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58-445: A clerk is a white-collar worker who conducts record keeping as well as general office tasks, or a worker who performs similar sales-related tasks in a retail environment. The responsibilities of clerical workers commonly include record keeping , filing, staffing service counters, screening callers, and other administrative tasks. In City of London livery companies , the clerk is the chief executive officer . The word clerk

116-445: A QWERTY computer keyboard layout to Dvorak is helpful, but meta-analyses of the available studies note limited supported evidence. There are more than 50 types of treatments for CTS with varied levels of evidence and recommendation across healthcare guidelines, with evidence most strongly supporting surgery, steroids, splinting for wrist positioning, and physical or occupational therapy interventions. When selecting treatment, it

174-418: A restaurant manager who may wear more formal clothing yet still assist with cooking food or taking customers' orders, or a construction worker who also performs desk work. Comprehensive Employment and Training Act Carpal tunnel syndrome Carpal tunnel syndrome ( CTS ) is a nerve compression syndrome associated with the collected signs and symptoms of compression of the median nerve at

232-404: A wrist splint . Injection of corticosteroids may or may not alleviate better than simulated ( placebo ) injections. There is no evidence that corticosteroid injection sustainably alters the natural history of the disease, which seems to be a gradual progression of neuropathy. Surgery to cut the transverse carpal ligament is the only known disease modifying treatment . The carpal tunnel

290-444: A cascade of physiological changes in the nerve itself. There is a dose-respondent curve such that greater and longer periods of pressure are associated with greater nerve dysfunction. The symptoms and signs of carpal tunnel syndrome causes are hypertrophy of the synovial tissue surrounding the flexor tendons such as with rheumatoid arthritis. Prolonged pressure can lead to a cascade of physiological changes in neural tissue. First,

348-747: A college degree, though some college education or 1 to 2 years in vocational programs are common qualifications. Familiarity with office equipment and certain software programs is also often required. Employers may provide clerical training. In 2006, the median salary for clerks was $ 23,000, while the national median income for workers age 25 or older was $ 33,000. Median salaries ranged from $ 22,770 for general office clerks to $ 34,970 for secretaries and $ 41,030 for administrative supervisors. Clerical workers are considered working class by American sociologists such as William Thompson, Joseph Hickey or James Henslin as they perform highly routinized tasks with relatively little autonomy. Sociologist Dennis Gilbert , argues that

406-449: A key factor in increased life-style related health conditions such as fatigue , obesity , diabetes , hypertension , cancer , and heart disease . Also, working at a computer could potentially lead to diseases associated with monotonous data entry such as carpal tunnel syndrome . Workplace interventions such as alternative activity workstations, sit-stand desks , and promotion of stair use are among measures being implemented to counter

464-462: A majority in industrialized countries due to modernization and outsourcing of manufacturing jobs. The blue-collar and white-collar phrases may no longer be literally accurate, as office attire has broadened beyond a white shirt. Employees in many offices may dress in colourful casual or business casual clothes. In addition, the work tasks have blurred. "White-collar" employees may perform "blue-collar" tasks (or vice versa). An example would be

522-516: A normal median nerve. Even more important, notable symptoms with mild disease is strongly associated with unhelpful thoughts and symptoms of worry and despair. Notable CTS should remind clinicians to always consider the whole person, including their mindset and circumstances, in strategies to help people get and stay healthy. A joint report published by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM),

580-582: A period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging. There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination of characteristic symptoms (how it feels) and signs (what the clinician finds on exam) are associated with a high probability of CTS without electrophysiological testing. Electrodiagnostic testing including electromyography , and nerve conduction studies can objectively measure and verify median neuropathy. Ultrasound can image and measure

638-561: A person elects to proceed directly to surgical treatment. Recommendations may differ when carpal tunnel syndrome is found in association with the following conditions: diabetes mellitus , coexistent cervical radiculopathy , hypothyroidism , polyneuropathy , pregnancy , rheumatoid arthritis , and carpal tunnel syndrome in the workplace. CTS related to another pathophysiology is addressed by treating that pathology. For instance, disease-modifying medications for rheumatoid arthritis or surgery for traumatic acute carpal tunnel syndrome. There

