2021. The cross-sectional area and anteroposterior diameter of the MN, as well as the TCL thickness and stiffness, were measured from images. The intra-group and intra-patient subgroup differences were compared using a t-test and a rank test. We also utilized receiver operating characteristic (ROC) curves to diagnose CTS and evaluate the severity.

Results

The final cohort consisted of 120 wrists (bilateral) from 60 samples, evenly balanced across the patient and control groups according to their CTS diagnosis. In the unilateral positive patient subgroup, the MN and TCL of the positive hand were significantly thicker and stiffer than the negative counterparts (both, p &lt; 0.05). The values from the right were also thicker and stiffer than the left (both, p &lt; 0.05) in patients with bilateral CTS. The MN and TCL of the patient group were also significantly thicker and stiffer than those of the control group (both, p &lt; 0.001). For diagnosing CTS, the area under the curve (AUC) of TCL thickness and stiffness at the distal carpal tunnel (DCT) ranged between 0.925 and 0.967. For evaluating CTS severity, we found that the optimal TCL stiffness is sufficient for diagnosing mild and non-mild patient cases (AUC: Emean = 0.757, Emax = 0.779).

Conclusions

Shear wave elastography is therefore an effective method for CTS diagnosis and management.

Electrodiagnostic signs of carpal tunnel syndrome in ocular pseudoexfoliation syndrome

PURPOSE

To assess the occurrence and severity of electrodiagnostic signs of carpal tunnel syndrome (ED-CTS) in patients with ocular pseudoexfoliation (PEX) and compare them with normal subjects.

METHOD

A cross-sectional study with comparison group was designed and 60 patients with PEX were recruited from May 2019 to February 2021, and the findings were compared with 59 healthy subjects. All patients underwent complete ophthalmologic examination and nerve conduction velocity test at the median nerve was used to assess the occurrence and severity of ED-CTS in both hands.

RESULTS

The mean age of participants was 59.8 ± 4.5 years. Occurrence of ED-CTS was 38.3% in PEX patients and 20.3% in control subjects (P = 0.025). There was also a significant difference in the severityand presence of asymptomatic CTS (P < 0.05). Adjusting other variables, including; age and sex, having severe ED-CTS showed a 3.07fold higher chance in the PEX group (P = 0.005).

CONCLUSION

According to our finding, it seems there is a direct association between PEX and the occurrence, as well as severity of ED-CTS.

Evaluation of a New Simplified Inertial Sensor Method against Electrogoniometer for Measuring Wrist Motion in Occupational Studies

Wrist velocity is an important risk factor for work-related musculoskeletal disorders in the elbow/hand, which is also difficult to assess by observation or self-reports. This study aimed to evaluate a new convenient and low-cost inertial measurement unit (IMU)-based method using gyroscope signals against an electrogoniometer for measuring wrist flexion velocity. Twelve participants performed standard wrist movements and simulated work tasks while equipped with both systems. Two computational algorithms for the IMU-based system, i.e., IMU_norm and IMU_flex, were used. For wrist flexion/extension, the mean absolute errors (MAEs) of median wrist flexion velocity compared to the goniometer were <10.1°/s for IMU_norm and <4.1°/s for IMU_flex. During wrist deviation and pronation/supination, all methods showed errors, where the IMU_norm method had the largest overestimations. For simulated work tasks, the IMU_flex method had small bias and better accuracy than the IMU_norm method compared to the goniometer, with the MAEs of median wrist flexion velocity <5.8°/s. The results suggest that the IMU-based method can be considered as a convenient method to assess wrist motion for occupational studies or ergonomic evaluations for the design of workstations and tools by both researchers and practitioners, and the IMU_flex method is preferred. Future studies need to examine algorithms to further improve the accuracy of the IMU-based method in tasks of larger variations, as well as easy calibration procedures.

Effects of slight flexion-extension and radial-ulnar deviation postures on carpal tunnel volume

BACKGROUND

Non-neutral wrist postures are a commonly reported risk factor for carpal tunnel syndrome. It is unclear how slight flexion-extension and radial-ulnar deviation postures affect the carpal tunnel. The objective was to determine the effects of slight non-neutral postures by quantifying carpal tunnel volume.

METHODS

Computed tomography images were collected on ten cadaveric specimens in target postures of -20°, -10°, -5°, 0°, 5°, 10°, and 20° of flexion and - 10°, -5°, 0°, 5°, and 10° of radial-ulnar deviation. Surface meshes of the carpal tunnel, carpal bones, radius, and third metacarpal were generated with manual segmentation. Carpal tunnel volume was calculated as the volume between proximal and distal boundaries defined with anatomical landmarks and the orientation of the tunnel. The precise wrist posture of each scan was determined with inertial-based coordinate systems of the radius and third metacarpal.

FINDINGS

Through multiple linear regression it was determined that, over the observed range of postures, flexion-extension angle does not have a significant effect (p = 0.99) while radial-ulnar deviation angle has a significant effect of -5.9 mm³/degree (p = 0.003). The findings were consistent with previous studies of postural effects on carpal tunnel pressure.

