Predictors of return to work following carpal tunnel release

Association Between Pain Coping and Symptoms of Anxiety and Depression, and Work Absenteeism in People With Upper Limb Musculoskeletal Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the prospective association of pain coping strategies and symptoms of anxiety and depression with work absenteeism in people with upper limb musculoskeletal disorders.

DATA SOURCES

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases was conducted from inception to September 23, 2022.

STUDY SELECTION

Prospective observational studies of adults with upper limb musculoskeletal disorders were included. Included studies had to provide data on the association of pain coping strategies (catastrophizing, kinesiophobia, self-efficacy or fear avoidance) or symptoms of anxiety and depression with work absenteeism.

DATA EXTRACTION

Study selection, data extraction, and assessment of methodological quality (Newcastle Ottawa Scale) were performed by 2 independent authors. Random-effects models were used for quantitative synthesis.

DATA SYNTHESIS

Eighteen studies (n=12,393 participants) were included. Most studies (77.8%) reported at least 1 significant association between 1 or more exposure factors (pain coping strategies or symptoms of anxiety and depression) and work absenteeism. Meta-analyses showed a statistically significant correlation between the exposure factors of catastrophizing (r=0.28, 95% confidence interval [CI]: 0.15 to 0.40; P<.0001) and symptoms of anxiety and depression (r=0.23, 95% CI: 0.10 to 0.34; P=.0003) with work absenteeism. The correlation between self-efficacy and work absenteeism was non-significant (r=0.24, 95% CI: -0.02 to 0.47; P=.0747).

CONCLUSIONS

Rehabilitation teams should consider assessing catastrophizing and symptoms of anxiety and depression to identify patients at risk for work absenteeism. Addressing these variables may also be considered in return-to-work programs for individuals with upper limb disorders.

Short incision versus minimally invasive surgery with tool-kit for carpal tunnel syndrome release: a prospective randomized control trial to evaluate the anterior wrist pain and time to return to work or activities

Trial design

The prospective randomized controlled trial.

Background

This study compares outcomes in terms of early postoperative anterior wrist pain and time to return to work or activities of daily living of patients who underwent carpal tunnel syndrome (CTS) release with short incision and those who had minimally invasive surgery (MIS) with CTS kits.

Methods

A total of 24 patients diagnosed with primary CTS confirmed with electrodiagnosis at an academic university hospital were randomly assigned into one of two groups of 12 patients each: a short incision group and an MIS with tool-kit group using computer-generated block randomization (block of four). Sequentially numbered, opaque, sealed envelopes were used in the allocation concealment process. In the short incision group, skin was incised longitudinally from Kaplan’s line to the area distal to transverse wrist crease (2.5–4.0 cm) while in the tool-kit group, an incision of less than 2.5 cm. was made using special MIS-CTS kits. Primary outcomes evaluated include visual analogue scale (VAS) measurement of pain intensity in the anterior carpal area both while at rest and while conducting daily activities at the 2nd week postoperatively as well as the time to return to activities of daily living and work. Improvement in the Michigan hand questionnaire (MHQ) score, a secondary outcome, was also measured at the 2nd week postoperatively. Patients, allocator and outcome assessor were blinded.

Results

Demographic data, including preoperative electrodiagnostic severity and occupation, were similar in the two groups. There were no significant differences in terms of VAS of the early postoperative anterior carpal area at rest (p > 0.99), while conducting daily activities (p = 0.89) and time to return to activities of daily living (p = 0.46) and work (p = 0.24). The MHQ score improvement at the 2nd week postoperatively showed no significant difference between the groups (p = 0.95). The MIS wound length in the tool-kit group was significantly shorter than in the short incision group (1.95 vs 2.92 cm, p < 0.01).

Conclusions

There is no difference in early postoperative anterior wrist pain, time to return to work or to activities of daily living between the surgical techniques. Short incision is recommended for benefit in term of cost-effectiveness, while MIS with tool-kit could be preferred in patients who concerned in cosmetic appearance between the surgical techniques.

Trial registration

www.clinicaltrials.in.th (TCTR20200530003). Registered 30 May 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05663-5.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects

PURPOSE

Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.

METHODS

Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.

RESULTS

Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.

CONCLUSIONS

In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The effects of a new seat suspension system on whole body vibration exposure and driver low back pain and disability: Results from a randomized controlled trial in truck drivers

Through a randomized controlled trial, we evaluated the effects of an electro-magnetic active seat suspension that reduces exposure of a long-haul truck driver to whole body vibration (WBV) on low back pain (LBP) and disability. Among 276 drivers recruited from six trucking terminals of a major US trucking company, 135 eligible drivers were assigned to either having an Active Seat (Intervention: n = 70) - the BoseRide® electro-magnetic active seat - or Passive Seat (reference: n = 65) - a new version of their current seat (passive air suspension seat) - installed in their truck via block (terminal) randomization. Low back pain (LBP) severity, on a 0-10 scale and the Oswestry LBP Disability Index were collected before and 3-, 6-, 12-, 18-, and 24-months post seat installation. LBP severity and LBP disability scores were significantly lower post seat installation in both groups. At 3 months, LBP severity decreased -1.4 [95% CI: -2.1 to -0.7: n = 46] for drivers in the Active Seat arm, and -1.5 [95% CI: -2.3 to -0.8: n = 41] for drivers in the Passive Seat arm. In a subset of drivers, WBV exposures were collected before and after the seat installation. WBV exposures significantly decreased post seat installation for Active Seat (p < 0.01) but not for Passive Seat (p = 0.15). While the new seat-suspension technology reduced WBV exposures, LBP appeared to be improved by multiple factors. These results were limited by the secondary prevention approach and the longer-term loss to follow up due to large rates of driver turnover typical for the industry.

Early Outcomes of Endoscopic Versus Open Carpal Tunnel Release

PURPOSE

To compare the short-term outcomes of endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR), including patient-reported outcomes, pain and satisfaction scores, return to work, and postoperative prescription pain medication use.

METHODS

We included all patients over 18 years of age undergoing carpal tunnel release at a single hand center between January 2018 and December 2019. The carpal tunnel release method was driven by variations in surgeon practice. Data from patient-reported outcomes measurement information system (PROMIS) questionnaires and brief Michigan hand outcomes questionnaires and data on patient-reported pain levels, satisfaction with care, return to work, and postoperative prescription pain medication use were collected at preoperative visits and the first follow-up visit between postoperative days 7 and 14.

