Favorable effects of explanatory illustrations attached to a self-administered questionnaire for upper extremity disorders

Development and pilot administration of the amputation-related pain and sensation assessment tool

PURPOSE

To develop and administer an assessment tool for facilitating patient-clinician discussions regarding amputation-related pain and sensation.

MATERIALS AND METHODS

An assessment tool was developed to measure the impact of different types of amputation-related pain and sensation on a patient's life. The tool first provides patients with written descriptions and images of three common types of amputation-related pain or sensations: residual limb pain, phantom limb sensation, and phantom limb pain. The tool then asks them to rate the frequency, intensity, and interference of each experience. Participants were also asked to provide qualitative descriptions of these experiences.

RESULTS

Fifty Veterans with lower limb amputation participated in the study. In the past month, 74% reported experiencing residual limb pain, 76% reported phantom limb sensation, and 84% reported phantom limb pain, with 52% reporting all three. Participants' descriptions of some experiences were distinct, while others (e.g., "tingling") were common between experiences. Phantom limb pain had the most varied descriptions.

CONCLUSIONS

The amputation-related pain and sensation assessment tool can be used to identify and measure the effects of different experiences on patients' lives, thereby improving the specificity of diagnosis and informing clinical treatment recommendations. Further development of this tool should include evaluating its psychometric properties.

Clinical and radiographic results of lunate resection and vascularized os pisiform transfer for Kienböck's disease

Although various treatments for advanced stages of Kienböck's disease have been reported, clinical evidence demonstrating the efficacy of lunate resection and vascularized os pisiform transfer for Kienböck's disease is limited. Herein, we investigated the clinical and radiographic results of this procedure. We retrospectively investigated eight patients who were followed up for ≥1 year. The mean age at the time of surgery was 52 years. The mean follow-up period was 3.4 years. The preoperative and postoperative mean wrist flexion-extension ranges were 84° and 111°, respectively, and grip strengths were 18.5 and 26.3 kg, respectively. Pain decreased in five patients postoperatively. The mean preoperative and postoperative carpal height ratios were 0.47 and 0.46, respectively, and radio scaphoid angles were 63° and 65°, respectively. Osteoarthritic changes were observed in or around the transferred pisiform in all five patients who were surveyed using radiographs. Most patients demonstrated satisfactory clinical results, including pain relief and improved wrist motion and grip strength, regardless of osteoarthritic wrist changes on postoperative radiographs. In summary, this procedure was effective for treating Kienböck's disease, especially in the advanced stages. Level of evidence: Ⅳ.

Test-retest reliability, convergent validity and cross-cultural adaptation of Turkish version of the Hand10 questionnaire

BACKGROUND

The Hand10 Questionnaire is composed of 10 short, easy to understand and illustrated questions and was developed to measure upper extremity disorders. Thanks to these features, unlike other questionnaires that assess upper extremity disorders, it can be used in the elderly and children as well as adults. The aim of this study was to cross-culturally adapt the Hand10 into Turkish and to test its reliability and validity.

METHODS

Translation and back-translation of the Hand10 were performed according to Beaton guidelines. Patients completed the Disabilities of the Arm, Shoulder and Hand Questionnaire once and the final version of the Hand10 Questionnaire twice, with 7-days interval. Test-retest reliability and internal consistency were determined using Intraclass Correlation Coefficient analysis and Cronbach's alpha, respectively. Convergent validity of Hand10 was determined with Disabilities of the Arm, Shoulder and Hand Questionnaire using Pearson Correlation Coefficient analysis.

RESULTS

One hundred patients participated in the study. Cronbach's alpha value was 0.919, indicating an excellent internal consistency. Intraclass Correlation Coefficient value for test-retest reliability were found to be 0.890 that indicates a high reliability. Hand10 showed very good correlation with Disabilities of the Arm, Shoulder and Hand Questionnaire (r: 0.669).

CONCLUSIONS

The Turkish version of the Hand10 met set criteria of reliability and validity. As a result of this study, we determined that Hand10 is a useful instrument to measure upper extremity disorders in Turkish-speaking patients. It is recommended to be used in clinical settings and researches.

