Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

The Diagnostic Utility of Ultrasound and Electrodiagnostic Studies in The Young and Old

Purpose

Carpal tunnel syndrome is the most common compressive neuropathy. The diagnostic parameters currently used for the general adult population may not be valid in elderly or younger cohorts. The purpose of this study is to determine the diagnostic accuracy of nerve conduction studies (NCS) and ultrasound (US) in different age groups utilizing the 6-item Carpal tunnel syndrome (CTS) symptoms scale (CTS-6) as the reference standard.

Methods

A retrospective database of patients who underwent US and NCS as part of the diagnostic work-up for suspected peripheral nerve compression was reviewed. Subjects were separated into three groups based on the median age of carpal tunnel syndrome patients (55 years of age) and two standard deviations (standard deviation 13.5 years) above and below the median. The young group was 28 years of age or less, the middle group was 29-71 years of age, and the old group was 72 years of age or greater. CTS-6 and Boston Carpal Tunnel Syndrome Questionnaire scores were recorded. Using CTS-6 as a reference standard, the sensitivity and specificity were calculated for NCS and US.

Results

A total of 295 hands were included in the analysis with 23 hands in the young group and 24 hands in the old group. NCS showed 31% sensitivity and 100% specificity in the young group compared to 54% sensitivity and 90% specificity for US. NCS showed 94% sensitivity and 25% specificity in the old group compared to 81% sensitivity and 38% specificity for US. Overall accuracy for US and NCS was 66% for both tests when looking at all age groups. The accuracy in the young group was 70% for US and 61% for NCS, whereas the accuracy in the old group was 67% for US and 71% for NCS.

Conclusions

US has comparable sensitivity and specificity to NCS in patients two or more standard deviations above or below the mean age for presentation of CTS. US may be more accurate in younger patients, although NCS limits the number of false positive tests. There remains a substantial amount of inaccuracy for both tests when using a validated clinical diagnostic tool (CTS-6) as the reference standard.

Type of study/level of Evidence

Diagnostic IV.

Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome

BACKGROUND

Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS.

METHODS

This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care.

RESULTS

In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care.

CONCLUSION

Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Effects of socioeconomic status on patient-reported outcome after surgically treated trigger finger: a retrospective national registry-based study

OBJECTIVES

To investigate if socioeconomic status impacts patient-reported outcomes after a surgically treated trigger finger (TF).

DESIGN AND SETTING

Data on patients with TF treated with surgery were collected from the Swedish National Quality Registry of Hand Surgery (HAKIR) 2010-2019 with an evaluation of symptoms and disability before surgery and at 3 and 12 months after surgery, using the short version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaire.Data from HAKIR and the Swedish National Diabetes Registry (ndr.nu) were combined with socioeconomic data from Statistics Sweden (scb.sc), analysing the impact of marital status, education level, income, occupation, sickness benefits, days of unemployment, social assistance and migrant status on the outcome by a linear regression model.

PARTICIPANTS

In total, 5477 patients were operated on for primary TF during the study period, of whom 21% had diabetes, with a response rate of 35% preoperatively, 26% at 3 months and 25% at 12 months.

RESULTS

At all time points, being born in Sweden (preoperatively B-coefficient: -9.74 (95% CI -13.38 to -6.11), 3 months postoperatively -9.80 (95% CI -13.82 to -5.78) and 12 months postoperatively -8.28 (95% CI -12.51 to -4.05); all p<0.001) and high earnings (preoperatively -7.81 (95% CI -11.50 to -4.12), 3 months postoperatively -9.35 (95% CI -13.30 to -5.40) and 12 months postoperatively -10.25 (95% CI -14.37 to -6.13); all p<0.0001) predicted lower QuickDASH scores (ie, fewer symptoms and disability) in the linear regression models. More sick leave during the surgery year predicted higher QuickDASH scores (preoperatively 5.77 (95% CI 3.28 to 8.25; p<0.001), 3 months postoperatively 4.40 (95% CI 1.59 to 7.22; p<0.001) and 12 months postoperatively 4.38 (95% CI 1.35 to 7.40; p=0.005)). No socioeconomic factors impacted the change in QuickDASH score from preoperative to 12 months postoperatively in the fully adjusted model.