RESULTS

We included 678 (586 ECTR and 92 OCTR) patients. The median age was 58 years, and 75% of the patients were women. At early follow up, patients who underwent OCTR reported significantly lower postoperative PROMIS upper-extremity scores than those who underwent ECTR (median, 32 vs 36 points, respectively) but similar postoperative PROMIS pain interference, global physical health, global mental health, and brief Michigan hand outcomes questionnaire scores. The postoperative pain and satisfaction scores were similar between the 2 groups. In multivariable models, patients who underwent OCTR had 62% lower odds of returning to work and 30% greater odds of remaining on a postoperative pain prescription at the first follow-up visit.

CONCLUSIONS

This study found no evidence suggesting the definitive superiority of 1 surgical technique with regard to clinical outcomes in the early postoperative period. However, OCTR was associated with lower postoperative PROMIS upper-extremity scores of unclear clinical significance, higher odds of remaining on pain medication, and lower odds of returning to work by the first postoperative visit. Endoscopic carpal tunnel release may be preferred in patients who need to return to work within the first 2 weeks after the procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Influence of Illness Perception and Mental Health on Return to Work After Carpal Tunnel Release Surgery

PURPOSE

Although multiple factors influencing return to work after a carpal tunnel release (CTR) have been identified, little is known about the influence of psychological patient factors on return to work. Therefore, this study aimed to identify the psychological factors that play a role in the return to work after a CTR surgery.

METHODS

Patients who planned to undergo a CTR were asked to fill out the Brief Illness Perception Questionnaire and the Patient Health Questionnaire before surgery to measure their illness perceptions and mental health status, respectively. Return to work was defined as the time until returning to work for 50% of normal hours and was measured using a questionnaire at 6 weeks, 3 months, and 6 months. To identify associations between nonpsychological and psychological patient factors and the return to work after CTR surgery, a Cox proportional hazards model was constructed.

RESULTS

In total, 615 patients were included in our study. Six months after surgery, 91% of the patients returned to work. For the psychological patient factors, we found that increases of 1 point on the items of worrying about carpal tunnel syndrome and having faith preoperatively in a beneficial effect of the CTR surgery were associated with hazard ratios of 0.92 (95% confidence interval, 0.88-0.96) and 1.10 (95% confidence interval, 1.02-1.19), respectively, for returning to work in the first 6 months after surgery. An increase of 1 point on the depression subscale of the Patient Health Questionnaire was associated with a hazard ratio of 0.88 (95% confidence interval, 0.78-0.99) for returning to work in the first 6 months after surgery.

CONCLUSIONS

Our study showed that multiple psychological patient factors are associated with return to work after a CTR surgery. Addressing these psychological factors before surgery might be a low-cost intervention to improve return to work after the CTR surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Clinical predictors of surgical outcomes of severe carpal tunnel syndrome patients: utility of palmar stimulation in a nerve conduction study

Background

Carpal tunnel syndrome is a common peripheral nerve compression disorder. However, there is no established opinion regarding the predictors of symptom improvement after surgery. This study aimed to identify the predictors of surgical outcomes of severe carpal tunnel syndrome patients.

Methods

In the patients who underwent a carpal tunnel syndrome surgery, we selected the patients who had a preoperative Bland’s classification of grade 5 or 6, and assessed for the changes in Bland’s classification grade before and after surgery. Those who showed improvement from preoperative grades 5–6 to postoperative grades 1–4 comprised the improvement group. In contrast, those who did not show improvement and had postoperative grades 5 or 6 comprised the non-improvement group. In a nerve conduction study, amplitudes of the compound muscle action potential and sensory nerve action potential of the palms were assessed between the improvement and non-improvement groups.

Results

Among the 60 hands of 46 patients who had a preoperative Bland’s classification of grade 5 or 6, 49 hands of 37 patients comprised the improvement group, and 11 hands of 9 patients comprised the non-improvement group. The amplitudes of the compound muscle action potential and sensory nerve action potential of the palms before surgery were significantly higher in the improvement group. The degree of improvement in Bland’s classification grade was correlated with the degree of clinical symptom improvement.

Conclusions

Amplitudes of compound muscle action potential and sensory nerve action potential before surgery induced by palmar stimulation can predict improvements in nerve conduction study scores and clinical findings after surgical treatment.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

Creating Value by Prioritizing Mental and Social Health After Injury

Given the strong influence of mental and social health on symptom intensity and magnitude of limitations, attempts to increase value in orthopedic trauma must attend to emotional and social recovery. Low value and potentially harmful interventions after trauma such as excessive reliance on medication, low value surgeries for "delayed healing" or "symptomatic implants," repeated visits with a physical therapist, and other biomedical interventions often reflect misdiagnosis and mismanagement of social and mental health. A better approach is to anticipate emotional and social recovery; to get social and mental health specialists involved immediately after injury; and to develop strategies that set firm limits on biomedical tests and treatments that are unlikely to contribute to health and risk reinforcing stress, distress, and less effective coping strategies.

Impact of Economic Downturn on the Surgical Volumes of Common Hand Procedures

BACKGROUND

Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises.

METHODS

The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure.

RESULTS

The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation.

CONCLUSIONS

The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

A prognostic model for the patient-reported outcome of surgical treatment of carpal tunnel syndrome

INTRODUCTION

Many prognostic factors have been studied in carpal tunnel decompression, but most studies consider only a subset of variables.

METHODS

Three thousand three hundred thirty-two operations were used to develop prognostic models, and 885 operations were used for validation. Outcome recorded on a Likert scale was dichotomized into success or failure. Modeling was performed with both logistic regression and artificial neural networks using 87 candidate variables.

RESULTS

Both approaches produced predictive multivariate models for outcome with areas under a receiver operating characteristic curve of 0.7 in the validation data set. Patients with moderately severe nerve conduction abnormalities, night waking, a family history of carpal tunnel syndrome, a good response to corticosteroid injection, and women have better outcomes. Greater functional impairment, diabetes, hypertension, and surgery on the dominant hand are associated with poorer outcomes.

DISCUSSION

A multivariate model partially predicts the outcome of carpal tunnel surgery, aids decision making, and helps to manage patient expectations. Muscle Nerve 58:784-789, 2018.

Outcomes Following Carpal Tunnel Release in Patients Receiving Workers' Compensation: A Systematic Review

BACKGROUND

Carpal tunnel syndrome (CTS) is a common occupational pathology, representing a high percentage of workers' compensation (WC) claims.

