by Mondelli et al. with 79.7% of cases in women. Atroshi et al. found the male to female ratio to be 1: 1.4. Within women, using a nested case control design, Ferry et al. found associations with previous history of another musculoskeletal complain, past use of oral contraception, obesity and diabetes and myxedema. ● Age, gender and insomnia: There is extensive literature that links age and gender with sleep disturbances. Insomnia is more common in women and increases with age, increasing more in women than in men. Recently, Shepertycky has shown that women with obstructive sleep apnea often presented with complaints of insomnia. This suggests some of these women with insomnia may have also had obstructive sleep apnea. ● BMI: The associations of CTS with obesity or increased BMI have been noted and found repeatedly. Nordstrom et al. found the risk of CTS increased 8% for each unit increase of BMI (about 6 pounds). Nathan and Keniston summarized that being overweight, older and physically inactive are major risk factors for slowing of the median nerve and clinical CTS. Bland found some complexity in the relationship between age and obesity, and CTS. Bland found that “increased BMI is a significant independent risk factor for CTS in patients under the age of 63 but is less important in older patient” and further suggested that “CTS in the elderly population may have different underlying pathogenetic mechanisms.” BMI can be influenced by exercise and Nathan reported that people with CTS who embarked on an exercise program decreased body fat, BMI, sensory latency at the carpal tunnel and carpal tunnel symptoms. ● Age, gender, BMI and sleep disorders: Snoring and sleep apnea are known to be associated with age and BMI. Gislason et al. reported that 15.5% of Swedish men and 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.
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