Position of the wrist associated with the lowest carpal-tunnel pressure: implications for splint design

Impact of Neurodynamic Sequencing on the Mechanical Behaviour of the Median Nerve and Brachial Plexus: An Ultrasound Shear Wave Elastography Study

BACKGROUND

When performing the Upper Limb Neurodynamic Test 1 (ULNT1), the order of joint movement can be varied to place more stress onto certain nerve segments. However, the mechanisms underlying this phenomenon are still unclear. This study aimed to analyze the differences in the stiffness of the median nerve (MN) and the brachial plexus (BP) using ultrasound shear wave elastography during three sequences of the ULNT1: standard (ULNT1-STD), distal-to-proximal (ULNT1-DIST), and proximal-to-distal (ULNT1-PROX).

METHODS

Shear wave velocity (SWV) was measured at the initial and final position of each sequence at the MN (wrist) and at the C5 and C6 nerve roots (interscalene level) in 31 healthy subjects.

RESULTS

A significant interaction was found between ULNT1 sequence and location (p < 0.001). The ULNT1-STD and ULNT1-DIST induced a greater stiffness increase in the MN (5.67 ± 0.91 m/s, +113.94%; 5.65 ± 0.98 m/s, +115.95%) compared to C5 and C6 (p < 0.001). The ULNT1-PROX resulted in a significantly smaller increase in stiffness at the MN (4.13 ± 0.86 m/s, +54.17%, p < 0.001), but a greater increase at C5 (4.88 ± 1.23 m/s, +53.39%, p < 0.001) and at C6 (4.87 ± 0.81 m/s, +31.55%). The differences for the ULNT1-PROX at C6 were only significant compared to the ULNT1-STD (p < 0.001), but not the ULNT1-DIST (p = 0.066).

CONCLUSIONS

BP and MN stiffness vary depending on the joint movement sequence during neurodynamic testing. However, the influence of the surrounding tissues may have affected SWV measurements; consequently, these results should be interpreted with caution.

Changes in Ultrasound Parameters of the Median Nerve at Different Positions of the Radiocarpal Joint in Patients with Carpal Tunnel Syndrome

Ultrasound imaging (US) is being increasingly used to aid in the diagnosis of entrapment neuropathies. This study aims to evaluate the shear modulus and cross-sectional area (CSA) of the median nerve in patients with carpal tunnel syndrome (CTS). A total of 35 patients with CTS participated in the study. CSA and shear modulus testing were performed in shear wave elastography (SWE) mode in five positions of the right and left radiocarpal joints (intermediate position 0°, 45° of extension, maximum extension, 45° of flexion, and maximum flexion). There were significant side-to-side differences in the median nerve shear modulus at each wrist position as compared to the asymptomatic side. There were significant side-to-side differences in the median nerve CSA at each wrist position as compared to the asymptomatic side. Shear modulus increases in patients with CTS at different angular positions of flexion and extension of the radiocarpal joint. In individuals with CTS, the CSA of the median nerve is greater on the symptomatic side compared to the asymptomatic side. The CSA decreases in positions of maximum extension and 45° of flexion and in maximum flexion relative to the resting position.

Shear wave elastography of transverse carpal ligament increased with simulated carpal tunnel pressure

BACKGROUND

Elevation of carpal tunnel pressure is known to be associated with carpal tunnel syndrome. This study aimed to correlate the shear wave elastography in the transverse carpal ligament (TCL) with carpal tunnel pressures using a cadaveric model.

METHODS

Eight human cadaveric hands were dissected to evacuate the tunnels. A medical balloon was inserted into each tunnel and connected to a pressure regulator to simulate tunnel pressure in the range of 0-210 mmHg with an increment of 30 mmHg. Shear wave velocity and modulus was measure in the middle of TCL.

RESULTS

SWV and SWE were significantly dependent on the pressure levels (p < 0.001), and positively correlated to the tunnel pressure (SWV: R = 0.997, p < 0.001; SWE: R = 0.996, p < 0.001). Regression analyses showed linear relationship SWV and pressure (SWV = 4.359 + 0.0263 * Pressure, R2 = 0.994) and between SWE and pressure (SWE = 48.927 + 1.248 * Pressure, R2 = 0.996).

CONCLUSION

The study indicated that SWV and SWE in the TCL increased linearly as the tunnel pressure increased within the current pressure range. The findings suggested that SWV/SWE in the TCL has the potential for prediction of tunnel pressure and diagnosis of carpal tunnel syndrome.

Current Insights into Carpal Tunnel Syndrome: Clinical Strategies for Prevention and Treatment

BACKGROUND

Carpal tunnel syndrome (CTS) is a condition that is caused by medial nerve compression, resulting in symptoms such as numbness, tightness, or weakness in the hand.

OBJECTIVES

The aim of the study was to find out the genetic modulation, mechanism, available treatment, and recommendation for carpal tunnel syndrome at its specific stage.

METHODS

Almost 200 papers were searched for this review article, and 145 articles were selected. The literature was collected from different sources like Google scholar, PubMed, a directory of open-access journals, and science.gov by using keywords, such as treatment, risk factors, recommendation, and clinical features of carpal tunnel syndrome.

RESULTS

The most efficient non-surgical treatment is methylprednisolone acetate, which reduces inflammation by acting on the glucocorticoid receptor in conjunction with immunofilling. It has also been used successfully as a second-line drug for the treatment of patients with mild or moderate conditions in order to provide relief. New non-pharmacological options include laser therapy in acupuncture, transcutaneous electric nerve stimulation (TENS), and sham therapy. Modern treatments like TENS, laser therapy, splints, and injections of methylprednisolone acetate have been demonstrated to be helpful in sporadic situations. For patients with mild and moderate problems, more research should be conducted that includes the combination of these surgical and non-surgical treatments.

CONCLUSION

We propose a multifunctional panel construct and define standard data items for future research into carpal tunnel syndrome. A discussion on idiopathic carpal tunnel syndrome, risk factors, combination of therapies, using guidelines-based recommendations and treatment should be initiated.

Neuromodulation of the median nerve in carpal tunnel syndrome, a single-blind, randomized controlled study

Background

This study aimed to evaluate the efficacy of pulsed radiofrequency applied using transcutaneous electrodes in carpal tunnel syndrome (CTS).

Methods

After randomization, the patients received two cycles of noninvasive pulsed radiofrequency (NiPRF), once weekly, or splinting (the control group) for three months. Clinical evaluations were recorded at baseline and weeks 4 and 8. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to determine the functional status and symptom severity.