METHODS

The literature was reviewed for all studies evaluating CTS outcomes including WC patients between 1993 and 2016. A total of 348 articles were identified; 25 of which met inclusion and exclusion criteria. A systematic review was generated; patient demographics, outcomes, and complications were recorded. Weighted averages were calculated for the demographic and outcome data. Categorical data such as complications were pooled from the studies and used to determine the overall complication rate. Statistical significance was determined between WC and non-WC cohorts when applicable with the chi-square statistic.

RESULTS

The WC cohort included 1586 wrists, and the non-WC cohort included 2781 wrists. The WC cohort was younger and more often involved the dominant extremity. The WC cohort was less likely to have appropriate physical exam findings confirming diagnosis and electrodiagnostic studies. WC patients took almost 5 weeks longer to return to work, were 16% less likely to return to preinjury vocation, and had lower Standard Form (SF)-36 scores. Finally, WC patients had nearly 3 times the number of complications and nearly twice the rate of persistent pain.

CONCLUSIONS

WC patients undergoing carpal tunnel release (CTR) fare poorly as compared with non-WC patients in nearly every metric. Higher rates of postoperative pain with delayed return to work can be anticipated in a WC cohort. In addition, WC patients receive suboptimal preoperative workup, and it is possible that unnecessary surgery is being completed in these cases. These findings are important to consider when treating the WC patient with CTS.

The Effect of Psychological Factors on the Outcomes of Carpal Tunnel Release: A Systematic Review

Background: Several studies report that psychological factors are associated with outcomes of carpal tunnel release. However, interpretation of the association is difficult as there are diverse outcome parameters and patient expectations are different. We performed a systematic review to assess the relationships between psychological factors and the various outcome parameters.

Methods: We identified 611 papers and selected 8 papers that fit the inclusion criteria. Psychological factors assessed were anxiety, depression, pain catastrophizing, coping, and mental health status. Outcomes of interest included satisfaction and measures of perceived level of function, pain, and physical measures of recovery.

Results: For satisfaction and perceived level of function as the outcome, three studies reported a significant association, one study found an association approaching a value of significance, and one study reported no association. For pain as the outcome, two studies reported a significant association. For physical measures, one study reported no association.

Conclusions: This systematic review found that depression correlates with postoperative pain, but that the association is less clear between psychological factors and outcomes such as satisfaction, perceived level of symptom and function, and physical measures of recovery. As pain may not be a primary symptom or outcome of CTS, we consider that the current literature does not strongly support the association between psychological factors and outcomes of CTR. This review could be of benefit during preoperative counseling in patients with psychological disturbances.

Prognostic Variables for Patient Return-to-Work Interval Following Carpal Tunnel Release in a Workers' Compensation Population

BACKGROUND

We hypothesize that depressive and anxiety disorders, chronic pain conditions, and work-related factors are significant determinants of the time interval for return to work (RTW) in the workers' compensation (WC) population following carpal tunnel release (CTR) surgery.

METHODS

We retrospectively reviewed records of all WC patients who underwent open CTR surgery over a 5-year period by 1 of 3 fellowship-trained hand surgeons. One hundred fifty-two wrists in 108 patients (64 unilateral, 44 bilateral) met the inclusion criteria. Demographic, medical, and surgical data were obtained from patient records. Bivariate and multivariate analyses were performed to assess predictors of RTW.

RESULTS

Eighty-nine percent of all patients returned to work full-duty. Average RTW duration in all wrists was 12.5 ± 11.3 weeks. Predictors of delayed RTW in bivariate and multivariate analyses were depression with or without anxiety, chronic pain disorders including fibromyalgia, preoperative opioid use, and modified preoperative work status. Job type, motor nerve conduction velocity, and bilateral surgery were not predictive of delayed RTW interval.

CONCLUSIONS

WC patients with depression, anxiety, or fibromyalgia and other chronic pain disorders were significantly more likely to have delayed RTW following CTR than were WC patients without these conditions. In addition, those who use opioid medications preoperatively and those with preoperative work restrictions were also found to have a significantly delayed RTW after CTR. Knowledge of these risk factors may help care providers and employers identify those WC patients who are most likely to have a protracted postoperative recovery period.

Subjective symptoms of carpal tunnel syndrome correlate more with psychological factors than electrophysiological severity

AIM

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and is one of the most common requests for electrodiagnosis. We aimed to note the relationship of subjective symptom severity of CTS, with objective electrophysiological severity and psychological status of patients.

PATIENTS AND METHODS

One hundred and forty-four consecutive patients of CTS referred to neurophysiology laboratory of a tertiary care hospital over 1 year were prospectively studied. Boston CTS Assessment Questionnaire (BCTSAQ) and visual analog scale (VAS) were used to assess subjective symptom severity. Psychological status was assessed by Hospital Anxiety and Depression Scale (HADS). Electrophysiological severity of CTS was estimated by median motor distal latency and median to ulnar peak sensory latency difference across the wrist. Each parameter in both hands was scored from 0 to 3 depending on the severity grade, and a composite electrophysiological severity score (CEPSS) was calculated for each patient by summing up the scores in both hands. Statistical analysis was done by Spearman's rank correlation test.

RESULTS

There was significant correlation of BCTSAQ with VAS (P = 0.001), HADS anxiety score (P < 0.001), and HADS depression score (P = 0.01). CEPSS had no significant correlation with VAS (P = 0.103), HADS anxiety score (P = 0.211), or HADS depression score (P = 0.55). CEPSS had a borderline correlation with BCTSAQ (P = 0.048).

CONCLUSIONS

While the subjective symptoms of CTS are well correlated with psychological factors, their correlation with objective electrophysiological severity is weak. Hence, prompt treatment of psychological comorbidity is important in symptomatic management of CTS; decision about surgical intervention should be based on electrophysiological severity rather than symptom severity.

Predictors of the patient-centered outcomes of surgical carpal tunnel release - a prospective cohort study

BACKGROUND

Carpal tunnel syndrome (CTS) causes a substantial burden of disease in society. While CTS can be resolved by surgical carpal tunnel release, it still remains unclear as to what degree outcomes depend on patients' characteristics. This study assesses patient-centered outcomes after surgical carpal tunnel release in a large outpatient clinic in Germany.