INTERPRETATION

For the treatment and prevention of carpal tunnel syndrome, results suggest that attention should be given to slight radial-ulnar deviation postures (<10°), while slight flexion-extension postures (<20°) are of lesser consequence to carpal tunnel volume.

Personal factors associated with carpal tunnel syndrome (CTS): a case-control study

BACKGROUND

Carpal tunnel syndrome (CTS) is one of the most common nerve entrapments in the upper limb. In Saudi Arabia, few studies have investigated CTS in the general population. This study aimed to determine the association between personal factors and CTS.

METHODS

A case-control study involved adults aged 18 and above. Cases were recruited from electrophysiology lab records as consecutive case series, while controls were individuals who were free of CTS symptoms according to the Boston Carpal Tunnel Questionnaire (BCTQ). The electronic medical records of participants were reviewed to obtain age, height, weight, medical conditions, and mobile numbers. Cases and controls were contacted via phone to complete a questionnaire that was designed based on previous literature. We used multivariate binary logistic regression to identify the personal factors significantly associated with CTS.

RESULTS

A total of 95 cases and 190 controls were included. Most of the participants were female (84.2%) and Saudi (93%). Most of cases were above 45 years of age (73.7%), while 84.7% were 45 year - old or younger among the control group. Stratified logistic regression showed that performance of household chores was significantly associated with CTS. While physical exercise associated with decreased odds of CTS.

CONCLUSIONS

This study adds to the body of evidence on personal factors associated with CTS. However, the degree of differences in the age structure of the cases compared with the controls suggest that there is a considerable potential for residual confounding affecting the results.

TRIAL REGISTRATION NUMBER

Not applicable.

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache

BACKGROUND

Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies.

METHODS

One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data.

RESULTS

The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups.

CONCLUSIONS

The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.

Less Complexity in Hemodialysis Machines Reduces Time and Physical Load for Operator Actions

Purpose

Innovative hemodialysis systems are designed to ensure user safety and reduce operational time to allow health-care personnel to focus on patient care. The 6008 CareSystem has been developed to simplify the extracorporeal circuit of the system through a disposable cassette, automate operation steps, and facilitate handling in comparison to its predecessor - the 5008 CorDiax. The present investigations were performed with the aim of evaluating usability, safety, and ergonomic aspects of the new therapy system.

Methods

A time-motion study compared these two hemodialysis systems with video and time recording of handling steps required to prepare, operate, and dismantle a dialysis machine. The ergonomic burden on hands and finger joints was evaluated in a second study, again by video-recording the simulated operation of both dialysis systems.

Results

The number of handling steps required for the 6008 CareSystem and critical contact points were reduced by 26% in comparison to the 5008 CorDiax for patients with arteriovenous fistula used for vascular access and by 22% for those with a catheter used for vascular access. Total process time was reduced by 2.83 and 2.57 minutes using fistulae and catheters for vascular access, respectively. The number of hand grips and finger and thumb presses was reduced by approximately 50% and required less strength to execute.

Conclusion

The most recent hemodialysis system confirmed its ease of use and user safety through fewer handling steps and less physical burden on the user. Shorter operational time should enable more patient-focused care.

Association between smartphone use and carpal tunnel syndrome: A case-control study

Context

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the upper limb. No published Saudi Arabian study has explored the effect of smartphones on the median nerve.

Aim

To assess the association between smartphone use and the development of CTS.

Settings and Design

This case-control study involved adults aged 18 years and older who visited King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia.

Materials and Methods

Patients were clinically diagnosed with CTS, and the diagnosis was confirmed by a nerve conduction study (NCS) and electromyography. The controls were free of CTS based on the disease-specific Boston Carpal Tunnel Questionnaire. Statistical analyses were performed using IBM-SPSS version 25.0.

Results

In total, 95 cases and 190 controls were included. Most of the participants were females (84.2%). The mean ages in the controls and cases were 34.6 +/- 10.2 years and 51.8 +/- 10.6 years, respectively. Using smartphones for 2 hours per day or more was significantly associated with the occurrence of CTS. After adjusting for covariates, 4 hours or more per day of smartphone use was associated with CTS. Moreover, those who held the smartphone with both hands had 7.8 times higher odds of developing CTS than those who held it with one hand.

Conclusion

CTS has a negative impact on patients' daily activities and work. This study showed that an increased number of hours of smartphone use is associated with the development of CTS. Further prospective studies are needed to examine the long-term effects of smartphone use.

