Carpal tunnel syndrome

Carpal tunnel syndrome
Classification and external resources

Transverse section at the wrist. The median nerve is colored yellow. The carpal tunnel consists of the bones and flexor retinaculum.
ICD-10 G56.0
ICD-9 354.0
OMIM 115430
DiseasesDB 2156
MedlinePlus 000433
eMedicine orthoped/455 pmr/21 emerg/83 radio/135
MeSH D002349

Carpal Tunnel Syndrome (CTS) is associated by symptoms and signs, which are caused by compression of the median nerve travelling through the carpal tunnel.[1] Carpal Tunnel Syndrome affects the hands since it is an upper limb neuropathy that results in motor and sensory disturbance of the median nerve.[2]

This condition affects individuals by causing pain, paresthesias, and sometimes weakness in the median nerve distribution. Those diagnosed with Carpal Tunnel Syndrome may experience pain, numbness and tingling sensations in the arm, which may extend to the shoulder and neck area; these feelings are more prevalent at night due to various sleeping positions.[3] To aid in the prevention of Carpal Tunnel Syndrome, stretching exercises of the wrist, hand, and fingers have been used to combat against the pain and numbness caused by repetitive actions. Other than using recommended stretches and exercises, useful treatments for CTS include use of night splints, corticosteroid injections and ultimately surgery.

Most cases of Carpal Tunnel Syndrome have been found to be without a specific cause and certain individuals may be genetically predisposed to this condition.

Contents

History

The condition known as Carpal Tunnel Syndrome has had major appearances throughout the years but it was most commonly heard of in the years following World War II.[4] Individuals who had suffered from this condition have been depicted in surgical literature for the mid 1800’s.[4] In 1854, Sir James Paget was the first to report median nerve compression at the wrist in a distal radius fracture.[5] Following the early 1900s there were various cases of median nerve compression underneath the transverse carpal ligament.[5] Carpal Tunnel Syndrome was most commonly noted in medical literature in the early 20th century but the first use of the term was noted 1939. Physician Dr. George S. Phalen of the Cleveland Clinic identified the pathology after working with a group of patients in the 1950s and 1960s.[6] Carpal Tunnel Syndrome, a disabling overuse injury to the hand is one of the most frequent work injuries reported by the medical profession [7]

Anatomy

The carpal tunnel is an anatomical compartment located at the base of the wrist. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The nerve and the tendons provide function, feeling, and movement to some of the fingers. The finger and wrist flexor muscles including their tendons originate in the forearm at the medial epicondyle of the elbow joint and attach to the Metaphalangeal (MP), Proximal Interphalangeal (PIP), and Distal Interphalangeal bones of the fingers and thumb (BSI). The carpal tunnel is approximately as wide as the thumb and its boundary lies at the distal wrist skin crease and extends up the arm towards the elbow for approximately 3 cm.[2]

The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Simply flexing the wrist to 90 degrees will decrease the size of the canal.

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament. There is a superficial sensory branch of the median nerve, which branches proximal to the TCL and travels superficial to it. This branch is therefore spared, and it innervates the palm towards the thumb.[8]

Symptoms

Carpal tunnel syndrome produces a series of symptoms from mild to extreme. These symptoms worsen over time and patients that have been diagnosed with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, particularly the index and middle fingers, which are affected by the median nerve. Individuals also experience pain in the hands or wrists and some report to have lost gripping strength. Pain also develops in the arm and shoulder and swelling of the hand, which increases at night.[9]

Numbness and paresthesias in the median nerve distribution are the neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.[10]

Women are three times more likely than men to develop carpal tunnel syndrome, perhaps because the carpal tunnel itself may be smaller in women than in men.

Causes

Most cases of CTS are of unknown causes, or idiopathic.[11] Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, hypothyroidism, arthritis, diabetes, and trauma.[12]

Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation.[13] It is unclear whether there is a close relationship between work and CTS or if it’s due to underlying medical problems.

Work related

The international debate regarding the relationship between CTS and repetitive motion in work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. However, the American Society for Surgery of the Hand (ASSH) has issued a statement that the current literature does not support a causal relationship between specific work activities and the development of diseases such as CTS.

The relationship between work and CTS is controversial; in many locations workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.[14] In the USA Carpal tunnel syndrome results in an average of $30,000 in lifetime costs (medical bills and lost time from work).[15]

Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulating activities and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations,[16] but it is unclear if this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.