Results

Sixty-two patients were followed up for three months. There was no difference between the groups in the BCTQ scores before and after treatment. The NiPRF group found a significant difference between the BCTQ measurements at all time intervals (paired sample t -test; P < 0.001). In the splint group, there was a significant difference only between the basal-1st month and basal-3rd month (paired samples t -test; P < 0.001). The main effect of the time variable was statistically significant (ANOVA; P < 0.001), but the group variable was not. There was no correlation between the BCTQ results measured at any time and the electroneuromyelogragphy findings in either group.

Conclusions

NiPRF effectively improves symptoms and functionality in patients with CTS for up to 3 months. Thus, NiPRF can be considered an easy, safe, and useful alternative treatment modality for CTS.

Biomechanical Evaluation of Pneumatic Sleeve Orthosis for Lofstrand Crutches

Crutch walking, especially when using a swing-through gait pattern, is associated with high, repetitive joint forces, hyperextension/ulnar deviation of the wrist, and excessive palmar pressure that compresses the median nerve. To reduce these adverse effects, we designed a pneumatic sleeve orthosis that utilized a soft pneumatic actuator and secured to the crutch cuff for long-term Lofstrand crutch users. Eleven non-disabled young adult participants performed both swing-through and reciprocal crutch gait patterns with and without the custom orthosis for comparison. Wrist kinematics, crutch forces, and palmar pressures were analyzed. Significantly different wrist kinematics, crutch kinetics, and palmar pressure distribution were observed in swing-through gait trials with orthosis use (p <0.001, p=0.01, p=0.03, respectively). Reductions in peak and mean wrist extension (7%, 6%), wrist range of motion (23%), and peak and mean ulnar deviation (26%, 32%) indicate improved wrist posture. Significantly increased peak and mean crutch cuff forces suggest increased load sharing between the forearm and cuff. Reduced peak and mean palmar pressures (8%, 11%) and shifted peak palmar pressure location toward the adductor pollicis denote a redirection of pressure away from the median nerve. In reciprocal gait trials, non-significant but similar trends were observed in wrist kinematics and palmar pressure distribution, whereas a significant effect of load sharing was noticed (p=0.01). These results suggest that Lofstrand crutches modified with orthosis may improve wrist posture, reduce wrist and palmar load, redirect palmar pressure away from the median nerve, and thus may reduce or prevent the onset of wrist injuries.

Measurement of the median nerve strain within the carpal tunnel using a capacitance-type strain sensor: A cadaver study

BACKGROUND

Direct and quantitative measurement of median nerve strain within the carpal tunnel has been difficult because of the technical limitations associated with conventional devices. We used capacitive sensors (C-stretch), which are thin and flexible, to measure the median nerve strain within the carpal tunnel.

METHODS

We used 12 fresh frozen upper extremity specimens. The transverse carpal ligament was left in situ, and we attached the sensor to the palmar surface of the median nerve to measure the nerve strain at 60 degrees of wrist extension. The sensor measured the median nerve strain at both the carpal tunnel site and the proximal to the carpal tunnel site before and after the carpal tunnel release. The amount of nerve excursion during wrist extension was also measured with the length change of the attached suture by a digital caliper.

FINDINGS

The mean median nerve strain within the carpal tunnel [8.07% (95 %CI:7.17-8.97)] was significantly higher than that proximal to the carpal tunnel [5.21% (95 %CI:4.46-5.97)] at the wrist extension. There was no significant difference of the mean nerve excursion within and proximal to the carpal tunnel. The mean nerve strain and excursion were unaffected by carpal tunnel release.

INTERPRETATION

These results indicated that wrist extension position might lead to increased strain on the median nerve within the carpal tunnel compared with at the proximal to the carpal tunnel. We believe that the current study might provide new information and help us understand the pathogenesis of carpal tunnel syndrome.

Carpal tunnel mechanics and its relevance to carpal tunnel syndrome

The carpal tunnel is an elaborate biomechanical structure whose pathomechanics plays an essential role in the development of carpal tunnel syndrome. The purpose of this article is to review the movement related biomechanics of the carpal tunnel together with its anatomical and morphological features, and to describe the pathomechanics and pathophysiology associated with carpal tunnel syndrome. Topics of discussion include biomechanics of the median nerve, flexor tendons, subsynovial tissue, transverse carpal ligament, carpal tunnel pressure, and morphological properties, as well as mechanisms for biomechanical improvement and physiological restoration. It is our hope that the biomechanical knowledge of the carpal tunnel will improve the understanding and management of carpal tunnel syndrome.

A comparative study of the efficacy and functionality of 10 commercially available wrist-hand orthoses in healthy females during activities of daily living

Objective

Optimal wrist/hand function facilitates the performance of activities of daily living (ADL), which are associated with independent living and increased quality of life. Rheumatological, musculoskeletal, and neurological conditions or injuries can negatively impact hand/wrist function, with wrist-hand orthoses (WHOs) being prescribed to control motion and improve wrist alignment whilst enhancing hand/wrist functionality. The objective of this follow-up study was to quantify and assess the efficacy and functionality of 10 commercially available WHOs during five ADLs.

Design

Randomised comparative functional study of the wrist/hand with and without WHOs.

Participants

Ten right-handed healthy female participants with no underlying condition or pain affecting the wrist/hand that could influence their ability to undertake ADLs.

Main outcome measures

The primary outcome was ascertaining the impact of each WHO during five ADLs. Movement was quantified in sagittal, coronal, and transverse planes with and without WHO use. The resting position, maximum mean flexion, extension, pronation, supination, and radial and ulnar deviation attained were quantified, with the time spent in wrist flexion, wrist flexion and ulnar deviation, wrist extension >15°, and radial deviation recorded. Finally, the time to complete each task was compared between conditions.

Results

At rest, four WHOs maintained the desired sagittal plane wrist position, with only one preventing radial deviation with variation observed in the transverse plane. All WHOs reduced mean maximum flexion, with only 10 out of 50 tests (20%) showing a successful restriction of flexion (p < 0.05) and 14 out of 50 (28%) showing a reduction of the time spent in flexion (p < 0.05). In 42 out of 50 tests (84%), the wrist was extended >15° for a significant amount of time (p < 0.05), with the wrist in radial deviation in 98% for a significant amount of time (p < 0.001). The wrist was flexed and in ulnar deviation for a significant time for 6 out of 50 tests (12%, p < 0.05), whilst all WHOs impacted transverse movement, with 27% reducing it significantly, and all tasks took a longer time to complete, with 46% taking a significantly longer time (p < 0.05).

Conclusion

The WHOs did not control movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief and were found to increase the time to complete the ADLs. Multifactorial design aspects influenced functionality, and there is a clear need for WHO redesign.