Association of clinically relevant carpal tunnel syndrome with type of work and level of education: a general-population study

Carpal tunnel syndrome (CTS) is a common cause of work disability. The association with occupational load and education level has not been established in general-population studies. The purpose of this study was to investigate the association of clinically relevant CTS with work and education. From the Healthcare Register of Skane region (population 1.2 million) in southern Sweden we identified all individuals, aged 17–57 years, with first-time physician-made CTS diagnosis during 2004–2008. For each case we randomly sampled 4 referents, without a CTS diagnosis, from the general population matched by sex, age, and residence. We retrieved data about work and education from the national database. The study comprised 5456 individuals (73% women) with CTS and 21,667 referents. We found a significant association between physician-diagnosed CTS and type of work and level of education in both women and men. Compared with white-collar workers, the odds ratio (OR) for CTS among blue-collar workers was 1.67 (95% CI 1.54–1.81) and compared with light work, OR in light-moderate work was 1.37 (1.26–1.50), moderate work 1.70 (1.51–1.91), and heavy manual labor 1.96 (1.75–2.20). Compared with low-level education, OR for CTS in intermediate level was 0.82 (0.76–0.89) and high-level 0.48 (0.44–0.53). In women and men there is significant association with a dose–response pattern between clinically relevant CTS and increasing manual work load and lower education level. These findings could be important in design and implementation of preventive measures.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Upper extremity musculoskeletal disorders and work exposures among railroad maintenance-of-way workers

BACKGROUND

Our objective was to examine occupational risk factors for musculoskeletal disorders of the shoulders, elbows, wrists, and hands among railroad maintenance-of-way (MOW) workers. Little systematic research on musculoskeletal disorders has been conducted in this occupational group.

METHODS

In total, 3995 active members of the Brotherhood of Maintenance of Way Employes Division (BMWED) completed a standardized survey focusing on disorders caused by hand-transmitted vibration. We computed adjusted prevalence ratios (aPRs) using Poisson regression for shoulder, elbow, carpal tunnel syndrome, and vibration white finger musculoskeletal symptoms by work exposures, adjusted for age, region, race/ethnicity, smoking, potential second job, and spare time vehicle vibration exposure, and other work exposures.

RESULTS

Among active male BMWED members, we found associations between >5.2 years (vs. 0.0-0.7 years) duration of full-time equivalent power tool use and shoulder pain (aPR = 2.01; 95% confidence interval [CI], 1.43-2.85), elbow pain (aPR = 2.88; 95% CI, 1.86-4.46), vibration white finger symptoms (aPR = 2.49; 95% CI, 1.06-5.85), hand/wrist pain (aPR = 2.40; 95% CI, 1.74-3.32), finger numbness or tingling (aPR = 1.86; 95% CI, 1.38-2.50) and self-reported carpal tunnel syndrome diagnosis (aPR = 2.16; 95% CI, 1.24-3.77). Associations were not consistent across outcomes for the duration of non-powered hand tool use and "repeated lifting, pushing, pulling, or bending." Positive gradients were observed for most outcomes.

CONCLUSIONS

Hand-arm vibration and some other biomechanical exposures were associated with shoulder, elbow, wrist, hand, and finger symptoms. Prevention programs should address occupational risk factors for upper extremity musculoskeletal disorders among MOW workers.

Increased Risk of Carpal Tunnel Syndrome in People With Spinal Cord Injury: A Nationwide Longitudinal Follow-Up Study

OBJECTIVE

To investigate the long-term risk of carpal tunnel syndrome (CTS) in people with spinal cord injury (SCI).

DESIGN

Retrospective cohort study.

SETTING

Taiwan's Longitudinal Health Insurance Database 2005, containing data about 1 million people randomly sampled from among those registered in the National Health Insurance Program as of 2005.

PARTICIPANTS

The SCI group consisted of 1681 subjects with SCI, and the comparison group comprised 6724 propensity score-matched subjects without SCI (N=8405). The variables included in propensity-score matching were age, sex, comorbid conditions, and socioeconomic status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The occurrence of newly diagnosed CTS, defined by at least 1 hospital discharge or 2 outpatient visits with a diagnosis of CTS.

RESULTS

The incidence density of CTS in the SCI group was 7.55 per 1000 person-years (95% confidence interval [CI], 6.03-9.33), and in the comparison group, 4.61 per 1000 person-years (95% CI, 4.08-5.19). The hazard ratio (HR) of CTS for the SCI group was therefore 1.59 (95% CI, 1.24-2.03). Additionally, the HR of CTS for the cervical-SCI subgroup, 1.90 (95% CI, 1.21-2.97) was considerably higher than that of its noncervical counterpart, 1.47 (95% CI, 1.09-1.98).

CONCLUSIONS

People with both cervical and noncervical SCI have an increased risk of developing CTS, as compared with those without SCI. Moreover, the CTS risk appears to be higher for individuals with cervical SCI than their noncervical SCI counterparts.

The association between manual handling operations and pain in the hands and arms in the context of the 2018 BIBB/BAuA Employment Survey

BACKGROUND

Manual handling operations (MHO) are tasks performed by hand that require repetitive and forceful hand and arm movements. MHO are currently performed in many workplaces in skilled and unskilled jobs in the production and service sectors. MHO are considered as work-related health risk factors. The relationship between MHO and the occurrence of disorders of the upper extremities has been established. MHO can cause diseases such as tenosynovitis or carpal tunnel syndrome. This study aims to assess the current prevalence of MHO in the German workforce and to evaluate the relationship between MHO and the occurrence of hand and arm complaints.

