Tag Archives: University of Texas Southwestern Medical Center

Removing unwanted hair


Earlier it was only women who were concerned about excessive body hair and its removal. They visited the friendly neighbourhood parlour to get their eyebrows shaped and moustaches removed. Times have changed; now both men and women want to get rid of unwanted hair – from face, arms, legs, chest and back. A hairy torso (male or female) is no longer considered attractive!

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In men excessive body hair is often, paradoxically, paired with male pattern baldness. This excessive hair not only looks cosmetically unappealing but can result in excessive sweating, and infections in the hair follicles.
Excessive hair growth in women is usually familial or due to obesity. Such women may have hair in areas such as the face, chin and back.

Women produce both male and female hormones. If the balance is disturbed, and more male hormones are secreted then the woman can become very hairy. This can occur during the teens or in later life. It may be due to polycystic ovarian syndrome (PCOS), congenital adrenal hyperplasia, if excessive steroids are administered or produced in the body as in Cushing’s syndrome, with some anti depressants and medications like danazole. In rare cases, it may be due to male hormone secreting tumours. If the hirsuitism is accompanied by deepening of the voice, loss of scalp hair and acne, it is called virilisation.

Shaving is a time tested method to remove hair from the arms, legs, axilla [armpits] and face. Shaving facial hair does not make it grow back thicker, coarser or faster. Apply shaving gel or foam first to soften the hair. Poor technique can cause ingrown hair.

A few unwanted hairs can be plucked using tweezers but it is painful. Pulling in the direction opposite to hair growth can cause ingrown hair and scarring. Apply ice immediately to the tweezed area to reduce swelling and redness.

Hair removing creams are available OTC (over the counter). The chemicals dissolve the hair shaft. Allergy can develop to the chemicals so it needs to be tested on a small area first. It can burn the skin if it is left on for too long.

Hot or cold wax can be used to remove hair. This can be done professionally in a salon or at home. It is messy and painful. Infection and burns can occur. It should be avoided if acne creams are also being used.

Twisting thread and then pulling the hair out is called threading. It is a technique done in parlours. It can cause pain.

Laser treatments have become very popular in recent times. Beauty parlours and spas offer such treatments. Only a licensed pro-fessional should do it. A physician should be available on the premises to tackle any side effects. Lasers suitable for Indian skin need to be used. The sittings need to be scheduled at the correct intervals 8-10 weeks apart. It does not get rid of unwanted hair permanently. After repeated sittings, hair growth is reduced by upto 80 per cent. It can cause scarring, keloid formation and pigment changes. That is why it should be tried on a small area first.

Hair can be removed permanently with electrolysis. A professional uses a needle to apply an electric current in the hair follicle. There may be tingling and pain. The process is slow and time consuming but is permanent. It can cause pigment changes. Several sittings spaced out over a period of months are required.

Resources: The Telegraph (Kolkata, India)

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Chest X-Ray

Definition:The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest.

An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

Doctors have used x-rays for over a century to see inside the body in order to diagnose a variety of problems, including cancer, fractures, and pneumonia. During this test, you usually stand in front of a photographic plate while a machine sends x-rays, a type of radiation, through your body. Originally, a photograph of internal structures was produced on film; nowadays, the image created by the x-rays goes directly into a computer. Dense structures, such as bone, appear white on the x-ray films because they absorb many of the x-ray beams and block them from reaching the plate (see Figure 16). Hollow body parts, such as lungs, appear dark because x-rays pass through them. (In some other countries, like the United Kingdom, the colors are reversed, and dense structures are black.)

Back x-rays and chest x-rays are among the most common conventional x-ray tests. You should not have an x-ray if you’re pregnant, because radiation can be harmful to a developing fetus.

A chest x-ray provides black-and-white images of your lungs, ribs, heart, and diaphragm.

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Some common uses:
The chest x-ray is performed to evaluate the lungs, heart and chest wall.