METHODS

Patients with CTS were recruited prospectively between August 1st and December 31st, 2013. We assessed socio-demographic and psychological factors as well as nerve conduction velocities at baseline (before the surgery) and at three and six months after surgery. We analyzed the improvement of patient-centered outcomes (symptoms and function of the affected hand as well as measures of well-being and subjective quality of life) at the two follow-up time points and investigated if socio-demographic characteristics and CTS-related variables predict the success of the surgery with respect to nerve conduction velocities and patient-centered outcomes by means of analysis of covariance (ANCOVA). Factors influencing the duration of sick leave were investigated by means of Cox regression.

RESULTS

The study sample consisted of 71 CTS cases. Surgical carpal tunnel release generally improved nerve conduction velocity and patient-centered outcomes. Regarding the former, the improvement was proportional to the severity score at baseline. The presence of muscular atrophy in the thenar area at baseline displayed medium size effects for the patient-centered outcomes. Other socio-demographic characteristics and CTS-related variables did not have a strong predictive effect on the improvement of nerve conduction velocity and patient-centered outcomes.

CONCLUSIONS

There is a significant improvement of clinical and subjective outcomes after CTS surgery in the outpatient sector. The improvement is largely independent of socio-demographic and clinical characteristics of the patients.

[Delay of professional activity recovery after implant based breast augmentation surgery: Influence of healthcare coverage]

AIM OF THE STUDY

The main goal is to determine if the delay before going back to work after implant-based breast augmentation surgery is influenced by the healthcare coverage criteria.

MEANS AND METHODS

In this retrospective, single center based study, patients who underwent implant-based breast augmentation surgery (excluding reconstructive surgery) in the past 3 years with a minimum follow-up of 1 month were questioned by telephone. Patients who had early postoperative complications, or no professional activity, were excluded. The demographic and perioperative data were collected and two groups were compared: those who were covered by the healthcare system and those who were not.

RESULTS

Sixty patients were included. The two groups were comparable concerning the demographic (age, BMI, children, work intensity, smoking status, comorbidity) and surgical data (surgical approach, type, volume and position of the implant, operative time and drainage). There was a significant difference between the groups concerning the delay of return to work (P=0.0001): 18.4 days for reimbursed patients versus 9.45 days for patients without healthcare coverage.

CONCLUSION

For the same implant-based breast augmentation surgery, and for the same population, the duration of postoperative recovery period doubles for the patients for whom surgery is reimbursed by the healthcare system.

Carpal tunnel syndrome and work

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, and it frequently presents in working-aged adults. Its mild form causes 'nuisance' symptoms including dysaesthesia and nocturnal waking. At its most severe, CTS can significantly impair motor function and weaken pinch grip. This review discusses the anatomy of the carpal tunnel and the clinical presentation of the syndrome as well as the classification and diagnosis of the condition. CTS has a profile of well-established risk factors including individual factors and predisposing co-morbidities, which are briefly discussed. There is a growing body of evidence for an association between CTS and various occupational factors, which is also explored. Management of CTS, conservative and surgical, is described. Finally, the issue of safe return to work post carpal tunnel release surgery and the lack of evidence-based guidelines are discussed.

Ultrasound imaging of the median nerve as a prognostic factor for carpal tunnel decompression

INTRODUCTION

The diagnostic value of ultrasound imaging in carpal tunnel syndrome is established, but reports on its prognostic value have been contradictory.

METHODS

This investigation was an observational study of subjective surgical results, evaluated by symptom severity and functional status scales, and an ordinal scale for overall outcome, for 145 carpal tunnel decompressions in relation to preoperative measurement of median nerve cross-sectional area.

RESULTS

The surgical success rate was 86%. In univariate analyses no significant correlation existed between outcome and preoperative cross-sectional area, nor with preoperative nerve conduction studies or patient variables, except for body mass index and gender. A multivariate model including electrophysiological, imaging, and patient variables was moderately predictive of success with an area under the receiver operating characteristic curve of 0.82.

CONCLUSIONS

Cross-sectional area alone is unlikely to be a sufficiently reliable predictor of outcome for use in counseling individual patients, but imaging results may be useful in multivariate prognostic models.

An exploration of alternative methods for assessing return-to-work success following occupational injury

PURPOSE

To explore alternative methods for assessing return-to-work success.

METHOD

This exploratory study employed a prospective design. Participants (N = 150) were all vocational rehabilitation recipients who sustained a work-related injury that resulted in them being off work for at least 6 months, and were unable to return to their pre-injury position. At baseline (B), all were reported to have found post-injury employment. Qualitative features of the participants' post-injury employment were assessed at the time of initial interview (T1), which was conducted a mean of approximately one year following the participants' scheduled workplace re-entry (mean 344 days). Participants' T1 employment characteristics were then compared to their outcomes at the time of follow-up (T2), which was approximately 3 months later (mean 85 days).

RESULTS

Findings indicate that 25% of participants were not in their baseline jobs at the time of last contact; some were in different jobs, however others were not working. At T1 many of those working reported experiencing difficulties. Comparisons revealed significant relationships between problem indicators at T1 and employment outcomes at T2, with significant problem indicators including worries that symptoms might interfere with their ability to continue in the job, difficulties with the job's physical demands and a strong desire to leave their current job. When problem indicators were used in combination, stronger relationships were observed and self-assessed performance contributed to the effect.

CONCLUSIONS

Results add support to the contention that rather than a single event, RTW is an evolving, complex and sometimes nonlinear process. This should be kept in mind when assessing the success of an injured worker's RTW.

Influences of Labour Participation Among Persons With Disabilities: A Systematic Review and Best Evidence Synthesis

A systematic literature review was conducted to assess the individual, organisation, societal, and legal influences of labour participation among individuals with a disability.Methods: Nine databases were searched, for peer-reviewed studies of individual, organisation, societal, and legal influences among disabled populations published between 1990 and 2010.

Results: Of a total of 809 papers initially selected, only 46 studies were deemed to be of sufficient quality to be included in the review.Conclusions: Numerous studies have examined labour participation among persons with physical disabilities, some among persons with chronic disabilities, and few among persons with mental disabilities. Strong evidence was found for individual and organisation influences of labour participation among persons with physical disabilities in particular pain, catastrophising, job strain, and support. Only individual influences provided strong evidence among persons with chronic disabilities and no influences provided strong evidence among those with mental disabilities. The results are presented along with methodological weaknesses and future recommendations.

Pre-surgery disability compensation predicts long-term disability among workers with carpal tunnel syndrome

BACKGROUND

We sought to identify early risk factors for work disability compensation prior to and after carpal tunnel syndrome (CTS) surgery, and to determine whether pre-surgery disability compensation is associated with long-term disability.