The effects of wrist position and radioulnar wrist compression on median nerve longitudinal mobility

BACKGROUND

Carpal tunnel syndrome is an entrapment neuropathy at the wrist characterized by compromised median nerve mobility. The purpose of this study was to investigate the effect of wrist position on median nerve longitudinal mobility in healthy subjects and the effect of radioulnar wrist compression on the median nerve mobility under non-neutral wrist positions.

METHODS

Dynamic B mode ultrasound images captured longitudinal median nerve motion in the carpal tunnel in 10 healthy subjects at wrist neutral position, 30-degree flexion, and 30-degree extension. In each position, RWC of 0, 5, 10, and 15 N were applied. One-way repeated measure analysis of variance (ANOVA), Post-hoc Tukey's tests, and the Friedman Test were used to show the significant differences of median nerve longitudinal mobility at different wrist positions and force conditions.

FINDINGS

Median nerve longitudinal mobility was found to be significantly influenced by wrist position (P < 0.05). The mobility under wrist neutral position was 3.02 mm/s, 38% higher than under wrist flexion (2.18 ± 0.60 mm/s), and 32% higher than under wrist extension (2.29 ± 0.43 mm/s). The impaired median nerve mobility was significantly restored under 10 N radioulnar wrist compression (P < 0.05), by 34.4% under wrist flexion (3.03 ± 0.85 mm/s), and 38.9% under wrist extension (3.07 ± 0.79 mm/s).

INTERPRETATION

Non-neutral wrist positions compromise median nerve longitudinal mobility, but moderate radioulnar compressive forces are beneficial in the recovery of median nerve longitudinal mobility, and may help to prevent symptoms associated with carpal tunnel syndrome.

Pharmaceutical and nutraceutical potential of natural bioactive pigment: astaxanthin

Astaxanthin (3,3'-dihydroxy-β,β-carotene-4,4'-dione) is an orange-red, lipophilic keto-carotenoid pigment. It is majorly found in marine ecosystems particularly in aquatic animals such as salmon, shrimp, trout, krill, crayfish, and so on. It is also synthesized in microalgae Heamatococcus pluvialis, Chlorococcum, Chlorella zofingiensis, red yeast Phaffia rhodozyma and bacterium Paracoccus carotinifaciens. Some aquatic and terrestrial creatures regarded as a primary and secondary sources of the astaxanthin producing and accumulating it through their metabolic pathways. Astaxanthin is the powerful antioxidant, nutritional supplement as well as promising therapeutic compound, observed to have activities against different ravaging diseases and disorders. Researchers have reported remarkable bioactivities of astaxanthin against major non-communicable chronic diseases such as cardiovascular diseases, cancer, diabetes, neurodegenerative, and immune disorders. The current review discusses some structural aspects of astaxanthin. It further elaborates its multiple potencies such as antioxidant, anti-inflammatory, anti-proliferative, anti-cancer, anti-obese, anti-diabetic, anti-ageing, anti-TB, anti-viral, anti-COVID 19, neuro-protective, nephro-protective, and fertility-enhancing properties. These potencies make it a more precious entity in the preventions as well as treatments of prevalent systematic diseases and/or disorders. Also, the review is acknowledging and documenting its powerful bioactivities in relation with the pharmaceutical as well as nutraceutical applicability.

Effectiveness of therapeutic ultrasound for the treatment of carpal tunnel syndrome (the USTINCTS trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

There has no consensus on optimal management of carpal tunnel syndrome (CTS), the most common compression neuropathy. Conservative therapy is generally accepted as first-line intervention. Therapeutic ultrasound has been widely reported to be treatment beneficial in nerve regeneration and conduction, and further accelerate compression recovery. The purpose of this study is to investigate the effectiveness of therapeutic ultrasound for CTS treatment.

METHODS AND ANALYSIS

This study protocol entails a three-arm, prospective, multicentre, randomised controlled trial. 162 eligible adult participants diagnosed with mild to moderate CTS by using criteria developed from a consensus survey by the UK Primary Care Rheumatology Society will be assigned to either (1) therapeutic ultrasound, (2) night splint or (3) therapeutic ultrasound +night splint (combined) group. Primary outcome will be difference in Symptom Severity Scale of Boston Carpal Tunnel Questionnaire (BCTQ-SSS) at 6-week between night splint and therapeutic ultrasound +night splint groups. Secondary outcomes include Functional Status Scale of BCTQ, sleep questionnaire for interrupted sleep, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Work Limitations Questionnaire-25 for functional limitations at work, Global Rating of Change for treatment success and recurrence rate, physical examination, electrophysiological and ultrasound parameters. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-152. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050701.

Short-term effects of dry needling of thenar muscles in manual laborers with carpal tunnel syndrome: a pilot, randomized controlled study

STUDY DESIGN

Pilot, randomized, single-blinded controlled clinical trial.

BACKGROUND AND OBJECTIVE

Trigger point (s) (TrPs) in thenar muscles could be a cause of narrowing of carpal tunnel in manual laborers with carpal tunnel syndrome (CTS). Effects of dry needling (DN) on the treatment of muscle tension have been reported, but no research has been done on the effect of DN on thenar tight muscles on reducing CTS symptoms. The aim of this study was to assess the effect of DN of thenar muscles TrPs in the treatment of mild-to-moderate carpal tunnel syndrome.

METHODS

Thirty manual laborers with mild-to-moderate CTS and the presence of TrP(s) in thenar muscles were randomized to DN group (n = 15) and control group (waiting list) (n = 15). The DN group received 2 sessions of DN of thenar muscles TrP(s), with a 48-h interval. The control group received no treatment. Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores were the primary outcome, while secondary outcomes included electrophysiological domains, pinch and grip strength. Outcome measures were obtained at baseline, 48 hours, and 2 weeks after treatment (follow-up). Two-way analysis of variance (2 groups × 3 times) was used to compare within- and between-group differences. Bonferroni post hoc test was used to find any significant differences in the main effect for group, time, or interaction (group time).

RESULTS

A baseline assessment revealed no intergroup differences in all evaluated parameters (P > .05). Compared to the control group, the DN group had a statistically significant improvement in pinch and grip strength, median SDL, and BCTQ score after 2 weeks (P < .05). There were no between-group differences in the assessment of motor electrophysiologic and SNCV findings (P > .05).

CONCLUSION

Dry needling of thenar TrP(s) is effective in short-term improvement of function in manual laborers with mild-to-moderate CTS.