A chest x-ray is typically the first imaging test used to help diagnose symptoms such as:

*shortness of breath
*a bad or persistent cough
*chest pain or injury
*fever.
Physicians use the examination to help diagnose or monitor treatment for conditions such as:

*pneumonia
*heart failure and other heart problems
*emphysema
*lung cancer
*other medical conditions.


How should you prepare for the test?

A chest x-ray requires no special preparation.

You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.

You are usually asked to remove all clothing, undergarments, and jewelry above your waist, and to wear a hospital gown.

What does the equipment look like?
The equipment typically used for chest x-rays consists of a wall-mounted, box-like apparatus containing the x-ray film or a special plate that records the image digitally and an x-ray producing tube, that is usually positioned about six feet away.
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The equipment may also be arranged with the x-ray tube suspended over a table on which the patient lies. A drawer under the table holds the x-ray film or digital recording plate.

A portable x-ray machine is a compact apparatus that can be taken to the patient in a hospital bed or the emergency room. The x-ray tube is connected to a flexible arm that is extended over the patient while an x-ray film holder or image recording plate is placed beneath the patient.

What happens when the test is performed?
Chest x-rays usually are taken while you are standing. A technician positions you against the photographic plate (which looks like a large board) to obtain the clearest pictures. He or she takes pictures from the front and from one side while asking you to take in a deep breath just before each picture. The technician leaves the room or stands behind a screen while the x-rays are taken.

How does the procedure work?
X-rays are a form of radiation like light or radio waves. X-rays pass through most objects, including the body. Once it is carefully aimed at the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an image on photographic film or a special digital image recording plate.

Different parts of the body absorb the x-rays in varying degrees. Dense bone absorbs much of the radiation while soft tissue, such as muscle, fat and organs, allow more of the x-rays to pass through them. As a result, bones appear white on the x-ray, soft tissue shows up in shades of gray and air appears black.

On a chest x-ray, the ribs and spine will absorb much of the radiation and appear white or light gray on the image. Lung tissue absorbs little radiation and will appear dark on the image.

Until recently, x-ray images were maintained as hard film copy (much like a photographic negative). Today, most images are digital files that are stored electronically. These stored images are easily accessible and are sometimes compared to current x-ray images for diagnosis and disease management.

How is the procedure performed?

Typically, two views of the chest are taken, one from the back and the other from the side of the body as the patient stands against the image recording plate. The technologist, an individual specially trained to perform radiology examinations, will position the patient with hands on hips and chest pressed the image plate. For the second view, the patient’s side is against the image plate with arms elevated.

 

Patients who cannot stand may be positioned lying down on a table for chest x-rays.

You must hold very still and may be asked to keep from breathing for a few seconds while the x-ray picture is taken to reduce the possibility of a blurred image. The technologist will walk behind a wall or into the next room to activate the x-ray machine.

When the examination is complete, you will be asked to wait until the radiologist determines that all the necessary images have been obtained.

The chest x-ray examination is usually completed within 15 minutes.

Additional views may be required within hours, days or months to evaluate any changes in the chest.

What will you experience during and after the procedure?
A chest x-ray examination itself is a painless procedure.

You may experience discomfort from the cool temperature in the examination room and the coldness of the recording plate. Individuals with arthritis or injuries to the chest wall, shoulders or arms may have discomfort trying to stay still during the examination. The technologist will assist you in finding the most comfortable position possible that still ensures diagnostic image quality.
Who interprets the results and how do you get them?
A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will discuss the results with you.

In an emergency, the results of a chest x-ray can be available almost immediately for review by your physician.
What are the benefits vs. risks?
Benefits:

*No radiation remains in a patient’s body after an x-ray examination.
*X-rays usually have no side effects in the diagnostic range.
*X-ray equipment is relatively inexpensive and widely available in emergency rooms, physician offices, ambulatory care *centers, nursing homes and other locations, making it convenient for both patients and physicians.
*Because x-ray imaging is fast and easy, it is particularly useful in emergency diagnosis and treatment.

Risks:

*There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk.

*The chest x-ray is one of the lowest radiation exposure medical examinations performed today. The effective radiation dose from this procedure is about 0.1 mSv, which is about the same as the average person receives from background radiation in 10 days. See the Safety page for more information about radiation dose.

*Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. See the Safety page for more information about pregnancy and x-rays.

How long is it before the result of the test is known?
Although digital images may be available immediately, it will take additional time for a doctor to examine and interpret them. You’ll probably get the results later in the day.

A Word About Minimizing Radiation Exposure:
Special care is taken during x-ray examinations to use the lowest radiation dose possible while producing the best images for evaluation. National and international radiology protection councils continually review and update the technique standards used by radiology professionals.

State-of-the-art x-ray systems have tightly controlled x-ray beams with significant filtration and dose control methods to minimize stray or scatter radiation. This ensures that those parts of a patient’s body not being imaged receive minimal radiation exposure.

What are the limitations of Chest Radiography?
The chest x-ray is a very useful examination, but it has limitations. Because some conditions of the chest cannot be detected on an x-ray image, this examination cannot necessarily rule out all problems in the chest. For example, very small cancers may not show up on a chest x-ray. A blood clot in the lungs, a condition called a pulmonary embolism, cannot be seen on chest x-rays.

Further imaging studies may be necessary to clarify the results of a chest x-ray or to look for abnormalities not visible on the chest x-ray.

Click for More Additional Information and Resources: ->
*RadiologyInfo: Radiation Therapy for Lung Cancer

*RTAnswers.org: Radiation Therapy for Lung Cancer

Resources:
https://www.health.harvard.edu/diagnostic-tests/chest-x-ray.htm
http://www.radiologyinfo.org/en/info.cfm?PG=chestrad

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Acid Reflux Disease Hits Americans Hard

Today, approximately 60% experience occasional episodes of acid reflux, and about 25% deal with the problem on a weekly basis. The prevalence of the condition in North America is increasing by about 5% a year, according to a 2007 study in the journal Clinical Gastroenterology and Hepatology.

A report in January from the Agency for Healthcare Research and Quality found that more than 95,000 people in the U.S. were hospitalized with acid reflux as a primary diagnosis in 2005, up 4.5% from 1998. But the number of people hospitalized with reflux as either a primary or secondary diagnosis reached 3 million in 2005 — an increase of 216% from 1998.

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As this old Alka-Seltzer commercial makes apparent, Americans have grappled with acid reflux for decades.

Gastroesophageal reflux disease, GERD or acid reflux, occurs when the small ring of muscle at the bottom of the esophagus weakens and allows stomach acid and food to back up, or reflux, into the esophagus after a meal. Common symptoms include heartburn, difficulty swallowing, an acidic taste in the mouth and nausea or vomiting.

The increase in obesity is speculated to be one cause of its growing prevalence. Excess fat in the abdominal area pushes on the stomach’s contents; stomach fat causes distention and relaxes the lower esophagus; and fat-laden foods slow down the stomach’s emptying process. Other factors include Americans’ notoriously poor nutritional habits and a heightened awareness of the condition induced by pharmaceutical advertising.

Medications also may be contributing to the problem.

“If people didn’t have good medications to treat it and something they ate made them sick, they would avoid it — but it’s human nature to pop a pill and continue eating,” said Dr. Prateek Sharma, a professor of medicine and director of the GI Fellowship Training at the University of Kansas School of Medicine.

Medical therapy:

Although medication is not a cure for acid reflux, a majority of patients find relief through prescription and over-the-counter drugs. Aside from traditional antacids, including Alka-Seltzer and Tums, there are now two main medications used to treat reflux.

H2 blockers reduce the amount of histamine-2, which produces acid in the stomach. They are recommended for people with less frequent and severe bouts of reflux. Zantac 75, Pepcid AC, Tagamet HB and Axid AR are some of the products available without a prescription.

A second medication is the proton pump inhibitor, which shuts down proton pumps in the stomach that produce acid. These are stronger than H2 blockers and recommended for people with more persistent, acute symptoms. Products such as Prilosec, Prevacid and Nexium are available only by prescription; Prilosec OTC is the only proton pump inhibitor available over the counter.