CONCLUSION

Individuals with low earnings, high sick leave the same year as the surgery and those born outside of Sweden reported more symptoms both before and after surgery, but the relative improvement was not affected by socioeconomic factors.

Do Socioeconomic Factors Affect Symptom Duration and Disease Severity at Presentation for Cubital Tunnel Syndrome?

BACKGROUND

Socioeconomic factors have been implicated in delayed presentation for compressive neuropathies of the upper extremity. Our article seeks to elucidate the effect of socioeconomic factors on self-reported symptom duration and objective disease severity at presentation for cubital tunnel syndrome.

METHODS

This retrospective cohort study included 207 patients with surgical management of cubital tunnel syndrome at 2 institutions between June 1, 2015, and March 1, 2020. Exclusion criteria included age under 18 years, revision surgery, lack of preoperative electrodiagnostic studies, and concurrent additional surgeries. Response variables were self-reported symptom duration, time from presentation to surgery, McGowan grade, and electrodiagnostic measures. Explanatory variables included age, sex, white race, diabetes mellitus, depression, anxiety, and the Distressed Communities Index.

RESULTS

Symptom duration was associated with nonwhite race, and time from presentation to surgery was associated with insurance provider. More clinically severe disease was associated with older age, male sex, and not having carpal tunnel syndrome. Nonrecordable sensory nerve action potential latency was associated with older age, higher body mass index, male sex, diabetes mellitus, and unemployment. Nonrecordable conduction velocities were associated with older age, and having fibrillations at presentation was associated with older age, male sex, and unemployment.

CONCLUSIONS

Economic distress is not associated with self-reported symptom duration, time from presentation to surgery, or presenting severity of cubital tunnel syndrome. White patients presented with shorter self-reported symptom duration. Insurance type was associated with delay from presentation to surgery. Older age and male sex were risk factors for more clinically severe disease at presentation.

Motor Imagery and Pain Processing in Patients With Entrapment Neuropathies: A Cross-sectional Study

OBJECTIVES

(1) To assess the ability to generate both kinesthetic and visual motor imagery in participants with carpal tunnel syndrome (CTS), compared with asymptomatic participants. (2) To assess the influence of psychophysiological and functional variables in the motor imagery process.

METHODS

Twenty patients with unilateral CTS and 18 pain-free individuals were recruited. An observational case-control study with a nonprobability sample was conducted to assess visual and kinesthetic movement imagery ability and psychophysiological variables in patients with CTS compared with asymptomatic participants in a control group. The trial was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement.

RESULTS

CTS patients have more difficulties in generating visual motor images compared with asymptomatic individuals ( t =-2.099; P <0.05; d=0.70). They need more time to complete the mental tasks (visual t =-2.424; P <0.05 and kinesthetic t =-2.200; P <0.05). A negative correlation was found between the ability to imagine and functional deficits ( r =-0.569; P =0.021) for the kinesthetic subscale and temporal summation ( r =-0.515; P <0.5). A positive correlation was found between pain pressure threshold homolateral (homolateral) and time to generate the visual mental images ( r =0.537; P <0.05).

DISCUSSION

CTS patients have greater difficulty generating motor images than asymptomatic individuals. Patients also spend more time during mental tasks. CTS patients present a relationship between temporal summation and the capacity to generate kinesthetic images. In addition, the CST patients presented a correlation between chronometry mental tasking and mechanical hyperalgesia.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

PURPOSE

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.

METHODS

A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.

RESULTS

The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.

CONCLUSIONS

Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.

CLINICAL RELEVANCE

Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Indication for Carpal Tunnel Release

BACKGROUND

Disparities in the utilization of orthopaedic surgery based on race and ethnicity continue to be reported. We examined the impact of sociodemographic factors on treatment recommendation by hand surgeons for carpal tunnel syndrome (CTS) of similar disease severity.

METHODS

Patients with electrodiagnostic study (EDS)-confirmed CTS were evaluated at a single institution between 2016 and 2020. Data including patient age, sex, race/ethnicity, ZIP Code, and EDS severity were collected. The primary outcome was the recommended treatment by the hand surgeon at the first clinic visit according to patient race/ethnicity and the Social Deprivation Index (SDI). Secondary outcomes included the treatment selected by patients (nonsurgical or surgical) and the time to surgery.