A Comparative Study of Efficacy and Functionality of Ten Commercially Available Wrist-Hand Orthoses in Healthy Females: Wrist Range of Motion and Grip Strength Analysis

Objective: Wrist-hand orthoses (WHOs) are prescribed for a range of musculoskeletal/neurological conditions to optimise wrist/hand position at rest and enhance performance by controlling its range of motion (ROM), improving alignment, reducing pain, and optimising grip strength. The objective of this research was to study the efficacy and functionality of ten commercially available WHOs on wrist ROM and grip strength.

Design: Randomised comparative functional study of the wrist/hand with and without WHOs.

Participants: Ten right-handed female participants presenting with no underlying condition nor pain affecting the wrist/hand which could influence motion or grip strength. Each participant randomly tested ten WHOs; one per week, for 10 weeks.

Main outcome measures: The primary outcome was to ascertain the impact of WHOs on wrist resting position and flexion, extension, radial, and ulnar deviation. A secondary outcome was the impact of the WHOs on maximum grip strength and associated wrist position when this was attained.

Results: From the 2,400 tests performed it was clear that no WHO performed effectively or consistently across participants. The optimally performing WHO for flexion control was #3 restricting 86.7%, #4 restricting 76.7% of extension, #9 restricting 83.5% of radial deviation, and #4 maximally restricting ulnar deviation. A grip strength reduction was observed with all WHOs, and ranged from 1.7% (#6) to 34.2% (#4).

Conclusion: WHOs did not limit movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief. The array of motion control recorded might be a contributing factor for the current conflicting evidence of efficacy for WHOs. Any detrimental impact on grip strength will influence the types of activities undertaken by the wearer. The design aspects impacting wrist motion and grip strength are multifactorial, including: WHO geometry; the presence of a volar bar; material of construction; strap design; and quality of fit. This study raises questions regarding the efficacy of current designs of prefabricated WHOs which have remained unchanged for several decades but continue to be used globally without a robust evidence-base to inform clinical practise and the prescription of these devices. These findings justify the need to re-design WHOs with the goal of meeting users' needs.

Ultrasound-Guided Hydrodissection With Corticosteroid Injection in the Treatment of Carpal Tunnel Syndrome: A Pilot Study

OBJECTIVES

Corticosteroid injections can provide (temporary) relief in patients with mild to moderate carpal tunnel syndrome (CTS). Hydrodissection as part of an injection has been associated with positive clinical outcomes but data for CTS so far has been scarce. This study is designed to assess patient tolerance and secondarily provide pilot data on the added effect of hydrodissection.

METHODS

Twenty CTS patients were randomized to an ultrasound-guided betamethasone injection with hydrodissection (5 mL) or without (2 mL). Patient tolerance was assessed directly after intervention and patient-reported outcome after 4 and 24 weeks. Intra-group data were compared using Wilcoxon Signed Rank and inter-group with Wilcoxon rank-sum tests.

RESULTS

Tolerance and pain scores did not differ between the two groups. Symptom scores decreased in both groups, but to a lesser extent in the hydrodissection group with a mean difference of -0.8 versus -1.5 in the control group at 4 weeks (P = .02). At 6 months, this difference was no longer present (P = .81). No statistically significant differences were found between the hydrodissection and control groups in the function or pain scores at follow-up at either time point.

CONCLUSION

After injection, both symptomatic and functional scores improved, but the hydrodissected group did not show additional improvement. Data presented can be used to support larger studies to assess the value of hydrodissection in CTS management.

Shear wave elastography of the median nerve: A mechanical study

BACKGROUND

Shear wave elastography (SWE) shows promise in peripheral neuropathy evaluation but has potential limitations due to tissue size and heterogeneity. We tested SWE sensitivity to elasticity change and the effect of probe position in a median nerve cadaver model.

METHODS

Ten specimens were used to measure median nerve elasticity under increasing loads using SWE and indentation. Measurements were compared using repeated-measures analysis of variance.

RESULTS

Indentation and SWE-based longitudinal nerve elasticity increased with tensile loading (P < .01), showing a similar relationship. Acquisition in a transverse plane showed lower values compared with longitudinal measurements, mostly under higher loads (P = .03), as did postdissection elasticity (P = .02). Elasticity did not change when measured proximal to the carpal tunnel.

CONCLUSIONS

Longitudinal SWE is sensitive to changes in median nerve elasticity. Measuring elasticity of peripheral nerves noninvasively could elucidate intra-neural pathology related to compression neuropathies, and proof to be of added value as a diagnostic or prognostic tool.

Non-operative Treatment of Carpal Tunnel Syndrome

PURPOSE OF REVIEW

To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.

Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome

STUDY DESIGN

Prospective randomized study.

INTRODUCTION

Carpal tunnel syndrome (CTS) has been described as the most common compression neuropathy. Many modalities exist for conservative treatment. Efficacy of each modality has been described in the literature. However, the effectiveness of combination of these modalities is not well established. The purpose of this study is to assess the short-term clinical outcome of conservative treatment for CTS comparing orthosis alone with combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy.

METHODS

Forty-one patients who presented to Upper Limb Reconstructive and Microsurgery Clinic, University Malaya Medical Centre with CTS and positive electrodiagnostic study were recruited. Fifteen patients had bilateral CTS. Fifty-six wrists were equally randomized to orthosis alone and a combined therapy of orthosis, nerve/tendon gliding exercise, and ultrasound therapy. All patients were required to complete the Boston Carpal Tunnel Questionnaire during the first visit and 2 months after treatment.

RESULTS

Both the orthosis and combined therapy groups showed a significant improvement in symptoms and function after treatment. The mean difference of symptoms in the orthosis group was 0.53; 95% confidence interval [CI]: 0.23-0.83 (P = .001) and in the combined therapy group was 0.48; 95% CI: 0.24-0.72 (P < .001). Mean difference of function in the orthosis group was 0.59; 95% CI: 0.28-0.91 (P = .001) and combined group was 0.69; 95% CI: 0.49-0.89 (P < .001). However, there was no significant difference in symptom severity and functional status scores between the groups.

DISCUSSION

Our findings support other findings where orthosis and exercises improved symptom severity and functional status scores, however, there was no significant difference between orthosis alone and combined treatment.

CONCLUSION

Patients who underwent conservative management for CTS showed improvement in symptoms and function. However, the combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy did not offer additional benefit compared to orthosis alone.

Work-related risk factors for Carpal Tunnel Syndrome among Majmaah University female touchscreen users

Objectives:

This study aimed to explore the prevalence of carpal tunnel syndrome symptoms among female touchscreen users at Majmaah University, Saudi Arabia and to make a comparison for the wrist range of motion between probable CTS and non-CTS female touchscreen users.

