Subjective and employment outcome following secondary carpal tunnel surgery.

To evaluate the connection between the type of patient insurance and the time taken to return to work after carpal tunnel surgery. Two hundred and thirty-three patients in full-time work were operated on for carpal tunnel syndrome between 1 January and 30 June 1998. They were divided into three groups: independent workers (n=87), wage earners in the private sector (n=90) and civil servants (n=56). Four categories were defined: manual workers, non-manual workers, patients with social security insurance and patients with workers compensation. The average return-to-work interval after surgery for each of the groups was evaluated and compared group by group. For independent workers the average time off work is 17 days, for those in the private sector it is 35 days, and for civil servants it is 56 days. Patients with social security insurance were off work for 32 days and those with workers compensation for 49 days. The comparison shows significant differences with regard to social security insurance: the return-to-work interval in civil servants is larger than for private sector workers, and this is higher than in independent workers. The difference between patients with workers compensation and those with social security insurance is 17 days and significant. There is a significant difference between manual and non-manual workers in independent and private sector workers. There is no significant difference between the sub-groups in the civil servants. These cross references enable us to work out the influence that social security status has on the return-to-work time following surgery.

Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. To review the effectiveness of rehabilitation following CTS surgery compared with no treatment, placebo, or another intervention. On 3 April 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register (3 April 2012), CENTRAL (2012, Issue 3), MEDLINE (January 1966 to March 2012), EMBASE (January 1980 to March 2012), CINAHL Plus (January 1937 to March 2012), AMED (January 1985 to April 2012), LILACS (January 1982 to March 2012), PsycINFO (January 1806 to March 2012), PEDRO (29 January 2013) and clinical trials registers (29 January 2013). Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery. Two reviewers independently selected trials for inclusion, extracted data and assessed the risk of bias according to standard Cochrane methodology. In this review we included 20 trials with a total of 1445 participants. We studied different rehabilitation treatments including: immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multimodal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo comparison; three trials compared rehabilitation to a no treatment control; three trials compared rehabilitation to standard care; and 14 trials compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Eleven trials explicitly reported random sequence generation and, of these, three adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five studies were at high risk of bias from incompleteness of outcome data at one or more time intervals. Eight trials had a high risk of selective reporting bias.The trials were heterogenous in terms of the treatments provided, the duration of interventions, the nature and timing of outcomes measured and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or longer. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high quality trial studied a desensitisation program compared to standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (MD -0.03; 95% CI -0.39 to 0.33). One moderate quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a two-week course of multimodal therapy commenced at five to seven days post surgery (MD 1.00; 95% CI -4.44 to 6.44). One very low quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39; 95% CI -0.45 to 1.23).The differences between the treatments for the secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events. There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have had CTS surgery should be informed about the limited evidence of the effectiveness of postoperative rehabilitation interventions. Until the results of more high quality trials that assess the effectiveness and safety of various rehabilitation treatments have been reported, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a certain treatment and those who do not, and to undertake high quality studies that evaluate the severity of iatrogenic symptoms from the surgery, measure function and return-to-work rates, and control for confounding variables.

Many cancer survivors face challenges remaining at work during treatment or returning to work posttreatment. Workplace supports can ease the strain associated with managing the cancer-work interface. Limited research has examined the employment experiences of low-wage earning survivors, who are less likely to have access to workplace supports, overlooking a factor that may influence survivors' employment outcomes. This study assessed differences in employment experiences between working poor (WP) and working nonpoor (WNP) cancer survivors in the United States. Data from the 2011 Medical Expenditure Panel Survey (MEPS) and the 2011 MEPS Experiences with Cancer Survivorship Supplement were analyzed to evaluate differences in workplace supports, cancer-related psychological job distress, productivity, and employment outcomes between WP and WNP cancer survivors. The sample included adults diagnosed with cancer within 5years prior to survey completion and engaged in paid employment since diagnosis. Working poor respondents had income below 200% of the poverty level. Chi-square tests assessed differences between WP (n=57) and WNP (n=164) cancer survivors' demographic, cancer, and employment characteristics; cancer-related psychological job distress; employee productivity; and employment outcome measures. Multiple logistic regression analyses determined the independent association between WP status and these same variables controlling for sociodemographic confounders. Working poor survivors were more likely to take unpaid time off, change from full-time to part-time, to report cancer-related psychological job distress, negative influences on job productivity and employment outcomes, and less likely to have health insurance. In logistic regression analyses, those who took unpaid time off were more likely to be WP; being WP was also associated with poorer employment outcomes, after controlling for sociodemographics differences between WP and WNP. Working poor survivors had fewer workplace supports and poorer employment outcomes than WNP survivors, highlighting important occupational disparities for cancer survivors. Areas for future research are discussed.