Even though there are a number of brands, Sharma said they all work similarly. He recommends patients use them for periodic acid reflux problems — once a week or twice a month.

There are some side effects associated with the medications, though most physicians say they are rare. Dr. Nicholas Shaheen, an associate professor of medicine and epidemiology and director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, said acid-suppressive medications are among the safest drugs he prescribes.

One potential issue is that stomach acid helps fight infection, so reducing acid could make individuals more prone to infections like pneumonia, said Dr. Stuart Spechler, chief of gastroenterology at the Dallas Veterans Affairs Medical Center and professor of medicine at the University of Texas Southwestern Medical Center at Dallas.

The medications also may block the absorption of vitamins and minerals such as B-12 and calcium, which could lead to hip fractures.

Surgical options:-For people who have responded to medication but continue to experience symptoms such as heartburn or regurgitation, surgery is an option. Only about 5% of reflux patients undergo the minimally invasive procedure in which the upper part of the stomach is wrapped around the lower esophagus to re-create the weakened valve.

Some doctors are skeptics of the surgery, Spechler included. He said the procedure tends to “break down” over time, and though many of his surgical patients tell him their symptoms are improved afterward, few are completely cured.

In the late 1980s, Spechler and his colleagues performed a study comparing the results of patients on medication and those receiving surgery. A follow-up study in 2001 found that almost two-thirds of the surgical patients were back on medication.

Dr. David Rattner, professor of surgery at Harvard Medical School and chief of gastroenterology and general surgery at Massachusetts General Hospital, said the surgery is relatively simple; most people go home after 24 hours and are “100%” after about two weeks. Side effects of surgery are rare. They include difficulty swallowing, excessive gas or return of symptoms, particularly among obese patients. Spechler said deaths occur in about one in every 1,000 operations.

One final way to treat reflux is through various endoscopic procedures, including stitching or using radio-frequency waves to restore the lower esophageal muscles. Studies have shown that these procedures can reduce medication usage, are relatively safe and can improve quality of life.

But they are not time-tested and not commonly used. In 2002, the American Gastroenterological Assn. said endoscopic treatment is not a recommended therapy for reflux sufferers.

Sources: health@latimes.com

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Mapping the Face

New research into how the face stores fat could lead to more effective anti-aging strategies, better facial reconstruction techniques, and may even help doctors assess heart-disease risks.

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Compartmentalization: The face has a new map.

In the fight to protect our faces from the ravages of aging, gravity is one of our biggest enemies. As we get older, Newton’s favorite force pulls everything from our brows to our chins south, and despite the claims of the multibillion-dollar anti-aging industry there is only so much we can do to pull back. And new research indicates that the face is a much more complicated battlefield than previously thought.

Rather than being a single area, the face is made up of not one, but 16 anatomically distinct compartments that gain and lose fatty tissue independently of one another over time, scientists at the University of Texas Southwestern Medical Center announced in a recent issue of Plastic and Reconstructive Surgery. The discovery is upending previous assumptions about the face’s structure, and its implications may reach beyond better face-lifts to a new understanding of obesity.

“For the last 100 years or so, we thought that facial skin and fat were held up by a handful of ligaments, and that the visual effects of aging come as those ligaments break down and gravity takes over, says James Stuzin, a plastic surgeon in Coconut Grove, Fla., who was not involved in the study. œIt turns out we got that wrong.

One clue into the face’s complexity is the fact that it does not age uniformly. As your cheeks begin to sag, for example, the area around your eyes may remain young and sprightly looking. This led Rod Rohrich, a professor and plastic surgeon at the University of Texas Southwestern Medical Center and the study’s lead author, to speculate that something might be separating sections of the face from one another. To test this theory, he and his colleagues injected blue dye into the faces of 30 cadavers. Rather than disperse evenly, which is what you’d expect if the face were a single area, the dye only spread throughout a specific facial area, depending on where it was injected. In all, they found eight distinct compartments on each side of the face.

