How T118M peripheral myelin protein 22 predisposes humans to Charcot-Marie-Tooth disease.

Data from gnomAD indicate that a missense mutation encoding the T118M variation in human peripheral myelin protein 22 (PMP22) is found in roughly one of every 75 genomes of western European lineage (1:120 in the overall human population). It is unusual among PMP22 variants that cause Charcot-Marie-Tooth (CMT) disease in that it is not 100% penetrant. Here, we conducted cellular and biophysical studies to determine why T118M PMP22 predisposes humans to CMT, but with only incomplete penetrance. We found that T118M PMP22 is prone to mistraffic but differs even from the WT protein in that increased expression levels do not result in a reduction in trafficking efficiency. Moreover, the T118M mutant exhibits a reduced tendency to form large intracellular aggregates relative to other disease mutants and even WT PMP22. NMR spectroscopy revealed that the structure and dynamics of T118M PMP22 resembled those of WT. These results show that the main consequence of T118M PMP22 in WT/T118M heterozygous individuals is a reduction in surface-trafficked PMP22, unaccompanied by formation of toxic intracellular aggregates. This explains the incomplete disease penetrance and the mild neuropathy observed for WT/T118M CMT cases. We also analyzed BioVU, a biobank linked to deidentified electronic medical records, and found a statistically robust association of the T118M mutation with the occurrence of long and/or repeated episodes of carpal tunnel syndrome. Collectively, our results illuminate the cellular effects of the T118M PMP22 variation leading to CMT disease and indicate a second disorder for which it is a risk factor.

A positioning approach to upper extremity sonographic evaluation and intervention.

Total supported abduction, or TSA, is a position for ultrasound evaluations and guided interventions of the upper extremity. It provides optimal access to the medial arm through the volar wrist and palmar hand for diagnostic evaluations of the median and ulnar nerves as well as procedures including injections for carpal tunnel syndrome, ulnar neuropathy at the elbow, and stenosing tenosynovitis. It enables ease of both ipsilateral and bilateral evaluations/interventions without the need for significant positional changes by the patient or physician. Incorporation of TSA may enhance clinical efficiency by reducing the amount of time, materials, and space required to provide such services.

T2 magnetic resonance imaging mapping and morphology of the median nerve before and after surgery in carpal tunnel syndrome.

INTRODUCTION/AIMS: T2 magnetic resonance imaging (MRI) mapping has been applied to carpal tunnel syndrome (CTS) for quantitative assessment of the median nerve. However, quantitative changes in the median nerve before and after surgery using T2 MRI mapping remain unclear. We aimed to investigate whether pathological changes could be identified by pre- and postoperative T2 MRI mapping of the median nerve in CTS patients after open carpal tunnel release. METHODS: This was a prospective study that measured median nerve T2 and cross-sectional area (CSA) values at the distal carpal tunnel, hamate bone, proximal carpal tunnel, and forearm levels pre- and postoperatively. Associations between T2, CSA, and nerve conduction latency were also evaluated. RESULTS: A total of 36 patients with CTS (mean age, 64.5 ± 11.7 years) who underwent surgery were studied. The mean preoperative T2 values significantly decreased from 56.3 to 46.9 ms at the proximal carpal tunnel levels (p = .001), and from 52.4 to 48.7 ms at the hamate levels postoperatively (p = .04). Although there was a moderate association between preoperative T2 values at the distal carpal tunnel levels and distal motor latency values (r = -.46), other T2 values at all four carpal tunnel levels were not significantly associated with CSA or nerve conduction latency pre- or postoperatively. DISCUSSION: T2 MRI mapping of the carpal tunnel suggested a decrease in nerve edema after surgery. T2 MRI mapping provides quantitative information on the median nerve before and after surgery.

Refining quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome to account for acceptable variations in practice: Expert review process.