A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated with incidents of CTS, but causation was not established, and the distinction from work related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. While addressing these factors has been found to improve comfort in some studies,[17] there is no evidence that they affect the natural history of carpal tunnel syndrome.

CTS is found mostly in the working adult population; for this reason, it is very likely to be associated with the workplace whether or not it is caused by the work itself. When a single muscle performs more than one task, for example twisting and flexing of the wrist muscles, the increased muscle load plays an important role in the development of musculoskeletal disorders. Despite the findings that the association between work and CTS is high, there is still a deficit of knowledge regarding the pattern and the causality of this relation. Extensive research needs to be conducted in order to establish the relationship between the ergonomics of work and work-related injuries including CTS [18]

Carpal tunnel syndrome associated with other diseases

A variety of patient factors can lead to CTS including heredity, size of the carpal tunnel, associated local and systematic diseases and certain habits contribute to its etiology[19] Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging.[20]

Examples include:

Diagnosis

The reference standard for the diagnosis of carpal tunnel syndrome is electrophysiological testing. Patients with intermittent numbness in the distribution of the median nerve along with positive Phalen's, Durkan's and eletrophysiological tests have at worst, a very mild case of carpal tunnel syndrome. A predominance of pain rather than numbness is unlikely to be due to carpal tunnel syndrome no matter the result of electrophysiological testing.

Clinical assessment by history taking and physical examination can support a diagnosis of CTS.

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific and reliable test is the Combined Sensory Index (also known as Robinson index).[28]

Nerve conduction studies (NCS) are a sensitive measure of detecting compression of the median nerve. Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities [19]

The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.[29][30][31]

Prevalence

Carpal tunnel syndrome can affect anyone in the world. Within the U.S., an approximation of 50 out of 1000 people within the general public will suffer from the effects of carpal tunnel syndrome. Caucasians have the highest risk of being diagnosed with CTS compared with other races such as non-white South Africans.[32] Surprisingly, women suffer more from CTS than men with a ratio of 3:1 in between the ages of 45–60 years of age. Only 10% of reported cases of CTS are younger than 30 years of age.[32]

CTS is not a life-threatening condition, but it can negatively affect lifestyle if left untreated. In worst case scenarios, the median nerve can become severely damaged and result in total loss of movement within that hand.

Prevention

A 2007 study conducted by Lozano-Calderon et al. the Department of Orthopaedic Surgery at Massachusetts General Hospital states that carpal tunnel syndrome is primarily determined by genetics and structure.[33] Therefore, carpal tunnel syndrome is probably not preventable. However, others think it is preventable by developing healthy habits like avoiding repetitive stress, practicing healthy work habits like using ergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives (digital pen, voice recognition and dictate) and early passive treatment like taking turmeric (anti-inflammatory), omega-3 fatty acids, and B vitamins. Those who favor activity as a cause of carpal tunnel syndrome speculate that activity-limitation might limit the risk of developing carpal tunnel syndrome, but there is little or no data to support these concepts[33] and they stigmatize arm use in ways that risks increasing illness.[34][35] Having the preconception that using the arms will greatly increase the probability of obtaining CTS is nonsensical. It is hard to determine where an idiopathic condition originates from, especially with something as common as CTS.

Possible Misdiagnosis

There are some, such as Dr. Janet G. Travell and David G. Simons who believe that carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain, numbness, swelling, and/or burning in the radial side of the hands and/or wrists. Travell and Simons concluded from research that myofascial(Skeletal muscle) contraction knots called "trigger points" may actually be producing these symptoms. For example, it is argued by trigger point therapists that trigger points in any of the many muscles of the neck, arms, chest, and forearms can result in compression of the median nerve in the forearm and cause numbness and/or a burning sensation in the hands. Furthermore, trigger points in the scalene muscles of the neck can shorten the thoracic outlet and compress nerves and blood vessels in the arm, which limits the flow of blood and lymph fluid, causing swelling in the hands and fingers. Carpal tunnel surgery will reduce strain on the median nerve by cutting the carpal ligament and provide relief of some or all symptoms in some patients, but is unnecessary when trigger points are the root of the problem. As a whole, the medical community is not currently embracing or accepting trigger point theories. [36]

Treatment

There have been numerous scientific papers evaluating treatment efficacy in CTS. It is important to distinguish treatments that are supported in the scientific literature from those that are advocated by any particular device manufacturer or any other party with a vested financial interest. Generally accepted treatments, as described below, may include splinting or bracing, steroid injection, activity modification, physical or occupational therapy (controversial), regular massage therapy treatments, medications, and surgical release of the transverse carpal ligament.

