Sleep Position in Patients With Carpal Tunnel Syndrome

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DOI: 10.17795/zjrms990
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Abstract
Background: Carpal tunnel syndrome is one of the most common entrapment neuropathy. Recent studies suggest that this syndrome may be more frequent in some specific sleep positions. Objectives: The aim of this study was evaluation of sleep position in patients with carpal tunnel syndrome. Patients and Methods: This cross-sectional study was conducted on 220 patients with carpal tunnel syndrome. The diagnosis was confirmed with electromyography. The sleep position in the patients was assessed via the questionnaire. The sleep position of the patients was compared with the sleep position of 320 healthy persons. The χ2 test was used for statistical analysis. Results: Carpal tunnel syndrome was more frequent in women. About two thirds of the patients had moderate to severe carpal tunnel syndrome. The prevalence of carpal tunnel syndrome was more frequent in patients who slept on their sides than who slept in other positions (P < 0.01). There was no significant relationship between the severity of carpal tunnel syndrome and sleep position. Conclusions: Our study showed that carpal tunnel syndrome was more frequent in some sleep positions, however, no significant relationship was found between the sleep position and the severity of this syndrome.
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Zahedan J Res Med Sci. 2015 June; 17(6):e990. DOI: http://sx.doi.org/10.17795/zjrms990
Published online 2015 June 27. Research Article
Sleep Position in Patients With Carpal Tunnel Syndrome
Farhad Iranmanesh 1,*; Hossein Ali Ebrahimi 1; Ali Shahsavari 1
1Department of Neurology, Neurology Research Center, Kerman University of Medical Sciences, Kerman, IR Iran
*Corresponding author: Farhad Iranmanesh, Department of Neurology, Neurology Research Center, Kerman University of Medical Sciences, Kerman, IR Iran.
E-mail: fpp_farhad@yahoo.com
Received: March 5, 2014; Accepted: May 20, 2014
Background: Carpal tunnel syndrome is one of the most common entrapment neuropathy. Recent studies suggest that this syndrome
may be more frequent in some specific sleep positions.
Objectives: The aim of this study was evaluation of sleep position in patients with carpal tunnel syndrome.
Patients and Methods: This cross-sectional study was conducted on 220 patients with carpal tunnel syndrome. The diagnosis was
confirmed with electromyography. The sleep position in the patients was assessed via the questionnaire. The sleep position of the patients
was compared with the sleep position of 320 healthy persons. The χ2 test was used for statistical analysis.
Results: Carpal tunnel syndrome was more frequent in women. About two thirds of the patients had moderate to severe carpal tunnel
syndrome. The prevalence of carpal tunnel syndrome was more frequent in patients who slept on their sides than who slept in other
positions (P < 0.01). There was no significant relationship between the severity of carpal tunnel syndrome and sleep position.
Conclusions: Our study showed that carpal tunnel syndrome was more frequent in some sleep positions, however, no significant
relationship was found between the sleep position and the severity of this syndrome.
Keywords: Carpal tunnel syndrome; Position; Sleep
Copyright © 2015, Zahedan University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-
Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial
usages, provided the original work is properly cited.
1. Background
Carpal tunnel syndrome (CTS) is one of the most com-
mon entrapment neuropathy in the world. About 10% of
general population is involved with this syndrome. The
main symptoms are pain and paresthesia and weakness
may be seen at the distal wrist in some patients [1, 2]. This
disease is more frequent in women and clinical diagnosis
will be confirmed by electromyography [3-6]. The main
causes are obesity, pregnancy, diabetes, thyroid disor-
ders and wrist deformities. In addition to these factors, it
seems that some other factors may be having a role in CTS
pathophysiology [7-10]. Among them, sleep position is
noted in the recent studies. At now, all published articles
have showed that the symptoms of CTS are more severe
at night [11, 12]. According to this finding, McCabe et al.
in a review article assessed the relation between CTS and
sleep and observed that all researches point to worsening
of symptoms during sleep but they could not find any fac-
tor that might explain this finding. Then, the authors hy-
pothesized that sleep position may be have a role in CTS
[13]. Also, Jensen et al. found that there is a relationship
between bilateral sleeping position and CTS [14]. McCabe
and Xue in another study observed that the incidence of
this syndrome is significantly higher in the patients who
sleep on their left or right side compared to the patients
who sleep on other positions [15]. McCabe et al. retested
their study on patients with this syndrome but with con-
trol group and obtained the same results [16].
2. Objectives
Because this issue is new and studies in this area are
limited and also relationship between the severity of this
syndrome and sleep positions was not assessed in the
previous researches, the present study was designed.