INTRODUCTION/AIMS: Using a set of process-of-care quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS), the research team previously documented large variations in electrodiagnostic testing practices and adherence to quality measures. This study sought to enhance the applicability and validity of the quality measures by integrating acceptable variations in testing practices. METHODS: We recruited 13 expert electrodiagnostic medicine specialists from five specialty societies. The experts iteratively refined five quality measures, and then rated the validity of the refined quality measures (1-9 scale). During this process, the experts reviewed data on adherence to existing quality measures and variations in electrodiagnostic testing practices, and considered recently published quality measures from the American Association of Neuromuscular and Electrodiagnostic Medicine. RESULTS: Three quality measures (electrodiagnostic testing before surgery for CTS, temperature assessment during electrodiagnostic testing, and electrodiagnostic criteria for severe median neuropathy) underwent few refinements and were rated valid (medians 8-9). Two measures (essential components of electrodiagnosis, criteria for interpreting electrodiagnostic tests as median neuropathy) were judged valid (medians 8) after revisions. For these measures, experts' ratings on the recommended components of sensory or mixed nerve conduction studies varied: agreement among the experts about the use of sensory peak latency was greater than for onset latency or sensory velocity. DISCUSSION: This study produced quality measures that provide minimum standards for electrodiagnostic testing for suspected CTS that are more comprehensive and nuanced than prior versions. Future work can assess the feasibility, reliability, and validity of these refined measures in diverse physician practices.

Comparison of the Effect of Intracarpal Injection of Ketorolac With Triamcinolone in Carpal Tunnel Syndrome: A Randomized Controlled Trial.

BACKGROUND: The most prevalent entrapment neuropathy is carpal tunnel syndrome (CTS). Although nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed for musculoskeletal disorders, oral NSAIDs do not provide any additional benefits for CTS. Nevertheless, the use of NSAID phonophoresis has shown significant improvement, possibly due to increased concentration in the target tissue. The effects of intracarpal injection of NSAIDs on CTS have not been studied. OBJECTIVE: We conducted a controlled trial to compare the efficacy of ketorolac and triamcinolone in treating CTS. METHODS: Mild to moderate CTS patients were randomly assigned to receive either a local injection of 30 mg ketorolac or 40 mg triamcinolone. Patients were evaluated using visual analog scale (VAS) for pain, severity, function, electrodiagnostic findings, patient satisfaction, and any complications at the injection site, at baseline and 12 weeks after the procedures. RESULTS: Fifty patients participated, and 43 completed the study. Both groups showed significant improvement in the VAS, severity, function, and electrodiagnostic scores at 3 months compared with the baseline. A comparison of the groups showed significant differences in VAS, severity, and function, with the improvement being significantly higher in the triamcinolone group. CONCLUSION AND RELEVANCE: The present study showed that injection of triamcinolone or ketorolac into the carpal tunnel relieved pain, increased function, and improved electrodiagnostic findings in patients with mild to moderate CTS. It also showed that triamcinolone was superior to ketorolac in terms of analgesic effect and resulted in greater improvement in symptom severity and function.

Efficacy of topical curcumin on mild to moderate carpal tunnel syndrome: a randomized double-blind, placebo-controlled clinical trial.

OBJECTIVES: Recently, there has been a renewed interest in traditional medicine for carpal tunnel syndrome (CTS). Curcumin has been reported as an agent with antioxidant, anti-inflammatory, analgesic, and neuroprotective attributes. This study is one of the first investigations to assess the effect of curcumin gel on CTS. METHODS: This study is a prospective, 8-week, randomized, placebo-controlled, parallel-group clinical trial. A total of 70 patients with CTS were analyzed. The intervention group (n = 35) received a topical curcumin gel and a night wrist splint and the control group (n = 35) received a placebo gel and a night wrist splint for 8 weeks. The primary outcome was the assessment of the symptom severity scale (SSS) and functional status scale (FSS) of the participants using the Boston Carpal Tunnel Questionnaire (BCTQ) after 8 weeks. In addition, all participants were evaluated by electrodiagnostic (EDX) test at baseline and after 8 weeks. RESULTS: The mean scores of SSS demonstrated a significant decrease in the curcumin group compared to the placebo group; P-value= 0.021. The mean change score of SSS after the intervention was 12.45 ± 8.18 in curcumin and 3.28 ± 7.06 in the placebo group; P-value = 0.0001 and the mean change score of FSS were 6.24 ± 4.91 and 2.31 ± 4.95 in curcumin and placebo groups, respectively; P-value = 0.002. However, the EDX study showed no significant changes in both groups. CONCLUSIONS: It seems that curcumin gel could be effective in the improvement of the symptom severity and daily activity of patients with CTS.