RESULTS

The 949 patients had a mean age of 58 years (range, 18 to 80 years); 60.5% (n = 574) were women. The race/ethnicity of the patient cohort was 9.8% (n = 93) Black non-Hispanic, 11.2% (n = 106) Hispanic/Latino, 70.3% (n = 667) White non-Hispanic, and 8.7% (n = 83) "other." Overall, Black non-Hispanic patients (38.7%; odds ratio, [OR] 0.62; 95% confidence interval [CI], 0.40 to 0.96) and Hispanic/Latino patients (35.8%; OR, 0.55; 95% CI, 0.36 to 0.84) were less likely to have surgery recommended at their first visit compared with White non-Hispanic patients (50.5%). This was no longer apparent after adjusting for demographic and clinical variables including EDS severity and SDI (Black non-Hispanic patients: adjusted odds ratio [aOR], 0.67; 95% CI, 0.4 to 1.11; Hispanic/Latino patients: aOR, 0.69: 95% CI, 0.41 to 1.14). Across all categories of EDS severity, surgeons were less likely to recommend surgery to patients with a higher SDI (aOR: 0.66, 0.64, and 0.54 for quintiles 2, 3 and 4, respectively). When surgery was recommended, patients in the highest SDI quintile were less likely to proceed with surgery (p = 0.032). There was no association between patient race/ethnicity and the treatment selected by the patient or time to surgery (p = 0.303 and p = 0.725, respectively).

CONCLUSIONS

Patients experiencing higher levels of social deprivation were less likely to be recommended for CTS surgery and were less likely to proceed with surgery, regardless of patient race/ethnicity. Additional investigation into the social factors influencing both surgeon and patient selection of treatment for CTS, including the impact of patient socioeconomic background, is warranted.

LEVEL OF EVIDENCE

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

Socioeconomic deprivation status predicts both the incidence and nature of Achilles tendon rupture

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon rupture (ATR) and its relationship with socioeconomic deprivation status (SEDS). The hypothesis was that ATR occurs more frequently in socioeconomically deprived patients. Secondary aims were to determine variations in circumstances of injury between more and less deprived patients.

METHODS

A 6-year retrospective review of consecutive patients presenting with ATR was undertaken. The health-board population was defined using governmental population data and SEDS was defined using the Scottish Index of Multiple Deprivation. The primary outcome was an epidemiological description and comparison of incidence in more and less deprived cohorts. Secondary outcomes included reporting of the relationship between SEDS and patient and injury characteristics with univariate and binary logistic regression analyses.

RESULTS

There were 783 patients (567 male; 216 female) with ATR. Mean incidence for adults (≥ 18 years) was 18.75/100,000 per year (range 16.56-23.57) and for all ages was 15.26/100,000 per year (range 13.51 to 19.07). Incidence in the least deprived population quintiles (4th and 5th quintiles; 18.07 per 100,000/year) was higher than that in the most deprived quintiles (1st and 2nd; 11.32/100,000 per year; OR 1.60, 95%CI 1.35-1.89; p < 0.001). When adjusting for confounding factors, least deprived patients were more likely to be > 50 years old (OR 1.97; 95%CI 1.24-3.12; p = 0.004), to sustain ATR playing sports (OR 1.72, 95%CI 1.11-2.67; p = 0.02) and in the spring (OR 1.65, 95%CI  1.01-2.70; p = 0.045) and to give a history of preceding tendinitis (OR  4.04, 95%CI 1.49-10.95; p = 0.006). They were less likely to sustain low-energy injuries (OR 0.44, 95%CI 0.23-0.87; p = 0.02) and to be obese (OR 0.25-0.41, 95%CI  0.07-0.90; p ≤ 0.03).

CONCLUSIONS

The incidence of ATR was higher in less socioeconomically deprived populations and the hypothesis was therefore rejected. Significant variations in patient and predisposing factors, mechanisms of injury and seasonality were demonstrated between most and least deprived groups, suggesting that circumstances and nature of ATR may vary with SEDS and these are not a homogenous group of injuries.

LEVEL OF EVIDENCE

Prognostic Study Level III.

Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release

PURPOSE

Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR.

METHODS

Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities.

RESULTS

Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered.