3. Patients and Methods
In this cross-sectional study, 220 patients with CTS were
evaluated in 2011. The patients selected from Besat clinic
and a private health center in Kerman. Everyone with
identified cause of CTS (obesity, pregnancy, diabetes, thy-
roid disorders, rheumatic diseases and wrist deformities)
excluded from the study. It should be noted that all these
cases were evaluated in every patient. The assessment of
obesity was based on BMI and the patients with BMI ≥ 30
were excluded from the study [17]. Diagnosis of CTS was
confirmed by electromyography and patients were ex-
cluded from the study if there were any changes in elec-
tromyography except the changes compatible with CTS.
The severity of the disease was categorized in the fol-
lowing conditions; mild: sensory peck latency > 3.6 ms
Iranmanesh F et al.
Zahedan J Res Med Sci. 2015;17(6):e9902
and motor onset latency ≤ 4.1, moderate: both sensory
and motor are involved, (sensory peck latency ≥ 3.6 ms
and motor latency > 4.1) but the waves have not disap-
peared, sever: sensory or motor waves have disappeared
[18]. The sleep positions of the patients were recorded
through interviews with the patients and were catego-
rized into following groups: (a) sleeping on the right
side, (b) sleeping on the left side, (c) sleeping on supine,
(d) sleeping on the prone, (e) others. Also, patients with
following conditions were excluded from our study: (I)
if they could not identify their sleeping position, (II) if
they had any certain underlying sleep disorder, (III) if
they were alcohol or opium addict or drug consumer.
In this study 320 healthy persons were evaluated as the
control group. They were selected from the patients’
relatives. These individuals had the same age and sex
as the patients. Sample size was determined as 220 pa-
tients and 320 healthy with 5% alpha, 10% beta and also,
power of study was 90% [16]. Participation in the study
was voluntary and the research was approved by the
ethics committee of Kerman University. To analyze the
data, SPSS-21 software and χ2 test were used.
4. Results
In this study, 220 patients and 320 healthy persons were
evaluated. In patients group, 67 (30.5%) were male and the
rest were female. In control group, 94 (29.4%) were male and
the others were female, the age range of both groups was
from 20 to 70 years. The mean age of patients was 46 ± 9.4
years and the mean age of control group was 41.3 ± 8.7 years.
There was no significant difference in terms of age and
sex between two groups. Regarding severity of the disease,
64 (29.1%) patients had mild, 95 (43.2%) patients had mod-
erate and 61 (27.7%) patients had severe CTS. CTS was in 122
(55.5%) patients in right side and in 44 (20%) patients in left
side and in 54 (24.5%) patients in both sides. Comparison
of sleep positions between two groups (Table 1) showed
that there was a significant difference (P = 0.04). Also,
comparison of affected side of the patients and the sleep
position (Table 2) showed a significant difference between
sleeping on left and right sides and the side affected with
the disease (P = 0.0001). According to Table 3, there is no
significant relationship between severity of carpal tunnel
syndrome and sleep position (P = 0.07).
Table 1. Frequency of Sleep Positions in the Patients and Control Groups a
Right Side Left Side Others Supine Prone Total
Patients 68 (41) 31 (18.7) 17 (10.2) 36 (21.7) 14 (8.4) 166 (100)
Control 75 (23.4) 61 (19.1) 24 (7.5) 116 (36.2) 44 (13.8) 320 (100)
P Value 0.04 0.35 0.059 0.063 0.087
a Data are presented as No. (%).
Table 2. Frequency of Sleep Positions According to the Involved Hand a,b
Right side Left Side Others Supine Prone Total
Right-side CTS 63 (51.6) 10 (8.2) 13 (10.7) 26 (21.3) 10 (8.2) 122 (100)
Left-side CTS 5 (11.4) 21 (47.7) 4 (9.1) 10 (22.7) 4 (9.1) 44 (100)
P Value 0.001 0.032 0.075 0.095 0.0121
a Abbreviations: CTS, Carpal tunnel syndrome.
b Data are presented as No. (%).
Table 3. Frequency of Intensity of the Disease According to the Sleep Positions a
Sleep position Intensity of the Disease
Mild Moderate Severe P Value
Right side 18 (34) 33 (50.8) 17 (35.4) 0.07
Left side 7 (13.2) 13 (20) 11 (22.9) 0.062
Others 8 (15.1) 7 (10.7) 2 (4.2) 0.078
Supine 12 (22.6) 10 (15.4) 14 (29.2) 0.086
Prone 8 (15.1) 2 (3.1) 4 (8.3) 0.068
a Data are presented as No. (%).
Iranmanesh F et al.