"Mild", "Moderate", or "Severe" Carpal Tunnel Syndrome? Depends on Who You Ask: Analysis of Existing Classification Systems in 665 Hands.

OBJECTIVES: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in the body and impacts approximately 5% of the U.S. population costing nearly $5 billion/year. Electrodiagnostic (EDX) testing is considered the gold standard for CTS diagnosis. Classification systems exist that categorize CTS severity based on EDX findings. This investigation evaluated EDX findings across consecutive CTS severity categories within existing classification systems and consolidated classifications. METHODS: This retrospective study analyzed 665 hands from 468 patients undergoing EDX testing for suspected CTS. Complete classification systems and consolidated classifications were evaluated for discrimination capability across consecutive CTS severity categories based on EDX findings. Additional analysis evaluated the relationship of sex and age factors and CTS severity. RESULTS: Consolidated classifications demonstrated superior discrimination capability between consecutive CTS severity categories regardless of classification system used. Demographic factors significantly influenced EDX findings and categorization of CTS severity. CONCLUSIONS: This study underscores the value of consolidated classifications for enhancing discrimination between consecutive CTS severity categories based on EDX findings. Demographic factors should be considered when interpreting EDX findings for the purpose of categorizing CTS severity. Future research should refine existing classification systems and explore additional factors influencing CTS severity used to inform medical management.

Minimal Clinically Important Differences in Hand Pain Intensity (Numerical Pain Rate Scale) and Related-Function (Boston Carpal Tunnel Questionnaire) in Women With Carpal Tunnel Syndrome.

OBJECTIVE: To calculate the minimal clinically important differences (MCIDs) for hand pain intensity and the Boston Carpal Tunnel Questionnaire (BCTQ) in a sample of women with carpal tunnel syndrome (CTS). DESIGN: Secondary analysis of a randomized controlled trial. SETTING: A Hospital Rehabilitation Unit. PARTICIPANTS: One hundred twenty women with clinical and electromyographic diagnosis of CTS who were randomly assigned into 2 groups (N=120). INTERVENTIONS: One group received 3 sessions of manual physical therapy (n=60) and the other group received surgery (n=60). MAIN OUTCOME MEASURES: Mean and the worst pain intensity (numerical pain rate scale, 0-10 points) and functional status and symptoms' severity subscales of the BCTQ questionnaire were assessed before and 1 month after treatment. The Global Rating of Change (GROC) was used as the anchor variable for determining the MCID. RESULTS: A change of 1.5 and 2.5 points in mean and the worst pain intensity represents the MCID for Numerical Pain Rating Scale, whereas a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for each subscale of the BCTQ. All variables showed acceptable discrimination between patients classified as "improved" and those classified as "stable/not improved" (area under the curve≥0.72). Mean pain intensity (Youden index, 0.53; sensitivity: 73.3%; specificity: 80%) and symptoms' severity (Youden index, 0.69; sensitivity: 90%; specificity: 77.8%) showed the best discriminative ability expressed as a percentage of prediction. Participants classified as "improved" had significantly greater improvements in pain intensity, functional status, and symptoms' severity compared with those classified as "stable/not improved". CONCLUSION: A change of 1.5 and 2.5 points in mean and the worst pain and a change of 0.23 and 0.64 points in functional status and symptoms' severity represents the MCID for pain intensity and BCTQ in women with CTS 1 month after treatment.