CONCLUSIONS

Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication

We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

PURPOSE

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

METHODS

We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

RESULTS

There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

CONCLUSIONS

Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

METHODS

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

RESULTS

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

CONCLUSION

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

LEVEL OF EVIDENCE

III.

Signs Indicative of Central Sensitization Are Present but Not Associated with the Central Sensitization Inventory in Patients with Focal Nerve Injury

Objective: Carpal tunnel syndrome (CTS) is the most common focal nerve injury. People with CTS may show alterations in central processing of nociceptive information. It remains unclear whether the central sensitization inventory (CSI) is capable of detecting such altered central pain processing. Methods: Thirty healthy volunteers were matched with 30 people with unilateral CTS from the orthopaedic waitlist. Changes to central pain processing were established through psychophysical sensory testing (bilateral pressure pain thresholds (PPT), conditioned pain modulation, temporal summation) and pain distribution on body charts. Patients also completed pain severity and function questionnaires, psychological questionnaires and the CSI. Results: Compared to healthy volunteers, patients with CTS have lower PPTs over the carpal tunnel bilaterally (t = −4.06, p < 0.0001 ipsilateral and t = −4.58, p < 0.0001 contralateral) and reduced conditioned pain modulation efficacy (t = −7.31, p <0.0001) but no differences in temporal summation (t = 0.52, p = 0.60). The CSI was not associated with psychophysical measures or pain distributions indicative of altered central pain processing. However, there was a correlation of the CSI with the Beck Depression Inventory (r = 0.426; p = 0.019). Conclusion: Patients with CTS show signs of altered central pain mechanisms. The CSI seems unsuitable to detect changes in central pain processing but is rather associated with psychological factors in people with focal nerve injuries.

Demographic Disparities amongst Patients Receiving Carpal Tunnel Release: A Retrospective Review of 92,921 Patients

Despite strong evidence supporting the efficacy of surgical release for carpal tunnel syndrome (CTS), previous studies have suggested that surgery is not performed equally amongst races and sex. The purpose of this study was to investigate potential socioeconomic disparities in the surgical treatment for CTS.

Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study

Purpose

To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.

Methods

Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.

Results

At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker’s compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.

Conclusions

Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.

Type of study/level of evidence

Prognostic III.

Compression Neuropathies of the Upper Extremity: A Review

Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm.

Increased Risk of Carpal Tunnel Syndrome in People With Spinal Cord Injury: A Nationwide Longitudinal Follow-Up Study

OBJECTIVE

To investigate the long-term risk of carpal tunnel syndrome (CTS) in people with spinal cord injury (SCI).

DESIGN

Retrospective cohort study.

SETTING

Taiwan's Longitudinal Health Insurance Database 2005, containing data about 1 million people randomly sampled from among those registered in the National Health Insurance Program as of 2005.

PARTICIPANTS

The SCI group consisted of 1681 subjects with SCI, and the comparison group comprised 6724 propensity score-matched subjects without SCI (N=8405). The variables included in propensity-score matching were age, sex, comorbid conditions, and socioeconomic status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The occurrence of newly diagnosed CTS, defined by at least 1 hospital discharge or 2 outpatient visits with a diagnosis of CTS.

RESULTS

The incidence density of CTS in the SCI group was 7.55 per 1000 person-years (95% confidence interval [CI], 6.03-9.33), and in the comparison group, 4.61 per 1000 person-years (95% CI, 4.08-5.19). The hazard ratio (HR) of CTS for the SCI group was therefore 1.59 (95% CI, 1.24-2.03). Additionally, the HR of CTS for the cervical-SCI subgroup, 1.90 (95% CI, 1.21-2.97) was considerably higher than that of its noncervical counterpart, 1.47 (95% CI, 1.09-1.98).

CONCLUSIONS

People with both cervical and noncervical SCI have an increased risk of developing CTS, as compared with those without SCI. Moreover, the CTS risk appears to be higher for individuals with cervical SCI than their noncervical SCI counterparts.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores

Background

Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS).

Methods

We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status).

Results

Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70–0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94–0.96; p < 0.001).

Conclusions

Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND

We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution.

QUESTIONS/PURPOSES

Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment?

METHODS

In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores.

RESULTS

Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (β 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (β 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (β -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment.