METHODS

Washington State workers' compensation administrative data and data from interviews with workers 18 days (median) after submitting new workers' compensation claims for CTS were examined. Baseline risk factors for pre-surgery disability compensation and for long-term disability (>365 days of work disability compensation prior to 2 years after claim filing) were evaluated for workers who underwent CTS surgery and had at least 1 day of disability compensation (N = 670).

RESULTS

After adjustment for baseline long-term disability risk factors, workers with pre-surgery disability compensation had over five times the odds of long-term disability. Baseline factors in multiple domains, including job, psychosocial, clinical, and worker pain and function, were associated with both pre-surgery disability compensation and long-term disability.

CONCLUSIONS

Risk factors for work disability prior to and after CTS surgery are similar, and early work disability is a risk factor for long-term CTS-related disability. An integrated approach to CTS-related disability prevention could include identifying and addressing combined risk factors soon after claim filing, more efficient use of conservative treatments and appropriate work modifications to minimize early work loss, and, when indicated, timely surgical intervention.

Determinants of return to work after carpal tunnel release

PURPOSE

The determinants of time to return to work-a common measure of treatment effectiveness-are incompletely defined. Our primary hypothesis was that employment circumstances are the strongest determinant of earlier return to work. Our secondary hypothesis was that return to work in patients with desk-based jobs is predicted by patient expectations and other psychosocial factors.

METHODS

We enrolled 65 employed patients with limited incision open carpal tunnel release in a prospective cohort study. Patients completed validated measures of depression, coping strategies, pain anxiety, and job burnout. Heavy lifting was not allowed for 1 month after surgery. Return to modified and full work duty was recorded in days. Although not specifically an exclusion criterion, none of the patients had a workers' compensation claim or other source of secondary gain.

RESULTS

Patients returned to modified duty an average of 11.8 days and full duty at an average of 18.9 days after surgery. Predictors of earlier return to modified duty in multivariate analyses included desk-based work and both the number of days patients expected to take off and the numbers of days they wanted to take off for the entire cohort, with an additional influence from catastrophic thinking in desk-based workers. Predictors of earlier return to full duty in multivariate analyses included desk-based work and number of days patients expected to take off before for the entire cohort, fewer days off desired in non-desk-based workers, fewer days off desired and change in work role in desk-based workers, and lower pain anxiety in part-time workers.

CONCLUSIONS

The most important determinant of return to full duty work after limited incision open carpal tunnel release is job type, but psychological factors such as patient expectations, catastrophic thinking, and anxiety in response to pain also have a role.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Factors affecting return to work after carpal tunnel syndrome surgery in a large French cohort

OBJECTIVE

To evaluate occupational outcomes after surgical release of the median nerve in carpal tunnel syndrome (CTS).

DESIGN

Retrospective study 12 to 24 months after surgery.

SETTING

Hand centers (N=3) in 2 different areas.

PARTICIPANTS

Patients who had undergone surgical release of the median nerve in 2002 to 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Duration of sick leave after surgery and associated factors were analyzed by using bivariate (log rank) and multivariate analyses of survival (Cox model).

RESULTS

Questionnaires mailed in 2004 regarding medical condition (history and surgery), employment (occupational category codes in 1 digit), and compensation were returned (N=1248; 62%), with 253 men and 682 women stating they were employed at the time of surgery (N=935). Most were working at the time of the study (n=851; 91.0%). Median duration of sick leave before returning to work was 60 days. The main factors associated with adverse occupational outcome (long duration of sick leave) were simultaneous intervention for another upper-extremity musculoskeletal disorder, belief (by the patient) in an occupational cause, and "blue-collar worker" occupational category (the strongest determinant).

CONCLUSION

This study emphasizes the multifactorial nature of the occupational outcome of CTS after surgery, including occupational category. The probability of return to work for each risk factor provides a fair description of prognosis for physicians and patients.

Surgical techniques and return to work following carpal tunnel release: a systematic review and meta-analysis

INTRODUCTION

This systematic review was conducted to evaluate return to work (RTW) following minimally invasive carpal tunnel surgery versus open carpal tunnel release. This study also assesses how RTW as an outcome measure was examined in previous randomized controlled trials (RCTs).

METHODS

The bibliographic databases Medline, AMED and CINAHL were systematically searched. We found 15 relevant RCTs. Meta-analysis was possible only for four studies.

RESULTS

The result indicates that minimally invasive surgery offers earlier return to work compared to open carpal tunnel release (mean difference -7.2 days; 95% CI -10 to -4.4 days). There were remarkable inconsistencies in how return to work as an outcome measure was examined in different RCTs.

CONCLUSIONS

Calculating standardised mean difference in future RCTs would allow future reviews to be more inclusive of the evidence. The authors suggest more consistent approach for evaluating work-related features in future studies. We recommend that new fit note categories introduced by UK Department of Work and Pension (unfit for all work/return to modified work or work adaptations/return to normal work) would be used to identify different levels of return to work.

Clinical quality measures for intraoperative and perioperative management in carpal tunnel surgery

BACKGROUND

Previous research documents suboptimal preoperative or postoperative care for patients undergoing surgery. However, few existing quality measures directly address the fundamental element of surgical care: intra-operative care processes. This study sought to develop quality measures for intraoperative, preoperative, and postoperative care for carpal tunnel surgery, a common operation in the USA.

METHODS

We applied a variation of the well-established RAND/UCLA Appropriateness Method. Adherence to measures developed using this method has been associated with improved patient outcomes in several studies. Hand surgeons and quality measurement experts developed draft measures using guidelines and literature. Subsequently, in a two-round modified-Delphi process, a multidisciplinary panel of 11 national experts in carpal tunnel syndrome (including six surgeons) reviewed structured summaries of the evidence and rated the measures for validity (association with improved patient outcomes) and feasibility (ability to be assessed using medical records).

RESULTS

Of 25 draft measures, panelists judged 22 (88%) to be valid and feasible. Nine intraoperative measures addressed the location and extent of surgical dissection, release after wrist trauma, endoscopic release, and four procedures sometimes performed during carpal tunnel surgery. Eleven measures covered preoperative and postoperative evaluation and management.

CONCLUSIONS

We have developed several measures that experts, including surgeons, believe to reflect the quality of care processes occurring during carpal tunnel surgery and be assessable using medical records. Although quality measures like these cannot assess a surgeon's skill in handling the instruments, they can assess many important aspects of intraoperative care. Intraoperative measures should be developed for other procedures.