METHODS

The analysis was based on the German 2018 BIBB/BAuA Employment Survey. For this analysis we included subjects aged between 16 and 66 who work at least 35 h per week. The self-reported frequency of MHO (never; rarely; sometimes; often) was considered as the exposure of interest and was stratified by gender and occupation. Prevalence ratios (PR) were used to report the relationship between MHO and self-reported pain in the hands and arms (robust log-linear Poisson regression). Adjustments were made for age, gender, actual weekly working hours, psychosocial workload, and other physical workloads. The regression analyses considered complete cases.

RESULTS

The analyses included 14,299 employees. Frequent MHO were reported by 32.6% of men and 31.1% of women. These workloads were often reported by respondents who work in the agricultural sector (men: 70.1%; women: 79.0%), in unskilled (men: 59.4%; women: 66.9%), and skilled manual occupations (men: 72.7%; women: 66.7%). A higher frequency of self-reported MHO was associated with a higher prevalence of hand complaints (PR 2.26 CI 2.00-2.55 "often" vs. "never" = ref.) as well as arm pain (PR 1.73 CI 1.55-1.92 for "often" vs. "never" = ref.).

CONCLUSION

MHO are still frequent in many occupations. The shown association between MHO and pain in the hands and arms demonstrates the importance of MHO in the current German workforce and the necessity to further develop prevention strategies.

Asymptomatic common extensor tendon pathology in patients with carpal tunnel syndrome

INTRODUCTION/AIMS

Carpal tunnel syndrome (CTS) and lateral epicondylitis are both highly prevalent conditions. Our objective was to determine the prevalence of B-mode ultrasound abnormalities of the common extensor tendon (CET) in patients with CTS and establish the relationship between CET stiffness, as measured by shear wave elastography (SWE) and CTS severity.

METHODS

Patients without symptoms or signs of lateral epicondylitis were recruited from referrals to a neurophysiology laboratory for possible CTS. These patients were examined for clinical features of CTS before undergoing electrodiagnostic testing followed by an ultrasound examination, consisting of B-mode, power Doppler, and SWE.

RESULTS

Thirty-nine limbs with clinically diagnosed CTS and 20 control limbs were included. Of the CTS limbs, 61.5% had sonographically abnormal CET compared with 35% of the controls. The mean CET sonographic abnormality score was higher in CTS patients compared with controls (P = .006). CTS patients with sonographically abnormal CET had more severe CTS by electrophysiological criteria. The mean CET stiffness in CTS patients was lower than in controls (P = .033).

DISCUSSION

Sonographic abnormalities of the CET are common in CTS patients with no clinical evidence of lateral epicondylitis and may relate to common pathogenetic mechanisms. These findings suggest that isolated ultrasound abnormalities in the CET are not diagnostically useful in patients presenting with upper limb pain unless there are clinical features of lateral epicondylitis.

Personal, biomechanical, psychosocial, and organizational risk factors for carpal tunnel syndrome: a structural equation modeling approach

This longitudinal study aimed at exploring the direct and indirect relationships between organizational, psychosocial, biomechanical, and personal factors and carpal tunnel syndrome (CTS) in French workers. Between 2002 and 2005, 3710 workers were included in the Cosali cohort. Between 2007 and 2010, 1611 workers were re-examined using the same standardized clinical protocol. Subjects free from CTS at baseline were studied (804 men and 563 women). We used structural equation models to examine the relationships between incident CTS cases and organizational (machine-paced work or work pace dependent on customers' demand), psychosocial (job strain model), biomechanical (Borg's rating perceived exertion, wrist bending, pinching, and hand-transmitted vibrations), and personal factors at baseline. Symptomatic CTS risk was directly increased by biomechanical factors (standardized coefficient = 0.19, P = 0.011), female gender (0.25, P < 0.001), and age (0.15, P = 0.042). No psychosocial factors had a direct impact on CTS, but decision authority and skill discretion had an indirect impact by influencing biomechanical exposure. Exposure to machine-paced work had an indirect impact on increasing CTS, either by raising biomechanical exposure (0.19, P < 0.001) or by lowering decision authority (-0.18, P < 0.001) and skill discretion (-0.20, P < 0.001), which in turn increased biomechanical exposure. Similar complex relationships were observed between risk factors and CTS defined by a more strict case definition. Biomechanical exposure had a direct impact on CTS, while organizational factors and psychosocial factors had an indirect impact on CTS. The findings support conceptual models linking work organization to CTS.

