Validity and Responsiveness of the DASH Questionnaire as an Outcome Measure following Ulnar Nerve Transposition for Cubital Tunnel Syndrome:

Electrodiagnostic severity does not predict short- to midterm outcomes of cubital tunnel release surgery

HYPOTHESIS

This study aimed to explore the prognostic value of electrodiagnostic studies (EDS) to clarify their utility in clinical practice prior to cubital tunnel release surgery and to identify patient factors associated with patient-reported functional improvement after surgery. Our hypothesis was that patients with severe preoperative findings on EDS will tend to experience less functional improvement after surgery given the extent of ulnar nerve compressive injury.

METHODS

Patients with cubital tunnel syndrome and preoperative electrodiagnostic data treated from 2012 to 2022 with cubital tunnel release were assessed regarding demographic information, preoperative physical examination findings, EDS findings, postoperative complications, and patient-reported outcomes. Short- to midterm quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) scores were collected for all patients for further evaluation of preoperative EDS data. Patients were grouped into those who had met the minimal clinically important difference (MCID) in delta qDASH at short- to midterm follow-up and those who did not. EDS data included sensory nerve onset latency, peak latency, amplitude, conduction velocity, as well as motor nerve latency, velocity, and amplitude. Electromyographic (EMG) studies were also reviewed, which included data pertaining to fibrillations, presence of abnormal fasciculation, positive sharp waves, variation in insertional activity, motor unit activity, duration of activity, and presence of increasing polymorphisms.

RESULTS

Of the 257 patients included, 160 (62.0%) were found to meet the MCID for short- to midterm qDASH scores. There were no significant differences between patients who did or did not meet the MCID regarding baseline demographics, comorbidities, preoperative examination findings, and operative technique. Patients who met MCID tended to have lower complication (3.80% vs. 7.20%, P = .248) and revision (0.60% vs. 4.10%, P = .069) rates, but these findings were not statistically significant. The cubital tunnel severity as determined by the EDS was similar between cohorts (14.1% vs. 14.3%, P = .498). Analysis of EMG testing showed there were no significant differences in preoperative, short- to midterm qDASH, or delta short- to midterm qDASH scores for patients with or without abnormal EMG findings. Multivariate regression suggested that only age (P = .003) was associated with larger delta qDASH scores.

CONCLUSION

Patient-reported preoperative disease severity may predict the expected postoperative change in ulnar nerve functional improvement, and EDS may not have prognostic value for patients undergoing cubital tunnel decompression. Therefore, physicians may suggest surgical treatment without positive EDS findings and still expect postoperative improvement in functional outcomes.

Evaluation of PROMIS Outcomes for Surgical Treatment of Cubital Tunnel Syndrome With and Without Carpal Tunnel Syndrome

BACKGROUND

Assessment of outcomes for cubital tunnel syndrome (CuTS) surgeries has been difficult due to heterogeneity in outcome reporting. Our objective was to evaluate the outcomes for 2 cohorts treated surgically for isolated CuTS and for combined CuTS and carpal tunnel syndrome (CTS) using Patient Reported Outcomes Measurement Information System (PROMIS).

METHODS

There were 29 patients in the isolated CuTS cohort and 30 patients in the combined CuTS and CTS cohort. PROMIS Physical Function (PF), Pain Interference (PI), Depression, and Upper Extremity (UE) were completed preoperatively and 1-week, 6-weeks, and 3-months postoperatively. Responsiveness was evaluated by standardized response means (SRM).

RESULTS

Significant improvements from the 1-week to 6-week postoperative period are shown in the isolated CuTS cohort for PROMIS PF (P = .002), PI (P = .0002), and UE (P = .02), but scores plateau after 6-weeks postoperatively. A similar pattern for the same time points was seen for the combined CuTS and CTS group for PROMIS PF (P = .001), PI (P = .02), and UE (P = .04), with a plateau of scores beyond 6 weeks postoperatively. PROMIS UE was more responsive (SRM range: 0.11-1.03) than the PF (SRM range: 0.02-0.52) and PI (SRM range: 0.11-0.40), which were both mildly responsive for both cohorts.