Comparative Efficacy of 5% Dextrose and Corticosteroid Injections in Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aims to assess the effectiveness of 5% dextrose (D5W) in comparison to corticosteroids for treating carpal tunnel syndrome (CTS). DATA SOURCES: A comprehensive systematic search was conducted across MEDLINE (PubMed), Embase, and the Cochrane Central Register of Controlled Trials on November 13, 2023. These were supplemented by manual searches using Google Scholar. STUDY SELECTION: Two independent authors reviewed the literature, resolving any discrepancies through detailed discussions and consultation with a third author. DATA EXTRACTION: Data on primary outcomes (pain assessment) and secondary outcomes (symptom severity and functional status using the Boston Carpal Tunnel Questionnaire, electrophysiologic measures, cross-sectional area, and adverse effects) were extracted independently by the two authors. DATA SYNTHESIS: The analysis included 4 randomized controlled trials and 1 quasi-experimental study, encompassing a total of 212 patients (220 hands) with mild to moderate CTS. RESULTS: Within 3 months, the D5W injections showed a statistically significant improvement in functional status compared to the corticosteroids with a standard mean difference of -0.34 (95% confidence interval (CI), -0.62 to -0.05). D5W was associated with fewer adverse incidents than corticosteroids (risk ratio 0.13; 95% CI 0.03 to 0.51). No difference was observed between the two treatments in other areas. CONCLUSION: For patients with mild to moderate CTS, D5W injections were more effective than corticosteroid injections in improving functional status and demonstrated fewer adverse effects. D5W injections also paralleled corticosteroids in pain reduction, symptom severity, electrodiagnostic measures, and cross-sectional area of nerve, recommending D5W as a preferred treatment for mild to moderate CTS.

Comparison of the Effectiveness of 2 Different Kinesio Taping Techniques Added to Exercises in the Treatment of Carpal Tunnel Syndrome: Randomized Controlled Trial, Double-Blind, Parallel Groups.

OBJECTIVE: To compare the effectiveness of I-tape and button hole kinesio taping (KT) techniques added to exercises in the treatment of carpal tunnel syndrome (CTS). DESIGN: Prospective randomized controlled blinded study. SETTING: Physical Medicine and Rehabilitation Outpatient Clinic. PARTICIPANTS: A total of 108 patients (165 wrists) diagnosed with CTS (N=108). INTERVENTIONS: Button hole technique (BG), I-band technique (IG), and exercises (EG). MAIN OUTCOME MEASURES: Visual analog scale (VAS), Douleur Neuropathique 4 Questions (DN4), Boston carpal tunnel syndrome questionnaire, and Jamar dynamometer were used. Median sensory nerve action potential (SNAP), compound muscle action potential (CMAP), median distal sensory latency (DSL), median distal motor latency (DML), sensory conduction velocity, and motor conduction velocity were recorded. Measurements were made at baseline, week 3, and week 12. RESULTS: Thirty-six patients were in each group. Significant statistical improvements in VAS and DN4 scores were found in the BG and IG compared with EG (P<.05). Statistically significant improvements in hand grip strength were observed in the IG compared with the EG (P<.05). Significant improvements in DML levels and motor conduction velocity were observed in the BG and IG compared with the EG (P<.05). A significant increase in sensory conduction velocity was detected in the BG compared with the other groups (P<.05). CONCLUSIONS: Both KT techniques are effective in terms of pain, functionality, symptom severity, grip strength, and electrophysiologically. The button hole technique was more effective in DSL, sensory conduction velocity, CMAP amplitude, and SNAP.

Comparison of the Effect of Out-of-plane and In-plane Injection Approaches on Injection Pain and Functionality in Patients with Carpal Tunnel Syndrome Undergoing Ultrasound-guided Injection: A Patient- and Assessor-blinded Randomized Study.