Collagenase Clostridium histolyticum Injection Therapy Improves Health-related Quality of Life in Patients with Dupuytren's Disease

Objectives:

This study was conducted to investigate the changes in clinical and psychosocial outcomes in patients with Dupuytren’s disease after initial treatment with collagenase Clostridium histolyticum (CCH) injection.

Methods:

This study involved 14 patients with Dupuytren’s disease who underwent treatment with CCH injection. The range of motion of each phalangeal joint was measured before treatment and at 6 months posttreatment. The following assessments were also carried out pre- and posttreatment: the Geriatric Depression Scale Short – Japanese version (GDS-J) to evaluate depressive status, Hand 10 to assess hand health status, and EuroQol-5-dimension-3-level Japanese version to evaluate health-related quality of life

Results:

Significant improvements were found in metacarpophalangeal joint extension and proximal interphalangeal joint extension. Significant differences were also found between values before the initiation of CCH injection and those at 6 months posttreatment for the EuroQol index score and the EuroQol Visual Analog Scale (VAS). Significant positive correlations were found between the pre- to posttreatment change in GDS-J scores and for the change in Hand 10 scores. Moreover, a significant negative correlation was found between the change in GDS-J scores and change in EuroQol index scores/EuroQol VAS scores before and at 6 months after CCH injection.

Conclusions:

For patients with Dupuytren’s disease, CCH therapy directly improved the health-related quality of life. The degree of improvement of depressive status was associated with the degree of improvement of hand health status and health-related quality of life.

Development of a patient-oriented outcome measure for patients with hand and elbow disorder: HandQ

PURPOSE

The Disabilities of the Arm, Shoulder, and Hand (DASH) is the most widely used patient-oriented outcome measure for the upper extremities in the world, and high reliability and validity of it has already been confirmed. However, there are several problems with using the DASH, some of which are culturally related. We aimed to (1) develop a patient-oriented disease-specific outcome measure for patients with disorders of the hand and elbow, which we call the HandQ and (2) examine the practical applicability, reliability, and validity of the HandQ for any patient with disorders of the hand and elbow.

METHODS

A total of 216 patients were surveyed with the HandQ, as well as the Hand20 and the DASH to assess psychometric characteristics.

RESULTS

There were no considerable floor and ceiling effects regarding the total HandQ score. Test-retest reliability and internal consistency determined using the intraclass correlation coefficient (0.942) and Cronbach's α test (0.961) were excellent. The HandQ was well correlated with the Hand20 and the DASH scores. Scree plot showed unidimensionality of the HandQ, and the graphical model showed the questionnaire items of the HandQ had reasonable correlation among each item.

CONCLUSIONS

The HandQ has a sufficient reliability and internal consistency, and an excellent validity, and was shown to be able to be practically applicable in all patients with hand and elbow disorders.

Disturbance of somatotopic spatial cognition and extra-territorial pain in carpal tunnel syndrome

BACKGROUND

Several studies on carpal tunnel syndrome have reported pain that exists beyond the median nerve territory of the affected hand. However, the mechanism is unknown.

PURPOSE

We investigated the cause of extra-territorial pain by the analysis of clinical assessments and cortical activity using magnetoencephalography.

METHODS

To compare patients with and without extra-territorial pain, fourteen patients with carpal tunnel syndrome were assessed using clinical examination, such as patients' profile, paresthesia, physical tests, and psychological tests. The physical assessment included tactile threshold and static and moving two-point discrimination sensations on digital pulp. Neural activation in the cerebral cortex was also measured using z-scores calculated by magnetoencephalography.

RESULTS

Among fourteen patients, ten patients had pain in the affected median nerve territory only and four patients had extra-territorial pain. When comparing the groups, the static and moving two-point discrimination sensation values in patients with extra-territorial pain were larger than those of patients without the pain (p < 0.05). The supra-marginal gyrus, mid-part of the precentral sulcus, angular gyrus in the left hemisphere, bilateral sensorimotor areas for legs, and bilateral isthmus-cingulate areas showed larger z-scores in patients with extra-territorial pain than in patients without the pain (p < 0.05).