CONCLUSIONS

PROMIS lacks the sensitivity to show improvement beyond 6-weeks postoperatively for both isolated CuTS and combined CuTS and CTS. Patients with combined nerve compressions follow similar trajectories in the postoperative period as those with isolated CuTS.

LEVEL OF EVIDENCE

Level IV.

Beyond the Cubital Tunnel: Use of Adjunctive Procedures in the Management of Cubital Tunnel Syndrome

BACKGROUND

Our management of cubital tunnel syndrome has expanded to involve multiple adjunctive procedures, including supercharged end-to-side anterior interosseous to ulnar nerve transfer, cross-palm nerve grafts from the median to ulnar nerve, and profundus tenodesis. We also perform intraoperative brief electrical stimulation in patients with severe disease. The aims of this study were to evaluate the impact of adjunctive procedures and electrical stimulation on patient outcomes.

METHODS

We performed a retrospective review of 136 patients with cubital tunnel syndrome who underwent operative management from 2013 to 2018. A total of 38 patients underwent adjunctive procedure(s), and 33 received electrical stimulation. A historical cohort of patients who underwent cubital tunnel surgery from 2009 to 2011 (n = 87) was used to evaluate the impact of adjunctive procedures. Study outcomes were postoperative improvements in Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, pinch strength, and patient-reported pain and quality of life.

RESULTS

In propensity score-matched samples, patients who underwent adjunctive procedures had an 11.3-point greater improvement in DASH scores than their matched controls (P = .0342). In addition, patients who received electrical stimulation had significantly improved DASH scores relative to baseline (11.7-point improvement, P < .0001), whereas their control group did not. However, when compared between treatment arms, there were no significant differences for any study outcome.

CONCLUSIONS

Patients who underwent adjunctive procedures experienced greater improvement in postoperative DASH scores than their matched pairs. Additional studies are needed to evaluate the effects of brief electrical stimulation in compression neuropathy.

Psychometric Properties of the Patient-Reported Outcome Measures for People With Ulnar Nerve Entrapment at the Elbow: A Systematic Review

OBJECTIVE

The objective of this study was to systematically review, critically appraise, and synthesize evidence on the measurement properties of patient-reported outcome measures (PROMs) for people with ulnar nerve entrapment at the elbow (UNE).

METHODS

CINAHL, MEDLINE, Embase, and Scopus were searched for studies reporting on the psychometric properties of the PROMs used to assess pain, disability, and quality of life of people with UNE. Relevant data were extracted based on the Consensus-Based Standards for the Selection of Health Measurement Instruments 2018 checklist. Two authors independently rated the quality and risk of bias of the studies. A qualitative synthesis was performed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines. The results were categorized based on the identified PROMs, and all the psychometric properties were summarized and presented.

RESULTS

Eight included studies had a quality score of very good or higher. Among all the included PROMs, the Patient-Rated Ulnar Nerve Evaluation (PRUNE) was comprehensively evaluated in 4 studies and had high reliability, appropriate correlation to the physical component summary score of the 36-Item Short-Form Health Survey (r = -0.68), excellent content (cognitive interviews), structural (factor analysis) and discriminative validities, and high responsiveness. The Disabilities of the Arm, Shoulder and Hand Questionnaire was assessed in 5 studies and had appropriate properties, showing a high correlation with the 8-Item Short-Form Health Survey (r = 0.77) and PRUNE (r = 0.75) and moderate responsiveness.

CONCLUSIONS

The PRUNE was the most specific to UNE, had the most supporting studies and evidence of excellent reliability, validity, and responsiveness and therefore was the preferred PROM. The Disabilities of the Arm, Shoulder and Hand Questionnaire demonstrated more limited validation across 5 studies and had moderate responsiveness. Information on other included PROMs was limited in terms of psychometric properties.

