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Carpal tunnel syndrome
during pregnancy: prevalence and bloodlevel of
pyridoxine.
Atisook R, Benjapibal M, Sunsaneevithayakul P,
Roongpisuthipong A Department of Obstetrics and
Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok, Thailand.
J Med Assoc Thai 1995 Aug;78(8):410-4
The prevalence of CTS in third trimester pregnant women
in the study in 28 per cent. With the use of NCS it was
able to detect nearly 80 per cent of them who had no
symptoms or signs. There was no association between the
level of vitamin B6 or B6 deficiency and CTS. Since CTS may
result in a permanent disability if undiagnosed or left
untreated it is essential to make an early diagnosis and
treat it especially older women and those who are
edematous.
Carpal tunnel syndrome:
clinical outcome after low-level laser acupuncture,
microamps transcutaneous electrical nerve stimulation, and
other alternative therapies--an open protocol
study.
Branco K, Naeser MA Acupuncture Healthcare Services,
Westport, Massachusetts, USA.
J Altern Complement Med 1999 Feb;5(1):5-26
OBJECTIVE: Outcome for carpal tunnel syndrome (CTS)
patients (who previously failed standard medical/surgical
treatments) treated primarily with a painless, noninvasive
technique utilizing red-beam, low-level laser acupuncture
and microamps transcutaneous electrical nerve stimulation
(TENS) on the affected hand; secondarily, with other
alternative therapies.
DESIGN: Open treatment protocol, patients diagnosed with
CTS by their physicians.
SETTING: Treatments performed by licensed acupuncturist
in a private practice office.
SUBJECTS: Total of 36 hands (from 22 women, 9 men), ages
24-84 years, median pain duration, 24 months. Fourteen
hands failed 1-2 surgical release procedures.
INTERVENTION/TREATMENT: Primary treatment: red-beam, 670
nm, continuous wave, 5 mW, diode laser pointer (1-7 J per
point), and microamps TENS (< 900 microA) on
affected hands. Secondary treatment: infrared low-level
laser (904 nm, pulsed, 10 W) and/or needle acupuncture on
deeper acupuncture points; Chinese herbal medicine formulas
and supplements, on case-by-case basis. Three treatments
per week, 4-5 weeks.
OUTCOME MEASURES: Pre- and posttreatment Melzack pain
scores; profession and employment status recorded.
RESULTS: Posttreatment, pain significantly reduced (p
< .0001), and 33 of 36 hands (91.6%) no pain, or
pain reduced by more than 50%. The 14 hands that failed
surgical release, successfully treated. Patients remained
employed, if not retired. Follow-up after 1-2 years with
cases less than age 60, only 2 of 23 hands (8.3%) pain
returned, but successfully re-treated within a few
weeks.
CONCLUSIONS: Possible mechanisms for effectiveness
include increased adenosine triphosphate (ATP) on cellular
level, decreased inflammation, temporary increase in
serotonin. There are potential cost-savings with this
treatment (current estimated cost per case, $12,000; this
treatment, $1,000). Safe when applied by licensed
acupuncturist trained in laser acupuncture; supplemental
home treatments may be performed by patient under
supervision of acupuncturist.
Injection with
methylprednisolone proximal to the carpal tunnel:
randomized double blind trial.
Dammers JW, Veering MM, Vermeulen M Department of
Neurology, Medical Centre Alkmaar, 1800 AM Alkmaar,
Netherlands. J.Dammers@mca.alkmaar.nl
BMJ 1999 Oct 2;319(7214):884-6
OBJECTIVE: To assess the effect of a 40 mg
methylprednisolone injection proximal to the carpal tunnel
in patients with the carpal tunnel syndrome.
DESIGN: Randomised double blind placebo controlled
trial.
SETTING: Outpatient neurology clinic in a district
general hospital.
PARTICIPANTS: Patients with symptoms of the carpal
tunnel syndrome for more than 3 months, confirmed by
electrophysiological tests and aged over 18 years.
NTERVENTION: Injection with 10 mg lignocaine (lidocaine)
or 10 mg lignocaine and 40 mg methylprednisolone.
Non-responders who had received lignocaine received 40 mg
methylprednisolone and 10 mg lignocaine and were followed
in an open study.
MAIN OUTCOME MEASURES: Participants were scored as
having improved or not improved. Improved was defined as no
symptoms or minor symptoms requiring no further
treatment.