CONCLUSIONS

The static and moving two-point discrimination sensations signify the ability of tactile spatial acuity. Bilateral sensorimotor areas were activated in sites that were not the hand. Furthermore, the inferior parietal lobule in the left hemisphere, which synthesizes and integrates multiple sensations showed high activation. Our findings suggested that the mechanism of extra-territorial pain was associated with dysfunction of spatial cognition.

Cross-cultural translation, adaptation and validation of a Japanese version of the functional index for hand osteoarthritis (J-FIHOA)

Background

Hand osteoarthritis (OA) has a wide spectrum of clinical presentations and physical function is one of the core domains where patients suffer. The Functional Index for Hand Osteoarthritis (FIHOA) is a leading assessment tool for hand OA-related functional impairment. Our objective was to make a Japanese version of FIHOA (J-FIHOA) and validate it among Japanese hand OA patients.

Methods

Forward and backward translation processes were completed to create a culturally adapted J-FIHOA. A prospective, observational multicenter study was undertaken for the validation process. Seventeen collaborating hospitals recruited Japanese hand OA patients who met the American College of Rheumatology criteria. A medical record review and responses to the following patient-rated questionnaires were collected: J-FIHOA, Hand20, Health Assessment Questionnaire (HAQ), numerical rating scale for pain (NRS pain) and Short Form 36 Health Survey (SF-36). We explored the structure of J-FIHOA using factor analysis. Cronbach’s alpha coefficients and item-total correlations were calculated. Correlations between J-FIHOA and other questionnaires were evaluated for construct validity. Participants in clinically stable conditions repeated J-FIHOA at a one- to two-week interval to assess test-retest reliability. To evaluate responsiveness, symptomatic patients who started new pharmacological treatments had a 1-month follow-up visit and completed the questionnaires twice. Effect size (ES) and standardized response mean (SRM) were calculated with pre- and post-treatment data sets. We assessed responsiveness, comparing ES and SRM of J-FIHOA with other questionnaires (construct approach).

Results

A total of 210 patients participated. J-FIHOA had unidimensional structure. Cronbach’s alphas (0.914 among females and 0.929 among males) and item-total correlations (range, 0.508 to 0.881) revealed high internal consistency. Hand20, which measures upper extremity disability, was strongly correlated with J-FIHOA (r = 0.82) while the mental and role-social components of SF-36 showed no correlations (r = − 0.24 and − 0.26, respectively). Intraclass correlation coefficient for test-retest reliability was 0.83 and satisfactory. J-FIHOA showed the highest ES and SRM (− 0.68 and − 0.62, respectively) among all questionnaires, except for NRS pain.

Conclusions

Our results showed J-FIHOA had good measurement properties to assess physical function in Japanese hand OA patients both for ambulatory follow-up in clinical practice, and clinical research and therapeutic trials.

A magnetoencephalographic study of longitudinal brain function alterations following carpal tunnel release

We investigate changes in brain function before and after carpal tunnel release. Magnetoencephalography (MEG), during which we recorded somatosensory evoked cortical magnetic fields (SEFs), and a clinical evaluation were performed before surgery and 6 months after. The distance on the vertical axis between the equivalent current dipoles (ECDs) for the first and third digits before surgery was significantly less than after surgery. There were no significant differences in values between the control participant and patients after surgery. In terms of distal motor latency, there was a negative correlation with the distance. The recovery function of the root mean square (RMS) before surgery for the N20m was less suppressed at 10 ms of ISI in patients, compared to controls. There were no significant differences in the RMS values for patients before and after surgery. Our results indicate that treating peripheral nerve lesions, such as in carpal tunnel release, positively modifies brain function.

Validity and reliability of the Turkish version of the Cold Intolerance Symptom Severity Questionnaire

Background/aim

The aim of this study was to determine validity and reliability of the Turkish version of the Cold Intolerance Symptom Severity (CISS-T) Questionnaire.