OBJECTIVES: The aims were i) to compare the out-of-plane (OP) and in-plane (IP) approaches for carpal tunnel syndrome (CTS) in terms of pain during injection and post injection adverse effects, and ii) to investigate whether these approaches led to any difference in terms of pain/numbness, symptom severity, functionality, and median nerve cross-sectional area and to examine the relationship of these parameters with the pain during injection. DESIGN: Patient/assessor blinded randomized study SETTING: Hospital outpatient clinic. PARTICIPANTS: Fifty patients with mild to moderate CTS. INTERVENTIONS: The participants were randomized into OP and IP (both n = 25) ultrasound-guided injection groups. MAIN OUTCOME MEASURES: Each patient reported the pain felt during the injection at 1 h thereafter, and also any adverse effects at 4 weeks after injection. Before and 4 weeks after injection, patients used a visual analog scale to indicate pain/numbness; symptom severity and functionality were assessed using the Boston Carpal Tunnel Syndrome Questionnaire. The cross-sectional area of the median nerve was also obtained. RESULTS: The average pain during injection was 2.64±0.82 in the IP group and 1.96±0.86 in the OP group (p=0.017). Post-injection adverse effects were similar between the two groups (p<0.05). After injection, the percentage change in symptom severity was 49.8±11.8 in the IP group and 40.6±11.5 in the OP group (p=0.008). In the IP group, day pre-injection pain/numbness, night pain/numbness percentage change scores, and symptom severity percentage change scores were moderately correlated with the pain during injection (r=0.439, 0.469, and 0.429, respectively). CONCLUSIONS: IP injection caused greater pain during injection compared to OP injection and led to greater reduction in symptom severity at 1 month after injection. In that group, injection pain was associated with the baseline day pain score, change in night pain score, and change in symptom severity score.

The Effect of Proprioceptive Training on Hand Function and Activity Limitation After Open Carpal Tunnel Release Surgery: A Randomized Controlled Study.

OBJECTIVE: To investigate the effect of proprioceptive training on hand function and activity limitation in patients undergoing open carpal tunnel release surgery. DESIGN: Randomized controlled study. SETTING: A university hospital. PARTICIPANTS: Thirty patients were included in the study and randomized to proprioceptive training (PT) and conventional rehabilitation (CR) groups. INTERVENTION: One week after surgery, both groups received CR for 6 weeks. All participants were asked to perform home-based exercises daily in 3 sets with 10 repetitions. For the PT group, a 6-step PT program was conducted starting from Week 6. Both groups received face-to-face interventions twice a week for 12 weeks. MAIN OUTCOME MEASURES: The outcome measures included the Purdue Pegboard Test (PPT), the joint position sense test (JPST), the Boston Carpal Tunnel Questionnaire, and the Patient-Specific Functional Scale. In total, 3 assessments were performed (at 1, 6 and 12 weeks postoperatively). RESULTS: In the PT group, the results for PPT were statistically significant (P<.05). Although there was a greater decrease in the absolute angular error value (JPST) of the PT group compared to the CR group, the difference was nonsignificant (P>.05). Similar reductions in activity limitation were seen in both groups (PT: 176%, CR: 175%). Symptom severity decreased by 40% in the PT group vs 32% in the CR group. The effect sizes were larger for the changes between the second and third assessments in the PT group compared to the CR group in all parameters tested. CONCLUSION: When applied after carpal tunnel release surgery, PT may potentially to improve hand functions, reduce activity limitation, increase participation in activities of daily living, and thus improve quality of life.

Phenotypic correlations of carpal gland diverticular number with production traits and its genome-wide association analysis in multiple pig populations.

Pig carpal glands play crucial roles in territorial recognition, reproductive behavior, and information exchange; however, their effects on production traits and underlying genetic mechanisms remain unclear. In this study, 1028 pigs from six populations were counted for the carpal gland diverticular numbers (CGDNs) on the left (CGDNL) and right (CGDNR) legs, and their carcass and meat quality traits were assessed. The CGDNs were significantly different among the populations, and Licha Black pigs had a lower CGDN than the Bama Xiang breed. It was also significantly different between sexes, with males having more diverticula than females (p ≤ 0.0391). Moreover, the number was asymmetric, with CGDNR being significantly higher than CGDNL. Notably, CGDNs was significantly correlated with each other in phenotype and genetics and with 24-h pH, 24-h meat color score, 24-h marbling score, fat content, moisture content, sodium salt content, and saturated fatty acid content in phenotype. Furthermore, genome-wide association analyses identified seven SNPs in association with CGDNs at a 5% genome-wide significance level, all of which were located in a 1.78-Mb (35.347-37.129 Mb) region on chromosome 1. CNC10010837 and CNC10010840 were the top SNPs: both had an additive effect of 0.789 ± 0.120 on CGDNR with p = 8.31E-10. These findings provide important insights into the functions and underlying genetic mechanisms of swine carpal glands.