CONCLUSION

Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The association between surgery for carpal and cubital tunnel syndrome: analysis of incidence and risk factors within a geographical area

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

The effect of social deprivation on the incidence rate of carpal and cubital tunnel syndrome surgery

We sought to establish whether carpal and cubital tunnel syndrome requiring surgery is associated with deprivation in England. Data from 10,496 adult patients who were treated in our hand unit over a 20-year period were reviewed. The Index of Multiple Deprivation was used to measure deprivation from the patients' postcode. The mean age at surgery in the most deprived three quintiles was significantly lower than in the least deprived two quintiles for carpal tunnel release (55 vs 59 years, respectively) and cubital tunnel release (52 vs 57 years, respectively). The incidence rate was significantly lower for the three least deprived quintiles when compared with the most deprived quintile for both conditions. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for carpal tunnel release was 0.70 for men and 0.76 for women. The incidence rate ratio of the least deprived quintile compared with the most deprived quintile for cubital tunnel release was 0.79 for men and 0.49 for women. Carpal tunnel and cubital tunnel syndrome requiring surgery is more common in deprived patients and occurs at an earlier age.Level of evidence: IV.

Socioeconomic factors predicting outcome in surgically treated carpal tunnel syndrome: a national registry-based study

The study aimed to investigate socioeconomic factors in patients with carpal tunnel syndrome (CTS) and to evaluate their impact on outcome following open carpal tunnel release (OCTR). Data from the National Quality Register for Hand Surgery were combined with socioeconomic data (marital status, education level, earnings, migrant status, occupation, sick leave, unemployment, and social assistance) from Statistics Sweden to evaluate OCTRs performed from 2010 to 2016 (total 10,746 OCTRs). Patients completed QuickDASH (short version of Disabilities of Arm, Shoulder and Hand) questionnaires preoperatively (n = 3597) and at three (n = 2824) and 12 months (n = 2037) postoperatively. The effect of socioeconomic factors on QuickDASH scores was analyzed with linear regression analysis. Socioeconomically deprived patients scored higher on the QuickDASH on all occasions than patients with higher socioeconomic status. Being widowed, having a low education level, low earnings, immigrant status, frequent sick leave and dependence on social assistance all increased the postoperative QuickDASH score at 12 months. The change in total score for QuickDASH between preoperative and 12 months postoperatively did not vary between the groups. We conclude that such factors as being widowed, having a lower education level, low earnings, immigrant status, frequent sick leave and social assistance dependence are associated with more symptoms both before and after OCTR for CTS, but these factors do not affect the relative improvement in QuickDASH.

Value of ultrasonography in the diagnosis of carpal tunnel syndrome-a new ultrasonographic index in carpal tunnel syndrome diagnosis: A clinical study

We analyze the effectiveness of ultrasonography in diagnosing carpal tunnel syndrome (CTS) and propose the use of sonographic index of median nerve (MN) in carpal tunnel (SIMNCT) in a diagnostic algorithm and in establishing a scale of severity.We studied a group of 344 patients with CTS symptoms, examining them by ultrasound. We measured in all patients, on the affected hand: the size of the cross-sectional area of the MN at carpal tunnel (CT) inlet and outlet, nerve morphology at passage through CT, the vertical thickness of the MN entering into the CT - G1, the lowest vertical thickness into the CT or leaving the CT - G2, the thickness of the MN in the transversal plane as entering in the CT - L. Normal values were considered the similar measurements taken on the healthy hand and we established as normal SIMNCT = 16%. We proposed the formula SIMNCT = 100% (1-G2/G1) in order to calculate the index.Statistics show a significant sensitivity of SIMNCT (P < .0001) compared with cross-sectional area (CSA) and flattening ratio in the diagnosis of CTS. Analyzing the SIMNCT developed by us, we demonstrated a sensitivity of 94.81% and a specificity of 99.66% in CTS diagnosis. Thereby, we propose a CTS severity classification: normal = 16%, mild = 16-19%, moderate = 19% to 28%, severe = 28% to 50%, very severe > 50%.Ultrasonography is an effective method of studying the morphology of the tunnel and compressed nerve at various CTS stages and determining the cause of compression. The SIMNCT is a valuable and practical indicator and it can be used in the CTS diagnosis.