IMPACT

This study provides insight into which PROM is potentially more suitable for measuring outcomes related to UNE.

Reliability and validity of the modified McGowan grade in patients with cubital tunnel syndrome

INTRODUCTION

This study aimed to assess the reliability and validity of the modified McGowan grading system and to determine its ability to distinguish the severity of cubital tunnel syndrome (CuTS) between the different grades.

MATERIALS AND METHODS

We prospectively enrolled 39 consecutive patients with CuTS from March 2018 to December 2020. Inter- and intra-observer reliability was assessed by two orthopaedic surgeons with a minimum 2-week interval using Cohen kappa coefficients. Validity was assessed by Spearman's correlation with objective clinical outcomes (grip strength, Semmes-Weinstein monofilament test [SWMT], static two-point discrimination [2PD], and motor conduction velocity [MCV]). In addition, the relationship between the grading system and patient-reported outcomes (Disabilities of the Arm, Shoulder and Hand score and Boston Questionnaire) was evaluated using Spearman's correlation. The ability to distinguish the severity between the different grades was assessed using the Kruskal-Wallis analysis.

RESULTS

The inter-observer kappa value was 0.54 and intra-observer kappa value was 0.59, which imply a moderate reliability. The modified McGowan grade had a moderate correlation with objective clinical outcomes (grip strength [r = - 0.350, p = 0.029], SWMT [r = 0.552, p < 0.001], 2PD [r = 0.456, p = 0.004], and MCV [r = - 0.394, p = 0.021]). However, patient-reported outcomes did not correlate with this grading system. Kruskal-Wallis analysis revealed significant differences between grades in terms of SWMT, 2PD, grip strength, and Boston Questionnaire functional score (p = 0.006, 0.025, 0.014, and 0.043, respectively); however, these differences were statistically significant only for a limited number of parts.

CONCLUSIONS

The modified McGowan grade has a moderate inter- and intra-observer reliability. This grading system moderately correlates with objective sensory-motor functions and MCV of patients with CuTS. However, the modified McGowan grade does not reflect the patient's perceived disabilities and has a weakness in distinguishing the severity of patients' conditions among the different grades.

Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters

BACKGROUND

Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement.

METHODS

The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery.

RESULTS

The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not.

CONCLUSIONS

Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, III.

Outcome of Simple Decompression of Primary Cubital Tunnel Syndrome Based on Patient-Reported Outcome Measurements

PURPOSE

To evaluate the patient-reported outcome measures of patients with primary cubital tunnel syndrome and to assess whether they are affected by preoperative symptom severity.

METHODS

Patients who underwent simple decompression for primary cubital tunnel syndrome were selected from a prospectively maintained database. Outcome measurements consisted of the Boston Carpal Tunnel Questionnaire at intake and at 3 and 6 months after surgery. Also, 6 months after surgery, the patients received a question about their satisfaction with the treatment result. To determine a possible influence of preoperative symptom severity on postoperative outcomes, the sample was divided into quartiles based on symptom severity at intake.

RESULTS

One hundred and forty-five patients were included in the final analysis. On average, all patients improved on the Boston Carpal Tunnel Questionnaire. The subgroup of patients with the mildest symptoms at intake did not improve significantly on symptom severity but did improve significantly on their functional status. In addition, the patients with the most severe symptoms at intake did improve on both aspects. Moreover, no difference in satisfaction with treatment result between the severity of symptoms at intake was found.

CONCLUSIONS

The patients with the mildest symptoms at intake may not improve on symptom severity, but they do improve on functional status after simple decompression for cubital tunnel syndrome. In addition, patients with the most severe symptoms at intake do improve on both symptom severity and functional status. Moreover, all patients reported to be equally satisfied with the treatment result, which suggests that satisfaction is not dependent on the symptom severity at intake. Even those patients with both the mildest symptoms before surgery and the least improvement still seem to benefit from simple decompression.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Content Validity of the Disability of the Arm, Shoulder, and Hand Questionnaire in a College-Age Patient Population

Objective

The Disability of the Arm, Shoulder, and Hand questionnaire (DASH) is a region-specific Patient Reported Outcome Measure and has been found to be valid and reliable. However, it has not been evaluated in a young patient population. Our objective was to understand how often the uninjured ‘collegiate’ population completes the specific tasks on the DASH.