Methods:

Two hundred and twenty-two female touchscreen users were enrolled in the present study. Among this cohort, fifty-two were academic members, 40 were employees and 130 were undergraduates. A Digital Inclinometer device was used to assess ROM of the wrist movements. A computer-based questionnaire, Phalen’s test, and Tinel’s sign were used to investigate the presence of CTS symptoms. The study was conducted between November 2018 and February 2019 at Majmaah University.

Results:

The prevalence of probable CTS was 34.2% among touchscreen users; the percent of probable CTS was significantly higher in undergraduates compared to other touchscreen users. There was a significant reduction in wrist flexion between the tested groups.

Conclusion:

Female touchscreen users at Majmaah University tended to have a high-risk for CTS. Wrist ROM measurements, particularly wrist flexion, could be a beneficial indicator for anticipating deviations in wrist posture after long-term touchscreen use. It is necessary to consider the job nature, age, BMI, and duration of using touchscreen as risk factors for CTS symptoms.

Prospective evaluation of sleep improvement after cubital tunnel decompression surgery

BACKGROUND

Compromised sleep is a known phenomenon with compressive neuropathies such as carpal tunnel syndrome. However, the prevalence of sleep disturbance with cubital tunnel syndrome (CuTS) and the effect on sleep after ulnar nerve decompression are not well understood. We hypothesized that CuTS results in sleep disturbances and that decompression surgery would result in improvement in overall sleep quality.

METHODS

Consecutive patients with electrodiagnostic-proven CuTS indicated for decompression were prospectively enrolled. Demographic data, McGowan grade, electrodiagnostic (electromyography) severity, visual analog scale pain score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Insomnia Severity Index scale data were collected preoperatively and at 2 weeks and 3 months postoperatively.

RESULTS

There were 145 patients enrolled, with 97% available at 2 weeks and 72% available at the final 3-month follow-up. Surgical decompression procedures consisted of 102 in situ releases and 43 transpositions. The average preoperative Insomnia Severity Index score for the entire cohort was 10.7, above the threshold for a diagnosis of insomnia, which subsequently improved to 4.1 by final follow-up postoperatively, consistent with resolution of the insomnia. There was no difference in the extent of sleep improvement between in situ decompression and transposition. Similarly, electromyography severity and McGowan grade also did not appear to significantly affect the extent of sleep improvement.

CONCLUSION

CuTS decompression surgery, irrespective of surgical type and preoperative severity, resulted in improvement in sleep by the 3 month postoperative visit.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

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

Preferences in Sleep Position Correlate With Nighttime Paresthesias in Healthy People Without Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome has been associated with sleep position preferences. The aim of this study is to assess self-reported nocturnal paresthesias and sleeping position in participants with and without carpal tunnel syndrome diagnosis to further clinical knowledge for preventive and therapeutic interventions.

METHODS

A cross-sectional survey study of 396 participants was performed in young adults, healthy volunteers, and a patient population. Participants were surveyed on risk factors for carpal tunnel syndrome, nocturnal paresthesias, and sleep preferences. Binary logistic regression analysis was performed comparing participants with rare and frequent nocturnal paresthesias. Subanalyses for participants without carpal tunnel syndrome under and over 21 years of age were performed on all factors significantly associated with subclinical compression neuropathy in the overall population.

RESULTS

Thirty-three percent of the study population experienced nocturnal paresthesias at least weekly. Increased body mass index ( P < .001) and sleeping with the wrist flexed ( P = .030) were associated with a higher frequency of nocturnal paresthesias. Side sleeping was associated with less frequent nocturnal symptoms ( P = .003). In participants without carpal tunnel syndrome, subgroup analysis illustrated a relationship between nocturnal paresthesias and wrist position. In participants with carpal tunnel syndrome, sleeping on the side had a significantly reduced frequency of nocturnal paresthesias.

CONCLUSION

This study illustrates nocturnal paresthesias in people without history of carpal tunnel syndrome including people younger than previously reported. In healthy patients with upper extremity subclinical compression neuropathy, sleep position modification may be a useful intervention to reduce the frequency of nocturnal symptoms prior to developing carpal tunnel syndrome.

Ultrasonographic imaging of the effects of continuous, pulsed or sham ultrasound treatments on carpal tunnel syndrome: A randomized controlled study

BACKGROUND

Clinical and electrophysiological effects of therapeutic ultrasound (US) were researched in many studies on patients with CTS with conflicting results.

OBJECTIVE

To assess the effects of continuous and pulsed US treatments by ultrasonographic imaging in addition to clinical and electrophysilogical parameters in patients with carpal tunnel syndrome (CTS).

METHOD

Fifty-four patients with idiopathic CTS were randomly divided into three groups. All patients used night splints for two weeks. In addition to splint therapy, continuous, pulsed or sham US treatments were applied to patients 10 min/session, 5 sessions/week for two weeks. Clinical situation (pain, hand function, strength), electrophysiological studies (motor distal latency, MDL, sensorial distal latency, SDL), and ultrasonographic area measurements of median nerve were evaluated. All evaluations were applied at pretreatment (baseline), posttreatment (2nd week) and in the 6th week.

RESULTS

Whereas significant differences were detected for clinical, functional and ultrasonographic imaging findings in each group in the 2nd week and 6th week compared to baseline (p< 0.0167 for both), no electrophysiological improvements were detected in pulsed-US (p> 0.0167) and only improvement for SDL in sham US group in the 2nd week evaluation (p< 0.0167).

CONCLUSION

According to the results of this study, continuous, pulsed or sham US treatments combined with splinting had similar effects on clinical, electrophysiological and ultrasonographic imaging improvements. Additionally, ultrasonographic imaging may be a preferable objective evaluation tool to prove the early posttreatment clinical improvements when electrophysiological changes could not be detected.

Differences in typing forces, muscle activity, wrist posture, typing performance, and self-reported comfort among conventional and ultra-low travel keyboards

This study investigated the relative impact of ultra-low travel keyboards on typing force, muscle activity, wrist posture, typing performance, and self-reported comfort/preference as compared to a conventional keyboard. In a repeated-measures laboratory-based study, 20 subjects were invited to type for 10 min on each of five keyboards with different travel distances of 0.5, 0.7, 1.2, 1.6 (ultra-low travel keyboards), and 2.0 mm (a conventional keyboard). During the typing sessions, we measured typing force; muscle activity in extrinsic finger muscles (flexor digitorum superficialis and extensor digitorum communis), shoulder (trapezius) and neck (splenius capitis); wrist posture; typing performance; and self-reported comfort/preference. While using the ultra-low travel keyboards, subjects typed with less force and wrist extension, and had more ulnar deviation (p's < 0.0001) compared with conventional keyboard. However, these differences in typing forces were less than 0.5 N and less than 4° for both wrist extension and ulnar deviation. The general trend of data did not show any consistent or substantial differences in muscle activity (less than 2 %MVC) and typing performance (<5 WPM in speed; < 3% in accuracy), despite the observed statistical difference in the finger flexors and extensors muscle activity (p's < 0.19) and typing performance (p < 0.0001). However, the subjects preferred using conventional keyboards in most of the investigated self-reported comfort and preference criteria (p's < 0.4). In conclusion, these small differences indicate that using ultra-low travel keyboards may not have substantial differences in biomechanical exposures and typing performance compared to conventional keyboard; however, the subjective responses indicated that the ultra-low keyboards with the shortest key travel tended to be the least preferred.