Proportion and Number of Upper-Extremity Musculoskeletal Disorders Attributable to the Combined Effect of Biomechanical and Psychosocial Risk Factors in a Working Population

The objective of this paper is to assess the combined effect of occupational biomechanical and psychosocial risk factors on the incidence of work-related upper-extremity musculoskeletal disorders (UEMSDs) and estimate the proportion and number of incident cases attributable to these risk factors in a working population. Using data from the French COSALI (COhorte des SAlariés LIgériens) cohort (enrolment phase: 2002–2005; follow-up phase: 2007–2010), a complete case analysis including 1246 workers (59% men, mean age: 38 years ± 8.6 at baseline) was performed. All participants underwent a standardized clinical examination at enrolment and 1611 workers were re-examined at follow-up. Population attributable fractions and the number of UEMSD cases attributable to occupational risk factors were calculated. During follow-up, 139 UEMSD cases were diagnosed, representing an estimated 129,320 projected incident UEMSD cases in the working population. After adjusting for personal factors, in model 1, 8664 cases (6.7%) were attributable to low social support, 19,010 (14.7%) to high physical exertion, and 20,443 (15.8%) to co-exposure to both factors. In model 2, 16,294 (12.6%) cases were attributable to low social support, 6983 (5.4%) to posture with arms above shoulder level, and 5043 (3.9%) to co-exposure to both factors. Our findings suggest that many cases of UEMSD could be potentially prevented by multidimensional interventions aimed at reducing exposure to high physical exertion and improving social support at work.

Median nerve travel and deformation in the transverse carpal tunnel increases with chuck grip force and deviated wrist position

Background

We assessed median nerve travel and deformation concurrently to better understand the influence of occupational risk factors on carpal tunnel dynamics, including forceful chuck gripping and deviated wrist positions.

Methods

Fourteen healthy right-hand dominant participants performed a chuck grip in 6 experimental conditions: two relative force levels (10% and 40% of maximum voluntary effort); three wrist positions (15° radial deviation, 0° neutral, 30° ulnar deviation). Chuck grip forces were measured with a load cell while the transverse cross-section of the carpal tunnel was imaged via ultrasound at the distal wrist crease. Images of the median nerve were analyzed in ImageJ to assess cross-sectional area, circularity, width, and height as well as travel in the anterior-posterior and medial-lateral axes.

Results

We found a main effect of deviated wrist position on both anterior-posterior and medial-lateral travel, with the greatest nerve travel occurring in 30° ulnar deviation. There was also a significant interaction between chuck grip force and deviated wrist position on cross-sectional area. Specifically, the area decreased with 40% vs. 10% chuck grip force when the wrist was in 30° ulnar deviation; however, there were no changes in 0° neutral and 15° radial deviation.

Discussion

Overall, we demonstrated that forceful chuck gripping in deviated wrist positions influenced carpal tunnel dynamics, resulting in both migratory and morphological changes to the median nerve. These changes may, in turn, increase local strain and stress with adjacent structures in the carpal tunnel. Future studies mapping contact stress between structures may further elucidate injury development of work-related carpal tunnel syndrome.

Manufacturing Workers Have a Higher Incidence of Carpal Tunnel Syndrome

OBJECTIVE

It is unclear whether clerical or labor-type work is more associated with risk for developing work-related carpal tunnel syndrome (WrCTS).

METHODS

National employment, demographic, and injury data were examined from the Bureau of Labor Statistics databases for the years 2003 to 2018. Injuries for clerical and labor industries were compared using linear regression, two-group t test, and one-way analysis of variance (ANOVA) analysis.

RESULTS

WrCTS injuries are decreasing over time (B = -1002.62, P < 0.001). The labor industry demonstrated a significantly higher incidence of WrCTS when compared with the clerical industries (P < 0.001). Within labor industries, the manufacturing industry had the highest incidence of WrCTS over time (P < 0.001).

CONCLUSIONS

Our study showed WrCTS injuries have declined over time. Additionally, our findings may suggest that the labor industry has a stronger association with WrCTS than the clerical industry.

Carpal Tunnel Syndrome: A National Survey to Monitor Knowledge and Operating Methods

The aim of this article was to investigate the knowledge, management, and clinical practice of Italian physiotherapists concerning patients with carpal tunnel syndrome (CTS). A national cross-sectional survey consisted of 24 questions was administered from December 2019 until February 2020. A Chi-squared independence test was run to study any difference between subgroups of the sample and responses to the questionnaire. Five hundred and eight respondents completed the survey. Most respondents (n = 225/508; 44.3%) are under 29 years old, female (n = 256/508; 50.4%) and have been working as physiotherapists for less than 5 years (n = 213/508; 41.9%). Most of respondents correctly knows about the cause (n = 455/508, 89.6%), main signs and symptoms of CTS (n = 415/508, 81.70%) and administer education, manual therapy, myofascial techniques and therapeutic exercises (n = 457/508, 89.88%). Three hundred and sixty-four (71.68%) respondents were aware of the influence of psychosocial factors on the patient’s outcomes. The survey showed greater adherence to evidences by physiotherapists holding a master’s degree. The results are mostly comparable with other surveys structured all over the world on the same topic. Italian physiotherapists management of the CTS was not always in line with current evidence. Interventions such as education, manual therapy, therapeutic exercise, nerve and tendon glide techniques are widely used, while the orthotic is only offered by half of the sample.