According to the 2007 guidelines by the American Academy of Orthopaedic Surgeons,[37] early surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. Otherwise, the main recommended treatments are local corticosteroid injection, splinting (immobilizing braces), oral corticosteroids and ultrasound treatment. The treatment should be switched when the current treatment fails to resolve the symptoms within 2 to 7 weeks. However, these recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.[37]

Stretching

Various stretching exercises can aide in the prevention of CTS, but most people do not know how to effectively stretch the muscles of the wrist and hand. To reduce the probability of being diagnosed with CTS, the following stretch exercises are helpful:

Exercise 1, Range of Motion.

Exercise 1, Range of Motion: Clench your fist tightly for 3–5 seconds, then release, straightening out your fingers. Keep them extended for the same amount of time it was clenched. Repeat this exercise at least 5 times for each hand.

Exercise 2, Stretching: The next exercise that helps relieve the pain and tension caused by repetitive hand movements is the stretch exercise. With one hand, extend the fingers of the other hand as far back and as gently as possible without causing more pain. A stretching feeling should be felt on the palm and throughout the wrist. Hold this stretch for 3–5 seconds and then release. Complete this exercise at least 5x times with each hand in addition to the range of motion exercise.

Exercise 2, Stretching.

Before performing any of the described exercises, speak with a healthcare professional to receive more information about CTS prevention exercises.

Immobilizing braces

A rigid splint can keep the wrist straight.

A wrist splint helps limit numbness by limiting wrist flexion. Night splinting helps patients sleep.

The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology.[38] Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.[39][40][41]

Many health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists.[42][43]

There are braces with various extra functions and abilities on the market, but the evidence of such functions is usually limited.

Localized corticosteroid injections

Corticosteroid injections can be quite effective for temporary relief from symptoms of CTS for a short time frame while a patient develops a longterm strategy that fits with his/her lifestyle.[44] In certain patients, an injection may also be of diagnostic value. This treatment is not appropriate for extended periods, however. In general, medical professionals only prescribe local steroid injections until other treatment options can be identified. For most patients, surgery is the only option that will provide permanent relief.[45]

Other medication

Using an over-the-counter anti-inflammatory such as aspirin, ibuprofen or naproxen can be effective as well for controlling symptoms. Pain relievers like paracetamol will only mask the pain, and only an anti-inflammatory will affect inflammation. Non-steroidal anti-inflammatory medications theoretically can treat the swelling and thus the source of the problem. Oral steroids such as prednisone do the same, but are generally not used for this purpose because of significant side effects. Use of non-steroidal anti-inflammatory drugs may worsen asthma symptoms in some with a history of asthma, making the use of steroids such as prednisone the safer option for treating CTS. The most common complications associated with long-term use of anti-inflammatory medications are gastrointestinal irritation and bleeding. Also, some anti-inflammatory medications have been linked to heart complications. Use of anti-inflammatory medication for chronic, long-term pain should be done with doctor supervision.

A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel. Methylcobalamin (vitamin B12) has been helpful in some cases of CTS. [46]

Carpal tunnel release surgery

Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6 weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in the left hand, a common sign of advanced CTS

Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms.[47] In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.[48]

Procedure

In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. It forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerve inside, relieving the pressure.[49]

There are several carpal tunnel release surgery variations: each surgeon has differences of preference based on their personal beliefs and experience. All techniques have several things in common, involving brief outpatient procedures; palm or wrist incision(s); and cutting of the transverse carpal ligament.

The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. Most surgeons historically have performed the open procedure, widely considered to be the gold standard. However, since the 1990s, a growing number of surgeons now offer endoscopic carpal tunnel release.

Open surgery involves an incision on the palm about an inch or two in length. Through this incision, the skin and subcutaneous tissue is divided, followed by the palmar fascia, and ultimately the transverse carpal ligament.

Endoscopic techniques involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including a synovial elevator, probes, knives, and an endoscope used to visualize the underside of the transverse carpal ligament. The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does.