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.

Changes in the pressure distribution by wrist angle and hand position in a wrist splint

The study was conducted to provide basic data to develop a system that distributes pressure over a broader area by measuring and analyzing pressures in various wrist angles and hand positions while wearing a wrist splint. With 0, 15, 30, and 45 degrees of wrist extension, full-finger extension and finger flexion, pressure distribution changes were measured three times. Average peak pressure was analyzed and mean value picture (MVP) in zones 3-5 was calculated. A one-way Anova was conducted to identify changes in pressure distribution by wrist angle and hand position. Mean peak pressure values (kPa) in zones 3-5 changed depending on the wrist angle. Peak pressures (kPa) changed significantly in 15, 30, and 45 degrees wrist extension, depending on the hand position. Since pressure distributions differ depending the wrist angle and hand position (finger flexion), it is necessary to consider how pressure varies in each wrist position and to provide information on postures that should be avoided during tasks and occupational activities based on various wrist angles or hand positions.

The biomechanics of subsynovial connective tissue in health and its role in carpal tunnel syndrome

Carpal Tunnel Syndrome (CTS) is the most common surgically treated problem in the hand. Aside from the neuropathy itself, the most common findings are fibrosis of the subsynovial connective tissue (SSCT) and increased intra carpal tunnel pressure. Normally, the SSCT is a multilayer tissue interspersed among the carpal tendons and nerve. As the tendons move, successive SSCT layers are recruited, forming a gliding unit and providing a limit to differential movement. Exceeding this limit, damages the SSCT as has been shown in both cadavers and animal models. This damage leads to a non-inflammatory response with progressive fibrosis and nerve ischemia leaving the SSCT more susceptible to injury. Although the direct consequences for patients are not fully understood, ultrasound research shows that this fibrosis restricts median nerve displacement during tendon loading. This article aims to provide insights into the mechanical properties of SSCT described so far and place it in the context of CTS pathophysiology. A theoretical damage model concerning the SSCT is proposed showing a chain of events and vicious cycles that could lead to the nerve compression as it is found in CTS. Although not complete, this model could explain the pathophysiological pathway of idiopathic CTS.

The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol

BACKGROUND

Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months.

METHOD/DESIGN

A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up.

DISCUSSION

The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions.

TRIAL REGISTRATION

Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

Comparison of the efficacy of a neutral wrist splint and a wrist splint incorporating a lumbrical unit for the treatment of patients with carpal tunnel syndrome

BACKGROUND

Different types of splints have been used as a conservative intervention to improve symptoms in patients with Carpal tunnel syndrome (CTS). Although a number of studies have been undertaken to compare different splints, information and understanding of the influence of these interventions are lacking.

OBJECTIVES

The purpose of this study was to compare the effect of a classic thermoplastic wrist splint or a wrist splint with an additional metacarpophalangeal unit on pain, function, grip strength, and pinch strength in patients with mild-to-moderate carpal tunnel syndrome.

STUDY DESIGN

Quasi experimental design.

METHODS

A total of 24 patients received conservative treatment using either the classic wrist splint or the wrist splint with the metacarpophalangeal unit for a period of 6 weeks. Primary outcome measures were pain, function, grip strength, and pinch strength. Data were collected immediately before and after using the two types of splints at baseline (0 weeks) and 6 weeks. Statistical analysis was performed using the paired t-test and an independent t-test.

RESULTS

Compared to baseline, both the classic thermoplastic wrist splint and the wrist splint with a metacarpophalangeal unit significantly decreased pain and increased function, pinch strength, and grip strength. Comparisons of the two types of splints for grip strength (P = 0.675) and pinch strength (P = 0.650) revealed that there were no significant differences between the two after 6 weeks of wear. However, there were significant differences in pain levels (P = 0.022) and the Disability of the Arm, Shoulder, and Hand score (P = 0.027) between the two types of splints from baseline to 6 weeks.

CONCLUSION

The wrist splint with a metacarpophalangeal unit was more effective than the classic thermoplastic wrist splint in pain reduction and improvement of function.

CLINICAL RELEVANCE

A wrist splint with a metacarpophalangeal unit may be an appropriate conservative treatment in the rehabilitation of patients with mild-to-moderate carpal tunnel syndrome.

Influence of smartphone use styles on typing performance and biomechanical exposure

Twenty-seven subjects completed 2-min typing tasks using four typing styles: right-hand holding/typing (S-thumb) and two-hand typing at three heights (B-low, B-mid and B-high). The styles had significant effects on typing performance, neck and elbow flexion and muscle activities of the right trapezius and several muscles of the right upper limb (p < 0.0001 by repeated-measure analysis of variance). The subjects typed the fewest words (error-adjusted characters per minute: 78) with the S-thumb style. S-thumb style resulted in similar flexion angles of the neck, elbow and wrist, but significantly increased muscle activities in all tested muscles compared with the B-mid style. Holding the phone high or low reduced the flexion angles of the neck and right elbow compared with the B-mid style, but the former styles increased the muscle activity of the right trapezius. Right-hand holding/typing was not a preferable posture due to high muscle activities and slow typing speed. Practitioner Summary: Right-hand holding/typing was not favoured, due to increased muscle activities and slower typing speed. Holding the phone high or low reduced the flexion angles of the neck and right elbow, but the former styles increased the muscle activity of the right trapezius compared with holding the phone at chest level.

A vertical mouse and ergonomic mouse pads alter wrist position but do not reduce carpal tunnel pressure in patients with carpal tunnel syndrome

Non-neutral wrist positions and external pressure leading to increased carpal tunnel pressure during computer use have been associated with a heightened risk of carpal tunnel syndrome (CTS). This study investigated whether commonly used ergonomic devices reduce carpal tunnel pressure in patients with CTS. Carpal tunnel pressure was measured in twenty-one patients with CTS before, during and after a computer mouse task using a standard mouse, a vertical mouse, a gel mouse pad and a gliding palm support. Carpal tunnel pressure increased while operating a computer mouse. Although the vertical mouse significantly reduced ulnar deviation and the gel mouse pad and gliding palm support decreased wrist extension, none of the ergonomic devices reduced carpal tunnel pressure. The findings of this study do therefore not endorse a strong recommendation for or against any of the ergonomic devices commonly recommended for patients with CTS. Selection of ergonomic devices remains dependent on personal preference.

