General Anxiety Is Associated with Problematic Initial Recovery After Carpal Tunnel Release

Abstract

BackgroundCarpal tunnel release can stop the progression of idiopathic median neuropathy at the wrist (carpal tunnel syndrome). Intermittent symptoms tend to resolve after surgery, but loss of sensibility can be permanent. Both pathophysiology (severe neuropathy) and mental health (symptoms of despair or worry) contribute to problematic recovery after carpal tunnel release, but their relative associations are unclear.Question/purposeIs problematic initial recovery after carpal tunnel release associated with psychologic distress rather than with disease severity?MethodsWe retrospectively studied 156 patients who underwent in-office carpal tunnel release between November 2017 and February 2020, and we recorded their symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD]) and depression (Patient Health Questionnaire), signs of severe median neuropathy (loss of sensibility, thenar muscle atrophy, and palmar abduction weakness), and problematic recovery. The initial recovery (first 2 weeks) was categorized as problematic if the patient was upset about persistent numbness, experienced unsettling postoperative pain, developed hand stiffness, or experienced wound issues—all of which are routinely recorded in the medical record by the treating surgeon along with signs of severe median neuropathy. Twenty-four percent (38 of 156) of patients had a problematic initial recovery characterized by distress regarding persistent numbness (16% [25 of 156]), unsettling pain (8% [12 of 156]), hand stiffness (5% [8 of 156]), or wound issues (1% [2 of 156]); 6% (9 of 156) of patients had more than one issue. Associations between problematic initial recovery and age, gender, symptoms of anxiety and depression, disease severity, specific exam findings, and insurance were evaluated using t-tests, Mann-Whitney tests, and chi-square tests, with the plan to perform logistic regression if at least two variables had an association with p < 0.10.ResultsThe only factor associated with problematic initial recovery was greater symptoms of anxiety (median GAD score 1.5 [interquartile range 0 to 7.8] for problematic initial recovery compared with a median score of 0 [IQR 0 to 2] for nonproblematic recovery; p = 0.04), so we did not perform a logistic regression. Physical examination findings consistent with severe median neuropathy were not associated with problematic initial recovery.ConclusionThe finding that problematic initial recovery after carpal tunnel release was related to symptoms of anxiety and not to the severity of median neuropathy highlights the need to study the ability of efforts to ameliorate anxiety symptoms before carpal tunnel release as an effective intervention to reduce unplanned visits and additional tests, therapy, and repeat surgery, while improving patient-reported outcomes and experience.Level of EvidenceLevel III, therapeutic study.

The impact of psychological factors on outcome after salvage surgery for wrist osteoarthritis

“…Others have reported negative effects of pain catastrophizing and anxiety on PROMs after surgery for various chronic conditions and injuries to the hand and wrist (Egloff et al., 2017; London et al., 2014; Mosegaard et al., 2020; Ryan et al., 2022, Vranceanu et al., 2014). Similar results have also been reported in other fields of surgery, such as general, thoracic and cardiac surgery (Levett and Grimmett, 2019).…”

“…In recent years, there has been increasing interest in the impact of psychological factors on the post-surgical outcome. Anxiety, depression and pain catastrophizing have been reported to predict poor outcome, persisting pain and delayed recovery after surgery in a wide variety of chronic and traumatic medical conditions in the upper extremity (Crijns et al., 2019; Dekker et al., 2016; Egloff et al., 2017; Mosegaard et al., 2020; Ryan et al., 2022; Vranceanu et al., 2010; Yeoh et al., 2016). Sense of coherence (SOC), the ability to cope with stressful situations or challenges, has also been reported to influence outcomes after hand injuries (Carlsson and Dahlin, 2014; Cederlund et al., 2010; Rosberg, 2014).…”

CORR Insights®: General Anxiety Is Associated With Problematic Initial Recovery After Carpal Tunnel Release

“…Based on these findings [8], it is important for orthopaedic surgeons to champion the biopsychosocial model of medicine in their clinical practices because social and mental health are inseparable from physical health [7]. This can be accomplished by routinely collecting and efficiently reviewing—by both the surgeon alone and with patients—validated mental health-related patient-reported outcome measures.…”

“…This can be accomplished by routinely collecting and efficiently reviewing—by both the surgeon alone and with patients—validated mental health-related patient-reported outcome measures. If done, initial recovery—at the minimum reported in Ryan et al [8]—after a procedure like CTR may be improved for not only the patient but also surgeons and the health system. Indeed, a decrease in problematic initial recovery might be associated with improved patient-reported outcomes and a decline in unplanned clinic encounters, excess testing, and other wasteful use of healthcare resources [8].…”

CORR Insights®: What Are the Minimum Clinically Important Difference Values for the PROMIS and QuickDASH After Carpal Tunnel Release? A Prospective Cohort Study

“…In a physician-patient relationship, the physician is entrusted with not only technically addressing an anatomic or physiologic concern, but also guiding the patient through the different phases of recovery. Understanding the degree to which a patient's anxiety can affect his or her outcome [6,10] may help as we guide patients through what may be uncharted territory for many. Strategies to ameliorate anxiety and unhelpful thoughts by demonstrating empathy or employing strategies like motivational interviewing might help achieve the shared goal of a positive outcome [3,9].…”