Design

A questionnaire-based survey.

Methods

A total of 256 participants (age: 19.44 ± 1.83) completed the study. Participants were asked to track how often they completed 21 tasks taken from the DASH over a 14-day period. Data were analyzed using descriptive statistics and A Rasch partial-credit model.

Results

The 3 most commonly completed tasks are Recreational Activities in which you take some force or impact through your arm, shoulder, or hand (e.g., golf, hammering, tennis, etc.), Wash or blow-dry your hair, and Put on a pullover sweater while the least most commonly completed tasks were garden or do yard work, change a light bulb overhead, and sexual activities. Infit statistics ranged from .94 to 1.12, and Outfit ranged from .27 to 1.33. Person and item separation indices were 0.40 and 5.24, respectively. Person and item reliability indices were 0.14 and 0.96, respectively.

Conclusions

Findings from this study suggest that clinicians should be cautious when using the DASH with the ‘college aged’ patient population.

Assessment of responsiveness of four hand-related scales in stroke patients

Self-reporting scales are commonly utilized in determining appropriate treatment strategies and follow-up in hand-related disorders. Responsiveness is described as the ability of a scale to detect clinically significant changes. We aimed to evaluate responsiveness of Michigan Hand Outcomes Questionnaire (MHQ), Duruöz Hand Index (DHI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and ABILHAND questionnaire in stroke patients. Fifty-one stroke patients were assessed in this descriptive study. Participants received conventional stroke rehabilitation program consisting of 30 sessions. Brunnstrom stages of the stroke patients were recorded before and after treatment. MHQ, DHI, DASH, ABILHAND questionnaire and patient satisfaction scores were filled in by participants before and after the conventional rehabilitation program. Significant improvements were found in MHQ, DHI, DASH, ABILHAND, patient satisfaction scores and Brunnstrom motor recovery stages after the rehabilitation program (p < 0.001). Responsiveness values of the scales were calculated as MHQ (effect size (ES) = - 0.74; standardized response mean (SRM) = - 1.25), DHI (ES = 0.64; SRM = 1.22), DASH (ES = 0.71; SRM = 1.01), and ABILHAND (ES = - 0.55; SRM = - 1.22). Our study revealed that MHQ, DHI, DASH and ABILHAND are responsive scales in detecting treatment-related changes in stroke patients. MHQ, DHI, DASH and ABILHAND can be used in the evaluation of treatment responses in stroke patients.

Ulnar nerve dislocation in ulnar nerve entrapment at the elbow. Influence on surgical outcome

Our aim was to assess the incidence of symptomatic ulnar nerve dislocation and its influence on surgical outcome after primary and revision surgeries in ulnar nerve entrapment at the elbow (ulnar neuropathy at the elbow (UNE) or cubital tunnel syndrome). The influence of pre- or intra-operative ulnar nerve dislocation on postoperative outcome was assessed in 548 surgically treated cases (548 nerves) from two hand surgery departments reporting to the Swedish National Quality Registry for Hand Surgery, using QuickDASH, a patient-reported outcome measure (PROM), before surgery and at 3 and 12 months postoperatively, and a doctor-reported outcome measure (DROM), grading as "cured-improved "or "unchanged-worsened," at a median follow-up of 3.0 months [IQR, 1.5-6.0]. 109 of the 548 cases (20%) showed documented pre- or intra-operative ulnar nerve dislocation; more often found at revision (35/75, 47%) than at primary surgery (74/473, 16%) (p < 0.0001). Cases with dislocation presented higher QuickDASH scores at 12 months (p = 0.026). A linear regression model, adjusted for age and gender, predicted higher QuickDASH scores at 12 months postoperatively for cases with dislocation (unstandardized B 11.3 [95% CI 0.4-22.2], p = 0.043). DROM grading as unchanged-worsened at a median 3 months predicted worse QuickDASH scores (p < 0.0001) than in cured-improved cases at 3 (unstandardized B, 18.4 [95% CI 9.4-27.3]) and 12 months (unstandardized B, 18.1 [9.1-27.0]). Primary surgeries had better DROM grading than revision surgeries (p = 0.033; cured-improved, 75% and 63%, respectively), but QuickDASH scores did not differ. Presence of a clinically relevant ulnar nerve dislocation resulted in worse outcome, perhaps due to more extensive surgery with transposition. Nerve dislocation needs attention when treating UNE patients.

Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer Restores Intrinsic Function in Cubital Tunnel Syndrome

BACKGROUND

The supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer offers a viable option to enhance recovery of intrinsic function following ulnar nerve injury. However, in the setting of chronic ulnar nerve compression where the timing of onset of axonal loss is unclear, there is a deficit in the literature on outcomes after supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer.

METHODS

A retrospective study of patients who underwent supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for severe cubital tunnel syndrome over a 5-year period was performed. The primary outcomes were improvement in first dorsal interosseous Medical Research Council grade at final follow-up and time to reinnervation. Change in key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores were also evaluated using paired t tests and Wilcoxon signed rank tests.

RESULTS

Forty-two patients with severe cubital tunnel syndrome were included in this study. Other than age, there were no significant clinical or diagnostic variables that were predictive of failure. There was no threshold of compound muscle action potential amplitude below which supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer was unsuccessful.

CONCLUSIONS

This study provides the first cohort of outcomes following supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer in chronic ulnar compression neuropathy alone and underscores the importance of appropriate patient selection. Prospective cohort studies and randomized controlled trials with standardized outcome measures are required.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Reporting Outcomes and Outcome Measures in Cubital Tunnel Syndrome: A Systematic Review

PURPOSE

Comparison between studies assessing outcomes after surgical treatment of cubital tunnel syndrome (CuTS) has proven to be difficult owing to variations in outcome reporting. This study aimed to identify outcomes and outcome measures used to evaluate postoperative results for CuTS.

METHODS

We performed computerized database searches of MEDLINE and EMBASE. Studies with 20 or more patients aged 18 and older who were undergoing medial epicondylectomy, endoscopic decompression, open simple decompression, or decompression with subcutaneous, submuscular, or intramuscular transposition for ulnar neuropathy at the elbow were included. Outcomes and outcome measures were extracted and tabulated.

RESULTS

Of the 101 studies included, 45 unique outcomes and 31 postoperative outcome measures were identified. These included 7 condition-specific, clinician-reported instruments; 4 condition-specific, clinician-reported instruments; 8 patient-reported, generic instruments; 11 clinician-generated instruments; and one utility measure. Outcome measures were divided into 6 unique domains. Overall, 60% of studies used condition-specific outcome measures. The frequency of any condition-specific outcome measure ranged from 1% to 37% of included studies.

CONCLUSIONS

There is marked heterogeneity in outcomes and outcome measures used to assess CuTS. A standardized core outcome set is needed to compare results of various techniques of cubital tunnel decompression.

CLINICAL RELEVANCE

This study builds on the existing literature to support the notion that there is marked heterogeneity in outcomes and outcome measures used to assess CuTS. The authors believe that a future standardized set of core outcomes is needed to limit heterogeneity among studies assessing postoperative outcomes in CuTS to compare these interventions more easily and pool results in the form of systematic reviews and meta-analyses.

Polish version of the Patient-Rated Ulnar Nerve Evaluation in preoperative patients: Translation and psychometric testing

STUDY DESIGN

Cross-sectional design.