Effects of portable computing devices on posture, muscle activation levels and efficiency

Very little research exists on ergonomic exposures when using portable computing devices. This study quantified muscle activity (forearm and neck), posture (wrist, forearm and neck), and performance (gross typing speed and error rates) differences across three portable computing devices (laptop, netbook, and slate computer) and two work settings (desk and computer) during data entry tasks. Twelve participants completed test sessions on a single computer using a test-rest-test protocol (30min of work at one work setting, 15min of rest, 30min of work at the other work setting). The slate computer resulted in significantly more non-neutral wrist, elbow and neck postures, particularly when working on the sofa. Performance on the slate computer was four times less than that of the other computers, though lower muscle activity levels were also found. Potential or injury or illness may be elevated when working on smaller, portable computers in non-traditional work settings.

Biomechanical role of the transverse carpal ligament in carpal tunnel compliance

The transverse carpal ligament (TCL) is a significant constituent of the wrist structure and forms the volar boundary of the carpal tunnel. It serves biomechanical and physiological functions, acting as a pulley for the flexor tendons, anchoring the thenar and hypothenar muscles, stabilizing the bony structure, and providing wrist proprioception. This article mainly describes and reviews our recent studies regarding the biomechanical role of the TCL in the compliant characteristics of the carpal tunnel. First, force applied to the TCL from within the carpal tunnel increased arch height and area due to arch width narrowing from the migration of the bony insertion sites of the TCL. The experimental findings were accounted for by a geometric model that elucidated the relationships among arch width, height, and area. Second, carpal arch deformation showed that the carpal tunnel was more flexible at the proximal level than at the distal level and was more compliant in the inward direction than in the outward direction. The hamate-capitate joint had larger angular rotations than the capitate-trapezoid and trapezoid-trapezium joints for their contributions to changes of the carpal arch width. Lastly, pressure application inside the intact and released carpal tunnels led to increased carpal tunnel cross-sectional areas, which were mainly attributable to the expansion of the carpal arch formed by the TCL. Transection of the TCL led to an increase of carpal arch compliance that was nine times greater than that of the intact carpal tunnel. The carpal tunnel, while regarded as a stabile structure, demonstrates compliant properties that help to accommodate biomechanical and physiological variants such as changes in carpal tunnel pressure.

Carpal tunnel syndrome - Part II (treatment)

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2-0.5%.

Evaluation and treatment of chronic hand conditions

Hand and wrist problems are frequently the cause of patients' complaints in the primary care setting. Common problems include hand numbness, pain, loss of motion, or unexplained masses in the hand. Many problems can be successfully managed or treated with nonoperative measures. This article focuses on commonly encountered causes of chronic hand pain.

Effect of custom-made and prefabricated orthoses on grip strength in persons with carpal tunnel syndrome

BACKGROUND

Based on the literature, patients with carpal tunnel syndrome are suggested to wear a custom-made wrist orthosis immobilizing the wrist in a neutral position. Many prefabricated orthoses are available on the market, but the majority of those do not assure neutral wrist position.

OBJECTIVES

We hypothesized that the use of orthosis affects grip strength in persons with carpal tunnel syndrome in a way that supports preference for custom-made orthoses with neutral wrist position over prefabricated orthoses.

STUDY DESIGN

Experimental.

METHODS

Comparisons of grip strength for three types of grips (cylindrical, lateral, and pinch) were made across orthosis types (custom-made, prefabricated with wrist in 20° of flexion, and none) on the affected side immediately after fitting, as well as between affected side without orthosis and nonaffected side.

RESULTS

Orthosis type did not significantly affect grip strength (p = 0.661). Cylindrical grip was by far the strongest, followed by lateral and pinch grips (p < 0.050). The grips of the affected side were weaker than those of the nonaffected side (p = 0.002).

CONCLUSIONS

In persons with carpal tunnel syndrome, neither prefabricated orthoses with 20° wrist extension nor custom-made wrist orthoses with neutral wrist position influenced grip strength of the affected hand. Compared to the nonaffected side, the grips of the affected side were weaker.

CLINICAL RELEVANCE

The findings from this study can be used to guide application of orthoses to patients with carpal tunnel syndrome.

Effect of grip type, wrist motion, and resistance level on pressures within the carpal tunnel of normal wrists

Elevated carpal tunnel pressure (CTP) has been associated with carpal tunnel syndrome. This study systematically evaluated the effect of wrist motion resistance and grip type on CTP during wrist motion typical of occupational tasks. CTP during four wrist motion patterns, with and without resistance, and with and without gripping, was measured in vivo in 14 healthy individuals. CTP measured during compound motions fell between that measured in the cardinal planes of wrist flexion/extension and radial/ulnar deviation. Generally, with no active gripping there was little pressure change due to wrist angular displacement or resistance level. However, concurrent active pinch or power grip increased CTP particularly in motions including extension. CTP typically did not increase during wrist flexion, and in fact often decreased. Extension motions against resistance when employing a pinch or power grip increase CTP more than motions with flexion. Results could help inform design or modification of wrist motion intensive occupational tasks. © 2014 The Authors.

[Ergonomically designed radiology workplace]

An ergonomically designed radiology workplace is a key factor for concentrated work during the whole day and is essential in preventing negative long-term effects due to inappropriate physical strain. To avoid such negative effects it is of paramount importance to know the factors that might cause strain on the radiologist, the appropriate application for workplace design to address these factors and how work-related disorders emerge. To minimize physical strain due to long-lasting and repetitive movements, the workspace must be adapted to the physical needs of the radiologist. Adjustable settings for the work desk and seat, together with correct screen positioning and distance from the screen, are examples of such important factors in an ergonomic workplace design. In addition, adjustable ambient light, an adjustable conditioned climate, an appropriate color design for the environment and a reduction of unnecessary noise are also crucial factors for an ergonomic workplace. This review gives an overview about the factors that influence the radiology workspace and summarizes the current literature on this topic.

Sensitivity and specificity of clinical testing for carpal tunnel syndrome

OBJECTIVE

The present study evaluated the sensitivity, specificity and predictive values of six clinical tests in the diagnosis of carpal tunnel syndrome (CTS).