Prevalence and risk factors of self-reported wrist and hand symptoms and clinically confirmed carpal tunnel syndrome among office workers in China: a cross-sectional study

Background

Carpal tunnel syndrome (CTS) is a common cause of pain, numbness and tingling in the wrist and hand region and is associated with repetitive wrist and hand use in office workers. However, scarce knowledge exists about the epidemiology of clinically confirmed CTS among Chinese office workers. This study aimed to investigate the prevalence of wrist/hand symptoms and CTS in office workers in China and to identify associated risk factors.

Methods

A cross-sectional survey was carried out in a metropolitan city in China involving 969 respondents (aged 17–49 years) from 30 workplaces. A questionnaire was distributed to each participant to collect their demographic, work-related physical and psychosocial factors, and wrist and hand symptoms. The wrist and hand pain/numbness symptoms were marked on a body chart and the nature and intensity of symptoms, nocturnal symptoms, as well as aggravating activities were also recorded. Clinically confirmed CTS cases were screened based on the history, Phalen’s test, Tinel Sign and skin sensation testing among symptomatic respondents. Logistic regression was employed to estimate the odds ratio (OR) and 95% confidence interval (95% CI) for the occurrence of self-reported wrist and hand symptoms and clinically confirmed CTS.

Results

The clinically confirmed CTS prevalence was 9.6%. The prevalence of wrist and hand symptoms were 22 and 15%, respectively. Frequently working in pain was associated with higher odds of CTS. Multivariate modelling adjusted for age and gender showed that prolonged computer use time and working without breaks were associated with presence of wrist/hand symptoms (adjusted ORs: 1.11 (95% CI 1.02–1.22) and 1.88 (95% CI 1.12–3.14)). Educational level was inversely associated with CTS and smoking was associated with wrist/hand complaints (adjusted OR: 2.20 (95% CI 1.19–4.07)).

Conclusions

The prevalence of work-related clinically confirmed CTS symptoms among young office workers in China is high. Frequently working in pain is closely associated with clinically confirmed CTS. Intense computer use and no breaks at work are associated with wrist and hand symptoms.

A clinical and neurophysiological analysis of idiopathic carpal tunnel syndrome with respect to gender and occupation

Background:

Carpal tunnel syndrome (CTS) predominantly affects women. Previous studies observed more intense symptoms among women without a corresponding increase in disease severity and attributed it to reporting bias. In this study, we examined whether women are inherently more vulnerable to work related median nerve dysfunction at wrist and whether reported CTS symptoms among women correspond to the degree of median neuropathy at wrist.

Methods:

A cross-sectional study was designed for outpatients (aged 25-59 years) diagnosed with CTS. Occupational categorisation was done based on the analysis of their individual job tasks. Symptom severity (Boston Symptom Severity Scale – SSS), functional disability (Boston Functional Status Scale - FSS), and clinical (Hi – Ob scale) and neurophysiological severity (NCS grade) were determined, compared among occupational groups and were statistically analysed.

Results:

A total of 454 patients (348 women and 106 men; F: M ratio 3.28:1) were included. Among them, 191 were housewives. Female manual workers and housewives reported significantly more intense symptoms with a corresponding increase in clinical and electrophysiological severity (p < 0.001) when compared to female non-manual workers. However, no significant difference in symptoms, clinical or neurophysiological severity was found between male non-manual and manual workers. Among manual workers, women were more symptomatic than men, but clinical and neurophysiological severities were significantly higher only in the older age groups.

Conclusion:

The differential vulnerability of the female population to hand-intensive work predisposes them to severe median nerve dysfunction at wrist with proportionately higher CTS symptoms. Therefore, working women need focussed attention for remedial measures.

The Effect of High-Power and Low-Power Lasers on Symptoms and the Nerve Conduction Study in Patients With Carpal Tunnel Syndrome. A Prospective Randomized Single-Blind Clinical Trial

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment. Various treatments have been suggested for CTS and there is no consensus on their superiority and the order of their use. Laser therapy is a non-invasive treatment method for many musculoskeletal diseases, including CTS. This study aimed to determine and compare the effect of high-power lasers (HPLs) and low-power lasers (LPLs) on pain severity, function, pinch strength, and nerve conduction study findings in patients aged 30-50 years with mild or moderate CTS. Methods: This is a prospective, randomized, single-blind clinical trial. The study population included 45 patients aged 30-50 years who came to the physical medicine and rehabilitation clinic of Shohada-e-Tajrish hospital and mild or moderate CTS was confirmed for them. Patients were randomly assigned to control, LPL therapy, and HPL therapy groups. Pain, function, pinch strength, and nerve conduction study findings were recorded in all groups before, immediately and 12 weeks after the treatment. All data were compared using SPSS version 21. Results: All groups showed improvement regarding pain, function, and pinch strength. Laser therapy showed significantly better results compared to a wrist splint, but no significant difference was seen between high-power and LPL therapy groups. Nerve conduction evaluation findings did not reveal any significant difference. Conclusion: Both the wrist splint and laser therapy can improve the symptoms of carpal tunnel syndrome. HPL therapy showed better results, although not significantly different from LPL therapy.

Is Adiposity Associated with the Quality of Movement Patterns in the Mid-Adolescent Period?

This study examined the association between functional movement (FM) and adiposity in adolescent population (16–17 years). This study was conducted in a representative sample of urban adolescents as the part of the CRO-PALS longitudinal study (n = 652). Body mass index (BMI), a sum of four skinfolds (S4S), waist and hip circumference were measured, and FM was assessed via Functional Movement Screen^TM (FMS^TM). Furthermore, total FMS^TM screen was indicator of FM with the composite score ranged from 7 to 21, with higher score indicating better FM. Multilevel analysis was employed to determine the relationship between different predictors and total FMS score. In boys, after controlling for age, moderate-to-vigorous physical activity, and socioeconomic status, total FMS score was inversely associated only with BMI (β = −0.18, p < 0.0001), S4S (β = −0.04, p < 0.0001), waist circumference (β = −0.08, p < 0.0001), and hip circumference (β = −0.09, p < 0.0001). However, among girls, in adjusted models, total FMS score was inversely associated with S4S (β = −0.03, p < 0.0001), while BMI (β = −0.05, p = 0.23), waist circumference (β = −0.04, p = 0.06), and hip circumference: (β = −0.01, p = 0.70) failed to reach statistical significance. Results showed that the association between adiposity and FM in adolescence is sex-specific, suggesting that boys with overweight and obesity could be more prone to develop dysfunctional movement patterns. Therefore, exercise interventions directed toward correcting dysfunctional movement patterns should be sex-specific, targeting more boys with overweight and obesity rather than adolescent girls with excess weight.

The Palmaris Longus and Its Association with Carpal Tunnel Syndrome

Background  The palmaris tendon inserts into the palmar fascia and is positioned in close association with the transverse carpal ligament. Loading of this tendon has been demonstrated to increase carpal tunnel pressures. Purpose  The purpose of this study was to determine if a relationship exists between the palmaris tendon, carpal tunnel syndrome (CTS), and handedness. The sensitivity, specificity, positive predictive value, and negative predictive value for Schaeffer's test were calculated. Methods  A retrospective review of patient charts undergoing endoscopic carpal tunnel release was performed. Rates of palmaris longus agenesis (PLA) were compared to a population matched data set. Statistical analysis was performed using a one-proportion z -test. Schaeffer's test for the palmaris longus tendon was performed on all patients and compared to intraoperative confirmation. Results  A total of 520 carpal tunnel releases were performed in 389 consecutive patients. The frequency of PLA in this surgical cohort was significantly lower compared to the population matched dataset. No correlation between handedness and laterality of CTS or PLA was found. Schaeffer's test was evaluated to yield sensitivity (93.6%), specificity (100%), positive predictive value (100%), and negative predictive value (50.8%). Conclusion  The palmaris tendon was more prevalent in a population of patients undergoing carpal tunnel release. These findings can be used to provide further insight into the pathophysiology of CTS. While Schaeffer's test was accurate in detecting the palmaris longus tendon, a negative test was frequently incorrect. Further imaging is recommended in patients with a negative Schaeffer's test when the palmaris longus is desired for surgical utilization. Level of Evidence  This is a Level III, prognostic study.

Active and passive work breaks during simulated laparoscopy among laparoscopic surgeons: study protocol for a controlled, randomised cross-over laboratory trial

INTRODUCTION

Laparoscopy has partially replaced open surgery due to the lower infection rate for the patient and hence better and shorter recovery. However, the surgeon's physical load is higher due to longer duration static and awkward body postures, increasing the risk for developing work-related musculoskeletal disorders. Interventions of an organisational nature are work breaks, being either passive or active. The primary objectives of this study are to determine whether passive and active work breaks lead to less discomfort than no work breaks and whether active work breaks lead to less discomfort than passive work breaks.

METHODS AND ANALYSIS

A controlled, randomised cross-over trial will be performed in the laboratory, of which its protocol is described here according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement. Recruitment of 21 laparoscopic surgeons started in April 2019 and the study is ongoing. The participating surgeons will perform three 1.5 hour experimental conditions, one without work breaks, one with 2.5 min passive work breaks including rest, and one with 2.5 min active work breaks including mobility and stretching exercises. The work breaks will be taken after 30 and 60 min of work. During the experiments, outcomes will be recorded. The primary outcome is rating of perceived discomfort measured on an 11-point numeric rating scale. The secondary outcomes are performance, muscle activity of selected muscles, upper body angles, heart rate, workload and subjective evaluation of both interventions. The collected data will be tested using a one-way or two-factorial repeated-measures analysis of variance.

ETHICS AND DISSEMINATION

Ethical approval of the study protocol was received by the local medical ethical committee of the University of Tübingen in February 2019 (no 618/2018BO2). The results of this study will be presented at national and international conferences, submitted for publications in peer-reviewed journals and serve as the starting point for a feasibility study.

TRIAL REGISTRATION NUMBER

NCT03715816.