Correlation of return to work outcomes and hand impairment measures among workers with traumatic hand injury

INTRODUCTION

Hand impairment is a common and serious occupational injury among workers because it can affect the outcome to return to work (RTW) and even cause permanent dysfunction. The hand measures can directly describe the primary hand function and limitation. This study investigated the correlation of RTW and the overall hand impairment measures in the workers with traumatic hand injury.

METHODS

Ninety-six subjects with occupational hand injury were recruited in this study to answer the RTW questionnaire and received the hand evaluation and motion analysis for their affected hands. RTW outcomes assessed whether the subjects successfully returned to work, either from a job change or salary reduction, and the length of the time it took for them to return to work (TRTW). The hand impairment measures included the hand impairment ratio, total active motion loss, motion area loss, grasp power loss, lateral-pinch power loss, and palmar-pinch power loss.

RESULTS

A stepwise regression indicated that grasp power loss was a significant predictor for the length of TRTW. The motion area loss was firstly adopted to show statistically significance with RTW outcomes. Besides, the hand impairment ratio was also found to have mild positive correlation with TRTW significantly.

CONCLUSIONS

This study presented the subtle correlation of RTW outcomes and hand impairment measures. Both the strength loss and the motion area loss of the hand showed the significant correlation with RTW outcomes. The findings can point to some practical focuses in occupational rehabilitation for the workers with hand trauma.

Quality measures for the diagnosis and non-operative management of carpal tunnel syndrome in occupational settings

INTRODUCTION

Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations.

METHODS

Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility.

RESULTS

Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations.

CONCLUSIONS

These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

Predictors of pain intensity and disability after minor hand surgery

PURPOSE

To test the null hypothesis that there is no relationship between coping mechanisms and depression measured before surgery, and pain intensity and disability after surgery, as assessed at the time of suture removal.

METHODS

A total of 120 patients (39 electing surgery for carpal tunnel syndrome, 65 for trigger finger, and 16 for a benign tumor) completed questionnaires measuring depression, pain self-efficacy (confidence that one can perform various activities despite pain), pain anxiety (fear and anxiety in response to pain sensations), and pain catastrophizing (maladaptive cognitive activities such as pain-related rumination, magnification, and helplessness) before surgery. Before the surgery and at the time of suture removal (10 to 14 days after surgery) participants completed the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and a numerical pain intensity rating scale.

RESULTS

At the time of suture removal, there was a significant correlation between pain intensity and depression (r = 0.45, p<.001), pain catastrophizing (r = 0.41, p<.001), pain anxiety (r = 0.32, p<.01), and self-efficacy (r = -0.29, p<.01). Disability correlated with self-efficacy (r = -0.34; p<.001) and depression (r = 0.49; p<.001), but not with pain anxiety and catastrophizing (p>.05). In multivariate analyses, depression was the sole predictor of both disability and pain intensity and accounted for 26% of the variance in DASH scores and 25% of the variance in pain intensity, after removing the influence of preoperative DASH and diagnosis, which accounted for 14% variance.

CONCLUSIONS

Psychosocial factors, especially depression, explain a notable proportion of the variation in pain intensity and disability after minor hand surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Clinical quality measures for electrodiagnosis in suspected carpal tunnel syndrome

Extensive research has documented that medical care in the United States is not of optimal quality, meaning that well-established care processes are not consistently provided to the patients who would benefit from them. To assess and improve quality of care, specific measures are needed. The objective of this study was to develop quality measures for electrodiagnostic testing in suspected carpal tunnel syndrome (CTS). We used a variation of the well-established RAND/UCLA Appropriateness Method to develop the measures. A physiatrist and quality measurement experts developed draft measures based on guidelines and literature. Subsequently, in a two-round, modified-Delphi process, a multidisciplinary panel of 11 national experts in CTS reviewed a summary of the evidence and then rated the measures for validity and feasibility. Seven draft measures were developed. The expert panel combined two, modified the others, and then judged all resulting measures to be valid and feasible. The measures cover compelling indications for testing, essential test components when CTS is suspected, skin temperature measurement and normalization, and the appropriate interpretation of test results. These measures define a minimum standard of care for the use of electrodiagnostic tests in suspected CTS and are consistent with recent guidelines developed by the American Association of Neuromuscular and Electrodiagnostic Medicine. Provider organizations, insurance companies, and professional societies can use these measures in efforts to monitor and improve quality of care for this common and disabling condition.

A prospective study of prognostic factors for duration of sick leave after endoscopic carpal tunnel release

BACKGROUND

Endoscopic carpal tunnel release with a single portal technique has been shown to reduce sick leave compared to open carpal tunnel release, claiming to be a less invasive procedure and reducing scar tenderness leading to a more rapid return to work, and the purpose of this study was to identify prognostic factors for prolonged sick leave after endoscopic carpal tunnel release in a group of employed Danish patients.

METHODS

The design was a prospective study including 75 employed patients with carpal tunnel syndrome operated with ECTR at two hospitals. The mean age was 46 years (SD 10.1), the male/female ratio was 0.42, and the mean preoperative duration of symptoms 10 months (range 6-12). Only 21 (28%) were unable to work preoperatively and mean sick leave was 4 weeks (range 1-4). At base-line and at the 3-month follow-up, a self-administered questionnaire was collected concerning physical, psychological, and social circumstances in relation to the hand problem. Data from a nerve conduction examination were collected at baseline and at the 3-month follow-up. Significant prognostic factors were identified through multiple logistic regression analysis.

RESULTS

After the operation, the mean functional score was reduced from 2.3 to 1.4 (SD 0.8) and the mean symptom score from 2.9 to 1.5 (SD 0.7). The mean sick leave from work after the operation was 19.8 days (SD 14.3). Eighteen patients (24%) had more than 21 days of sick leave. Two patients (3%) were still unable to work after 3 months. Significant prognostic factors in the multivariate analysis for more than 21 days of postoperative sick leave were preoperative sick leave, blaming oneself for the hand problem and a preoperative distal motor latency.

CONCLUSION

Preoperative sick leave, blaming oneself for the hand problem, and a preoperative distal nerve conduction motor latency were prognostic factors for postoperative work absence of more than 21 days. Other factors may be important (clinical, demographic, economic, and workplace) in explaining the great variance in the results of sick leave after carpal tunnel release between studies from different countries.

Are there any correlations between social and hand functions in patients with carpal tunnel release surgery postoperatively?