3
Zahedan J Res Med Sci. 2015;17(6):e990
5. Discussion
The results of our study showed that sleep position in
patients with CTS differ with normal population and the
prevalence of CTS is higher in persons who sleep on their
left or right sides than persons who sleep on other posi-
tions. Our findings are as same as McCabe et al. study in
America in 2010. In this case-control study, a significant
relationship was found between sleeping on either sides
and the prevalence of CTS. Moreover, the findings of this
study showed this relationship is stronger in men com-
pared to the women [16].
There is not any case-control researches in this filed ex-
cept, McCabe and Xue study and our study and both of
them showed a significant relationship between sleeping
on either sides and the prevalence of CTS. Also, this study
showed that the prevalence of CTS is higher in the indi-
viduals who sleep on their sides than the individuals who
sleep on other positions [15]. It is not clear why individu-
als who sleep on their left or right sides are more prone
to CTS. We know that CTS is strongly dependent on the
morphology of the wrist [19]. It seems that sleeping on
either side’s increases extension or flections of the wrist.
Therefore, these sleep positions increases pressure on the
median nerve and ultimately increases prevalence of the
disease [16, 20].
Also, it should be noted that the symptoms are worse at
night. Then, undoubtedly, there are some factors at night
that stimulate the median nerve (maybe one of them is
sleep position) [13, 21]. The exacerbation of symptoms at
night is reported in 77% to 80% of the patients [21, 22] and
most of the patients with mild to moderate syndrome
were healed by wearing splint at nights [23, 24].
Then some aspects of CTS patophysiologyis related to
night. The reason of exacerbation of symptoms at night
may be due to redistribution of fluids in the upper parts
of the body. Wearing splint may also reduce this edema.
As a result, it helps improve symptoms of the disease (or
improve the CTS in some individuals) [13].
It also should be noted that individuals change their po-
sitions during sleep at nights several times; however, one
of the sleep positions is more prevalent than other posi-
tions among most of the people [25]. In our study, the re-
lationship between the severity of CTS and various sleep
positions was also examined. We found no significant re-
lationship between these variables. We also did not find
similar study conducted in this area. Accordingly, we can
conclude that all sleeping positions can cause carpal tun-
nel syndrome with any intensity. Also, prevalence of CTS
was higher in the women compared to the men in our
study. These finding is as same as published studies [15].
A recent meta analyzes suggested that the prevalence of
carpal tunnel syndrome is twice as common in female
but , it should be noted that this finding was not right
in the studies in which specific populations were consid-
ered, such as individuals who work with computer [26,
27]. Wrist Ratio is the ratio of height of the wrist to the
width of the wrist. This value of this ratio in the patients
with CTS is higher than healthy persons. The value of this
ratio is also higher in women than men. This is one of the
reasons for higher prevalence of CTS in women. In our
study, most of patients had CTS on right side. This finding
is consistent with those obtained in many studies [28, 29].
It seems that higher frequency of right-handed indi-
viduals than left-handed individuals and the higher fre-
quency of performing physical activities with the right
hand than left hand in all societies are the reason for
higher prevalence of this syndrome in right hand [29-
31]. In this study, this disorder was most common in pa-
tients aged 40 to 60 years old. This data is also, as same
as many researches. However, some studies showed that
prevalence of CTS increases with age [26, 27]. In our study,
we did not find a relationship between prevalence of CTS
and increased age. We excluded the individuals who had
diabetes and obesity from our study and it may be have
Influence on our findings because prevalence of diabetes
and obesity increase with age and we deleted them from
our study. Some studies suggested that the pathophysiol-
ogy of the disease is different at various ages [14].
In our study, about one-third of patients had mild CTS
while the rest of the patients were diagnosed with moder-
ate to severe CTS. In a study in Korea, two thirds of the pa-
tients had mild CTS and the others had moderate to severe
CTS [32]. It seems that patients in Iran refer to doctor for
specialized treatment of the disease very late (in compari-
son with study in Korea). Although clinical symptoms of
the disease had a direct relationship with electromyogra-
phy findings [33] but it should be noted that this relation-
ship is not always true because some patients with mild
symptoms might show severe CTS in electromyography
[34]. In our study, most of the healthy individuals in the
control group (42.5%) slept on their left or right sides. In
one study, it was observed that 58.8% of Canadian students
and 32.4% of Japanese students slept on their sides while
40.5% of Japanese students slept on their backs and 30.5%
of the Canadian students slept on their backs. The sleep
position is a habit of sleeping in adults, which may be im-
posed to them in childhood [21]. In our study, 59.7% of the
patients slept on their right sides. This finding was consis-
tent with a study in America [16]. Recent studies showed
sleep positions affect quality of life [21]. The limitation of
our study was that we did not investigate snoring in the
patients. Studies show that 6 to 27% of the patients have
snoring during sleep [35]. This cause sleep disorders; as a
result, it may affect the results. In conclusion, our findings
indicated that prevalence of CTS is higher in the individu-
als who sleep on their sides. However, no relationship was
found between sleep positions and the severity of CTS.