RESULTS: At 1 month 6 (20%) of 30 patients in the
control group had improved compared with 23 (77%) of 30
patients the intervention group (difference 57% (95%
confidence interval 36% to 77%)). After 1 year, 2 of 6
improved patients in the control group did not need a
second treatment, compared with 15 of 23 improved patients
in the intervention group (difference 43% (23% to 63%). Of
the 28 non-responders in the control group, 24 (86%)
improved after methylprednisolone. Of these 24 patients, 12
needed surgical treatment within one year.
CONCLUSION: A single injection with steroids close to
the carpal tunnel may result in long term improvement and
should be considered before surgical decompression.
Therapy with vitamin B6
with and without surgery for treatment of patients having
the idiopathic carpal tunnel syndrome.
Ellis J, Folkers K, Levy M, Takemura K, Shizukuishi S,
Ulrich R, Harrison P
Res Commun Chem Pathol Pharmacol 1981
Aug;33(2):331-44
Blood samples from four patients at the time of surgery
to relieve the compression of the carpal tunnel syndrome,
which was diagnosed by clinical and electromyographic
evaluation, were differentially assayed to determine the
specific activities and the % deficiencies of the
erythrocyte glutamic oxaloacetic transaminase (EGOT). The
data from these assays revealed that these four patients
had a severe deficiency of vitamin B6. These data, in
conjunction with previous biochemical and clinical results
over five years, underscore the desirability, and even
necessity, of testing by the EGOT analysis for the presence
of a severe deficiency of vitamin B6 in all such patients
before surgery. Treatment with vitamin B6 (pyridoxine) for
a minimum period of 12 weeks, depending upon the duration
and severity of the symptoms, has been effective without
exception. Surgery may relieve compression, but does not
correct a deficiency of vitamin B6. Surgery in addition to
therapy with vitamin B6 should be reserved for those
patients who have had the deficiency for so many years that
much tissue damage is irreversible by pyridoxine, and
additional relief from pain can be achieved through the
surgery.
Clinical results of a
cross-over treatment with pyridoxine and placebo of the
carpal tunnel syndrome.
Ellis J, Folkers K, Watanabe T, Kaji M, Saji S, Caldwell
JW, Temple CA, Wood FS
Am J Clin Nutr 1979 Oct;32(10):2040-6
Clinical evaluation was made of cross-over treatments by
pyridoxine and a placebo of patient 22 having the carpal
tunnel syndrome. Extraordinary monitoring of the specific
activities of the erythrocyte glutamic oxaloacetic
transaminase proved a severe vitamin B6 deficiency, which
was partially corrected by the Recommended Dietary
Allowance of 2 mg, and completely corrected by 100 mg. The
severity of the syndrome diminished on the Recommended
Dietary Allowances and the patient was asymptomatic at the
higher dosage. On placebo, both the vitamin B6 deficiency
and syndrome reappeared. Retreatment with 100 mg again
corrected both the deficiency and syndrome. Measurements
(total n = 19) of flexion of proximal interphalangeal
joints of the index fingers by a goniometer, and of pinch
by the Preston gauge revealed objective normalization.
Scores of 17 symptoms revealed reductions at both the 2- (P
less than 0.01) and 100-mg (P less than 0.001) dosages.
Conduction through the carpal tunnels had improved by
electromyography. These and previous data on a total of 22
patients showed the concomitant presence of a deficiency of
vitamin B6 and the carpal tunnel syndrome; a causal
relationship is apparent.
Successful therapy with
vitamin B6 and vitamin B2 of the carpal tunnel syndrome and
the need for determination of the RDAs for vitamins B6 and
B2 for disease states.
Folkers, K., Ellis, J.
Ann. N.Y. Acad. Sci. 1990; 585: 295-301.
No abstract available
Enzymology of the
response of the carpal tunnel syndrome to riboflavin and to
combined riboflavin and pyridoxine.
Folkers K, Wolaniuk A, Vadhanavikit S.
Proc Natl Acad Sci U S A 1984 Nov;81(22):7076-8
Differential enzymic analyses of the erythrocyte
glutamic-oxaloacetic transaminase and the erythrocyte
glutathione reductase of a patient with a 3-yr history of
the carpal tunnel syndrome (CTS) revealed high deficiencies
of both vitamin B-6 and riboflavin as based on
approximately equal to 30% levels of the specific
activities of these enzymes. Riboflavin for 5 months caused
nearly complete disappearance of the CTS and caused no
change in the specific activity of erythrocyte
glutamic-oxaloacetic transaminase. Combined riboflavin and
pyridoxine treatment increased (P less than 0.001) the
specific activities of erythrocyte glutathione reductase
and erythrocyte glutamic-oxaloacetic transaminase to normal
levels with total disappearance of the CTS. Objectively,
the strength of pinch of both hands increased (P less than
0.001) on treatment with riboflavin and further increased
(P less than 0.001) on the combined treatment. For the
first time, a significant riboflavin deficiency has been
found to be related to CTS. Riboflavin therapy was
effective biochemically, subjectively, and objectively, and
riboflavin and pyridoxine were even more effective when
concomitantly administered.