Many studies have been done to determine whether perceived benefits of a limited endoscopic or arthroscopic release are significant. Brown et al. conducted a prospective, randomized, multi-center study and found no significant differences between the two groups with regard to secondary quantitative outcome measurements.[3] However, the open technique resulted in more tenderness of the scar than the endoscopic method. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the endoscopic method. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. However, the open technique caused greater scar tenderness during the first three months after surgery, and a longer time before the patients could return to work. [4]

Some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been associated with a higher incidence of median nerve injury, and for this reason it has been abandoned at several centers in the United States. At the 2007 meeting of the American Society for Surgery of the Hand, a former advocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, retracted his advocacy of the technique, based on his assessment that the benefit of the procedure (slightly faster recovery) did not outweigh the risk of injury to the median nerve. Despite these views, many other surgeons have embraced limited incision methods. It is considered to be the procedure of choice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. Supporting this are the results of some of the previously mentioned series which cite no difference in the rate of complications for either method of surgery. Thus, there has been broad support for either surgical procedure using a variety of devices or incisions. The primary goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve. [5]

All of the surgical options (when performed without complication) typically have relatively rapid recovery profiles (weeks to a few months depending on the activity and technique), and all usually leave a cosmetically acceptable scar.

Efficacy

Surgery to correct carpal tunnel syndrome has a high success rate. Up to 90% of patients were able to return to their same jobs after surgery.[50][51][52] In general, endoscopic techniques are as effective as traditional open carpal surgeries,[53][54] though the faster recovery time typically noted in endoscopic procedures is felt by some to possibly be offset by higher complication rates.[55][56] Success is greatest in patients with the most typical symptoms. The most common cause of failure is incorrect diagnosis, and it should be noted that this surgery will only mitigate carpal tunnel syndrome, and will not relieve symptoms with alternative causes. Recurrence is rare, and apparent recurrence usually results from a misdiagnosis of another problem. Complications can occur, but serious ones are infrequent to rare.

Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic or plastic surgeon. Some neurosurgeons and general surgeons also perform the procedure.

Ultrasound treatment

Ultrasound radiation to the wrist gives significant improvement in people with CTS. [57] A treatment process may consist of 20 sessions of 15 minutes of ultrasound applied to the area over the carpal tunnel at frequency of 1 MHz and a power of 1.0 W/cm2.[57]

Physiotherapy and occupational therapy

Current evidence demonstrates a significant benefit (level B recommendations) from splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome.[58] Otherwise, there is little evidence to support the use of other physiotherapy or occupational therapy techniques for carpal tunnel syndrome. They seem to be oriented primarily towards non-specific activity related pain rather than the numbness of carpal tunnel syndrome.

Occupational therapy offers ergonomic suggestions to prevent worsening of the symptoms. Occupational therapies facilitate hand function through remedial adaptive approaches.

Any forceful and repetitive use of the hands and wrists can cause upper extremity pain. More frequent rest can be useful if it can be orchestrated into one's schedule. It has been shown that taking multiple mini-breaks during the stressful activity is more effective than taking occasional long breaks. There are computer applications that aid users in taking breaks. All of these applications have recommended defaults, following the most effective average break configuration—a 30 sec. pause every 3 to 5 minutes (the more severe the pain, the more often one should take this break). There are also programs that automatically click the mouse. Before investing in these types of programs, it's best to consult with a doctor and research whether computer use is causing or contributing to the symptoms, as well as getting a formal diagnosis.

More pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic work and life environment. Switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout such as Dvorak was commonly cited as beneficial in early CTS studies, however some meta-analyses of these studies claim that the evidence that they present is limited.[59][60]

It is also important that one's body be aligned properly with the keyboard. This is most easily accomplished by bending ones elbows to a 90 degree angle and making sure the keyboard is at the same height as the elbows. Also it is important not to put physical stress on the wrists by hanging the wrist on the edge of a desk, or exposing the wrists to strong vibrations (e.g. manual lawn mowing). Position the computer monitor directly in front of your seat, so the neck is not twisted to either side when viewing the screen.

Exercises that relax and strengthen the muscles of the upper back can reduce the risk of a double crush of the median nerve.

Massage is one of the most overlooked methods for treatment of the symptoms of CTS. The use of myofascial release and active stretch release can erase the pain, numbness, tingling and burning in minutes. Then following up with the stretches and exercises afore mentioned will lengthen the relief attained by these release techniques.

Long term recovery

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage".[61] Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting and weakness.