Carpal Tunnel Syndrome: A Review of Literature

Carpal tunnel syndrome (CTS) is a common medical condition that remains one of the most frequently reported forms of median nerve compression. CTS occurs when the median nerve is squeezed or compressed as it travels through the wrist. The syndrome is characterized by pain in the hand, numbness, and tingling in the distribution of the median nerve. Risk factors for CTS include obesity, monotonous wrist activity, pregnancy, genetic heredity, and rheumatoid inflammation. The diagnosis of CTS is conducted through medical assessments and electrophysiological testing, although idiopathic CTS is the most typical method of diagnosis for patients suffering from these symptoms. The pathophysiology of CTS involves a combination of mechanical trauma, increased pressure, and ischemic damage to the median nerve within the carpal tunnel. The diagnosis of CTS patients requires the respective medical professional to develop a case history associated with the characteristic signs of CTS. In addition, the doctor may question whether the patients use vibratory objects for their tasks, the parts of the arm where the sensations are felt, or if the patient may already have predisposing factors for CTS incidence. During the diagnosis of CTS, it is essential to note that other conditions may also provide similar symptoms to CTS, thus requiring vigorous diagnosis to assert the medical condition of the patients. Doctors use both non-surgical and surgical treatments when addressing CTS. Non-surgical treatments include wrist splinting, change of working position, medications, and the use of alternative non-vibrating equipment at work. On the other hand, surgical methods include open release and endoscopic surgeries. This review of literature has provided an overview of CTS with an emphasis on anatomy, epidemiology, risk factors, pathophysiology, stages of CTS, diagnosis, and management options.

Understanding the patient profile and health-related quality of life in patients presenting for hand surgery

The aim of this descriptive epidemiological study of patients, referred to and selected for surgery at a UK tertiary hand centre, was to investigate patterns of common hand disorders and their impact on those individuals. A prospective collection of patient-reported outcome scores was carried out in patients before operation using the Patient Outcomes of Surgery Hand/Arm and the Euro-Qol 5 dimension three-level measures. Patient participation was voluntary and data collected over a 4-year period are discussed. Patient-reported outcome scores were calculated using appropriate algorithms. The results show correlation between the number of comorbidities and both symptoms and activity domains of the Patient Outcomes of Surgery Hand/Arm; higher symptom scores were seen in women. There was no increase in scores for older patients or those from more deprived areas. Population-based research using recognized patient-reported outcome measurement tools could aid future health service planning. Level of evidence: IV.

Effectiveness of Lavendula stoechas essential oil in treatment of mild to moderate carpal tunnel syndrome: A randomized controlled trial

STUDY DESIGN

Randomized controlled trial.

INTRODUCTION

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity. To date, no previous study has evaluated the efficacy of topical Lavendula stoechas (Lavender) oil in CTS patients.

PURPOSE OF THE STUDY

To investigate the effectiveness of topical Lavender essential oil in pain intensity, isometric pinch strength, electrophysiological features, and functional status of patients with mild to moderate CTS.

METHODS

Forty eight patients with mild to moderate CTS were enrolled in this randomized placebo-controlled trial. Group A was treated with night wrist orthotic and topical lavender oil ointment. Group B was treated with night wrist orthotic and a placebo ointment. Patients were evaluated at baseline, and after 40 days of intervention with Boston CTS questionnaire (BCTQ), visual analog scale (VAS) for pain, pinch grip strength, power grip, median compound motor action potential latency, and median sensory nerve action potential latency.

RESULTS

At the end of the study period, both groups improved significantly in terms of BCTQ, VAS, isometric pinch powers, and electrodiagnosis study parameters. However, group A showed significantly greater improvements in BCTQ (mean difference, 0.39 ± 0.31 vs 0.6 ± 0.35; P = .03), VAS (3.37 ± 1.86 vs 1.33 ± 2.07; P = .001), and pinch grip strength (0.73 ± 0.63 vs 0.27 ± 0.54; P = .01) than group B. No significant differences in power grip, median compound motor action potential latency, and median sensory nerve action potential latency were seen between the 2 groups.

CONCLUSION

This study was the first trial of topical lavender oil used in patients with CTS. Wrist orthotic combined with topical lavender oil was more effective than orthotic and placebo in treatment of mild to moderate CTS.

LEVEL OF EVIDENCE

1b.

Validity of QuickDASH at day of surgery versus day of initial consultation: Does informed consent make a difference?