OBJECTIVE: We sought to examine the independent and interactive effects of common mental health disorders and chronic pain conditions on employment and work outcomes among individuals younger than 65 years of age. METHODS: We analyzed cross-sectional data from the second wave of Healthcare for Communities (HCC2), a household telephone survey of U.S. civilian adults conducted in 2000 to 2001 (N=5328). Common mental disorders were assessed using the short-form versions of the World Health Organization’s Composite International Diagnostic Interview (CIDI-SF). Chronic pain conditions and labor market outcomes were identified by self report. Logistic and linear regression analysis was used to provide estimates for work impairment based on the presence of a mental health disorder and/or a chronic pain condition. RESULTS: The interaction between presence of a mental health disorder and presence of a chronic pain condition was significantly associated with no work for pay in the past 12 months (OR 2.3 [1.2–4.2]) and number of days of work missed in the past month due to health (regression coefficient 1.5 [0.6]). In stratified analyses, this effect persisted in women but not men. The presence of a mental health disorder or chronic pain condition were each independently associated with limitations in work and any work missed in the past 30 days due to health, although the interaction was not significant. CONCLUSION: Mental health disorders and chronic pain are each associated with work disability. Mental health disorders are more highly associated with some work disability outcomes when accompanied by chronic pain, especially in women.

Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. This is the first update of a review first published in 2013. To review the effectiveness and safety of rehabilitation interventions following CTS surgery compared with no treatment, placebo, or another intervention. On 29 September 2015, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, AMED, LILACS, and PsycINFO. We also searched PEDro (3 December 2015) and clinical trials registers (3 December 2015). Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo, or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery. Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and assessed the quality of the body of evidence for primary outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach according to standard Cochrane methodology. In this review we included 22 trials with a total of 1521 participants. Two of the trials were newly identified at this update. We studied different rehabilitation treatments including immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi-modal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo, four compared rehabilitation to a no treatment control, three compared rehabilitation to standard care, and 15 compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Thirteen trials explicitly reported random sequence generation; of these, five adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five were at high risk of bias from incompleteness of outcome data at one or more time intervals, and eight had high risk of selective reporting bias.These trials were heterogeneous in terms of treatments provided, duration of interventions, the nature and timing of outcomes measured, and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or more. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high-quality trial studied a desensitisation programme compared with standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (mean difference (MD) -0.03, 95% confidence interval (CI) -0.39 to 0.33). One low-quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a group given a two-week course of multi-modal therapy commenced at five to seven days post surgery (MD 1.00, 95% CI -4.44 to 6.44). One very low-quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39, 95% CI -0.45 to 1.23).Differences between treatments for secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events. There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have undergone CTS surgery should be informed about the limited evidence of effectiveness of postoperative rehabilitation interventions. Until researchers provide results of more high-quality trials that assess the effectiveness and safety of various rehabilitation treatments, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a particular treatment and those who do not, and to undertake high-quality studies that evaluate the severity of iatrogenic symptoms from surgery, measure function and return-to-work rates, and control for confounding variables.

Most randomized trials have shown similar results with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR); however, there are studies suggesting less postoperative pain, faster improvement in grip and pinch strength, and earlier return to work with the endoscopic technique. The goal of this study was to prospectively examine subjective and functional outcomes, satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient, serving as their own control. This was a prospective, randomized study in which patients underwent surgery for bilateral carpal tunnel syndrome. The first carpal tunnel release was performed on the most symptomatic hand-determined by the patient. Operative approach was randomly assigned and, approximately 1 month later, the alternative technique was performed on the contralateral side. Demographic data were obtained, and functional outcomes were recorded preoperatively and postoperatively, including pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength, and overall grip strength. The carpal tunnel syndrome-functional status score and carpal tunnel syndrome-symptom severity score were recorded before surgery and at 2, 4, 8, 12, and 24 weeks postoperatively. Overall satisfaction with each technique was recorded at the conclusion of the study. Currently, 25 subjects have completed final visit testing. There were no differences in pain score, 2-point discrimination, Semmes-Weinstein monofilament testing, thenar strength, or overall grip strength at any of the postoperative time points. Carpal tunnel syndrome-symptom severity score and carpal tunnel syndrome-functional status score were not significantly different between groups at any of the evaluations. Overall satisfaction, where patients recorded a number from 0 to 100, was significantly greater in the ECTR group (95.95 vs 91.60, P = 0.04). There were no complications with either technique. This interim analysis, using the same patient as an internal control, suggests that both OCTR and ECTR are well tolerated with no differences in functional outcomes, symptom severity and functional status questionnaires, or complications. Although there were no differences between groups using our study metrics, patients still preferred the ECTR, demonstrated by significantly higher overall satisfaction scores at the conclusion of the study.