Acknowledgements
This article is extracted from Dr Iranmanesh’s project
in Kerman University of Medical Sciences Authors thank
the Neurology Research Center of Kerman for supporting
this project.
Iranmanesh F et al.
Zahedan J Res Med Sci. 2015;17(6):e9904
Authors’ Contributions
All authors had equal role in design, work, statistical
analysis and manuscript writing.
Funding/Support
Kerman University of Medical Sciences.
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  • ... Weakness may be observed in hand grip and opposition of the thumb [4]. It is confirmed that the most important predisposing factors for idiopathic CTS are old age, being female, family history and size of the carpal tunnel, while repeating hand movement, cold weather, sleep positioning and obesity are considered the least important [5] [6]. ...
  • ... Weakness may be observed in hand grip and opposition of the thumb [4]. It is confirmed that the most important predisposing factors for idiopathic CTS are old age, being female, family history and size of the carpal tunnel, while repeating hand movement, cold weather, sleep positioning and obesity are considered the least important [5] [6]. ...
  • ... And inconsistent with [19,22 ,23]. Iranmanesh et al., [23] found that most of cases had moderated CTS and less cases of mild and severe, respectively, while Mohamed et al., [22] found that most cases were having severe CTS followed by moderate and less mild cases. The relation between BMI and severity of CTS shows that there are significant differences among patient groups (P<0.05), as in Table (3). ...
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    To evaluate each digital branch of the median sensory nerve and motor nerves to abductor pollicis brevis (APB) and 2nd lumbrical (2L) according to the severity of carpal tunnel syndrome (CTS). A prospective study was performed in 67 hands of 41 patients with CTS consisting of mild, 23; moderate, 27; and severe cases, 17. Compound muscle action potentials (CMAPs) were obtained from APB and 2L, and median sensory nerve action potentials (SNAPs) were recorded from the thumb to the 4th digit. Parameters analyzed were latency of the median CMAP, latency difference of 2L and first palmar interosseous (PI), as well as latency and baseline to peak amplitude of the median SNAPs. The onset and peak latencies of the median SNAPs revealed significant differences only in the 2nd digit, according to the severity of CTS, and abnormal rates of the latencies were significantly lower in the 2nd digit to a mild degree. The amplitude of SNAP and sensory nerve conduction velocities were more preserved in the 2nd digit in mild CTS and more affected in the 4th digit in severe CTS. CMAPs were not evoked with APB recording in 4 patients with severe CTS, but obtained in all patients with 2L recording. 2L-PI showed statistical significance according to the severity of CTS. The branch to the 4th digit was mostly involved and the branch to the 2nd digit and 2L were less affected in the progress of CTS. The second digit recorded SNAPs and 2L recorded CMAPs would be valuable in the evaluation of severe CTS.
  • Article
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    Sleep disturbance is common in carpal tunnel syndrome (CTS), and we hypothesize that it has an important impact on the quality of life of CTS patients. The characteristic of sleep problems associated with CTS has not been evaluated. We performed a case-control study to measure the association between a variety of sleep disturbances and CTS. Sixty-two cases with clinically diagnosed CTS and a probable or classic hand diagram were compared to 138 primary care patients without CTS. In addition to demographic features, we collected the nature of sleep disturbance experienced by the patients from a categorical list and the nature, impact, and severity of sleep disturbance using the Insomnia Severity Index. Patients with CTS complained of significantly more severe problems with sleep than the control population and had multiple sleep complaints compared to the control group. Sixty-three of the 138 control patients indicated that they had one cause of sleeping disturbance with no control patient choosing more than one. In contrast, in CTS patients, 44 of 63 patients indicated they had two or more causes of sleep disturbance. The Insomnia Severity Index was significantly higher in CTS patients and the impact of sleep disturbance on quality of life was higher in the cases. Sleep disturbance in CTS patients is characterized by a broad array of physical symptoms that have a significant impact on quality of life.