While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters, alcohol use, yield much poorer overall results of treatment.[62]

Many mild carpal tunnel syndrome sufferers either change their hand use, pattern, or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness or pain, and without sleep disruption. Some find relief by adjusting their repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods of performing the movements. Other people end up prioritizing their activities and possibly avoiding certain hand activities so that they can minimize pain and perform the essential tasks. Keyboard re-mapping software can help people whose condition is aggravated by one-handed key strokes involving a combination of the Control, Shift, or Alt keys and an alpha-numeric key. Programs such as Autohotkey allow a person to disable key combinations while they train themselves to use two hands to perform the offending key strokes.

Recurrence of carpal tunnel syndrome after successful surgery is rare.[63] If a person has hand pain after surgery, it is most likely not due to carpal tunnel syndrome. It may be the case that a person who has hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel release has had no positive effect upon the patient's symptoms.

Notable cases

HRH Prince Philip, husband of Queen Elizabeth II[64]

Mike Dirnt, bassist with the band Green Day[65]

In popular culture

See also

References

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  32. ↑ 32.0 32.1 Ashworth-Nigel. Carpal Tunnel Syndrome. http://emedicine.medscape.com/article/327330-overview. 
  33. ↑ 33.0 33.1 Lozano-Calderón, Santiago; Shawn Anthony, David Ring (April 2008). "The Quality and Strength of Evidence for Etiology: Example of Carpal Tunnel Syndrome". J. Hand Surg. 33 (4): 525–538. doi:10.1016/j.jhsa.2008.01.004. PMID 18406957. 
  34. ↑ Scangas, George; Santiago Lozano-Calderón, David Ring (September 2008). "Disparity Between Popular (Internet) and Scientific Illness Concepts of Carpal Tunnel Syndrome Causation". J. Hand Surg. 33 (7): 1076–1080. doi:10.1016/j.jhsa.2008.03.001. PMID 18762100. 
  35. ↑ Anthony, Shawn; Santiago Lozano-Calderón, David Ring (March 2008). "Stigmatization of Repetitive Hand Use in Newspaper Reports of Hand Illness". HAND 3 (1): 30–33. doi:10.1007/s11552-007-9052-4. PMID 18780117. 
  36. ↑ Davies, Clair. The Trigger Point Therapy Workbook. Oakland: New Harbinger publications inc., 2004.
  37. ↑ 37.0 37.1 [1] American Academy of Orthopaedic Surgeons clinical guideline on diagnosis of carpal tunnel syndrome. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2007. 72 p. [381 references]
  38. ↑ American Academy of Neurology (2006). "Quality Standards Subcommittee: Practice parameter for carpal tunnel syndrome.". Eura Medicophys Neurology (43): 2406–2409. PMID 16557211. 
  39. ↑ American Academy of Orthopaedic Surgeons (1996). Clinical Guideline on wrist pain. National Guideline clearinghouse. http://www.guideline.gov. 
  40. ↑ Katz JN, Simmons BP (2002). "Carpal tunnel syndrome.". NEJM 346 (23): 1807–1812. doi:10.1056/NEJMcp013018. PMID 12050342. 
  41. ↑ Harris JS (1998). "ed. Occupational Medicine Practice Guidelines: evaluation and management of common health problems and functional recovery in workers.". Beverly Farms, Mass.: OEM Press. ISBN 978-1-883595-26-5. 
  42. ↑ Premoselli S, Sioli P, Grossi A, Cerri C (2006). "Neutral wrist splinting in carpal tunnel syndrome: a 3- and 6-months clinical and neurophysiologic follow-up evaluation of night-only splint therapy". Eura Medicophys 42 (2): 121–6. PMID 16767058. 
  43. ↑ Michlovitz SL (2004). "Conservative interventions for carpal tunnel syndrome". J Orthop Sports Phys Ther 34 (10): 589–600. PMID 15552705. 
  44. ↑ Marshall S, Tardif G, Ashworth N (2007). "Local corticosteroid injection for carpal tunnel syndrome". Cochrane database of systematic reviews (Online) (2): CD001554. doi:10.1002/14651858.CD001554.pub2. PMID 17443508. 