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696-925: A sensitivity greater than 85% and specificity greater than 95%. Given the key role of electrodiagnostic testing in the diagnosis of CTS, The AANEM has issued evidence-based practice guidelines, both for the diagnosis of carpal tunnel syndrome. The role of MRI or ultrasound imaging in the diagnosis of CTS is unclear. Their routine use is not recommended. Morphological MRI has high sensitivity but low specificity for CTS. High signal intensity may suggest accumulation of axonal transportation, myelin sheath degeneration or oedema. However, more recent quantitative MRI techniques which derive repeatable, reliable and objective biomarkers from nerves and skeletal muscle may have utility, including diffusion-weighted (typically diffusion tensor) MRI which has demonstrable normal values and aberrations in carpal tunnel syndrome. Cervical radiculopathy can also cause paresthesia abnormal sensibility in

754-403: 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

812-399: Is bordered on the anterior surface by the transverse carpal ligament, also known as the flexor retinaculum . The flexor retinaculum is a strong, fibrous band that attaches to the pisiform and the hamulus of the hamate. 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

870-415: Is characterized by a conduction block, segmental demyelination, and intact axons. With no further compression, the nerves will remyelinate and fully recover. Severe carpal tunnel syndrome patients may have degree II/III injuries (Sunderland classification), or axonotmesis , where the axon is injured partially or fully. With axon injury there would be muscle weakness or atrophy, and with no further compression

928-435: Is debated. There is also little research supporting that ergonomics is related to carpal tunnel syndrome. Given that biological factors such as genetic predisposition and anthropometric features are more strongly associated with carpal tunnel syndrome than occupational/environmental factors such as hand use, CTS might not be prevented by activity modifications. Some claim that worksite modifications such as switching from

986-548: Is derived from the Latin clericus meaning " cleric " or " clergyman ", which is the latinisation of the Greek κληρικός ( klērikos ) from a word meaning a "lot" (in the sense of drawing lots) and hence an "apportionment" or "area of land". The association derived from medieval courts, where writing was mainly entrusted to clergy because most laymen could not read. In this context, the word clerk meant " scholar ". Even today,

1044-451: Is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook. The carpal tunnel is formed by the carpal bones and the transverse carpal ligament. The median nerve passes through this space along with the flexor tendons . Increased compartmental pressure for any reason can squeeze the median nerve. Theoretically, increased pressure can interfere with normal intraneural blood flow, eventually causing

1102-457: Is important to consider the severity and chronicity of the CTS pathophysiology and to distinguish treatments that can alter the natural history of the pathophysiology (disease-modifying treatments) and treatments that only alleviate symptoms (palliative treatments). The strongest evidence for disease-modifying treatment in chronic or severe CTS cases is carpal tunnel surgery to change the shape of

1160-479: Is not clear if sit-stand desks may be effective at reducing sitting in the longer-term. An intervention to encourage office workers to stand and move reduced their sitting time by 22 minutes after 1 year; the effect was 3-times greater when the intervention included a sit-to-stand desk. The intervention also led to small improvements in stress, wellbeing and vigour. Formerly a minority in the agrarian and early industrial societies, white-collar workers have become

1218-630: Is not clear whether this association is due to an alteration of pathophysiology, a variation in symptoms, or a variation in care-seeking. Hereditary neuropathy with susceptibility to pressure palsies is a genetic condition that appears to increase the probability of developing CTS. Heterozygous mutations in the gene SH3TC2 , associated with Charcot-Marie-Tooth , may confer susceptibility to neuropathy , including CTS. Association between common benign tumors such as lipomas , ganglion , and vascular malformation should be handled with care. Such tumors are very common and are more likely to cause pressure on

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1276-442: Is numbness, tingling, or burning sensations in the thumb, index, middle, and radial half of the ring finger. These areas process sensation through the median nerve. Numbness or tingling is usually worse with sleep. People tend to sleep with their wrists flexed, which increases pressure on the nerve. Ache and discomfort may be reported in the forearm or even the upper arm . Symptoms that are not characteristic of CTS include pain in

1334-453: Is often stated that normal electrodiagnostic studies do not preclude the diagnosis of carpal tunnel syndrome. The rationale for this is that a threshold of neuropathy must be reached before study results become abnormal and also that threshold values for abnormality vary. Others contend that idiopathic median neuropathy at the carpal tunnel with normal electrodiagnostic tests would represent very, very mild neuropathy that would be best managed as