Materials and methods

The translation and back translation steps of the study were based on the Beaton guidelines. Sixty-eight patients between 18 and 65 years old with cold intolerance after amputation, replantation, multiple crush syndrome, and peripheral nerve injury were included in the study. Patients completed the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), the SF-36 Quality of Life Questionnaire, and the single questions assessing the cold sensitivity and cold intolerance once and the final version of the CISS-T twice with a 7-day interval.

Results

The internal consistency (Cronbach α = 0.844) and test-retest reliability (r = 0.938) of CISS-T were assessed and both were considerably high. Also, the correlations between the scores of the CISS-T, DASH-T, SF-36-T, and the single questions were analyzed by Spearman’s correlation coefficient. The CISS-T showed an excellent correlation with the single questions (rho = 0.8 and 0.877), a good and negative correlation with the pain subscale of the SF-36 (rho = 0.617), and a moderate correlation with the DASH-T (rho = 0.592).

Conclusion

As a result, the CISS-T is a valid and reliable instrument to assess the severity of cold intolerance.

Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome

BACKGROUND

The upper extremity disability in patients with carpal tunnel syndrome (CTS) is related to dysfunction due to the median nerve damage. However, there is no report on which dysfunctions affect the upper extremity disability.

PURPOSE

This study aimed to investigate which clinical factors influence upper extremity disability in women with CTS.

METHODS

We analyzed 60 hands of women with bilateral idiopathic CTS. Upper extremity disability was assessed using Hand10, a validated and self-administered tool. Pain intensity was measured using the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-J). We performed nerve conduction studies, assessed physical and psychological parameters, and collected demographic data. Physical parameters comprised grip strength, pinch strength, tactile threshold, static 2-point discrimination sensation, and severity of numbness. Psychological parameters include depression, pain anxiety, and distress.

RESULTS

The bivariate analysis revealed that Hand10 was significantly correlated with age, symptom duration, SF-MPQ-J, grip strength, pain anxiety, and distress. Multiple regression analysis demonstrated that SF-MPQ-J and grip strength were related to Hand10 score.

CONCLUSIONS

Pain intensity and grip strength were dysfunctions affecting the upper extremity disability in women with bilateral idiopathic CTS. Rehabilitation approaches for CTS should be considered based on the adaptive activities of the neural networks.

Facilitating patient-centered care: the development of illustrated multidimensional patient-reported outcome measures for children/adolescents with juvenile idiopathic arthritis

OBJECTIVES

To assess the validity, reliability, comprehensibility, and responsiveness to change of an illustrated child/parent multidimensional patient-reported outcome measures (PROMs) questionnaire which can assess construct outcome measures of children with juvenile inflammatory arthritis.

METHODS

A total of 122 children with juvenile idiopathic arthritis were included in this work in a multicenter study. The questionnaire included seven categories: (1) functional ability; (2) health-related quality of life; (3) disease activity measures: pain, global assessment, fatigue, and morning stiffness; (4) self-reported joint tenderness; (5) current medication, side effects, and adherence to therapy; (6) comorbidities; and (7) patient motivation. All the items were supported by illustrations to provide children with a visual impression of what was meant by the questions. The questionnaire has parent and patient versions. The disease activity status was assessed using JADAS-27.

RESULTS

The questionnaire was reliable as demonstrated by a high-standardized alpha (0.890-0.978). The questionnaire items correlated significantly (p < 0.01) with clinical parameters of disease activity. The patient-reported tender joints correlated significantly with the physician's scores (0.842). Changes in functional disability, quality of life, and the motivation score showed significant variation (p < 0.01) with disease activity status in response to therapy. The illustrated PROMs questionnaire showed also a high degree of comprehensibility (9.6).

CONCLUSIONS

Integrating PROMs into standard clinical practice is feasible and applicable. The illustrated questionnaire was valid and reliable. It provides an informative, quantitative measure for the disease activity score set data, and in the meantime, facilitates the assessment of the children's adherence to therapy, comorbidities, and motivation on an individual basis.

