11.2% of Icelandic women reported habitual snoring. They reported an increase with age for men and women until the age of 60 years after which there was some decline in men. These authors found sleep apnea to be more common in older postmenopausal women than in men, but this specific finding is not typical. Most studies of snoring and sleep apnea find these problems to be related to age and in contrast to insomnia, more common in men. Snoring and obstructive sleep apnea increase with age in adulthood and decrease in the elderly. Men are affected more than women. Redline looked at age strata found that BMI > 28 kg/m2 (OR 11.7) and male gender (OR 12.2) are significant risk factors for sleep apnea in subjects aged 22 to 55 years but not younger or older. Through its influence on sleep position, sleep apnea may offer insight to the potential causal relationship of sleep disturbances and sleep positions related to CTS. ● Pregnancy: There is a general belief that CTS is associated with pregnancy. Padua reported that 59% of women in their eighth or ninth month of pregnancy complained of paresthesia in at least one hand (56% R, 45% L, 41% bilateral). Electrodiagnostic studies were consistent with CTS with 43%. The duration of symptoms was a mean of 3.4 months. Stolp-Smith noted 50% of CTS cases in pregnant women occurred in the third trimester. It is widely recognized that CTS will usually resolve after pregnancy. ● Pregnancy and sleep positions: The relationship of pregnancy and sleep position offers further evidence of the association of sleep positions to CTS. As noted above, CTS is common in the third trimester of pregnancy. Because of the enlarging uterus, clinicians recommend that pregnant women adopt a sleeping position on the left side. ● Populations: Nathan found the prevalence of probably and definite CTS much lower in Japanese compared to American populations but the prevalence of slowing of the median nerve to be similar. ● Sleep position related to a specific population: In our review, we were intrigued by a sleep disorder called “Sleep Paralysis (SP) and Associated Hallucinations” because “it is widely believed that lying in the supine position is a proximate cause of SP.” We do not believe CTS is related to SP; however, research into SP has created some interesting information about sleep position. In one study of sleep positions of Japan and Canada, Fukuda found that 58.8% of Canadian university students and 32.4% of Japanese university students sleep on their side, whereas 40.5% of Japanese and 3.5% of Canadian students sleep on their back. ● Diabetes: Singh et al. wrote CTS occurs in 6-30% of individuals with Diabetes and in 2-3% of the general population. The prevalence increases with the duration of Diabetes. Those who had developed CTS had Diabetes longer than those who had not developed CTS. The calculated lifetime risk of CTS was 50% after 44 years and 85% after 54 years of having type 1 Diabetes. Becker et al
showed that while Diabetes may be a significant risk factor for CTS in women, Diabetes only appears to be a risk factor for CTS when combined with BMI. ● Diabetes, obesity and sleep disturbance: According to the National Sleep Foundation’s survey, 11% of those who claim that sleep problems also have been diagnosed with Diabetes. Khuram et at concluded that Diabetes Mellitus (65%) and sleep disorders (35%) were obesity-related complications in subjects of age range 50 to 59 years. Sleep disturbances and insomnia are more common in Diabetics than in control groups. Skomro et al concluded that adult type 2 Diabetics had higher incidences of insomnia than control groups. Compounding the problem of reduced sleep in DM patients, Gottlieb et al. showed that a study of sleep restriction suggested a casual association between shortened sleep and impaired glucose tolerance. Sixty-four percent of the respondents to the 2005 Sleep in America Poll conducted by the National Sleep Foundation had a BMI < 25.0. These individuals were more likely to get less than 6 hours of sleep a night, experience insomnia and are at a higher risk for sleep apnea. BMI/obesity have been found to be predictors of heavy snoring. As elevated BMI/obesity is an elevated risk of sleep problems, in kind, it puts an individual at a higher risk of acquiring Diabetes. Obstructive sleep apnea is more common among Diabetic populations as heavy snoring can lead to “oxygen desaturation which increases catecholamine and cortisol levels, thereby increasing insulin resistance.” Snoring caused by obstructive sleep apnea, or sleep-disordered breathing has been found to elevate the risk of acquiring type II Diabetes. There is a high prevalence of insomnia in Diabetic hemodialysis patients. ● Shift work: Shift work and night work are probably the most severe precipitating factors of insomnia. Shift work is one of the leading circadian rhythm disorders causing insomnia. Roth and Roehrs suggest that shift work is one of the leading risk factors for developing insomnia. ● Arthritis: A number of studies have noted that sleep disturbances are a common problem in children with juvenile rheumatoid arthritis. In a study by Power et al., pain was determined to be a key mediator in the correlation between arthritis and sleep disturbances. Similarly, Ohayon found that arthritis as a chronic painful condition was a cause of major sleep disturbance. Nicassio and Wallston observed that RA appears to be a strong cause of sleep disturbance and that RA patients attributed their sleep problems to their arthritic pain more often than other stresses in their life. ● Hypothesis: We believe, after reviewing of the literature, that the associations of CTS have a common causative pathway through sleep position and can be best explained as resulting from a sleep position on the side causing the wrist position to be deviated into flexion or extension, compressing the median nerve in the carpal tunnel, and initiating the sequence of events resulting in CTS.
NERVE ANATOMY
To better understand how carpal tunnel signs and symptoms manifest, a basic understanding of the anatomy and physiology of nerve tissue will aid our efforts. All nerves are composed of cells called neurons . Remember that a neuron is a single nerve cell; a nerve is a bundle of neurons wrapped together. All neurons have three components that regulate nerve signal conductivity and protect anatomical structure from damage. These three parts are depicted in Figure 3: 1. Cell body : The main portion of the cell that integrates electrical messages. Integration refers to the processing of the chemical pieces of the messages received. This portion contains the nucleus and the supporting cellular elements, which include Nissl bodies which are a site of protein synthesis within the cell body. A neuron damaged at the cell body will not regenerate.
Figure 3: Three Parts of the Neuron
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Book Code: MTX1323
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