  45. ↑ Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R (2005). "A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome". Neurology 64 (12): 2074–8. doi:10.1212/01.WNL.0000169017.79374.93. PMID 15985575. 
  46. ↑ Sato Y, Honda Y, Iwamoto J, Kanoko T, Satoh K (2005). "Amelioration by mecobalamin of subclinical carpal tunnel syndrome involving unaffected limbs in stroke patients.". J Neurol Sci 231 (1-2): 13–8. doi:10.1016/j.jns.2004.12.005. PMID 15792815. 
  47. ↑ Hui AC, Wong SM, Tang A, Mok V, Hung LK, Wong KS (2004). "Long-term outcome of carpal tunnel syndrome after conservative treatment". Int J Clin Pract 58 (4): 337–9. doi:10.1111/j.1368-5031.2004.00028.x. PMID 15161116. 
  48. ↑ Kouyoumdjian JA, Morita MP, Molina AF, Zanetta DM, Sato AK, Rocha CE, Fasanella CC (2003). "Long-term outcomes of symptomatic electrodiagnosed carpal tunnel syndrome". Arq Neuropsiquiatr 61 (2A): 194–8. PMID 12806496. 
  49. ↑ A patient's guide to endoscopic carpal tunnel release
  50. ↑ Schmelzer RE, Della Rocca GJ, Caplin DA (2006). "Endoscopic carpal tunnel release: a review of 753 cases in 486 patients". Plast Reconstr Surg 117 (1): 177–85. doi:10.1097/01.prs.0000194910.30455.16. PMID 16404264. 
  51. ↑ Quaglietta P, Corriero G (2005). "Endoscopic carpal tunnel release surgery: retrospective study of 390 consecutive cases". Acta Neurochir Suppl 92: 41–5. doi:10.1007/3-211-27458-8_10. PMID 15830966. 
  52. ↑ Park SH, Cho BH, Ryu KS, Cho BM, Oh SM, Park DS (2004). "Surgical outcome of endoscopic carpal tunnel release in 100 patients with carpal tunnel syndrome". Minim Invasive Neurosurg 47 (5): 261–5. doi:10.1055/s-2004-830075. PMID 15578337. 
  53. ↑ Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM (2004). "Surgical treatment options for carpal tunnel syndrome". Cochrane Database Syst Rev (4): CD003905. doi:10.1002/14651858.CD003905.pub2. PMID 15495070. 
  54. ↑ McNally SA, Hales PF (2003). "Results of 1245 endoscopic carpal tunnel decompressions". Hand Surg 8 (1): 111–6. doi:10.1142/S0218810403001480. PMID 12923945. 
  55. ↑ Thoma A, Veltri K, Haines T, Duku E (2004). "A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression". Plast Reconstr Surg 114 (5): 1137–46. doi:10.1097/01.PRS.0000135850.37523.D0. PMID 15457025. 
  56. ↑ Chow JC, Hantes ME (2002). "Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique". J Hand Surg [Am] 27 (6): 1011–8. doi:10.1053/jhsu.2002.35884. PMID 12457351. 
  57. ↑ 57.0 57.1 Ebenbichler GR, Resch KL, Nicolakis P, et al. (March 1998). "Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial". BMJ 316 (7133): 731–5. PMID 9529407. 
  58. ↑ Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, MacDermid J (2004). "Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review". J Hand Ther 17 (2): 210–28. doi:10.1197/j.jht.2004.02.009. PMID 15162107. 
  59. ↑ Lincoln A, Vernick J, Ogaitis S, Smith G, Mitchell C, Agnew J (2000). "Interventions for the primary prevention of work-related carpal tunnel syndrome.". Am J Prev Med 18 (4 Suppl): 37–50. doi:10.1016/S0749-3797(00)00140-9. PMID 10793280. 
  60. ↑ Verhagen AP, Karels CC, Bierma-Zeinstra SMA et al. (2009). "WITHDRAWN: Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults". Cochrane Database Syst Rev (3): CD003471. doi:10.1002/14651858.CD003471.pub4. PMID 19588342. 
  61. ↑ Olsen KM, Knudson DV (2001). "Change in strength and dexterity after open carpal tunnel release". Int J Sports Med 22 (4): 301–3. doi:10.1055/s-2001-13815. PMID 11414675. 
  62. ↑ Katz JN, Losina E, Amick BC 3rd, Fossel AH, Bessette L, Keller RB (2001). "Predictors of outcomes of carpal tunnel release". Arthritis Rheum 44 (5): 1184–93. doi:10.1002/1529-0131(200105)44:5<1184::AID-ANR202>3.0.CO;2-A. PMID 11352253. 
  63. ↑ Ruch DS, Seal CN, Bliss MS, Smith BP (2002). "Carpal tunnel release: efficacy and recurrence rate after a limited incision release". J South Orthop Assoc 11 (3): 144–7. PMID 12539938. 
  64. ↑ Prince Philip undergoes minor surgery on hand at bbc.co.uk
  65. ↑ [2]

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