Human anatomy has been studied for over 500 years, says study coauthor Joel Pessa, an assistant professor and plastic surgeon at UT Southwestern.  œItâ’s pretty unusual to see something this new at the macroscopic, anatomical level.
This illustration shows how blue dye settled in two of the 16 distinct fat compartments in the face as documented by researchers.

The compartments themselves are created by membranes that carry blood vessels to the face. Ligaments, once thought to play a leading role, are really the posts along an intricate series of membrane fences, according to the research. Knowing where these membranes are located, and where they intersect, may aid in the design of more specific flaps—tears of skin that plastic surgeons move from one area of the body to another. This could improve facial reconstruction techniques for those who’ve been injured in accidents or combat.

As the face ages, not only do ligaments break down, empowering gravity, but each compartment gains or loses fat independently of its neighbors. While plastic surgeons have long understood that part of the aging equation involves facial fat loss (a process they refer to as deflation), they may have underestimated its role in shaping the appearance of older faces. “Some of what looks like sagging, is really just deflation in deeper compartments,” says Pessa. “Knowing this will allow us to approach facial rejuvenation in a much more precise and individualized way.”

Researchers are looking into whether the case is the same for the rest of the body. “It opens a whole new avenue of investigation,” says Stuzin. “Now we can look at fat storage in a very scientific manner.” Scientists already know that people who store fat in certain regions of the body face a greater risk for developing heart disease. But Rohrich and Pessa’s research shows that common terms like “intra-abdominal” may actually refer to several distinct compartments. And that may lead to better predictions of risk. “Rather than saying ‘you store fat in the abdomen,’ we’ll be able to say, ‘you store fat in the deep axillary fat compartment’.” says Pessa. “It will be a much more fine-tuned diagnosis—but that’s a few years down the road.”

Source:NEWSWEEK

Carpal Tunnel Syndrome

Definition:
Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The mechanism is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel.  It appears to be caused by a combination of genetic and environmental factors. Some of the predisposing factors include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or work with vibrating tools. There is, however, little clinical data to prove that lighter, repetitive tasks can cause carpal tunnel syndrome. Other disorders such as bursitis and tendinitis have been associated with repeated motions performed in the course of normal work or other activities. Though considered a condition of modern times, carpal tunnel syndrome has actually been recognized since the 1880s…...CLICK & SEE

The carpal tunnel is an anatomical compartment located at the base of the palm. 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 median nerve provides feeling or sensation to the thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, or move away from the fingers, out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis of the ring finger. The proximal boundary is the distal wrist skin crease, and the distal boundary is approximated by a line known as Kaplan’s cardinal line. This line uses surface landmarks, and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook. 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 digits supplied by the median nerve. The superficial sensory branch of the median nerve, which provides sensation to the base of the palm, branches proximal to the TCL and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar sensatio.

Symptoms
Numbness or tingling in the thumb and the first three fingers.
Shooting pains in the wrist and forearm, which may radiate into the shoulder and neck.
Weakness in the hand; difficulty picking up and holding objects.
Feeling that the fingers are swollen when no swelling is visible.

The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring finger. The numbness often occurs at night, with the hypothesis that the wrists are held flexed during sleep. Recent literature suggests that sleep positioning, such as sleeping on one’s side, might be an associated factor. It can be relieved by wearing a wrist splint that prevents flexion. Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of palmar abduction (see carpometacarpal joint §?Movements).

People with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, in particular the index, middle fingers, and radial half of the ring fingers, which are innervated by the median nerve. Less-specific symptoms may include pain in the wrists or hands and loss of grip strength (both of which are more characteristic of painful conditions such as arthritis).

Some suggest that median nerve symptoms can arise from compression at the level of the thoracic outlet or the area where the median nerve passes between the two heads of the pronator teres in the forearm, but this is debatable. This line of thinking is an attempt to explain pain and other symptoms not characteristic of carpal tunnel syndrome. Carpal tunnel syndrome is a common diagnosis with an objective, reliable, verifiable pathophysiology, whereas thoracic outlet syndrome and pronator syndrome are defined by a lack of verifiable pathophysiology and are usually applied in the context of nonspecific upper extremity pain.