Symptom improvement is an important goal when considering surgery for carpal tunnel syndrome. There is currently no prediction model available to predict symptom improvement for patients considering a carpal tunnel release (CTR). To predict using a model the probability of clinically relevant symptom improvement at 6 mo after CTR. We split a cohort of 2119 patients who underwent a mini-open CTR and completed the Boston Carpal Tunnel Questionnaire preoperatively and 6 mo postoperatively into training (75%) and validation (25%) data sets. Patients who improved more than the minimal clinically important difference of 0.8 at the Boston Carpal Tunnel Questionnaire-symptom severity scale were classified as "improved." Logistic regression, random forests, and gradient boosting machines were considered to train prediction models. The best model was selected based on discriminative ability (area under the curve) and calibration in the validation data set. This model was further assessed in a holdout data set (N = 397). A gradient boosting machine with 5 predictors was chosen as optimal trade-off between discriminative ability and the number of predictors. In the holdout data set, this model had an area under the curve of 0.723, good calibration, sensitivity of 0.77, and specificity of 0.55. The positive predictive value was 0.50, and the negative predictive value was 0.81. We developed a prediction model for clinically relevant symptom improvement 6 mo after a CTR, which required 5 patient-reported predictors (18 questions) and has reasonable discriminative ability and good calibration. The model is available online and might help shared decision making when patients are considering a CTR.

Accessory Hand Muscles Over the Transverse Carpal Ligament: An Obstacle in Carpal Tunnel Surgery

The relationship between surgery for cubital tunnel and carpal tunnel syndrome was examined in this retrospective study. Between 1997 and 2018, data from consecutive patients who underwent carpal tunnel release (8352 patients), cubital tunnel release (1681 patients) or both procedures (692 patients) were analysed. The relative risk of undergoing cubital tunnel release in the population who had carpal tunnel release compared with those with no carpal tunnel release was 15.3 (male 20.3; female 12.5). The relative risk of undergoing carpal tunnel release in the population who had cubital tunnel release compared with those who did not undergo carpal tunnel release was 11.5 (male 16.5; female 9.1). Our study showed that men and women who undergo carpal tunnel release are over 20 times and 10 times more likely to have cubital tunnel release than those who did not undergo carpal tunnel release, respectively. These findings suggest that the two conditions may share a similar aetiology.Level of evidence: IV.

Functional Tests to Quantify Recovery Following Carpal Tunnel Release

Professional absenteeism and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients

Sonography and electrodiagnosis in carpal tunnel syndrome diagnosis, an analysis of the literature

Many patients have symptoms of bilateral carpal tunnel syndrome and require surgical release of both hands. Despite the intuitive savings to both the patient and the institution of simultaneous carpal tunnel release, many surgeons choose to repair one hand at a time under the assumption that the morbidity and disability following surgery, such as pain and hand incapacity, would be too great if both hands were repaired simultaneously. We reviewed the charts of 108 patients who underwent bilateral carpal tunnel release to ascertain information on both the relative costs and morbidities of the 2 approaches; mean follow-up time was 2.6 years. With regard to costs, the average number of clinic visits for the simultaneous group was 2 versus 4.5 for the consecutive group (P < 0.0001). The mean total operating room time for the simultaneous group was 48.5 minutes versus 72.5 minutes for the consecutive group (P < 0.0001). The average time off work for the simultaneous group was 3.25 weeks versus 6 weeks for the consecutive group (P = 0.08). To evaluate morbidity, 62 patients consented to telephone interviews regarding the outcome of their surgery, 51 of whom had undergone simultaneous release. Of the 51 patients who underwent simultaneous release, 48 (94%) were satisfied with the overall results of their surgery, and 38 (75%) stated that they would undergo simultaneous release again. All 11 patients in the consecutive group were satisfied with the results of their surgery and would do it again (P = 0.21 and 0.03, respectively). On the basis of these findings, we conclude first, the overall costs associated with simultaneous release are considerably less than consecutive bilateral release, and second, the disability following simultaneous bilateral carpal tunnel release is no greater than that following consecutive bilateral release. We, therefore, recommend simultaneous bilateral carpal tunnel release in patients who have bilateral carpal tunnel syndrome.

Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.

Little is known about factors that predict return to work following carpal tunnel release. Patients enrolled in a prospective, community-based study of carpal tunnel syndrome in Maine were evaluated with standardized questionnaires preoperatively and 6 months following carpal tunnel release. Univariate and multivariate analyses were performed to identify baseline factors associated with work disability 6 months following surgery. Thirty-one of 135 patients (23%) were out of work because of CTS 6 months following surgery. The predominant preoperative variables associated with work absence due to CTS 6 months postoperatively in logistic regression analyses were Workers' Compensation, work absence preoperatively, and worse mental health status (p < or = 0.01 for each). In analyses that considered postoperative as well as preoperative variables, persistence of symptoms following surgery was the most striking predictor of failure to return to work due to CTS (p < 0.0001). Preoperative correlates of less complete relief of symptoms in multivariate models included involvement of an attorney, milder preoperative symptom severity, preoperative work absence (p < 0.005 for each) and exposure to hand intensive work (p = 0.04). These data indicate that economic and psychosocial variables have a strong influence upon both return to work and the extent of symptom relief 6 months following surgery for carpal tunnel syndrome.