Elevated concentration of beta2-microglobulin among patients with carpal tunnel syndrome in the course of primary Sjögren syndrome - a prospective observational study on 50 patients.

INTRODUCTION: Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltrates in the exocrine glands. Carpal tunnel syndrome (CTS) is suggested to be more frequent among SS patients than in the general population. The aim of this study was to seek associations between the CTS and the laboratory and clinical findings of SS patients. METHODS: Fifty patients diagnosed with primary SS (pSS) were examined. Clinical evaluation by a rheumatologist and electrophysiological studies were conducted. Data on laboratory tests results was collected. Control group consisted of 50 sex and age-matched individuals with osteoarthritis (OA). RESULTS: Out of 50 patients in the study group 27 (54%) were diagnosed with CTS. The prevalence of CTS among 50 individuals in the control group was 8%. Among pSS patients with CTS the joint involvement was not more common than in those from the non-CTS group [15 vs. 13 (p = 0.945)]. There was an expected difference in sleep disorders [18 vs. 9 (p = 0.012)] and paresthesia [23 vs. 13 (p = 0.024)]. The major finding was a significant difference in elevated beta2-microglobulin (B2MG) [23 vs. 13 (p = 0.024)]. Other studied factors, suggested in the literature as significant in the pSS-related neuropathy, were not statistically different between the groups. CONCLUSION: Our study confirms that CTS is more prevalent among pSS patients than in the general population and suggests that a new approach is required towards the pathogenesis of this phenomenon. We hypothesize that CTS is more associated with an overall disease activity than joint involvement as such.

Anti-cancer therapeutic agents and carpal tunnel syndrome: Clinical, electrodiagnostic, and ultrasound findings in seven patients.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and rarely develops after drug therapy. This study describes the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in seven patients who experienced CTS due to anti-cancer therapeutic agents. METHODS: All patients underwent EDX testing, and four patients had an US study. RESULTS: CTS occurred in four patients with aromatase inhibitors, two with immune checkpoint inhibitors, and one with a selective estrogen receptor modulator. The mean duration between initiation of the anti-cancer therapeutic agents and symptom onset was 6 weeks (range: 2-12 weeks). Decreased digit sensation was noted in all patients; wasting and weakness of the abductor pollicis brevis (APB) was observed in three (42.8%) patients. The compound muscle action potentials (CMAP) of the APB and sensory nerve action potentials of the second or third digit could not be recorded in two (28.5%) and four (57.1%) patients, respectively. The needle EMG detected fibrillations and positive sharp waves in the APB in two patients. The motor unit potentials of the APB were decreased with large polyphasics in three (42.8%) patients. Of the four patients who underwent US testing, all had increased cross-sectional area of the median nerve at the carpal tunnel inlet, three (75%) had thenar muscle atrophy, and two (50%) had a loss of fascicular pattern. Three (42.8%) patients underwent a CTR. CONCLUSIONS: Physicians should be cognizant of the relationship between anti-cancer therapeutic agents and CTS. EDX studies and US play important roles in the diagnostic assessment of such patients.

Patient experiences and perspectives of health service access for carpal tunnel syndrome in Aotearoa New Zealand: a normalisation process theory-informed qualitative study.