1392-599: Is rare, even among people with carpal tunnel syndrome (0.55% incidence within 10 years of carpal tunnel release). In the absence of other factors associated with a notable probability of amyloidosis, it is not clear that biopsy at the time of carpal tunnel release has a suitable balance between potential harms and potential benefits. Other specific pathophysiologies that can cause CTS via pressure include: Work-related factors that increase risk of CTS include vibration (5.4 odds ratio ), hand force (4.2), and repetition (2.3). Exposure to wrist extension or flexion at work increases

1450-451: Is the double crush syndrome, where compression may interfere with axonal transport, and two separate points of compression (e.g. neck and wrist), neither enough to cause local demyelination, may together impair normal nerve function. Carpal tunnel syndrome is estimated to affect one out of ten people during their lifetime and is the most common nerve compression syndrome . There is notable variation in such estimates based on how one defines

1508-476: 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 symptoms of CTS, but there was not a clear distinction of paresthesia (appropriate) from pain (inappropriate) and causation was not established. The distinction from work-related arm pains that are not carpal tunnel syndrome

1566-420: The carpal tunnel in the wrist . Carpal tunnel syndrome is an idiopathic syndrome but there are environmental, and medical risk factors associated with the condition. CTS can affect both wrists. Other conditions can cause CTS such as wrist fracture or rheumatoid arthritis . After fracture, swelling, bleeding, and deformity compress the median nerve. With rheumatoid arthritis, the enlarged synovial lining of

1624-553: The thenar muscles at the base of the thumb. Work-related factors such as vibration, wrist extension or flexion, hand force, and repetition are risk factors for CTS. Other than work related causes there are many known risk factors for CTS including being overweight, female, diabetes mellitus, rheumatoid arthritis and thyroid disease, and genetics. Diagnosis can be made with a high probability based on characteristic symptoms and signs. It can also be measured with electrodiagnostic tests . People wake less often at night if they wear

1682-471: The 5   million carpal tunnel diagnosed in the US that year were related to work. Women are more likely to be diagnosed with work-related carpal tunnel syndrome than men. Many if not most patients described in published series of carpal tunnel release are older and often not working. Normal pressure of the carpal tunnel has been defined as a range of 2–10 mm (0.079–0.394 in). Wrist flexion increases

1740-488: The American Academy of Physical Medicine and Rehabilitation (AAPM&R), and the American Academy of Neurology defines practice parameters, standards, and guidelines for EDX studies of CTS based on an extensive critical literature review. This joint review concluded median and sensory nerve conduction studies are valid and reproducible in a clinical laboratory setting and a clinical diagnosis of CTS can be made with

1798-403: The blood-nerve barrier breaks down (increased permeability of perineureum and endothelial cells of endoneural blood vessels). If the pressure continues, the nerves will start the process of demyelination under the area of compression . This will result in abnormal nerve conduction even when the pressure is relieved leading to persistent sensory symptoms until remyelination can occur. If

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1856-410: The carpal tunnel. The American Academy of Orthopedic Surgeons recommends proceeding conservatively with a course of nonsurgical therapies tried before release surgery is considered. A different treatment should be tried if the current treatment fails to resolve the symptoms within 2 to 7 weeks. Early surgery with carpal tunnel release is indicated where there is evidence of median nerve denervation or

1914-519: The carpal tunnel. Severe CTS is also associated with weakness and atrophy of the muscles at the base of the thumb. The ability to palmarly abduct the thumb may be lost. CTS can be detected on examination using one of several maneuvers to provoke paresthesia (a sensation of tingling or "pins and needles" in the median nerve distribution). These so-called provocative signs include: Diagnostic performance characteristics such as sensitivity and specificity are reported, but difficult to interpret because of

1972-422: The compression continues and is severe enough, axons may be injured and Wallerian degeneration will occur. At this point there may be weakness and muscle atrophy , depending on the extent of axon damage. The critical pressure above which the microcirculatory environment of a nerve becomes compromised depends on diastolic/systolic blood pressure . Higher blood pressure will require higher external pressure on

2030-407: The cross sectional diameter of the median nerve, which has some correlation with CTS. The role of ultrasound in diagnosis—just as for electrodiagnostic testing—is a matter of debate. EDX cannot fully exclude the diagnosis of CTS due to the lack of sensitivity. The role of confirmatory electrodiagnostic testing is debated. The goal of electrodiagnostic testing is to compare the speed of conduction in