Favorable Responsiveness of the Hand10 Questionnaire to Assess Treatment Outcomes for Lateral Epicondylitis

BACKGROUND

The aim of our study was to compare the responsiveness of the Hand10 questionnaire and the Pain visual analogue scale (VAS) for the assessment of lateral epicondylitis.

METHODS

The standardized response mean and effect size were used as indicators of responsiveness, measured at baseline and after 6 months of treatment. Among the 54 patients enrolled, 28 were treated using a forearm band, compress and stretching, with the other 26 patients treated using compress and stretching.

RESULTS

The standardized response mean and the effect size were 1.18 and 1.38, respectively, of the Hand10 and 1.39 and 1.75, respectively, for the Pain VAS.

CONCLUSIONS

The responsiveness of both tests was considered to be large, based on Cohen's classification of effect size, supporting the use of the Hand10 questionnaire to assess treatment outcomes for lateral epicondylitis.

Efficacy of a forearm band in addition to exercises compared with exercises alone for lateral epicondylitis: A multicenter, randomized, controlled trial

BACKGROUND

A forearm band is frequently used for lateral epicondylitis worldwide. However, evidence regarding its efficacy has been insufficient. The objective of this prospective, randomized, controlled trial was to analyze the effects of a forearm band for treatment of lateral epicondylitis at 1, 3, 6, and 12 months.

METHODS

Patients with lateral epicondylitis were randomly allocated into a band (n = 55) or non-band (n = 55) group. Patients in the band group were instructed to wear a forearm band for more than 6 h daily for at least 6 months. Patients in both groups were instructed to perform wrist extensor stretching exercises for 30 s, 3 times daily, for 6 months. Hand10, pain, and satisfaction scores, and proportions of positive physical examinations, including tenderness assessment, Thomsen test, and middle finger extension test, were evaluated at 1, 3, 6, and 12 months after enrollment.

RESULTS

There were no significant differences between the band and non-band groups with regard to Hand10, pain, or satisfaction scores at 1, 3, 6, and 12 months. Likewise, there was no significant difference in proportions of positive physical examinations between groups at 1, 3, 6, and 12 months.

CONCLUSION

The results of the current study suggest that a forearm band may have no more than a placebo effect, and do not support the use of a forearm band based on its effectiveness.

Patients with benign hand tumors are indicated for surgery according to patient-rated outcome measures

INTRODUCTION

This study assessed the treatment outcomes of upper extremity benign tumors using the patient-rated outcome measures of Hand20 questionnaire.

METHODS

In total, 304 patients who underwent surgery for benign bone and soft tissue tumors of the upper limb were included. Tumors were classified into three size groups: <1 cm, 1-3 cm, and >3 cm. Tumors were divided with respect to location: digit, hand, wrist, forearm, elbow, upper arm, or axilla. We prospectively assessed responses to the Hand20 questionnaire that was administered both before and after surgery.

RESULTS

The mean Hand20 and pain scores significantly improved after surgery in patients with ganglion cysts, giant cell tumors of the tendon sheath, enchondromas, or pyogenic granulomas. For patients with hemangiomas, schwannomas, or glomus tumors, although the mean pain scores improved significantly following surgery, there were no significant changes in the mean Hand20 scores. However, the statistical power for this analysis was low. The mean Hand20 and pain scores improved significantly, regardless of the size grouping. The mean Hand20 scores significantly improved after surgery in patients with finger, thumb, hand, or wrist tumors. Except for elbow to axillary tumors, the mean pain scores significantly improved in all patients.

CONCLUSION

The results of Hand20 and pain scores suggest that most patients with benign hand tumors are indicated for surgery, but the degree of improvement differs according to tumor pathology and location but not size.

Association between dysfunction of upper extremity and locomotive syndrome in general population

OBJECTIVE

This study investigated the relation between self-assessment of upper extremity function and locomotive syndrome in a general population.