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

Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep. Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression.
Causes:
Most cases of CTS are of unknown causes, or idiopathic. 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, oral contraceptives, hypothyroidism, arthritis, diabetes, prediabetes (impaired glucose tolerance), and trauma. Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth syndrome type 1 called hereditary neuropathy with liability to pressure palsies.

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. Carpal tunnel syndrome often is a symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who later present with transthyretin amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome.

The median nerve can usually move up to 9.6 mm to allow the wrist to flex, and to a lesser extent during extension. Long-term compression of the median nerve can inhibit nerve gliding, which may lead to injury and scarring. When scarring occurs, the nerve will adhere to the tissue around it and become locked into a fixed position, so that less movement is apparent.

Normal pressure of the carpal tunnel has been defined as a range of 2–10 mm, and wrist flexion increases this pressure 8-fold, while extension increases it 10-fold. Repetitive flexion and extension in the wrist significantly increase the fluid pressure in the tunnel through thickening of the synovial tissue that lines the tendons within the carpal tunnel.

Work related:...click & see
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. The relationship between work and CTS is controversial; in many locations, workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.

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, but it is unclear as to whether 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. Addressing these factors has been found to improve comfort in some studies. A 2010 survey by NIOSH showed that 2/3 of the 5 million carpal tunnel cases in the US that year were related to work. Women have more work-related carpal tunnel syndrome than men.

Speculation that CTS is work-related is based on claims such as CTS being found mostly in the working adult population, though evidence is lacking for this. For instance, in one recent representative series of a consecutive experience, most patients were older and not working. Based on the claimed increased incidence in the workplace, arm use is implicated, but the weight of evidence suggests that this is an inherent, genetic, slowly but inevitably progressive idiopathic peripheral mononeuropathy.

Other Associated conditions:
A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel, associated local and systematic diseases, and certain habits. 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.
Examples include:

*Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.
*With hypothyroidism, generalized myxedema causes deposition of mucopolysaccharides within both the perineurium of the median nerve, as well as the tendons passing through the carpal tunnel.
*During pregnancy women experience CTS due to hormonal changes (high progesterone levels) and water retention (which swells the synovium), which are common during pregnancy.
*Previous injuries including fractures of the wrist.
*Medical disorders that lead to fluid retention or are associated with inflammation such as: inflammatory arthritis, Colles’ fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens.
*Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, in particular with a combination of forceful and repetitive activities
*Acromegaly causes excessive growth hormones. This causes the soft tissues and bones around the carpel tunnel to grow and compress the median nerve.
*Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).
*Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.
*Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck, or anywhere above the wrist, increases sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.
*Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome

Diagnosis:
There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination of described symptoms, clinical findings, and electrophysiological testing is used by a majority of hand surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle weakness/atrophy, positive Tinel’s sign at the carpal tunnel, and abnormal sensory testing such as two-point discrimination have been standardized as clinical diagnostic criteria by consensus panels of experts. A predominance of pain rather than numbness is unlikely to be caused by carpal tunnel syndrome no matter what the result of electrophysiological testing.

Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the median nerve dysfunction. Normal nerve conduction studies, however, do not exclude the diagnosis of CTS: waiting for nerve tests to become positive may well prejudice the eventual duration and completeness of recovery, particularly of the thenar motor branch is involved.

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

Phalen’s maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms.  A positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more advanced the condition. Phalen’s sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has been shown to correlate with CTS severity when studied prospectively.

Tinel’s sign, a classic — though less sensitive – test is a way to detect irritated nerves. Tinel’s is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or “pins and needles” in the nerve distribution. Tinel’s sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than Phalen’s sign.

Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.
Hand elevation test The hand elevation test has higher sensitivity and specificity than Tinel’s test, Phalen’s test, and carpal compression test. Chi-square statistical analysis confirms the hand elevation test is not ineffective compared with Tinel’s test, Phalen’s test, and carpal compression test.

As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area of the palm, branches off of the median nerve and passes over the carpal tunnel. This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, or pronator teres syndrome.