BACKGROUND

Carpal tunnel syndrome is one of the most common and disabling work injuries in North America. Patients with carpal tunnel syndrome are often associated with substantial productivity loss and cost both at work and at home. Several studies have examined the relationship of social supports as a predictor of returning to work following carpal tunnel release surgery (CTRS). However, no studies published to date have examined the relationship between social support and the ability to perform activities of daily living after having CTRS.

OBJECTIVE

To examine whether a correlation exists between the degree of social support and hand function in terms of the ability to perform activities of daily living in patients who have had CTRS.

METHODS

Patients in the present cross-sectional study were evaluated with two standardized questionnaires at least two months postoperatively following CTRS. The questionnaires consisted of the Multidimensional Scale of Perceived Social Support, which evaluated social support, and QuickDASH, which evaluated hand function. A correlation analysis was then performed to identify any relationships between the two questionnaires.

RESULTS

In a sample of 20 patients, correlation analyses revealed that perceived social support was significantly associated with hand function scores postoperatively (r=-0.73, P<0.01). In addition, a statistically significant relationship existed between social support and the preoperative self-rating pain scores (r=-0.51, P<0.05). These results indicate that there is a strong association between the degree of social support and the ability to perform hand activities of daily living following CTRS.

Determinants of Escalating Costs in Low Risk Workers’ Compensation Claims

OBJECTIVE

To identify and quantify attributes that lead to unanticipated cost escalation in workers' compensation claims.

METHODS

We constructed four claim categories: low initial reserve/low cost, migrated catastrophic (low initial reserve/high cost), high initial reserve/low cost, and catastrophic (high initial reserve/high cost). To assess the attributes associated with the increased cost of migrated catastrophic claims, we analyzed 36,329 Louisiana workers' compensation claims in the four categories over a 5-year period.

RESULTS

In the 729 claims initially thought to be low-cost claims (migrated catastrophic), the most significant predictors for cost escalation were attorney involvement and claim duration, followed by low back disorder, married/single/divorced status, male gender, small company size, high premium, reporting delays, and older age. These injuries accounted for 2% of all claims but 32.3% of the costs. Accelerated escalation of costs occurred late in the claim cycle (2 years).

CONCLUSION

Certain attributes, particularly attorney involvement and claim duration, are associated with unanticipated cost escalation in a small number of claims that drastically affect overall losses. The results of this study suggest that these cases may be identified and addressed before rapid escalation occurs.

Early predictors of chronic work disability associated with carpal tunnel syndrome: a longitudinal workers' compensation cohort study

BACKGROUND

The study objectives were to identify early predictors of chronic work disability associated with carpal tunnel syndrome (CTS) and to test the hypothesis that variables from each of several domains (sociodemographic, clinical, work-related, and psychosocial) would add unique predictive information.

METHODS

Washington State workers were interviewed 18 days (median) after submitting a new workers' compensation claim for CTS. Baseline predictors of chronic work disability (> or =180 days of work disability compensation in the year after claim submission) were examined for workers who had at least 1 day of disability compensation (N = 899).

RESULTS

Baseline demographic variables, symptom severity, functional limitations, lack of job accommodation, job physical demands, job psychosocial conditions, and worker psychosocial characteristics predicted chronic disability bivariately. Each domain of variables added significantly to the prediction of chronic disability. The final multivariable model had fair ability to discriminate individuals with versus without chronic disability (cross-validated area under the ROC curve = 0.76).

CONCLUSIONS

Sociodemographic, clinical, work-related, and worker psychosocial factors early in a claim contribute unique information to the prediction of subsequent work disability associated with CTS.

Treatment of carpal tunnel syndrome

Fifty years after its widespread recognition, a significant minority of patients with carpal tunnel syndrome continue to experience poor outcomes from treatment. Much current treatment is supported by an inadequate or nonexistent evidence base. Surgical decompression, often considered the definitive solution, gives excellent results in only 75% of cases in ordinary practice and leaves 8% of patients worse than previously. The only other interventions that are clearly of benefit are neutral-angle wrist splinting, with a success rate of 37%, and steroids, which are better given by local injection than as oral treatment. The initial response rate to injection is 70% but there are frequent relapses. Nevertheless, these conservative treatments have a negligible incidence of serious complications and should be used more widely until surgical failures can be reduced to similar levels.

Eight predictive factors associated with response patterns during physiotherapy for soft tissue shoulder disorders were identified

BACKGROUND AND OBJECTIVE

Combining information on initial and final state with information on speed of response may reflect the clinical reality of the course of recovery from soft tissue shoulder disorders. The purpose was to identify baseline factors that predict patterns of response to physiotherapy.

STUDY DESIGN AND SETTING

Prospective cohort of consecutive clients (n=361) with soft tissue shoulder disorders attending physiotherapy. A previous study identified four typical patterns of response such that each individual was assigned to one of four clusters (dependent outcome). Independent predictors (n=28) included demographics, disorder-related and disability measures, treatment factors, clinical findings, and expectations for recovery. Multivariable multinomial logistic regression techniques were used.

RESULTS

Predictors differentiating patterns of response were: Age (by decade), duration of current shoulder problem, worker's compensation claim, client's global rating of problem, Physical Component Score (SF-36), Mental Component Score (SF-36), over the counter medication use, and therapist prediction of client to return to usual activity.

CONCLUSION

Using a clinically sensible outcome, we have identified several predictors that can be used by clinicians in clinical decision making.

The role of job strain on return to work after carpal tunnel surgery

AIMS

To examine the impact of job strain (that is, high psychological job demands and low job control) on return to work and work role functioning at two months, six months, or both, following carpal tunnel release surgery.

METHODS

A community based cohort of carpal tunnel syndrome (CTS) patients from physician practices was recruited between April 1997 and October 1998 throughout Maine (USA). 128 patients at two months and 122 at six months completed all relevant questions. A three level outcome variable indicated whether patients had: (1) returned to work functioning successfully, (2) returned to work functioning with limitations, or (3) not returned to work for health reasons. Two job strain measures were created: one, by combining psychological job demands and job control; and two, by dividing demands by control. Ordinal logistic regression was used to identify predictors of the three level work outcome variable.

RESULTS

After adjustment, workers with high demands and high control (active work) were less likely to successfully return to work (OR = 0.22; p = 0.014) at two months. Having a job with higher demands than job control (high strain) predicted not returning to work or returning to work but not successfully meeting job demands (OR = 0.14; p = 0.001), at six months.