METHODS

Using the 25-question Geriatric Locomotive Function (GLFS-25) test, 320 Japanese people (115 men, 205 women, mean age 67.6 years, 40-92 years) were evaluated for locomotive dysfunction. All had completed a self-administered questionnaire including items for sex, weight, height, dominant hand, and the degree of frequency of hand in ADL. We measured the bilateral hand grip and key pinch strength as indicators of hand muscle function. Study participants were assessed for upper extremity dysfunction using Hand 10, a self-administered questionnaire for upper extremity disorders, and using the Japanese Society for Surgery of the Hand Version of Disability of the Arm, Shoulder, and Hand. Statistical analyses were conducted to clarify the association between upper extremity dysfunction and screening results for locomotive dysfunction.

RESULTS

Participants reporting any upper extremity dysfunction were 137 (47 men, 90 women) out of 320 participants. The GLFS25 score was found to have significant positive correlation with age and Hand 10 scores. Significant negative correlation was found with the GLFS25 score and dominant grip strength, non-dominant grip strength, dominant key pinch strength, and non-dominant key pinch strength. Univariate analysis revealed a significant association with age, sex, bilateral hand grip, and key pinch, and with the Hand 10 score and Locomotive syndrome. Logistic regression analysis applied after adjustment for age, sex, height, and weight revealed a significant association between Locomotive syndrome and each of non-dominant hand grip (OR 0.73, 95%CI 0.61-0.87) and the Hand 10 questionnaire score (OR 1.10, 95%CI 1.06-1.14).

CONCLUSION

Locomotive syndrome is associated with the decline of self-assessed and observed upper extremity function.

STUDY DESIGN

Cross-sectional study.

Cross-cultural adaptation, reliability, internal consistency and validation of the Hand Function Sort (HFS©) for French speaking patients with upper limb complaints

INTRODUCTION

Functional evaluation of upper limb is not only based on clinical findings but requires self-administered questionnaires to address patients' perspective. The Hand Function Sort (HFS©) was only validated in English. The aim of this study was the French cross cultural adaptation and validation of the HFS© (HFS-F).

METHODS

150 patients with various upper limbs impairments were recruited in a rehabilitation center. Translation and cross-cultural adaptation were made according to international guidelines. Construct validity was estimated through correlations with Disabilities Arm Shoulder and Hand (DASH) questionnaire, SF-36 mental component summary (MCS),SF-36 physical component summary (PCS) and pain intensity. Internal consistency was assessed by Cronbach's α and test-retest reliability by intraclass correlation.

RESULTS

Cronbach's α was 0.98, test-retest reliability was excellent at 0.921 (95 % CI 0.871-0.971) same as original HFS©. Correlations with DASH were-0.779 (95 % CI -0.847 to -0.685); with SF 36 PCS 0.452 (95 % CI 0.276-0.599); with pain -0.247 (95 % CI -0.429 to -0.041); with SF 36 MCS 0.242 (95 % CI 0.042-0.422). There were no floor or ceiling effects.

CONCLUSIONS

The HFS-F has the same good psychometric properties as the original HFS© (internal consistency, test retest reliability, convergent validity with DASH, divergent validity with SF-36 MCS, and no floor or ceiling effects). The convergent validity with SF-36 PCS was poor; we found no correlation with pain. The HFS-F could be used with confidence in a population of working patients. Other studies are necessary to study its psychometric properties in other populations.

Simple debridement has little useful value on the clinical course of recalcitrant ulnar wrist pain

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Comparative responsiveness of the Hand 20 and the DASH-JSSH questionnaires to clinical changes after carpal tunnel release

This study compared the responsiveness of the Hand 20 and the Japanese version of the disabilities of the arm, shoulder and hand (DASH-JSSH) questionnaires in carpal tunnel syndrome. The scores before and 3 months after surgery were used to calculate the standardized response mean and effect size. Of 57 patients enrolled in the study, 13 underwent open carpal tunnel release and 44 had endoscopic carpal tunnel release. The standardized response mean and the effect size of the Hand 20 scale were 0.60 and 0.54, respectively, and those of the disabilities of the arm, shoulder and hand scale were 0.39 and 0.36, respectively. Compared with the Disabilities of the Arm, Shoulder and Hand questionnaire, the Hand 20 questionnaire appears to have better responsiveness for assessing the effect of treatment by carpal tunnel release.