INTRODUCTION

This study examined the translated English to Polish version of the Patient-Rated Ulnar Nerve Evaluation (PRUNE) for its internal consistency, test-retest reliability, and construct validity.

METHODS

During the first assessment validity testing, a total of 39 consecutive patients with cubital tunnel syndrome completed the PRUNE, Michigan Hand Outcome Questionnaire, Disabilities of the Arm, Shoulder, and Hand questionnaire, and Patient Evaluation Measure in conjunction with the grip and key pinch tests and pain score (by Visual Analogue Scale). Cronbach's alpha (CA), intraclass correlation coefficient (ICC), and the Bland-Altman plot were used to evaluate internal consistency, test-retest reliability, and agreement, respectively. Analysis of variance compared the PRUNE score with the McGowan clinical stages.

RESULTS

After a 1-day interval, 19 patients completed the PRUNE for the second time. The total PRUNE score was 44.4 ± 20.4, CA = 0.93, and ICC = 0.921. The total PRUNE score limits of agreement varied from -9.87 to 7.55 points. PRUNE subscale CA ranged from 0.79 to 092; the ICC varied from 0.738 to 0.911. The construct validity revealed a strong association with Michigan Hand Outcome Questionnaire (R = -0.83; P < .000), and moderate with Disabilities of the Arm, Shoulder, and Hand (R = 0.75; P < .000), Patient Evaluation Measure (R = 0.75; P < .000), and Visual Analogue Scale (R = 0.69; P < .000). The grip and pinch tests had low and no correlation with the total PRUNE score, respectively.

CONCLUSION

The Polish version of PRUNE showed good psychometric properties for use in both clinical and research practice in patients with cubital tunnel syndrome of varying intensity.

Compound Muscle Action Potential Amplitude Predicts the Severity of Cubital Tunnel Syndrome

BACKGROUND

Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone.

METHODS

A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5-year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment.

RESULTS

Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not.

CONCLUSIONS

Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of responsiveness of Michigan Hand Outcomes Questionnaire, Disabilities of the Arm, Shoulder and Hand Questionnaire, and Duruöz Hand Index in patients with traumatic hand injury

OBJECTIVE

Patient-reported outcome measures assessing self-reported disability, pain, and function are primary endpoints for determination of optimal treatment strategies in hand-related conditions. In this study, we aimed to compare responsiveness of Michigan Hand Outcomes Questionnaire (MHQ), Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), and Duruöz Hand Index (DHI) in patients with traumatic hand injury.

METHODS

Consecutive patients with traumatic hand injury who were referred to our polyclinic for rehabilitation were included in the study. Depending on clinical status, patients underwent at least 14 sessions of physical therapy consisting of infrared heating, water submersion ultrasound, electrical stimulation, and exercise. MHQ, DASH, and DHI questionnaires were filled in by all patients both before and 3 months after physical therapy.

RESULTS

A total of 60 patients were enrolled in the study. MHQ (ES =-1.89; SRM =-1.84), DASH (ES = 1.66; SRM = 1.40), and DHI (ES = 1.68; SRM = 1.48) were all highly responsive in traumatic hand injuries.

CONCLUSION

Our study demonstrated that MHQ, DASH, and DHI are very responsive questionnaires for detection of treatment-induced changes in patients with traumatic hand injury. We suggest that when it is only intended to assess hand disability or when a quick assessment is desirable, DASH or DHI are more suitable, whereas MHQ will be more useful when a more detailed assessment including pain and aesthetical concerns is required.

Pain and Function Following Revision Cubital Tunnel Surgery

BACKGROUND

The purpose of this study was to determine pain and functional outcomes following revision cubital tunnel surgery and to identify predictors of poor postoperative outcome.