CONCLUSIONS

The findings underscore the role of psychosocial work conditions, as defined by the Karasek demand-control model, in explaining a worker's return to work. Clinicians, researchers, and employers should consider a multidimensional and integrative model of successful work role functioning upon return to work. Moreover, since the evidence of the effects of work process changes on the reduction of CTS is very scarce, these findings point to the opportunity for collaborative workplace interventions to facilitate successful return to work.

Time to return to work and surgeons' recommendations after carpal tunnel release

BACKGROUND

Time to return to work after carpal tunnel release is extremely variable suggesting that only a small proportion of total sick-leave is for medical reasons.

AIMS

To determine factors predicting a delayed return to work.

METHODS

Fifty consecutive employed patients undergoing carpal tunnel surgery were tested pre-operatively, and then at 1 month post-operatively using both questionnaires and objective testing. Further follow-up by telephone was carried out every 2 weeks up until 90 days.

RESULTS

Forty-nine of the 50 workers had returned to work by 3 months. Time to return to work was extremely variable ranging from 1 to 88 days in those who returned to work. Post-operative recommendations by the surgeon also varied widely from 1 to 36 days. The surgeons' recommendations were the strongest predictors of delayed return to work [odds ratio 30.5; 95% confidence interval (CI), 3.2-288], with physical work (odds ratio 27.7; 95% CI, 1.5-507) and lack of self-rated health (odds ratio 5.0; 95% CI, 1.11-100) adding significantly to the logistic regression model, which was highly predictive (area under the receiver-operator curve of 88%). Patient symptoms and objective findings of disability did not add significantly to a logistic regression model either predicting return to work or the surgeon's recommendations.

CONCLUSIONS

Our study suggests that workers will return to work in less than 3 weeks if recommended by the surgeon. A randomized controlled trial is warranted to determine if a higher proportion of workers returning in less than 3 weeks can be obtained by standardizing surgeons' recommendations.

Management and employee agreement on reports of organizational policies and practices important in return to work following carpal tunnel surgery

This study's purpose was to assess the agreement between management and employee ratings of organizational policies and practices (OPP) involved in the return to work process following carpal tunnel surgery. As a part of the prospective community-based Maine Carpal Tunnel II Study, 65 manager and employee pairs completed a questionnaire tapping four OPP dimensions. people oriented culture, safety climate, ergonomic practices, and disability management. It was hypothesized that managers and employees would agree on their assessment of the four OPPs and a composite organizational support index. Agreement was assessed using Lin's concordance correlation coefficient. Employee and manager ratings were similar for the organizational support index (rho(c) = 0.14, p = 0.08), and people oriented culture (rho(c) = 0.25, p = 0.01) but not the other three OPPs. In larger companies (>450 employees), ratings were also similar for safety climate (rho(c) = 0.24, p = 0.09), disability management (rho(c) = 0.22, p = 0.07) and ergonomic practices (rho(c) = 0.35, p = 0.02). In unionized companies there was agreement for safety climate (rho = 0.44, p = 0.02), disability management (rho(c) = 0.41, p = 0.01) and ergonomic practices (rho(c) = 0.40, p = 0.06). These preliminary results suggest employees can report on certain OPPs and that an employee questionnaire can be used to assess organizational support. Given recent evidence that employee ratings of OPPs are predictive of injury/illness incidence, work disability and return-to-work outcomes, further research is needed to confirm these findings.

Determinants of work absence following surgery for carpal tunnel syndrome

BACKGROUND

The objective was to identify factors across multiple domains associated with return to work in a community-based cohort of workers with carpal tunnel syndrome.

METHODS

Workers scheduled for carpal tunnel release were recruited into this prospective study. Subjects completed questionnaires preoperatively and at 2, 6, and 12 months postoperatively. The questionnaires contained demographic, clinical, and psychosocial factors and physical and psychosocial workplace stressors. Predictors of work absence at 6 and 12 months were examined in bivariate and multivariate logistic regression analyses.

RESULTS

Six months following surgery of 181 subjects, 29 (19%) were out of work. Twelve months postoperatively 33 subjects (22%) were out of work. In bivariate analyses, the factors associated with work absence at 6 months, at P < or = 0.01, included preoperative physical functional status, change in self-efficacy between preoperative assessment and 2 months, lower income, workers' compensation, representation by an attorney, work exposure to force and repetition, higher psychological job demands and lower control, lower social support by coworkers, lower job security and more supportive organizational policies and practices. The factors associated with work absence at 12 months in bivariate analyses included preoperative physical functional status, lower self-efficacy at 2 months, workers' compensation, and less supportive organizational policies and practices. Multivariate analyses documented a multidimensional model, with predictors from multiple domains.

CONCLUSIONS

Clinical, demographic, economic, and workplace factors were associated with work absence. Strategies to reduce work absence following carpal tunnel release should address multiple dimensions of the worker and workplace.

Randomized clinical trial of surgery versus conservative therapy for carpal tunnel syndrome [ISRCTN84286481]. BMC Musculoskelet Disord. 2005;6:2. [PMID: 15656907 PMCID: PMC546190 DOI: 10.1186/1471-2474-6-2]

BACKGROUND

Conservative treatment remains the standard of care for treating mild to moderate carpal tunnel syndrome despite a small number of well-controlled studies and limited objective evidence to support current treatment options. There is an increasing interest in the usefulness of wrist magnetic resonance imaging could play in predicting who will benefit for various treatments.

METHOD AND DESIGN

Two hundred patients with mild to moderate symptoms will be recruited over 3 1/2 years from neurological surgery, primary care, electrodiagnostic clinics. We will exclude patients with clinical or electrodiagnostic evidence of denervation or thenar muscle atrophy. We will randomly assign patients to either a well-defined conservative care protocol or surgery. The conservative care treatment will include visits with a hand therapist, exercises, a self-care booklet, work modification/ activity restriction, B6 therapy, ultrasound and possible steroid injections. The surgical care would be left up to the surgeon (endoscopic vs. open) with usual and customary follow-up. All patients will receive a wrist MRI at baseline. Patients will be contacted at 3, 6, 9 and 12 months after randomization to complete the Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ). In addition, we will compare disability (activity and work days lost) and general well being as measured by the SF-36 version II. We will control for demographics and use psychological measures (SCL-90 somatization and depression scales) as well as EDS and MRI predictors of outcomes.

DISCUSSION

We have designed a randomized controlled trial which will assess the effectiveness of surgery for patients with mild to moderate carpal tunnel syndrome. An important secondary goal is to study the ability of MRI to predict patient outcomes.