2088-535: The disease, including several loci previously known to be associated with human height. Some other factors that contribute to carpal tunnel syndrome are conditions such as diabetes, alcoholism, vitamin deficiency or toxicity as well as exposure to toxins. Conditions such as these don't necessarily increase the interstitial pressure of the carpal tunnel. One case-control study noted that individuals classified as obese ( BMI >29) are 2.5 times more likely than slender individuals (BMI <20) to be diagnosed with CTS. It

2146-412: The hands and wrist. The distribution usually follows the nerve root, and the paresthesia may be provoked by neck movement. Electromyography and imaging of the cervical spine can help to differentiate cervical radiculopathy from carpal tunnel syndrome if the diagnosis is unclear. Carpal tunnel syndrome is sometimes applied as a label to anyone with pain, numbness, swelling, or burning in the radial side of

2204-457: The hands or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms. When the symptoms and signs point to atrophy and muscle weakness more than numbness, consider neurodegenerative disorders such as Amyotrophic Lateral Sclerosis or Charcot-Marie Tooth . There is little or no data to support the concept that activity adjustment prevents carpal tunnel syndrome. The evidence for wrist rest

2262-408: The harms of sedentary workplace environments. The quality of evidence used to determine the effectiveness and potential health benefits of many of these interventions is weak. More research is needed to determine which interventions may be effective in the long-term. Low quality evidence indicates that sit-stand desks may reduce sitting in the workplace during the first year of their use; however, it

2320-687: The lack of a consensus reference standard for CTS. Most presentations of CTS have no known disease cause ( idiopathic ). The association of other factors with CTS is a source of notable debate. It is important to distinguish factors that provoke symptoms, and factors that are associated with seeking care, from factors that make the neuropathy worse. Genetic factors are believed to be the most important determinants of who develops carpal tunnel syndrome due. In other words, one's wrist structure seems programmed at birth to develop CTS later in life. A genome-wide association study ( GWAS ) of carpal tunnel syndrome identified 50 genomic loci significantly associated with

2378-457: The median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, it will conduct more slowly than normal and more slowly than other nerves. Nerve compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities. Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. It

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2436-462: The median nerve. Similarly, the degree to which transthyretin amyloidosis -associated polyneuropathy and carpal tunnel syndrome is under investigation. Prior carpal tunnel release is often noted in individuals who later present with transthyretin amyloid-associated cardiomyopathy . There is consideration that bilateral carpal tunnel syndrome could be a reason to consider amyloidosis, timely diagnosis of which could improve heart health. Amyloidosis

2494-479: The nerve to disrupt its microvascular environment. The critical pressure necessary to disrupt the blood supply of a nerve is approximately 30 mm Hg below diastolic blood pressure or 45mm Hg below mean arterial pressure . For normohypertensive (normal blood pressure) adults, the average values for systolic blood pressure is 116mm Hg diastolic blood pressure is 69mm Hg. Using this data, the average person would become symptomatic with approximately 39mm Hg of pressure in

2552-493: The nerves may only partially recover. While there is evidence that chronic compression is a major cause of carpal tunnel syndrome, it may not be the only cause. Several alternative, potentially speculative, theories exist which describe alternative forms of nerve entrapment. One is the theory of nerve scarring (specifically adherence between the mesoneurium and epineureum ) preventing the nerve from gliding during wrist/finger movements, causing repetitive traction injuries. Another

2610-422: The number of millimeters two points of contact need to be separated before you can distinguish them. A person with idiopathic carpal tunnel syndrome 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, separates from the median nerve and passes over

2668-726: The palm remains normal because the superficial sensory branch of the median nerve branches proximal to the TCL and travels superficial to it. Median nerve symptoms may arise from nerve 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, although this is debated. Severe CTS is associated with measurable loss of sensibility. Diminished threshold sensibility (the ability to distinguish different amounts of pressure) can be measured using Semmes-Weinstein monofilament testing. Diminished discriminant sensibility can be measured by testing two-point discrimination:

2726-428: The pressure eight-fold and extension increases it ten-fold. There is speculation that repetitive flexion and extension in the wrist can cause thickening of the synovial tissue that lines the tendons within the carpal tunnel. 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