METHODS

A retrospective cohort study was conducted of all patients undergoing revision cubital tunnel surgery over a 5-year period at a high-volume peripheral nerve center. Intraoperative findings, demographic and injury factors, and outcomes were reviewed. Average pain, worst pain, and impact of pain on self-perceived quality of life were each measured using a 10-cm visual analog scale (VAS). Function was evaluated using pinch and grip strength, as well as the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Differences in preoperative and postoperative pain, strength, and DASH were analyzed using nonparametric tests. Predictors of postoperative average pain were evaluated using odds ratios and linear regression analyses.

RESULTS

The final cohort consisted of 50 patients (mean age: 46.3 ± 12.5 years; 29 [68%] male) undergoing 52 revision ulnar nerve transpositions (UNTs). Pain VAS scores decreased significantly following revision UNT. Strength and DASH scores demonstrated nonsignificant improvements postoperatively. Worse preoperative pain and greater than 1 prior cubital tunnel procedure were significant predictors of worse postoperative average pain VAS scores.

CONCLUSIONS

Patients can and do improve following revision cubital tunnel surgery, particularly as it relates to pain. Intraoperative findings during the revision procedure suggest that adherence to specific principles in the primary operation is key to prevention of secondary cubital tunnel syndrome.

Efficacy of PROMIS Pain Interference and Likert Pain Scores to Assess Physical Function

PURPOSE

The Patient Reported Outcome Measurement Information System (PROMIS), developed by the National Institutes of Health, utilizes a health domain related to Pain Interference (PI). We evaluated this domain and its association with physical function (as determined by PROMIS Physical Function [PF]), administered as a computer adaptive test (CAT), and secondarily its association to a numerical 0 to 10 pain score. Our null hypothesis was that PI, as measured by CAT, has no correlation to PF and thus, there is no difference between comparisons of numerical pain scores and PROMIS PF.

METHODS

Adult patients presenting to an upper extremity clinic from February to December 2015 completed PROMIS PF, PI, and numerical 0 to 10 pain score questionnaires. The PROMIS modules were completed electronically in their computer adaptive form. Mean population scoring on each module is defined at 50. Patients were also asked to rate their pain on a 0 to 10 scale. These data were collected as routine clinical care and were extracted from the electronic health record for cross-sectional evaluation. Bivariate Pearson correlation analysis defined the association between the PROMIS modules and the numerical pain scores. Correlations between PF and PI were compared with correlations between PF and pain scores.

RESULTS

We recorded data from patients' 10,574 first, 5,210 second, 2,633 third, 1,382 fourth, and 722 fifth visits. The PROMIS PI was negatively correlated to the PROMIS PF. Numerical pain scores were also negatively correlated to PROMIS PF. Numerical pain scores were less correlated than PROMIS PI through time relative to PF.

CONCLUSIONS

Both PROMIS PI and numerical pain scores had significant correlations with PF for each office visit. The PI had a larger correlation to PF than did numerical pain scores. The PI and numerical pain scale scores are also correlated.

CLINICAL RELEVANCE

Patient-reported pain using a 0 to 10 pain score can be a predictor of patients' level of function, and although pain score does not replace other patient-reported outcomes, it can provide useful information, particularly when other patient-reported outcomes are not available.

Responsiveness and minimal important change of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) in patients with subacromial pain syndrome

Background

The Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) is a valid and reliable patient-reported outcome measure (PROM). It was designed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity, and is one of the most commonly used PROMs for patients with shoulder pain. The aim of this study was to examine responsiveness, the smallest detectable change (SDC) and the minimal important change (MIC) of the DASH, in line with international (COSMIN) recommendations.

Methods

The study sample consisted of 50 patients with subacromial pain syndrome, undergoing physical therapy for 3–4 months. Responsiveness to change was examined by calculating area under the receiver operating characteristic curves (AUC) and testing a priori-formulated hypothesis regarding correlations with changes in other instruments that measuring the same construct. The SDC was calculated using a test re-test protocol, and the MIC was calculated by the anchor-based MIC distribution. MIC values for patients with low and high baseline scores were also calculated.