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). 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 However, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a threshold of nerve injury must be reached before study results become abnormal and cut-off values for abnormality are variable. Carpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst.

The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is not very clear.

Differential diagnosis:
Carpal tunnel syndrome is sometimes applied as a label to anyone with pain, numbness, swelling, and/or burning in the radial side of the hands and/or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms. As a whole, the medical community is not currently embracing or accepting trigger point theories due to lack of scientific evidence supporting their effectiveness.

Treatment:
Conservative treatments include use of night splints and corticosteroid injection. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament.
Generally accepted treatments include: physiotherapy, steroids either orally or injected locally, splinting, and surgical release of the transverse carpal ligament. There is no or insufficient evidence for ultrasound, yoga, lasers, B6, and exercise therapy.

The American Academy of Orthopedic Surgeons recommends proceeding conservatively with a course of nonsurgical therapies tried before release surgery is considered. Early surgery with carpal tunnel release is indicated where there is evidence of median nerve denervation or a person elects to proceed directly to surgical 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.

How Supplements Can Help
Several studies have suggested that a vitamin B6 deficiency can make you susceptible to the numbness and pain of carpal tunnel syndrome. This vitamin is important in maintaining healthy nerve tissue, relieving inflammation, and improving circulation. It also may increase the brain’s production of the nerve chemical GABA (gamma-aminobutyric acid), which helps control pain sensations. If you don’t notice any improvement after taking vitamin B6 for three weeks, switch to pyridoxal-5-phosphate (P-5-P), a form of the vitamin that the body eventually produces as it breaks down vitamin B6. Some people find this form works better for them.
Taking vitamin C supplements may leave you vulnerable to carpal tunnel-unless you also get enough vitamin B6. One study involving 441 participants found that those deficient in B6 who took vitamin C daily were more likely to develop carpal tunnel syndrome than those who were B6 deficient but did not use vitamin C supplements.

In addition to B6, bromelain, a powerful anti-inflammatory enzyme found in pineapple, is very effective in treating the inflammation and any resulting pain. The combination of bromelain and vitamin B6 works better than either supplement alone. Turmeric, a member of the ginger family, is another useful herb. When turmeric is taken with bromelain, they enhance each other’s anti-inflammatory properties and together may help relieve the pain of carpal tunnel syndrome. Though turmeric is safe to use over the long term, cut the dose in half once your symptoms subside. (This herb can be expensive.)

What Else can be done:
Take frequent breaks when performing any repetitive hand activity, such as typing, knitting, or playing an instrument. Stop at least once an hour to flex your fingers and shake your hands.
Apply ice to your wrists when pain strikes. Use a flexible ice pack — or even a bag of frozen peas — and put it on for 10 minutes every hour to ease the pain and reduce the inlammation.
Elevate your wrists with a pillow when you lie down.
Salt promotes water retention, which can contribute to swelling and may aggravate the symptoms of carpal tunnel syndrome. Try reducing the amount of salt in your diet and see if it helps.

Supplement Recommendations
Vitamin B6
Bromelain
Turmeric

Vitamin B6
Dosage: 50 mg 3 times a day until symptoms subside.
Comments: 200 mg daily over long term can cause nerve damage.

Bromelain

Dosage: 1,000 mg twice a day during acute phase. Reduce to 500 mg twice a day when symptoms subside. Take between meals.
Comments: Provides 8,000 GDU or 12,000 MCU in acute phase.

Turmeric

Dosage: 400 mg 3 times a day.
Comments: Standardized to contain 95% curcumin. Should be used with bromelain.

Prognosis:
Most people relieved of their carpal tunnel symptoms with conservative or surgical management find minimal residual or “nerve damage”. 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. Those that undergo a carpal tunnel release are nearly twice as likely as those not having surgery to develop trigger thumb in the months following the procedure.

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 or alcohol use yields much poorer overall results of treatment.

Recurrence of carpal tunnel syndrome after successful surgery is rare. If a person has hand pain after surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case that the illness of a person with 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

Resources
Your Guide to Vitamins, Minerals, and Herbs
http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome