Pain threshold by pressure algometry in the Carpal Tunnel Syndrome
Main Article Content
Abstract
Background: Pain threshold evaluation in compressive neuropathy is very useful for explainig generalized symptoms. About peripheral sensitization process in the release of bradykinin and prostaglandin alters specific TRPV1 receptors leading to reduction of nerve fiber firing threshold. This repetition leads to a brain receptive field expansion with consequent central sensitization.
Methods: We have evaluated 160 female subdivided according to the neurophysiologic impairment of median nerve. Pressure algometry as well as discriminatory sensitivity between two points and The Boston Questionnaire were applied.
Results: The comparison of algometry data showed extremely significant differences between control group and another groups. Therefore, pain thresholds showed direct relation to mononeuropathy severity to a certain point. When sensory or motor potential were no longer obtained, painful thresholds returned close to normal values. We suggest this result could be due to small fibers destruction, when hyperalgesia would be replaced by hypoesthesia.
Conclusion: Pain threshold is lower in patients with carpal tunnel syndrome, either the median nerve innervated area or another areas.
Keywords:
Carpal tunnel syndrome, Compressive neuropathy., Pain threshold, Pain measurement
Article Details
How to Cite
BERNARDINO, Silvya Nery et al.
Pain threshold by pressure algometry in the Carpal Tunnel Syndrome.
Medical Research Archives, [S.l.], v. 7, n. 11, nov. 2019.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2009>. Date accessed: 19 apr. 2024.
doi: https://doi.org/10.18103/mra.v7i11.2009.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
Akelman E, Weiss AC: Carpal tunnel syndrome. Etiology and endoscopic treatment. Orthop Clin North Am. 1995 Oct;26(4):769-78.
Atroshi I, Gummesson C, Johnsson R, Sprinchorn A. Symptoms, disability, and quality of life in patients with carpal tunnel syndrome. J Hand Surg.1999 Mar;24:398-404.
Atzmon R, Eger G, Lindner D, Assaraf E, Lin E, Avissar E. Carpal tunnel syndrome in pregnancy. Harefuah. 2014 Nov;153(11):663-6.
Becker J, Nora DB, Gomes I, Stringari FF, Seitensus R, Panosso JS, Ehlers JC. An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Clin Neurophysiol. 2002 Sep;113(9):1429-34
Bernardino SN. Medidas dos limiares dolorosos por algometria de pressão em pacientes com cefaleia primária. Master Degree, Recife, Jun 2012, 25 p.
Bilgin SS, Olcay SE, Derincek A, Adiyaman S, Demirtas AM. Can simple release relieve symptoms of carpal tunnel syndrome caused by a persistent median artery? Clinical experience. Arch Orthop Trauma Surg. 2004 Apr;124(3):154-6. Epub 2004 Feb 6.
Bongers F, Schellevis F, Van Den Bosch W, Van Der Zee J. Carpal tunnel syndrome in general practice: incidence and the role of occupational and non-occupational factors. Br J Gen Pract. 2007 Jan 1; 57(534): 36–39.
Brain WR, Wright AD, Wilkinson M. Spontaneous compression of both median nerves inthe carpal tunnel: six cases treated surgically. Lancet. 1947 Mar 8;1(6443-6445):277-82
Buchthal F, Rosenfalck A. Sensory conduction from digit to palm and from palm to wrist in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1971 Jun;34(3):243-52.
Campbell J N, Meyer RA. Mechanisms of neuropathic pain. Neuron. 2006 Oct; 5(52):77-92.
Campos CC, Manzano GM, Andrade LB, Castelo A, Nóbrega JAM. Tradução e validação do questionário de avaliação de gravidade dos sintomas e do estado funcional da síndrome do túnel do carpo. Arq. Neuro-Psiquiatr. 2003 Mar;61(1):51-5.
Cannon BW, Love JG, Gender differences in pressure pain threshold in healthy humans. Pain, 1946;20:210-6.
Chesterton LS, Barlas P, Foster NE, Baxter GD, Wright CC. Gender differences in pressure pain threshold in healthy humans. Pain. 2003 Feb;101(3):259-66.
Coq JO, Barr AE, Strata F, "et. al". Peripheral and central changes combine to induce motor behavioral deficits in a moderate repetition task. Exp Neurol. 2009 Dec;220(2):234-45. doi: 10.1016/j.expneurol.2009.08.008. Epub 2009 Aug 15.
Crymble B. Brachial Neuralgia and the Carpal Tunnel Syndrome. Br Med J. 1968 Aug 24;3(5616):470-1.
Dale AM, Harris-Adamson C, Rempel D, "et. al". Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies. Scand J Work Environ Health. 2013 Sep 1;39(5):495-505. doi: 10.5271/sjweh.3351. Epub 2013 Feb 19.
Das SK, Brown HG. In search of complications in carpal tunnel decompression. Hand, Essex. 1976 Oct;8(3):243-9.
Dawson GD, Scott JW. The recording of nerve action potentials through skin in man. J Neurol Neurosurg Psychiatry. 1949;12(4):259-67.
De-la-Llave-Rincón AI, Puentedura EJ, Fernández-de-las-Peñas C. New advances in the mechanisms and etiology of carpal tunnel syndrome.. Discov Med. 2012 May;13(72):343-8.
Dellon AV. The moving two point discrimination test: clinical evaluation of the quicckly adapting fiber receptor system. J Hand Surg Am. 1978 Sep;3(5):474-81.
Demircay E, Civelek E, Cansever T, Kabatas S, Yilmaz C. Anatomic variations of the median nerve in the carpal tunnel: a brief review of the literature. Turk Neurosurg. 2011;21(3):388-96. doi: 10.5137/1019-5149.JTN.3073-10.1.
Dhond RP, Ruzich E, Witzel T, "et al". Spatio-temporal mapping cortical neuroplasticity in carpal tunnel syndrome. Brain. 2012 Oct; 135(10): 3062–3073.
Dorwart BB. Carpal tunnel syndrome: a review. Semin Arthritis Rheum. 1984 Nov;14(2):134-40.
El Miedany Y, El Gaafary M, Youssef S, Ahmed I, Nasr A. Ultrasound assessment of the median nerve: a biomarker that can help in setting a treat to target approach tailored for carpal tunnel syndrome patients. Springerplus. 2015 Jan 13;4:13. doi: 10.1186/s40064-014-0779-4. eCollection 2015.
Ettema AM, Amadio PC, Zhao C, Wold LE, An KN. A histological and immunohistochemical study of the subsynovial connective tissue in idiopathic carpal tunnel syndrome. J Bone Joint Surg Am. 2004 Jul;86(7):1458-66.
Fernández-de-Las-Peñas C, Madeleine P, Martínez-Perez A, Arendt-Nielsen L, Jiménez-García R, Pareja JA. Pressure pain sensitivity topographical maps reveal bilateral hyperalgesia of the hands in patients with unilateral carpal tunnel syndrome. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1055-64. doi: 10.1002/acr.20189.
Fernández-de-Las-Peñas C, Cleland JA, Plaza-Manzano G, "et al". Clinical, physical, and neurophysiological impairments associated with decreased function in women with carpal tunnel syndrome, J Orthop Sports Phys Ther. 2013 Sep;43(9):641-9. doi: 10.2519/jospt.2013.4830.
Fowler JR, Gaughan JP, Ilyas AM.FOWLER, J.R.; GAUGHAN, J.P.; ILYAS, A.M.: The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011 Apr;469(4):1089-94. doi: 10.1007/s11999-010-1637-5. Epub 2010 Oct 21.
Fu T, Cao M, Liu F, "et al". Carpal Tunnel Syndrome Assessment with Ultrasonography: Value of Inlet-to-Outlet Median Nerve Area Ratio in Patients versus Healthy Volunteers. PLoS One. 2015 Jan 24;10(1):e0116777. doi: 10.1371/journal.pone.0116777. eCollection 2015.
Gilliatt RW, Sears TA. Sensory nerve action potentials in patients with peripheral nerve lesions. J Neurol Neurosurg Psychiatry. 1958 May;21(2):109-18.
Gray H, Clemente CD. Anatomy of the human body. 13th ed. Lea & Febiger, Philadelphia. 1985, 531,542,551.
Greenslade JR, Mehta RL, Belward P, Warwick DJ. Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire? J Hand Surg Br. 2004 Apr;29(2):159-64.
Hirata H, Nagakura T, Tsujii M, Morita A, Fujisawa K, Uchida A. The relationship of VEGF and PGE2 expression to extracellular matrix remodelling of the tenosynovium in the carpal tunnel syndrome. J Pathol. 2004 Dec;204(5):605-12.
Hollinshead WH. Anatomy for surgeons: The Back and Limbs, vol 3, 3rd, ed. Philadelphia, Harper & Row, 1982, 420.
Horng YS, Chang HC, Lin KE, Guo YL, Liu DH, Wang JD. Accuracy of ultrasonography and magnetic resonance imaging in diagnosing carpal tunel syndrome using rest and grasp positions of the hands. J Hand Surg Am. 2012 Aug;37(8):1591-8. Epub 2012 Jul 4.
Hunt JR. The neural atrophy of the muscles of the hand without sensory disturbances. Rev Neurol Psych, Edinburgh, 1914, v. 12, p. 137-48.
IASP- International Association for Study of Pain. Consensus development conference statement: the integrated approach to the management of pain. J Accid Emerg Med, Bethesda, National Institutes of Health. 1994;6(3):491-2.
Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal Tunnel Syndrome: A Review of the Recent Literature. Open Orthop J. 2012;6:69-76. doi: 10.2174/1874325001206010069. Epub 2012 Feb 23.
Johnson EW, Wells RM, Duran RJ. Diagnosis of carpal tunnel syndrome. Arch Physi Med Rehabil. 1962;43:414–9.
Karolczak APB, Vaz MA, Freitas CR, Merlo ARC. Síndrome do Túnel do Carpo. Revista Brasileira de Fisioterapia. 2005;9(2):117-22.
Keele KD. Pain sensitivity tests: the pressure algometer. Lancet. 1954 Mar ;266 (6813): 636-9.
Kiani J, Goharifar H, Moghimbeigi A, Azizkhani H.Prevalence and risk factors of five most common upper extremity disorders in diabetics. J Res Health Sci. 2014 Winter;14(1):92-5.
Krendel DA, Jobsis M, Gaskell PCJr, Sanders DB. The flick sign in carpal tunnel syndrome. J Neurol-Neurosurg-Psychiatr. 1986 Feb;49(2);220-1.
Leblanc KE, Cestia W. Carpal tunnel syndrome. . 2011 Apr;83(8):952-8.
Levine DW, Simmons BP, Koris MJ, "et al". A self-administered questionnaire for the assessment of severity of symptons and funcional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993 Nov;75(11):1585-92.
Li J, Vause CV, Durham PL. Calcitonin gene-related peptide stimulation of nitric oxide synthesis and release from trigeminal ganglion glial cells. Brain Res.2008 Feb;1196: 22-32.
Macdermid JC,Doherty T. Clinical and electrodiagnostic testing of carpal tunnel syndrome: a narrative review. J Orthop Sports Phys Ther. 2004 Oct;34(10):565-88.
MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):309-19.
Maeda Y, Kettner N, Holden J, "et al". Functional deficits in carpal tunnel syndrome reflect reorganization of primary somatosensory cortex. Brain. 2014 Jun;137(Pt 6):1741-52. doi: 10.1093/brain/awu096. Epub 2014 Apr 16.
Maeda Y, Kettner N, Sheehan J, "et al". Altered brain morphometry in carpal tunnel syndrome is associated with median nerve pathology. Neuroimage Clin. 2013;2:313-319.
Martins RS, Siqueira MG, Simplício H, Agapito D, Medeiros M. Magnetic resonance imaging of idiopathic carpal tunnel syndrome correlation with clinical findings and electrophysiological investigation. Clin Neurol Neurosurg. 2008 Jan;110(1):38-45. Epub 2007 Oct 24.
Mbarki H, Akrichi A, Lazrak A, "et al". Carpal tunnel syndrome in chronic hemodialysis patients. Pan Afr Med J. 2013 Jan;14:19.
Meirelles LM, Santos JBG, Santos LL, "et al". Evaluation of Boston questionnaire applied at late post-operative period of carpal tunnel syndrome operated with the pain e retinaculatome through palmar port. Acta Ortop Bras.2006;14(3):123-32.
Meyer RA, Ringkamp M, Campbell JN. Peripheral Mechanisms of Cutaneous Nociception, em: McMahon SB, Koltzenburg M - Wall and Melzack's - Textbook of Pain. Elsevier. 2006:3-34.
Moberg E. Objective methods for determining the functional value of sensibility in the hand. J Bone Joint Surg Br.1958 Aug;40B(3):454-76.
Napadow V, Liu J, Li M, Kettner N, "et al". Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Hum Brain Mapp. 2007 Mar;28(3):159-71.
Padua L, LoMonaco M, Gregori B, Valente EM, Padua R, Tonali P. Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand. 1997 Oct;96(4):211-7.
Piovesan EC, Tatsui CE, Kowacs PA, Lange MC, Pacheco C, Werneck LC. Utilização da algometria de pressão na determinação dos limiares de percepção dolorosa trigeminal em voluntários sadios. Arq. Neuro- Psiquiatr. 2001 Mar;59(1):92-6.
Povlsen B, Aggelakis K, Koutroumanidis M. Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study. JRSM Short Rep. 2010 Dec;1(7):62.
Robinson LR, Micklesen PJ, Wang L. Strategies for analyzing nerve conduction data: superiority of a summary index over single tests. Muscle Nerve. 1998 Sep;21(9):1166-71.
Rolke RA, Campbell K, Magerl W, Treede RD. Deep pain thresholds in the distal limbs of healthy human subjects. Eur J Pain. 2005 Fev;9(1);39-48.
Schmidt AP. Estudo sobre os mecanismos envolvidos na atividade antinociceptiva das purinas: o papel dos derivados da guanina. Doctorate Tesis. Porto Alegre. Universidade Federal do Rio Grande do Sul. 2008, 14-20 p.
Shiri R. Hypothyroidism and carpal tunnel syndrome: a meta-analysis. Muscle Nerve 2014;50(6):879-83.
Siqueira MG, Martins RS. Síndromes compressivas de nervos periféricos. Dilivros, 1ª Ed, 2008:31.
Solomon L, Warwick D.; Nayagam S. Apley's concise system of orthopaedics and fractures. 3rd ed. London: Hodder Arnold, 2005, 118-20 p.
Weber EH. Uber den tastsinn. Arch Anat Physiol. 1835;1:152.
Werner RA, Andary M. Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clin Neurophysiol. 2002 Sep;113(9):1373-81.
Wood JN. Recent advances in understanding molecular mechanisms of primary afferent activation. Gut. 2004 Mar;53(2):9–12.
Yoon JH, Halper J. Tendon proteoglycans: biochemistry and function. J Musculoskelet Neuronal Interact. 2005 Mar;5(1):22-34.
Zanette G, Cacciatori C, Tamburin S. Central sensitization in carpal tunnel syndrome with extraterritorial spread of sensory symptoms. Pain. 2010 Feb;148(2):227-36.
Zanette G, Marani S, Tamburin S. Proximal pain in patients with carpal tunnel syndrome: a clinical neuro-physiological study. J Peripher Nerv Syst.2007 Jun;12(2): 91-7.
Zanette G, Marani S, Tamburin S. Extra-median spread of sensory symptoms in carpal tunnel syndrome suggests the presence of pain-related mechanisms. Pain. 2006 Mar;122(3):264-70.
Zhuo M. Neuronal mechanism for neuropathic pain. Molecular Pain, On line published. 2007 Jun;3:14, jun. 2007.
Zyluk A; Kosovets L. An assessment of the sympathetic function within the hand in patients with carpal tunnel syndrome. J Hand Surg Eur. 2010 Jun;35(5):402-8.
Atroshi I, Gummesson C, Johnsson R, Sprinchorn A. Symptoms, disability, and quality of life in patients with carpal tunnel syndrome. J Hand Surg.1999 Mar;24:398-404.
Atzmon R, Eger G, Lindner D, Assaraf E, Lin E, Avissar E. Carpal tunnel syndrome in pregnancy. Harefuah. 2014 Nov;153(11):663-6.
Becker J, Nora DB, Gomes I, Stringari FF, Seitensus R, Panosso JS, Ehlers JC. An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome. Clin Neurophysiol. 2002 Sep;113(9):1429-34
Bernardino SN. Medidas dos limiares dolorosos por algometria de pressão em pacientes com cefaleia primária. Master Degree, Recife, Jun 2012, 25 p.
Bilgin SS, Olcay SE, Derincek A, Adiyaman S, Demirtas AM. Can simple release relieve symptoms of carpal tunnel syndrome caused by a persistent median artery? Clinical experience. Arch Orthop Trauma Surg. 2004 Apr;124(3):154-6. Epub 2004 Feb 6.
Bongers F, Schellevis F, Van Den Bosch W, Van Der Zee J. Carpal tunnel syndrome in general practice: incidence and the role of occupational and non-occupational factors. Br J Gen Pract. 2007 Jan 1; 57(534): 36–39.
Brain WR, Wright AD, Wilkinson M. Spontaneous compression of both median nerves inthe carpal tunnel: six cases treated surgically. Lancet. 1947 Mar 8;1(6443-6445):277-82
Buchthal F, Rosenfalck A. Sensory conduction from digit to palm and from palm to wrist in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry. 1971 Jun;34(3):243-52.
Campbell J N, Meyer RA. Mechanisms of neuropathic pain. Neuron. 2006 Oct; 5(52):77-92.
Campos CC, Manzano GM, Andrade LB, Castelo A, Nóbrega JAM. Tradução e validação do questionário de avaliação de gravidade dos sintomas e do estado funcional da síndrome do túnel do carpo. Arq. Neuro-Psiquiatr. 2003 Mar;61(1):51-5.
Cannon BW, Love JG, Gender differences in pressure pain threshold in healthy humans. Pain, 1946;20:210-6.
Chesterton LS, Barlas P, Foster NE, Baxter GD, Wright CC. Gender differences in pressure pain threshold in healthy humans. Pain. 2003 Feb;101(3):259-66.
Coq JO, Barr AE, Strata F, "et. al". Peripheral and central changes combine to induce motor behavioral deficits in a moderate repetition task. Exp Neurol. 2009 Dec;220(2):234-45. doi: 10.1016/j.expneurol.2009.08.008. Epub 2009 Aug 15.
Crymble B. Brachial Neuralgia and the Carpal Tunnel Syndrome. Br Med J. 1968 Aug 24;3(5616):470-1.
Dale AM, Harris-Adamson C, Rempel D, "et. al". Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies. Scand J Work Environ Health. 2013 Sep 1;39(5):495-505. doi: 10.5271/sjweh.3351. Epub 2013 Feb 19.
Das SK, Brown HG. In search of complications in carpal tunnel decompression. Hand, Essex. 1976 Oct;8(3):243-9.
Dawson GD, Scott JW. The recording of nerve action potentials through skin in man. J Neurol Neurosurg Psychiatry. 1949;12(4):259-67.
De-la-Llave-Rincón AI, Puentedura EJ, Fernández-de-las-Peñas C. New advances in the mechanisms and etiology of carpal tunnel syndrome.. Discov Med. 2012 May;13(72):343-8.
Dellon AV. The moving two point discrimination test: clinical evaluation of the quicckly adapting fiber receptor system. J Hand Surg Am. 1978 Sep;3(5):474-81.
Demircay E, Civelek E, Cansever T, Kabatas S, Yilmaz C. Anatomic variations of the median nerve in the carpal tunnel: a brief review of the literature. Turk Neurosurg. 2011;21(3):388-96. doi: 10.5137/1019-5149.JTN.3073-10.1.
Dhond RP, Ruzich E, Witzel T, "et al". Spatio-temporal mapping cortical neuroplasticity in carpal tunnel syndrome. Brain. 2012 Oct; 135(10): 3062–3073.
Dorwart BB. Carpal tunnel syndrome: a review. Semin Arthritis Rheum. 1984 Nov;14(2):134-40.
El Miedany Y, El Gaafary M, Youssef S, Ahmed I, Nasr A. Ultrasound assessment of the median nerve: a biomarker that can help in setting a treat to target approach tailored for carpal tunnel syndrome patients. Springerplus. 2015 Jan 13;4:13. doi: 10.1186/s40064-014-0779-4. eCollection 2015.
Ettema AM, Amadio PC, Zhao C, Wold LE, An KN. A histological and immunohistochemical study of the subsynovial connective tissue in idiopathic carpal tunnel syndrome. J Bone Joint Surg Am. 2004 Jul;86(7):1458-66.
Fernández-de-Las-Peñas C, Madeleine P, Martínez-Perez A, Arendt-Nielsen L, Jiménez-García R, Pareja JA. Pressure pain sensitivity topographical maps reveal bilateral hyperalgesia of the hands in patients with unilateral carpal tunnel syndrome. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1055-64. doi: 10.1002/acr.20189.
Fernández-de-Las-Peñas C, Cleland JA, Plaza-Manzano G, "et al". Clinical, physical, and neurophysiological impairments associated with decreased function in women with carpal tunnel syndrome, J Orthop Sports Phys Ther. 2013 Sep;43(9):641-9. doi: 10.2519/jospt.2013.4830.
Fowler JR, Gaughan JP, Ilyas AM.FOWLER, J.R.; GAUGHAN, J.P.; ILYAS, A.M.: The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011 Apr;469(4):1089-94. doi: 10.1007/s11999-010-1637-5. Epub 2010 Oct 21.
Fu T, Cao M, Liu F, "et al". Carpal Tunnel Syndrome Assessment with Ultrasonography: Value of Inlet-to-Outlet Median Nerve Area Ratio in Patients versus Healthy Volunteers. PLoS One. 2015 Jan 24;10(1):e0116777. doi: 10.1371/journal.pone.0116777. eCollection 2015.
Gilliatt RW, Sears TA. Sensory nerve action potentials in patients with peripheral nerve lesions. J Neurol Neurosurg Psychiatry. 1958 May;21(2):109-18.
Gray H, Clemente CD. Anatomy of the human body. 13th ed. Lea & Febiger, Philadelphia. 1985, 531,542,551.
Greenslade JR, Mehta RL, Belward P, Warwick DJ. Dash and Boston questionnaire assessment of carpal tunnel syndrome outcome: what is the responsiveness of an outcome questionnaire? J Hand Surg Br. 2004 Apr;29(2):159-64.
Hirata H, Nagakura T, Tsujii M, Morita A, Fujisawa K, Uchida A. The relationship of VEGF and PGE2 expression to extracellular matrix remodelling of the tenosynovium in the carpal tunnel syndrome. J Pathol. 2004 Dec;204(5):605-12.
Hollinshead WH. Anatomy for surgeons: The Back and Limbs, vol 3, 3rd, ed. Philadelphia, Harper & Row, 1982, 420.
Horng YS, Chang HC, Lin KE, Guo YL, Liu DH, Wang JD. Accuracy of ultrasonography and magnetic resonance imaging in diagnosing carpal tunel syndrome using rest and grasp positions of the hands. J Hand Surg Am. 2012 Aug;37(8):1591-8. Epub 2012 Jul 4.
Hunt JR. The neural atrophy of the muscles of the hand without sensory disturbances. Rev Neurol Psych, Edinburgh, 1914, v. 12, p. 137-48.
IASP- International Association for Study of Pain. Consensus development conference statement: the integrated approach to the management of pain. J Accid Emerg Med, Bethesda, National Institutes of Health. 1994;6(3):491-2.
Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal Tunnel Syndrome: A Review of the Recent Literature. Open Orthop J. 2012;6:69-76. doi: 10.2174/1874325001206010069. Epub 2012 Feb 23.
Johnson EW, Wells RM, Duran RJ. Diagnosis of carpal tunnel syndrome. Arch Physi Med Rehabil. 1962;43:414–9.
Karolczak APB, Vaz MA, Freitas CR, Merlo ARC. Síndrome do Túnel do Carpo. Revista Brasileira de Fisioterapia. 2005;9(2):117-22.
Keele KD. Pain sensitivity tests: the pressure algometer. Lancet. 1954 Mar ;266 (6813): 636-9.
Kiani J, Goharifar H, Moghimbeigi A, Azizkhani H.Prevalence and risk factors of five most common upper extremity disorders in diabetics. J Res Health Sci. 2014 Winter;14(1):92-5.
Krendel DA, Jobsis M, Gaskell PCJr, Sanders DB. The flick sign in carpal tunnel syndrome. J Neurol-Neurosurg-Psychiatr. 1986 Feb;49(2);220-1.
Leblanc KE, Cestia W. Carpal tunnel syndrome. . 2011 Apr;83(8):952-8.
Levine DW, Simmons BP, Koris MJ, "et al". A self-administered questionnaire for the assessment of severity of symptons and funcional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993 Nov;75(11):1585-92.
Li J, Vause CV, Durham PL. Calcitonin gene-related peptide stimulation of nitric oxide synthesis and release from trigeminal ganglion glial cells. Brain Res.2008 Feb;1196: 22-32.
Macdermid JC,Doherty T. Clinical and electrodiagnostic testing of carpal tunnel syndrome: a narrative review. J Orthop Sports Phys Ther. 2004 Oct;34(10):565-88.
MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):309-19.
Maeda Y, Kettner N, Holden J, "et al". Functional deficits in carpal tunnel syndrome reflect reorganization of primary somatosensory cortex. Brain. 2014 Jun;137(Pt 6):1741-52. doi: 10.1093/brain/awu096. Epub 2014 Apr 16.
Maeda Y, Kettner N, Sheehan J, "et al". Altered brain morphometry in carpal tunnel syndrome is associated with median nerve pathology. Neuroimage Clin. 2013;2:313-319.
Martins RS, Siqueira MG, Simplício H, Agapito D, Medeiros M. Magnetic resonance imaging of idiopathic carpal tunnel syndrome correlation with clinical findings and electrophysiological investigation. Clin Neurol Neurosurg. 2008 Jan;110(1):38-45. Epub 2007 Oct 24.
Mbarki H, Akrichi A, Lazrak A, "et al". Carpal tunnel syndrome in chronic hemodialysis patients. Pan Afr Med J. 2013 Jan;14:19.
Meirelles LM, Santos JBG, Santos LL, "et al". Evaluation of Boston questionnaire applied at late post-operative period of carpal tunnel syndrome operated with the pain e retinaculatome through palmar port. Acta Ortop Bras.2006;14(3):123-32.
Meyer RA, Ringkamp M, Campbell JN. Peripheral Mechanisms of Cutaneous Nociception, em: McMahon SB, Koltzenburg M - Wall and Melzack's - Textbook of Pain. Elsevier. 2006:3-34.
Moberg E. Objective methods for determining the functional value of sensibility in the hand. J Bone Joint Surg Br.1958 Aug;40B(3):454-76.
Napadow V, Liu J, Li M, Kettner N, "et al". Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Hum Brain Mapp. 2007 Mar;28(3):159-71.
Padua L, LoMonaco M, Gregori B, Valente EM, Padua R, Tonali P. Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand. 1997 Oct;96(4):211-7.
Piovesan EC, Tatsui CE, Kowacs PA, Lange MC, Pacheco C, Werneck LC. Utilização da algometria de pressão na determinação dos limiares de percepção dolorosa trigeminal em voluntários sadios. Arq. Neuro- Psiquiatr. 2001 Mar;59(1):92-6.
Povlsen B, Aggelakis K, Koutroumanidis M. Effect of age on subjective complaints and objective severity of carpal tunnel syndrome: prospective study. JRSM Short Rep. 2010 Dec;1(7):62.
Robinson LR, Micklesen PJ, Wang L. Strategies for analyzing nerve conduction data: superiority of a summary index over single tests. Muscle Nerve. 1998 Sep;21(9):1166-71.
Rolke RA, Campbell K, Magerl W, Treede RD. Deep pain thresholds in the distal limbs of healthy human subjects. Eur J Pain. 2005 Fev;9(1);39-48.
Schmidt AP. Estudo sobre os mecanismos envolvidos na atividade antinociceptiva das purinas: o papel dos derivados da guanina. Doctorate Tesis. Porto Alegre. Universidade Federal do Rio Grande do Sul. 2008, 14-20 p.
Shiri R. Hypothyroidism and carpal tunnel syndrome: a meta-analysis. Muscle Nerve 2014;50(6):879-83.
Siqueira MG, Martins RS. Síndromes compressivas de nervos periféricos. Dilivros, 1ª Ed, 2008:31.
Solomon L, Warwick D.; Nayagam S. Apley's concise system of orthopaedics and fractures. 3rd ed. London: Hodder Arnold, 2005, 118-20 p.
Weber EH. Uber den tastsinn. Arch Anat Physiol. 1835;1:152.
Werner RA, Andary M. Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clin Neurophysiol. 2002 Sep;113(9):1373-81.
Wood JN. Recent advances in understanding molecular mechanisms of primary afferent activation. Gut. 2004 Mar;53(2):9–12.
Yoon JH, Halper J. Tendon proteoglycans: biochemistry and function. J Musculoskelet Neuronal Interact. 2005 Mar;5(1):22-34.
Zanette G, Cacciatori C, Tamburin S. Central sensitization in carpal tunnel syndrome with extraterritorial spread of sensory symptoms. Pain. 2010 Feb;148(2):227-36.
Zanette G, Marani S, Tamburin S. Proximal pain in patients with carpal tunnel syndrome: a clinical neuro-physiological study. J Peripher Nerv Syst.2007 Jun;12(2): 91-7.
Zanette G, Marani S, Tamburin S. Extra-median spread of sensory symptoms in carpal tunnel syndrome suggests the presence of pain-related mechanisms. Pain. 2006 Mar;122(3):264-70.
Zhuo M. Neuronal mechanism for neuropathic pain. Molecular Pain, On line published. 2007 Jun;3:14, jun. 2007.
Zyluk A; Kosovets L. An assessment of the sympathetic function within the hand in patients with carpal tunnel syndrome. J Hand Surg Eur. 2010 Jun;35(5):402-8.