METHODS

There were 29 carpal tunnel syndrome (CTS) subjects (mean age 48 years) and 30 control subjects (mean age 45 years). The six clinical tests included Tinel's sign, wrist flexion with fingers extended, wrist flexion with fingers flexed, wrist extension, combined wrist extension/median nerve pressure and combined wrist flexion/median nerve pressure.

RESULTS

The highest sensitivity and highest negative predictive value was found with wrist flexion with pressure (96%) and wrist extension with pressure (94%) at 60 s. The highest specificity was found with wrist flexion with fingers flexed for 30 s (95%). The highest positive predictive values were found with the wrist flexion with fingers flexed test for 30 s (91%) and the wrist extension test for 30 s (90%).

CONCLUSION

No one test possesses all the qualities necessary to be the ideal clinical test for the detection of carpal tunnel syndrome.

Finger position alters the median nerve properties within the carpal tunnel: a pre-post MRI comparison study

Purpose

The purpose of this study was to compare the properties of the median nerve and the flexor retinaculum within the carpal tunnel with Magnetic Resonance Imaging (MRI) under two conditions: (a) fingers extended, and (b) fingers in an isometric squeeze grip.

Methods

Thirty-Four volunteers participated in this experimental study. The flexor retinaculum and median nerve characteristics were measured during both conditions using MRI.

Results

The isometric squeeze grip condition resulted in significant palmar bowing of the flexor retinaculum (t = 7.67, p<.001), a significant flattening-ratio of the median nerve (t = 4.308, p<.001), and no significant decrease in the cross-sectional area of the median nerve (t = 2.508, p = 0.017).

Conclusion

The isometric squeeze grip condition resulted in anatomical deformations within the carpal tunnel, possibly explained by the lumbrical muscles incursion into the carpal tunnel during finger flexion.

Novel ergonomic postural assessment method (NERPA) using product-process computer aided engineering for ergonomic workplace design

Background

Musculoskeletal disorders (MSDs) that result from poor ergonomic design are one of the occupational disorders of greatest concern in the industrial sector. A key advantage in the primary design phase is to focus on a method of assessment that detects and evaluates the potential risks experienced by the operative when faced with these types of physical injuries. The method of assessment will improve the process design identifying potential ergonomic improvements from various design alternatives or activities undertaken as part of the cycle of continuous improvement throughout the differing phases of the product life cycle.

Methodology/Principal Findings

This paper presents a novel postural assessment method (NERPA) fit for product-process design, which was developed with the help of a digital human model together with a 3D CAD tool, which is widely used in the aeronautic and automotive industries. The power of 3D visualization and the possibility of studying the actual assembly sequence in a virtual environment can allow the functional performance of the parts to be addressed. Such tools can also provide us with an ergonomic workstation design, together with a competitive advantage in the assembly process.

Conclusions

The method developed was used in the design of six production lines, studying 240 manual assembly operations and improving 21 of them. This study demonstrated the proposed method’s usefulness and found statistically significant differences in the evaluations of the proposed method and the widely used Rapid Upper Limb Assessment (RULA) method.

A comparison study of the volar wrist cock-up splint and ulnar gutter splint in carpal tunnel syndrome

The objective of the study was to compare the effects of the volar wrist cock-up splint and the ulnar gutter splint on three dependent measures: level of comfort, pain relief and hand function, in clients with early symptoms of carpal tunnel syndrome. Four clients with initial onset of carpal tunnel syndrome symptoms participated in a study with alternating treatment design that compared the effects of the two splints. Comfort and pain were measured with perceived analogue scales and hand function was assessed using six sub-tests of the Jebsen Hand Function test. Evaluations were done every 2 weeks concurrent with the alternation of the splints for a period of 8 weeks. Descriptive analysis was used to identify differences in the dependent measures. Three participants showed improved performance in hand function tests with reduced time taken in tests following use of splints. Three participants showed reduced pain after splint use. One participant did not show changes with time taken in hand function tests or with level of pain. The study showed clinical evidence that both the splints contributed to alleviation of carpal tunnel syndrome symptoms. It is imperative that more efficacy studies be done to gain more confidence with the results of this study.

Effect of splinting and exercise on intraneural edema of the median nerve in carpal tunnel syndrome--an MRI study to reveal therapeutic mechanisms

Splinting and nerve and tendon gliding exercises are commonly used to treat carpal tunnel syndrome (CTS). It has been postulated that both modalities reduce intraneural edema. To test this hypothesis, 20 patients with mild to moderate CTS were randomly allocated to either night splinting or a home program of nerve and tendon gliding exercises. Magnetic resonance images of the wrist were taken at baseline, immediately after 10 min of splinting or exercise, and following 1 week of intervention. Primary outcome measures were signal intensity of the median nerve at the wrist as a measure of intraneural edema and palmar bowing of the carpal ligament. Secondary outcome measures were changes in symptom severity and function. Following 1 week of intervention, but not immediately after 10 min, signal intensity of the median nerve was reduced by ≈ 11% at the radioulnar level for both interventions (p = 0.03). This was accompanied by a mild improvement in symptoms and function (p < 0.004). A similar reduction in signal intensity is not observed in patients who only receive advice to remain active. No changes in signal intensity were identified further distally (p > 0.28). Ligament bowing remained unchanged (p > 0.08). Intraneural edema reduction is a likely therapeutic mechanism of splinting and exercise.

The validity of upper-limb neurodynamic tests for detecting peripheral neuropathic pain

The validity of upper-limb neurodynamic tests (ULNTs) for detecting peripheral neuropathic pain (PNP) was assessed by reviewing the evidence on plausibility, the definition of a positive test, reliability, and concurrent validity. Evidence was identified by a structured search for peer-reviewed articles published in English before May 2011. The quality of concurrent validity studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool, where appropriate. Biomechanical and experimental pain data support the plausibility of ULNTs. Evidence suggests that a positive ULNT should at least partially reproduce the patient's symptoms and that structural differentiation should change these symptoms. Data indicate that this definition of a positive ULNT is reliable when used clinically. Limited evidence suggests that the median nerve test, but not the radial nerve test, helps determine whether a patient has cervical radiculopathy. The median nerve test does not help diagnose carpal tunnel syndrome. These findings should be interpreted cautiously, because diagnostic accuracy might have been distorted by the investigators' definitions of a positive ULNT. Furthermore, patients with PNP who presented with increased nerve mechanosensitivity rather than conduction loss might have been incorrectly classified by electrophysiological reference standards as not having PNP. The only evidence for concurrent validity of the ulnar nerve test was a case study on cubital tunnel syndrome. We recommend that researchers develop more comprehensive reference standards for PNP to accurately assess the concurrent validity of ULNTs and continue investigating the predictive validity of ULNTs for prognosis or treatment response.