BACKGROUND: Early access to care for carpal tunnel syndrome (CTS) can avoid higher rates of surgery and permanent harm yet is often delayed, particularly for populations more likely to underutilise care. OBJECTIVE: We sought to explore patient experiences and perspectives of health service access for CTS to inform an equity-focussed co-design of a health service for improving early care access. METHODS: In this Normalisation Process Theory (NPT)-informed qualitative study we conducted semistructured in-depth interviews with 19 adults with experience of CTS. Recruitment prioritised New Zealand Maori, Pasifika, low-income, and rural populations. Data were analysed using deductive then inductive thematic analysis. RESULTS: We identified five major themes: (1) the 'Significant Impact of CTS' of the sense-making and relational work to understand the condition, deciding when to get care, compelling clinicians to provide care, and garnering help from others; (2) 'Waiting and Paying for Care'- the enacting, relational, and appraising work to avoid long wait times unless paying privately, particularly where quality of care was low, employment relations poor, or injury compensation processes faltered; (3) circumstances of 'Occupation and CTS Onset' whereby the burden of proof to relate onset of CT symptoms to occupation created excessive relational and enacting work; (4) the 'Information Scarcity' of good information about CTS and the high relational and appraising work associated with using online resources; (5) 'Negotiating Telehealth Perspectives' where telehealth was valued if it meant earlier access for all despite the challenges it held for many. CONCLUSION: Quality, culturally and linguistically responsive information and communication from clinicians and health services will improve equitable early access to CTS care including realising the potential of telehealth modes of care. Policy changes that reduce individual burden of proof in injury compensation claims processes, enable time off work to attend health appointments, and increase public funding for surgical resources would improve early access to CTS care particularly for Maori and Pacific populations and those in small and rural workplaces. NPT is valuable for understanding where opportunities lie to reduce inequitable delays to accessing care including the impact of racism, particularly for populations more likely to underutilise care.

Volume Effect of Nerve Hydrodissection for Carpal Tunnel Syndrome: A Prospective, Randomized, and Single-Blind Study.

OBJECTIVES: This study compared ultrasound-guided nerve hydrodissection (HD) outcomes using two commonly used injectate volumes (10 and 5 mL) of normal saline to explore if there is a volume effect of HD for patients with moderate carpal tunnel syndrome (CTS). METHODS: Twenty-four participants were randomly assigned to treatment with HD using ultrasound-guidance and either 10 mL or 5 mL of normal saline (HD-10 and HD-5 groups respectively). Our primary outcome measures were the change scores of the two subscales of the Boston Carpal Tunnel Syndrome Questionnaire: The Symptom Severity Scale (SSS) and Functional Status Scale (FSS). We conducted a one-way repeated analysis of variance for 3 time points (4, 12, and 24 weeks) for both SSS and FSS, respectively, for change scores from time 0, and percentage change from time 0. RESULTS: All participants (n = 12 per group) completed the study. From 0 to 24 weeks the HD-10 group outperformed the HD-5 group for improvement in SSS (median ± IQR; -0.8 ± 0.4 versus -0.5 ± 0.5; P = .024) and FSS scores (mean ± SD; -0.8 ± 0.2 versus -0.5 ± 0.5; P = .011). The HD-10 group improvement in FSS subtest significantly exceeded the MCID percentage-change-based threshold of 27% (34%; P = .039). CONCLUSIONS: Despite the limitations of small study size, a largely inert injectate, and a single injection approach, these findings in favor of the 10 mL group suggest that the volume used for ultrasound-guided HD in moderate CTS matters, and a higher volume is more effective.

Carpal tunnel syndrome among Manitoba workers: Results from the Manitoba Occupational Disease Surveillance System.

BACKGROUND: Carpal tunnel syndrome (CTS) is associated with occupational high-force repetitive tasks and vibration. This project examines the relationship between CTS and work to: (1) identify jobs and industries with increased CTS risk; (2) explore whether there is a sex difference in the risk of CTS after controlling for occupation; and (3) determine whether any observed relationships persist after excluding Workers Compensation Board (WCB) accepted time-loss CTS claims. METHODS: We linked 95.5% of time-loss WCB claims from 2006 to 2019 to provincial administrative health data. The cohort included 143,001 unique person-occupation combinations. CTS cases were defined as at least two medical claims for (ICD-9 354) within a 12-month period or a surgical claim for CTS from 2 years before the WCB claim to 3 years after. WCB accepted CTS time-loss claims not identified by the medical claims were also included. RESULTS: A total of 4302 individuals (3.0%) met the CTS definition. Analysis revealed that the hazard ratios (HRs) of CTS vary considerably with occupation. Sex-based differences in CTS risks were observed, both in low- and high-risk occupations. In many occupations with increased HR, the HR remained elevated after excluding accepted time-loss WCB cases. CONCLUSIONS: The risk of developing CTS varied with occupation. Job titles with ergonomic risk factors had higher risks than those with lower exposures. This finding remained after eliminating time-loss compensated WCB cases, suggesting that all cases of CTS in high risk jobs are not identified in WCB statistics. Female workers in some job titles had excess CTS cases compared to male workers within the same job title.