Vitamin B6 levels in
patients with carpal tunnel syndrome.
Fuhr JE, Farrow A, Nelson HS Jr Department of Medical
Biology, University of Tennessee Medical Center, Knoxville,
TN 37920.
Arch Surg 1989 Nov;124(11):1329-30
Vitamin B6 levels were determined in patients with
idiopathic carpal tunnel syndrome. Results from this
limited study strongly suggest that vitamin B6 deficiency
may accompany carpal tunnel syndrome. This study did not
address the question of the causal relationship between
vitamin B6 status and development of symptoms.
Carpal tunnel syndrome
and vitamin B6.
Kasdan ML, Janes C
Plast Reconstr Surg 1987 Mar;79(3):456-62
We reviewed 1075 patients presenting over a 12-year
period with symptoms of carpal tunnel syndrome. A total of
994 had a final diagnosis of carpal tunnel syndrome. There
were 444 male and 550 female patients with a mean age of 42
years. Three-hundred and ninety-five related symptoms to
their job. Surgery was performed in 27 percent of the total
diagnosed cases with approximately 97 percent relief of
symptoms. Satisfactory alleviation of symptoms was obtained
in 14.3 percent of patients treated conservatively prior to
1980, with one or a combination of splinting
anti-inflammatory agents, job or activity change, and
steroid injections. In 1980, vitamin B6 (pyridoxine) was
added as a method of conservative treatment. Satisfactory
improvement was obtained in 68 percent of 494 patients
treated with a controlled dosage (100 mg b.i.d.). While our
findings were not the result of a controlled scientific
study, we feel they suggest that regulated use of vitamin
B6 may be helpful in treating many cases of carpal tunnel
syndrome.
Demyelination: the role
of reactive oxygen and nitrogen species.
Smith KJ, Kapoor R, Felts PA Department of Clinical
Neurological Sciences, Guy's, King's and St. Thomas' School
of Medicine, London. k.smith@umds.ac.uk
Brain Pathol 1999 Jan;9(1):69-92
This review summarises the role that reactive oxygen and
nitrogen species play in demyelination, such as that
occurring in the inflammatory demyelinating disorders
multiple sclerosis and Guillain-Barre syndrome. The
concentrations of reactive oxygen and nitrogen species
(e.g. superoxide, nitric oxide and peroxynitrite) can
increase dramatically under conditions such as
inflammation, and this can overwhelm the inherent
antioxidant defences within lesions. Such oxidative and/or
nitrative stress can damage the lipids, proteins and
nucleic acids of cells and mitochondria, potentially
causing cell death. Oligodendrocytes are more sensitive to
oxidative and nitrative stress in vitro than are astrocytes
and microglia, seemingly due to a diminished capacity for
antioxidant defence, and the presence of raised risk
factors, including a high iron content. Oxidative and
nitrative stress might therefore result in vivo in
selective oligodendrocyte death, and thereby demyelination.
The reactive species may also damage the myelin sheath,
promoting its attack by macrophages. Damage can occur
directly by lipid peroxidation, and indirectly by the
activation of proteases and phospholipase A2. Evidence for
the existence of oxidative and nitrative stress within
inflammatory demyelinating lesions includes the presence of
both lipid and protein peroxides, and nitrotyrosine (a
marker for peroxynitrite formation). The neurological
deficit resulting from experimental autoimmune
demyelinating disease has generally been reduced by trial
therapies intended to diminish the concentration of
reactive oxygen species. However, therapies aimed at
diminishing reactive nitrogen species have had a more
variable outcome, sometimes exacerbating disease.
SUGGESTED
READING
Carpal tunnel syndrome:
is it work-related?
Atcheson SG Arthritis Specialists of Northern Nevada,
USA.
Hosp Pract (Off Ed) 1999 Mar 15;34(3):49-56; quiz
147
The reported incidence of work-related carpal tunnel
syndrome has skyrocketed; however, many cases have an
underlying systemic cause. A methodical
investigation--including appropriate imaging studies and
laboratory testing--can differentiate symptoms that are
primarily occupational from those with associated medical
illness or obesity.
