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One hundred twenty-eight patients with idiopathic carpal tunnel syndrome were evaluated before surgery and 3 and 6 months after unilateral endoscopic carpal tunnel release. The variables analyzed included patient demographics, symptoms and signs, activities of daily living (ADL), sensibility and strength measurements, preoperative distal motor latency of the median nerve, operating surgeon, postoperative palmar pain and tenderness, return to work, and patient satisfaction with the results of surgery. Multivariate statistical analyses were performed, with patient satisfaction at 6 months after surgery and the time until return to work after surgery as the dependent variables. On stepwise logistic regression analysis of all preoperative variables, significant predictors of patient dissatisfaction at 6 months after surgery were higher age, heavy vibration exposure, worse ADL score, and better distal motor latency. Analysis of all preoperative and 3-month postoperative variables showed heavy vibration exposure, better distal motor latency, and worse 3-month postoperative ADL score to have the strongest independent correlation with patient dissatisfaction at 6 months. No significant independent association was found between any of the preoperative variables studied and the length of time until return to work after surgery.

Objective: To evaluate symptom patterns on a hand diagram as predictors of surgical outcome in carpal tunnel syndrome (CTS)., Methods: 202 patients with CTS enrolled in a prospective, community based cohort study in Maine completed a hand symptom diagram before surgery and at 6 month followup. They were asked to mark on the hand diagram the location of 3 symptoms: pain, numbness/tingling (NT), and "other" symptoms. The diagram was first divided into 6 regions following a standardized procedure. For the 6 regions, symptom patterns were identified separately for each of the 3 symptoms. Outcomes 6 months after surgery were expressed as the percentage of change on the Symptom Severity Scale and Function Status Scale of the Carpal Tunnel Syndrome Assessment Questionnaire, and the satisfaction with the results of the surgery., Results: Several distinct symptom patterns were associated with the 3 principal outcomes in univariate and multivariate analysis. In linear regression models controlling for the baseline severity of symptoms and function, as well as other predictors, the hand symptom pattern variables accounted for 30, 14, and 24%, respectively, of the total explained variance in satisfaction, symptom severity, and functional status. Patients receiving Workers' Compensation (37% of the cohort) had more wrist pain and NT of the arm, and less pain involving the arm and upper palm. This group also had worse outcomes and were less satisfied with surgery. Drawing expansion was associated with a low score on the SF-36 mental health subscale. However, psychological impairment was not associated with a worse outcome., Conclusion: Symptom patterns identified preoperatively with a hand symptom diagram help to predict the outcome of carpal tunnel release.

Workers' compensation costs for management of soft tissue disorders continue to increase. The complexity of medical management of these cases has increased due to social factors. The purpose of this study is to improve the physician's ability to recognize nonmedical issues that prevent a rapid return to employment. A classification system is presented that will allow the clinician to identify administrative and pyschosocial issues that prolong disability. Additionally, the patients' job demands were classified by known ergonomic risk factors. The system was applied retrospectively to 50 random cases referred to two occupational hand clinics over a 1-year period. The results indicated that the psychosocial classification of the patient and the current employment status are the most important factors in prolonging disability workers.

We reviewed the records of all patients with carpal tunnel syndrome who underwent carpal tunnel release by the same neurosurgeon between 1980 and 1990. Of the total 102 patients, 71 patients (70%) had bilateral symptoms. Twenty-six patients in this group (37%) underwent bilateral surgery first on the more severely affected hand, and 1 month later on the contralateral hand. The remaining 45 patients with bilateral symptoms had surgery only on the more severely affected hand, contralateral surgery being withheld for various reasons. These 45 patients were sent follow-up questionnaires to evaluate the symptoms on the hand not treated surgically. The minimum follow up time after surgery was 14 months with an overall mean follow up of 5 years. Of the 33 respondents to the questionnaire, 15 patients stated that symptoms had disappeared in the non-operated hand, 4 said that their symptoms had improved, and 11 reported that symptoms had stayed the same. Three patients eventually underwent surgery on this previously non-operated hand. Thus, 58% of those who responded stated that; without surgery, the symptoms on their contralateral hand either improved or disappeared after surgery on the other hand. We suggest that simultaneous bilateral carpal tunnel surgery may be unnecessary for some patients with bilateral symptoms.

Psychomotor performance (PMP) involving a repeated, rapid pinch and release task was correlated with median nerve electrophysiologic parameters for control subjects (16 hands) and subjects with carpal tunnel syndrome (CTS) (14 hands). The psychomotor task was used because of its functional resemblance to many work related activities. A strain gauge dynamometer was repeatedly pinched to a predetermined force level using the index finger and thumb and then released as rapidly as possible, while measuring the actual isometric force exerted. Discrete visual and auditory feedback was provided. Median and ulnar nerve motor latencies and amplitudes, as well as median antidromic sensory latencies and amplitudes, and transcarpal latencies and amplitudes were obtained. CTS subjects had longer median motor and sensory latencies and were weaker than controls, however median motor and sensory amplitudes were not statistically different. A strong relationship was observed between electrophysiologic variables and PMP, which could not be accounted for by age differences alone. It is unclear whether the measured differences in PMP are related to sensory or motor deficits.

The injection of steroid preparations into the carpal canal is a recognized practice in the management of carpal tunnel syndrome. This procedure is associated with a risk of temporary or permanent damage to the median nerve. We present a new method of carpal tunnel injection based on anatomic dissections. We have used this technique successfully for more than 10 years, and there have been no cases of median nerve injury.

This paper introduces a practice model based on the occupational adaptation frame of reference (Schkade & Schultz, 1992). The occupational adaptation practice model emphasizes the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery. Practice based on occupational adaptation differs from treatment that focuses on acquisition of functional skills because the practice model directs occupational therapy interventions toward the patient's internal processes and how such processes are facilitated to improve occupational functioning. The occupational adaptation practice model is holistic. The patient's occupational environments (as influenced by physical, social, and cultural properties) are as important as the patient's sensorimotor, cognitive, and psychosocial functioning and the patient's experience of personal limitations and potential is validated. The integration of these concepts drives the treatment process. Through a description of treatment with a variety of patients, this paper presents the model's diversity and illustrates the relationship between the concepts. The occupational adaptation practice model reflects the uniqueness of occupational therapy and integrates the profession's historical practice with contemporary interventions and methods.

Ictal fear was found equally with left- and right-sided temporal lobe foci, suggesting that basic components of fear may be bilaterally represented. With regard to interictal fear, patients with left-sided foci reported more fear of social and sexual situations, but not of animals and physical injury, compared with other groups. Men with foci in the right temporal lobe reported less fear than men with left-sided foci. It is conceivable that the two hemisphere contribute differently in the cognitive elaboration of fear responses. Alternatively, differential patterns of self-report of fearfulness may be secondary responses to cognitive or sensorimotor loss. Finally, the present study not only demonstrates differences between right and left temporal lobe epileptics, but also between these groups and those with and without other CNS dysfunction.

Psychological evaluations with hand injury patients provide diagnostic information and treatment recommendations that can be included with the findings from physical and neurologic examinations. Assessment of psychosocial factors that can either complicate recovery from injury or aid in rehabilitation is discussed. Four clinical cases are presented.