2784-432: The problem, in particular whether one studies people presenting with symptoms vs. measurable median neuropathy whether or not people are seeking care. Idiopathic neuropathy accounts for about 90% of all nerve compression syndromes. The best data regarding CTS comes from population-based studies, which demonstrate no relationship to gender, and increasing prevalence (accumulation) with age. The characteristic symptom of CTS

2842-666: The risk of CTS by two times. Current evidence is insufficient to demonstrate that keyboard and computer use causes CTS as of 2014 . As of 2008 , a definitive study on the relationship between CTS and computer use had not been completed. The international debate regarding the relationship between CTS and repetitive hand use (at work in particular) is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding so-called "cumulative trauma disorders" based concerns regarding potential harm from exposure to repetitive tasks, force, posture, and vibration . A review of available scientific data by

2900-436: The tendons causes compression. The main symptoms are pain in the hand, numbness , and tingling in the thumb, index finger, middle finger and the thumb side of the ring finger. Symptoms are typically most troublesome at night. Many people sleep with their wrists bent, and the ensuing symptoms may lead to awakening. Untreated, and over years to decades, CTS causes loss of sensibility, weakness, and shrinkage ( atrophy ) of

2958-660: The term clerk regular designates a type of cleric (one living life according to a rule ). The cognate terms in some languages, notably Klerk in Dutch, became – at the end of the nineteenth century – restricted to a specific, fairly low rank in the administrative hierarchy. Clerical workers are the largest occupational group in the United States . In 2004, there were 3.1 million general office clerks, 1.5 million office administrative supervisors and 4.1 million secretaries. Clerical occupations often do not require

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3016-415: The thumb that allow it to abduct, move away from the other four fingers, as well as move 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. From the anatomical position, the carpal tunnel

3074-463: The tunnel pressure as high as 111mm Hg. Many of the activities associated with carpal tunnel such symptoms as driving, holding a phone, etc. involve flexing the wrist and it is likely due to an increase in carpal tunnel pressure during these activities. Nerve compression can result in various stages of nerve injury. The majority of carpal tunnel syndrome patients have a degree I nerve injury (Sunderland classification), also called neuropraxia . This

3132-646: The white dress shirts of male office workers common through most of the nineteenth and twentieth centuries in Western countries, as opposed to the blue overalls worn by many manual laborers. The term "white collar" is credited to Upton Sinclair , an American writer, in relation to contemporary clerical , administrative, and management workers during the 1930s, though references to white-collar work appear as early as 1935. White collar employees are considered highly educated as compared to blue collar. Less physical activity among white-collar workers has been thought to be

3190-664: The white and blue collar divide has shifted to a divide between professionals, including some semi-professionals, and routinized white collar workers. White collar office supervisors may be considered lower middle class with some secretaries being located in that part of the socio-economic strata where the working and middle classes overlap. White-collar worker In contrast, blue-collar workers perform manual labor or work in skilled trades ; pink-collar workers work in care, health care, social work, or teaching; and grey-collar jobs combine manual labor and skilled trades with non-manual or managerial duties. The term refers to

3248-474: The wrist (69 - 30 = 39 and 69 + (116 - 69)/3 - 45 ~ 40). Carpal tunnel syndrome patients tend to have elevated carpal tunnel pressures (12-31mm Hg) compared to controls (2.5 - 13mm Hg). Applying pressure to the carpal tunnel of normal subjects in a lab can produce mild neurophysiological changes at 30mm Hg with a rapid, complete sensory block at 60mm Hg. Carpal tunnel pressure may be affected by wrist movement/position, with flexion and extension capable of raising

3306-445: The wrists or hands, loss of grip strength, minor loss of sleep, and loss of manual dexterity. As the median neuropathy gets worse, there is loss of sensibility in the thumb, index, middle, and thumb side of the ring finger. As the neuropathy progresses, there may be first weakness, then to atrophy of the muscles of thenar eminence (the flexor pollicis brevis , opponens pollicis , and abductor pollicis brevis ). The sensibility of

3364-502: Was unclear. It is proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It is proposed that postural and spinal assessment along with ergonomic assessments should be considered, based on observation that addressing these factors has been found to improve comfort in some studies although experimental data are lacking and the perceived benefits may not be specific to those interventions. A 2010 survey by NIOSH showed that two-thirds of

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