Median Nerve Shear Wave Elastography Is Associated With the Neurophysiological Severity of Carpal Tunnel Syndrome.

OBJECTIVES: This study examines the associations between the median nerve (MN) shear wave elastography (SWE), the MN cross-sectional area (CSA), patient's symptoms, and the neurophysiological severity of carpal tunnel syndrome (CTS). The most appropriate site to perform SWE was also tested. METHODS: This prospective study comprised 86 wrists of 47 consecutive patients who volunteered for MN ultrasound after an electrodiagnostic study. The neurophysiological severity of CTS was assessed according to the results of a nerve conduction study (NCS). The MN CSA was measured at the carpal tunnel inlet (wCSA) and the forearm (fCSA). SWE was performed on the MN in a longitudinal orientation at the wrist crease (wSWE), at the forearm (fSWE), and within the carpal tunnel (tSWE). RESULTS: The wCSA and wSWE correlated positively with the neurophysiological severity of CTS (r = .619, P < .001; r = .582, P < .001, respectively). The optimal cut-off values to discriminate the groups with normal NCS and with findings indicating CTS were 10.5 mm2 for the wCSA and 4.12 m/s for the wSWE. With these cut-off values, wCSA had a sensitivity of 80% and specificity of 87% and wSWE a sensitivity of 88% and specificity of 76%. Neither tSWE nor fSWE correlated with the neurophysiological severity of CTS or differed between NCS negative and positive groups (P = .429, P = .736, respectively). CONCLUSION: Shear wave velocity in the MN at the carpal tunnel inlet increases in CTS and correlates to the neurophysiological CTS severity equivalently to CSA measured at the same site.

Sonographic Measurement of Median Nerve Cross-Sectional Area to Determine Severity of Carpal Tunnel Syndrome: A Cautionary Tale.

OBJECTIVES: Evaluate the diagnostic accuracy of median nerve cross-sectional area (CSA) to determine the severity of carpal tunnel syndrome (CTS) vs the presence of CTS across existing electrodiagnostic-based (EDX) classification systems. METHODS: Retrospective analysis of cross-sectional patient data. Receiver operating characteristic (ROC) analysis was used to determine CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS severity. Identification of CSA cutoff values associated with likelihood ratios capable of achieving conclusive (but at least moderate) shifts in diagnostic probability. RESULTS: Binary categorizations of CTS (ie, "Normal" vs "Absent") were statistically superior to consolidated categorizations of CTS severity (ie, "Normal," "Mild," "Moderate," or "Severe"). Binary categorizations established consistent CSA cutoff values across all EDX-based classifications examined and achieved conclusive shifts in diagnostic probability based on the following values of distal CSA or delta CSA: <7 or <1 mm2 to rule out and >13 or >7 mm2 to rule in CTS, respectively. Additionally, the following values of distal CSA and delta CSA may be used in certain circumstances because they produce only small shifts in diagnostic probability: ≤10 or ≤3 mm2 to rule out and ≥11 or ≥4 mm2 to rule in CTS, respectively. CONCLUSIONS: Using median nerve CSA to categorize the severity of CTS is not recommended based on lack of consistent and meaningful shifts in diagnostic probability. Rather, binary categorizations to rule out or rule in CTS based on the proposed CSA cutoff values consistently provided conclusive shifts in diagnostic probability across all EDX-based classifications examined.