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Introduction Carpal tunnel syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling, and numbness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS. Method We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for a causal mechanism of CTS.Results Epidemiologically, it has been shown that CTS is associated with age, gender, increased body mass index (BMI), diabetes, pregnancy, and is more common in some populations. The same associations noted above for CTS are strongly associated with sleep disturbances. Sleep disturbances due to age, gender, BMI, pregnancy, and population variations are all associated with sleeping in the lateral position supporting the hypothesis that a common causative mechanism of CTS is sleeping in a lateral position. Discussion We believe that the epidemiologic associations with CTS act through a common causative mechanism, increased sleeping in the lateral position which puts the wrist at increased risk of flexion or extension, compressing the median nerve in the carpal tunnel. This hypothesis is simple and explains the connection between a previously unconnected group of epidemiologic associations. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely reversible. It clarifies previously confused clinical circumstances, creates research questions that can be tested, and it invites us to change our clinical perspective in this most common form of nerve compression.

BackgroundFew investigations have been done to analyze the level of evidence in journals related to hand surgery, compared to other related research fields. The objective of this study was to assess the level of evidence of the clinical research papers published in the Ibero-american (RICMA), the European (JHSE) and American (JHSA) Journals of Hand Surgery.MethodsA total of 932 clinical research papers published between 2005 and 2009 (RICMA 60, JHSE 461, and JHSA 411) were reviewed. Two independent observers classified the level of evidence based on the Oxford International Classification, 5 being the lowest level and 1 the highest level. The observed frequencies of the level of evidence for each journal were compared with the expected frequencies by a chi-square (χ 2) test for categorical variables with a significance level of 0.05.ResultsInter-observer agreement analysis showed a Kappa of 0.617. Intra-observer agreement analysis presented a Kappa of 0.66 for the observer 1, and a Kappa of 0.751 for the observer 2. More than 80% of the papers in RICMA and JHSE and a 67.6% in the JHSA presented a level of 4. No level 1 or 2 studies were published in RICMA, compared to JHSE (0.9% level 1 and 5.0% level 2) and JHSA (8.3% level 1 and 10% level 2). The percentage of papers with level 3 published in RICMA (16.7%) was higher compared to the JHSE (11.1%) and the JHSA (14.1%). All the results were statistically significant (χ2=63.945; p<0.001).ConclusionsThe level of evidence in hand surgery is dependent on the type of journal; being the highest level evidence papers those published in the JHSA, followed by the JHSE and finally the RICMA. Knowing the status of the level of evidence published in hand surgery is the starting point to face the challenges of improving the quality of our clinical research

The objective of this study was to evaluate the responsiveness and construct validity of the Spanish version of the DASH as outcome measure for carpal tunnel surgery. The study population was 42 patients with the diagnosis of carpal tunnel syndrome (CTS) based on clinical and electrophysiological criteria. The clinical design was a classic Cohort study with measures the day before and 12 weeks after open carpal tunnel release. The Spanish version of the DASH was compared to the physical exam measures as dexterity time, grip and pinch strength, range of motion of the wrist (ROM) and two-point discrimination (2PPD). The responsiveness was evaluated based on the effect size (ES) and the standardised response means (SRM). The Spanish version of the CTS questionnaire (CTQ) and the Spanish version of the 36-item short-form health survey (SF-36) were self-administered to the same study population and followed the same clinical design. The hypothesis that the DASH instrument should present a responsiveness level higher than the SF-36 and lower than the CTQ was established to demonstrate the construct validity. The DASH instrument showed an ES of 0.68 and an SRM of 1.00. Responsiveness of traditional physical exam measures were lower, running from 0.35 (SRM) for dexterity time to 0.00 (ES) for key pinch strength. The SF-36 presented a responsiveness level (range from 0.07 to 0.14) lower that the DASH. The CTQ showed the highest level of responsiveness (ES = 1.41 and 0.7) (SRM = 1.75 and 0.51). In conclusion, The DASH instrument is more sensitive in detecting clinical change than the physical exam measures for use in clinical outcome studies of CTS done at 12 weeks after surgery. The Spanish DASH showed a responsiveness lower than the CTQ and higher than the SF-36 as a proof of a good construct validity.