Brief communication:
effect of pharmacologic doses of vitamin B6 on carpal
tunnel syndrome, electroencephalographic results, and
pain.
Bernstein AL, Dinesen JS. Department of Neurology,
Kaiser Permanente Medical Center, Hayward, CA 94545.
J Am Coll Nutr 1993 Feb;12(1):73-6
The role of vitamin B6 as a therapeutic agent in the
treatment of carpal tunnel syndrome was examined by
monitoring both the standard clinical and
electrophysiological parameters for entrapment neuropathy
at the wrist. Electroencephalogram (EEG) studies were done
in an attempt to identify patients most likely to benefit
from B6 treatment. EEGs did not prove useful as predictors
of clinical response to vitamin B6. Our patients, however,
did not show any abnormalities prior to treatment, and no
changes occurred during the treatment period. Motor
latency, while the most common screening test for carpal
tunnel syndrome, was not significantly changed during the
course of treatment. It did not prove to be a useful test
for monitoring clinical effectiveness of the treatment.
Parameters showing the greatest changes were pain scores
and sensory latency, which most closely paralleled clinical
assessments. Pain scores, more than any other parameters,
were improved in these patients following vitamin B6
treatment. Vitamin B6 has been shown to change pain
thresholds in clinical and laboratory studies. This may be
the basis of the significant improvement in pain scores
when electrophysiologic data showed only mild improvement.
This study suggests that vitamin B6 deficiency may not be a
cause of carpal tunnel syndrome in spite of the observed
therapeutic effect, without toxicity, of vitamin B6
treatment.
Carpal tunnel syndrome:
the cause dictates the treatment.
Carneiro RS Department of Plastic Surgery, Cleveland
Clinic, Florida, USA.
Cleve Clin J Med 1999 Mar;66(3):159-64
Mild carpal tunnel syndrome should be conservatively
treated and severe carpal tunnel syndrome usually requires
surgery; however, management of moderate carpal tunnel
syndrome is more complex. Usually, the treatment is
dictated by the cause, which may be occupational injury,
acute trauma, systemic diseases such as diabetes,
hypothyroidism, or rheumatoid arthritis, or other
causes.
Carpal tunnel syndrome:
surgical and nonsurgical treatment.
Harter BT Jr, McKiernan JE Jr, Kirzinger SS, Archer FW,
Peters CK, Harter KC
Hand Surg [Am] 1993 Jul;18(4):734-9
A retrospective study was performed to evaluate
treatment for carpal tunnel syndrome. Two hundred
sixty-five patients were treated over a 4 1/2-year period.
Only patients in whom studies showed abnormal nerve
conduction (a median nerve sensory latency greater than 3.6
msec or a median distal motor latency greater than 4.3
msec) were included in the evaluation. Nonsurgical
treatment consisted of patient education, wrist splinting,
B vitamins, nonsteroidal anti-inflammatory medication,
steroid injections, and job change or modification when
possible. A follow-up history, physical examination, and
repeat nerve conduction studies were performed at 3- to
9-month intervals, depending on the severity of symptoms
and the degree of abnormal latencies. Surgery was performed
on 77 patients and 95 hands. The remaining 188 patients
were treated nonsurgically. Both surgically and
nonsurgically treated patients considered the results to be
satisfactory.
Carpal tunnel syndrome:
current theory, treatment, and the use of B6.
Holm G, Moody LE. University of South Florida, USA.
dr.g.holm@usfaccess.com
J Am Acad Nurse Pract 2003 Jan;15(1):18-22
PURPOSE: To present the current state of the science of
pathophysiology, assessment and treatment of carpal tunnel
syndrome, including the use of pyridoxine (B6). DATA
SOURCES: Selected research articles, texts, Websites,
personal communications with experts, and the authors' own
clinical experience. CONCLUSIONS: Much is yet to be learned
about carpal tunnel syndrome. While the basic treatment of
NSAIDs and nighttime splints seems universally accepted,
much controversy remains. The use of vitamin B6 as a
treatment is one such controversy requiring further
investigation. IMPLICATIONS FOR PRACTICE: Current treatment
for carpal tunnel syndrome should include NSAIDs, nighttime
splinting, ergonomic workstation review, and vitamin B6 200
mg per day.