Carpal Tunnel Syndrome in Military Aviators

INTRODUCTION

The incidence of carpal tunnel syndrome (CTS) is increased in occupations exposed to repetitive motion, poor wrist posture, and vibration exposure. While all pilots are exposed to these factors, helicopter pilots are especially exposed to vibration. The study is to identify the incidence and risk factors for CTS in military aviators.

MATERIALS AND METHODS

Clearance was obtained from Tripler Army Medical Center IRB. The Defense Medical Epidemiological Database was queried for all new cases of CTS from 2006 to 2015. Incidence rates (IRs) were determined for helicopter pilots, fixed-wing pilots, and nonpilot officers. Poisson regression analysis was used to calculate adjusted IR in order to control for demographic factors. Race was also taken into account, where pilots would classify themselves into a white or non-white race, defined by each individual. Race was assessed in the study to see if there were any differences in IR of CTS between white and non-white pilots.

RESULTS

We identified 7,398 new cases of CTS among 2,319,352 person-years within the study period. Increasing age, female gender, and non-white race were significantly correlated with higher IR. Fixed-wing pilots demonstrated significantly lower adjusted IR than nonpilot officers in each age group. Helicopter pilots demonstrated higher IR than fixed-wing pilots in each age group. Helicopter pilots had lower incidence of CTS early in their career compared to nonpilot officers, but by age 40+, their IR ratio was significantly higher (1.21).

CONCLUSION

Analysis of the database indicates that fixed-wing pilot status is a protective factor against development of CTS among U.S. military officers. In contrast, helicopter pilots were found to be at an increased rate of CTS than their fixed-wing counterparts. Their incidence is comparable to their nonpilot officer peers early in their career, but is significantly increased at the senior level. Increasing age and female gender are risk factors in the military officer population as expected. Non-white race was found to increase risk in the military population, in contrast to reports of the civilian population.

Prevalence and severity of carpal tunnel syndrome symptoms among Iranian butchers and their association with occupational risk factors: Implications for ergonomic interventions

BACKGROUND

Carpal tunnel syndrome (CTS) is a common disorder among occupations where upper extremities are actively involved in. Many occupational and non-occupational risk factors may contribute to this disorder. Knowledge regarding occupational risk factors can guide us to implement interventional programs.

OBJECTIVE

The aim of the present study was to assess the prevalence and severity of CTS symptoms among butchers and their association with several occupational and non-occupational risk factors.

METHODS

In this study, 152 butchers in Hamadan, Iran, were examined. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to investigate the severity of CTS symptoms among the individuals. Several risk factors such as body mass index (BMI), wrist ratio, active working hours per day, working experience, and the ergonomic quality of hand tools used by butchers were also investigated. Statistical tests such as the crude and robust regression were used to analyze the data.

RESULTS

The prevalence of moderate and mild symptoms of CTS were 7% and 54%, respectively. Moreover, 39% of the butchers were free of CTS symptoms. Crude regression analyses showed that the severity of CTS symptoms had a significant relationship with age, work experience, active working hours per day, working hours per week, and ergonomic quality of the hand tools (p value <0.05). There was no significant relationship between the severity of CTS symptoms and wrist ratio and BMI. Results of the robust regression analysis showed a significant relationship between the severity of CTS symptoms with experience, active working hours, and quality of the hand tools.

CONCLUSION

Occupational risk factors such as working experience, active working hours per day, and the ergonomic quality of hand tools are significant risk factors of CTS symptoms among butchers. Slippery handle is the main non-ergonomic feature of knives and cleavers used by butchers. There was no association between BMI and wrist ratio with CTS symptoms.

Upper-extremity musculoskeletal disorders: how many cases can be prevented? Estimates from the COSALI cohort

Objective:

This study aimed to estimate the proportion and number of incident upper-extremity musculoskeletal disorders (UEMSD) cases attributable to occupational risk factors in a working population.

Methods:

Between 2002−2005, occupational physicians randomly selected 3710 workers, aged 20–59, from the Pays de la Loire (PdL) region. All participants underwent a standardized clinical examination. Between 2007−2010, 1611 workers were re-examined. This study included 1246 workers who were free of six main clinically diagnosed UEMSD at baseline but were diagnosed with at least one of these UEMSD at follow-up [59% of men, mean age: 38 (standard deviation 8.6) years]. Relative risks and population-attributable fractions (PAF) were calculated using Cox multivariable models with equal follow-up time and robust variance. The total number of incident UEMSD in the PdL region was estimated after adjustment of the sample weights using 2007 census data. The estimated number of potentially avoidable UEMSD was calculated by multiplying PAF by the total number of incident UEMSD in PdL.

Results:

At follow-up, 139 new cases of UEMSD (11% of the study sample) were diagnosed. This represented an estimated 129 320 incident cases in the PdL in 2007. Following adjustment for personal factors, 26 381 (20.4% of all incident UEMSD) were attributable to high physical exertion, 16 682 (12.9%) to low social support, and 8535 (6.6%) to working with arms above shoulder level.

Conclusions:

A large number and important proportion of incident UEMSD may be preventable by reducing work exposures to physical exertion and working with arms above shoulder level as well as improving social support from co-workers/supervisors.

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.