Results

DASH appeared to be responsive, as it was able to distinguish patients who reported to be improved from those unchanged (AUC 0.77). All of the hypotheses were accepted. The SDC was 11.8, and the MIC was 4.4.

Conclusion

This study shows that the Norwegian version of the DASH has good responsiveness to change and may thus be recommended to measure outcome in patients with shoulder pain in Norway.

Postoperative improvement in DASH score, clinical findings, and nerve conduction velocity in patients with cubital tunnel syndrome

We investigated a recovery pattern in subjective and objective measures among 52 patients with cubital tunnel syndrome after anterior subcutaneous transposition of the ulnar nerve. Disabilities of the Arm, Shoulder and Hand (DASH) score (primary outcome), numbness score, grip and pinch strength, Semmes-Weinstein (SW) score, static 2-point discrimination (2PD) score, and motor conduction velocity (MCV) stage were examined preoperatively and 1, 3, 6, 12, and ≥24 months postoperatively. Statistical analyses were conducted to evaluate how each variable improved after surgery. A linear mixed-effects model was used for continuous variables (DASH score, numbness, grip and pinch strength), and a proportional odds model was used for categorical variables (SW and 2PD tests and MCV stages). DASH score significantly improved by 6 months. Significant recovery in numbness and SW test scores occurred at 1 month. Grip and pinch strength, 2PD test scores, and MCV stage improved by 3 months. DASH scores and numbness recovered regardless of age, sex, or disease severity. It was still unclear if both subjective and objective measures improved beyond 1-year postoperatively. These data are helpful for predicting postoperative recovery patterns and tend to be most important for patients prior to surgery.

The relationship between the Patient-rated Ulnar Nerve Evaluation and the common impairment measures of grip strength, pinch strength, and sensation

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Grip strength, pinch strength, and sensory threshold are common evaluations used on a daily basis. Identifying how these variables relate to function for patients allows these assessments to be used for screening to identify who may benefit from surgical intervention, and provides valuable information about what impairments patients think are important with respect to functional use of their upper extremity. Therapists can use this information to focus rehabilitation programs on the most important impairments.

PURPOSE

To evaluate the relationship between the Patient-rated Ulnar Nerve Evaluation (PRUNE) and impairment measures of grip strength, pinch strength, and one-point sensory threshold.

METHODS

Data was prospectively collected from 77 patients before surgery and during regular time points for 2 years following surgery. Patients completed the PRUNE, grip and pinch strength measures, and a one-point sensory threshold evaluation. Correlations between these variables were calculated at baseline, 2 years after surgery, and for change scores during the 2-year follow up. A multiple regression analysis was used to determine the contribution of the impairment variables for determining functional change.

RESULTS

Grip strength showed moderate, statistically significant correlation with PRUNE scores at both baseline (r = -0.38) and at two years (r = -0.29). There was also a statistically significant correlation between one point sensory threshold for the small finger at two years (r = 0.36), but not at baseline. Change in grip strength (r = -0.28) and pinch strength (r = -0.30) both demonstrated significant correlations with PRUNE change scores. Overall, changes in grip strength, pinch strength, and sensation accounted for 20% of the variance in PRUNE changes.

CONCLUSION

Since grip strength was most highly correlated with PRUNE scores at baseline and at two years, rehabilitation programs that target grip strengthening is supported. While neither grip nor pinch strength were significant contributors to the regression when used together, each showed significant contributions to PRUNE variability when used in the model independently. Therefore, a combination of grip and pinch strengthening may be important during rehabilitation for improving functional results in patients that undergo surgical intervention for cubital tunnel syndrome.

LEVEL OF EVIDENCE

2b.

Pain and Hand Function

Pain is a unique somatosensory perception that can dramatically affect our ability to function. It is also a necessary perception, without which we would do irreparable damage to ourselves. In this article, the authors assess the impact of pain on function of the hand. Pain can be categorized into acute pain, chronic pain, and neuropathic pain. Hand function and objective measurements of hand function are analyzed as well as the impact of different types of pain on each of these areas.