[Carpal tunnel
syndrome. Current approaches]. [Article in
Portugese]
Kouyoumdjian JA Departamento de Ciencias Neurologicas,
Faculdade de Medicina de Sao Jose do Rio Preto, Sao Paulo,
Brasil. jaris@zaz.com.br
Arq Neuropsiquiatr 1999 Jun;57(2B):504-12
A clinical, epidemiological and nerve conduction studies
report on carpal tunnel syndrome was done after
electrophysiological author's experience on 668 cases and
literature review. The median nerve underwent focal (nodal)
or segmental demyelination after compression on carpal
tunnel, 3-4 distal to wrist fold. The symptomatic complex
includes nocturnal hands numbness and paraesthesia, mostly
bilateral and between 40-60 years old. Familial cases are
described and the gene could encode thick transverse carpal
ligament. Anthropomorphic findings could also bring about
an additional risk, but with low significance. Magnetic
resonance could be a useful tool for selected atypical
cases. Conservative treatment and controversies on surgery
timing are discussed. Classical conduction studies on
median nerve reveal a prolonged distal segmental sensory
latency and also on distal motor latency. Increasing
sensitivity may be reach using additional methods such as,
median mixed mid-palm latency, comparative mid-palm latency
median/ulnar, comparative sensory latency median/radial and
median/ulnar, inching method from wrist to palm recording
on index/middle finger and comparative motor median/ulnar
recording on lumbrical/interosseous muscle.
Nonoccupational risk
factors for carpal tunnel syndrome.
Solomon DH, Katz JN, Bohn R, Mogun H, Avorn J Division
of Pharmacoepidemiology and Pharmacoeconomics, Department
of Medicine, Brigham and Women's Hospital, Harvard Medical
School, Boston, Mass. 02115, USA.
J Gen Intern Med 1999 May;14(5):310-4
OBJECTIVE: To examine the relation between selected
nonoccupational risk factors and surgery for carpal tunnel
syndrome.
DESIGN: Case-control study using an administrative
database.
PARTICIPANTS: Enrollees of New Jersey Medicare or
Medicaid programs during 1989 to 1991.
MEASUREMENTS: The outcome of interest was open or
endoscopic carpal tunnel release. We examined the relation
between carpal tunnel release and diabetes mellitus,
thyroid disease, inflammatory arthritis, hemodialysis,
pregnancy, use of corticosteroids, and hormone replacement
therapy.
MAIN RESULTS: In multivariate models, inflammatory
arthritis was strongly associated with carpal tunnel
release (odds ratio [OR] 2.9; 95% confidence interval [CI]
2.2, 3.8). However, corticosteroid use also appeared to be
associated with a greater likelihood of undergoing carpal
tunnel release, even in the absence of inflammatory
arthritis (OR 1.6; 95% CI 1.2, 2.1). Diabetes had a weak
but significant association with carpal tunnel release (OR
1.4; 95% CI 1.2, 1.8), as did hypothyroidism (OR 1.7; 95%
CI 1.1, 2.8), although patients with hyperthyroidism did
not have any change in risk. Women who underwent carpal
tunnel release were almost twice as likely to be users of
estrogen replacement therapy as controls (OR 1.8; 95% CI
1.0, 3.2).
CONCLUSIONS: Although inflammatory arthritis is the most
important nonoccupational risk factor for carpal tunnel
release, these data substantiate the increase in risk
associated with diabetes and untreated hypothyroidism.
Further investigation in detailed clinical studies will be
necessary to confirm whether changes in corticosteroid use
and hormone replacement therapy offer additional means of
risk reduction for this common condition.
Chiropractic
manipulation in carpal tunnel syndrome.
Valente R, Gibson H Department of Chiropractic
Principles and Practice, Cleveland Chiropractic College and
Clinic, Kansas City, MO.
J Manipulative Physiol Ther 1994 May;17(4):246-9
OBJECTIVE: To determine if chiropractic manipulation
could relieve carpal tunnel syndrome (CTS).
CLINICAL FEATURES: A 42-yr-old female suffered from
pain, tingling and numbness in the right wrist. Paresthesia
along the C6 dermatome, a positive Phalen's test and
Tinel's sign was present. EMG testing confirmed the
clinical diagnosis of CTS.
INTERVENTION AND OUTCOME: Chiropractic manipulations
were rendered 3 times per week for 4 wk, to the subject's
cervical spine, right elbow and wrist using a low
amplitude, short lever, low force, high velocity thrust.
Significant increase in grip strength and normalization of
motor and sensory latencies were noted. Orthopedic tests
were negative. Symptoms dissipated.
CONCLUSION: In this case study, chiropractic made a
demonstrable difference through objective and subjective
outcomes. Further investigations using double-blind,
cross-over designs with larger samples are warranted.
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