  • Article
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    Carpal tunnel syndrome (CTS) is entrapment of median nerve in carpal tunnel of the wrist. The prevalence of CTS related to pregnancy and non-pregnancy is unknown in some countries such as Iran. The main aim of this study was to determine the prevalence of CTS in women of Boyerahmad Township located in South-West part of Iran. This cross-sectional descriptive analytic study was done since February 2010 to January 2011 in Obstetrics and Gynecology clinics in 2656 non-pregnant and 1508 pregnant women. The women that had clinical symptoms of CTS performed standard electro diagnostic techniques for rule in or rule out of CTS. The prevalence of CTS in pregnant and non- pregnant women was 3.4 and 2 .3 percent respectively. The prevalence of CTS in all women was 2.7%. Overall, 51 pregnant women had CTS that 59.4% had mild, 18.8 % had moderate and 21.9% had severe CTS. Sixty-one non-pregnant women had CTS that 73.6 %had mild, 20.8 %t had moderate and 5.6 % had severe CTS. Although the prevalence of CTS in Iranian pregnancy is higher than non-pregnancy women conservative treatment is safe and more effective.
  • Article
    Aim: The expert committee of the German Ministry for Labour and Social Affairs suggested carpal tunnel syndrome (CTS) as an "occupational disease". This systematic literature review and metaanalysis was aimed at identifying associated and risk factors for CTS. Part I addresses the general factors and possible concurrent factors of CTS. These results may be helpful in later experts' reviews of the "occupational disease CTS". Methods: A systematic literature review was performed by examining papers in PubMed, Cochrane, EMBASE and Web of Science databases that were published on or before February 15th, 2011. A total of 87 studies (27 longitudinal and 60 cross-sectional) were included in this metaanalysis. The PRISMA (preferred reporting items for systematic reviews and metaanalyses) guidelines for performing a metaanalysis were strictly followed. All of the effect sizes were calculated using a random effects model. Results: The CTS prevalence in all studies independent of study type was 10.6 % (95 % CI 7.8-14.2). The crude incidence calculated from the longitudinal studies was 10.4 (95 % CI 8.9-11.9)/1000 person years. Female patients more frequently suffered from CTS [OR = 1.9 (95 % CI 1.6-2.2), p < 0.001]. The prevalence of CTS was correlated with an increase in age. The highest prevalence was observed in middle-aged patients (40 to 60 years old). Other significant CTS-associated factors were overweight or obesity [OR = 1.4 (95 % CI 1.3-1.6), p < 0.001]. CTS more frequently occurred in the dominant hand [OR = 1.8 (95 % CI 1.4-2.3), p < 0.001] and in persons of "non-white race" [OR = 1.6 (95 % CI 1.2-1.9), p < 0.001]. Furthermore, CTS was often associated with numerous other general diseases. Real risk factors (results from longitudinal studies) were the following: female gender [OR = 3.7 (95 % CI 2.6-5.2), p < 0.001], middle age [OR = 2.2 (95 % CI 0.9-4.9), p < 0.001], overweight or obesity [OR = 1.5 (95 % CI 1.1-1.9), p < 0.001], diabetes mellitus [OR = 5.3 (95 % CI 1.6-16.8), p < 0.001], and excessive alcohol abuse [OR = 2.3 (95 % CI 0.7-2.3), p < 0.001]. Conclusion: CTS is an extremely frequent disease. Independent of occupational burden, many patients are suffering from this frequent peripheral nervous compressive syndrome. These data will be essential in later experts' reviews of the "occupational disease CTS".
  • Article
    To investigate the frequency of ‘rolling over’ in bed and to clarify sleeping posture characteristics in nocturnal sleep, the sleeping positions of 19 healthy men were videotaped over 7 h (0:00–7:00 hours) for two consecutive nights. Sleeping habits and the degree of satisfaction upon awakening were also surveyed by using questionnaires. A significant positive correlation (r = 0.60, P < 0.01) was observed between the most favorite hypnogenetic position of the body and the most frequently observed position of the head during nocturnal sleep. Furthermore, sleeping positions varied from individual to individual, and the same subject slept showing similar positions and roll over frequencies to those on the day before.
  • Article
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    Although carpal tunnel syndrome is the most common compressive neuropathy, there is no comprehensive theory of its etiology. Because of the prevalence of night symptoms, we are interested in the role of sleep position in the causation of carpal tunnel syndrome. We performed a case-control study comparing the prevalence of preferred sleep position in 68 cases and 138 controls. Analysis was stratified by age and gender and controlled for body mass index. We found a strong and significant association between a preference for sleeping on the side and the presence of carpal tunnel syndrome in men and in women less than 60 years of age. Body mass index was associated with carpal tunnel syndrome in women but not men. Our findings of a strong association between the presence of carpal tunnel syndrome and preferred sleeping on the side suggest a comprehensive unifying theory of causation.