INTRODUCTION

The trend toward requiring explicit consent from patients participating in observational research increases time and resources required to perform such research. Informed consent introduces the potential for "consent bias"-either through selection bias or through the "Hawthorne effect," where patients may alter responses based upon the awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that administering Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) to patients on the day of surgery with informed consent would alter responses in a statistically and clinically meaningful way compared to patients who complete QuickDASH as a quality control measure.

METHODS

We previously instituted the QuickDASH questionnaire as the standard new patient intake and postoperative questionnaire for quality assurance purposes. We retrospectively reviewed data on a cohort of patients who underwent isolated carpal tunnel release (CTR) who had completed preoperative and postoperative QuickDASH forms without providing consent for study participation. Next, a cohort of patients scheduled to undergo isolated CTR who completed the intake questionnaire was approached on the day of surgery for consent to participate in the study. After obtaining consent but prior to surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire on follow-up at a mean of 8 weeks postoperatively.

RESULTS

Thirty-nine patients and 35 patients were included in the retrospective and prospective cohorts, respectively. No significant differences were observed in age, gender, symptom duration, nerve conduction study/electromyography results, or disease severity between the two groups. We identified no statistically significant difference in preoperative or postoperative QuickDASH score between the retrospective and prospective cohorts (39.8 ± 22.7 vs. 39.7 ± 19.1 preoperatively; 27.3 ± 24.7 vs. 18.7 ± 13.3 postoperatively) or within the prospective cohort before and after obtaining informed consent.

CONCLUSION

Informed consent did not significantly alter patient responses to the QuickDASH questionnaire. These results suggest that both "opt-in" and "opt-out" approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice.

CLINICAL RELEVANCE

This study provides evidence that will inform the interpretation of observational research findings in hand surgery.

What is the Impact of Social Deprivation on Physical and Mental Health in Orthopaedic Patients?

BACKGROUND

The complex interrelationship among physical health, mental health, and social health has gained the attention of the medical community in recent years. Poor social health, also called social deprivation, has been linked to more disease and a more-negative impact from disease across a wide variety of health conditions. However, it remains unknown how social deprivation is related to physical and mental health in patients presenting for orthopaedic care.

QUESTIONS/PURPOSES

(1) Do patients living in zip codes with higher social deprivation report lower levels of physical function and higher levels of pain interference, depression, and anxiety as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) at initial presentation to an orthopaedic provider than those from less deprived areas; and if so, is this relationship independent of other potentially confounding factors such as age, sex, and race? (2) Does the relationship between the level of social deprivation of a patient's community and that patient's physical function, pain interference, depression, and anxiety, as measured by PROMIS remain consistent across all orthopaedic subspecialties? (3) Are there differences in the proportion of individuals from areas of high and low levels of social deprivation seen by the various orthopaedic subspecialties at one large, tertiary orthopaedic referral center?

METHODS

This cross-sectional evaluation analyzed 7500 new adult patients presenting to an orthopaedic center between August 1, 2016 and December 15, 2016. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index, a composite measure of community-level social deprivation, based on multiple census metrics such as income, education level, and housing type for a given nine-digit zip code was used to estimate individual social deprivation. Statistical analysis determined the effect of disparate area deprivation (based on most- and least-deprived national quartiles) for the entire sample as well as for patients categorized by the orthopaedic subspecialty providing care. Comparisons of PROMIS scores among these groups were based on an MCID of 5 points for each PROMIS domain (Effect size 0.5).

RESULTS

Patients living in zip codes with the highest levels of social deprivation had worse mean scores across all four PROMIS domains when compared with those living in the least-deprived quartile (physical function 38 +/- 9 versus 43 +/- 9, mean difference 4, 95% CI, 3.7-5.0; p < 0.001; pain interference 64 +/- 8 versus 60+/-8, mean difference -4, 95% CI, -4.8 to -3.7; p < 0.001; depression 50+/-11 versus 45+/-8, mean difference -5, 95% CI, -6.0 to -4.5; p < 0.001; anxiety 56+/-11 versus 50 +/-10, mean difference -6, 95% CI, -6.9 to -5.4; p < 0.001). There were no differences in physical function, pain interference, depression, or anxiety PROMIS scores between patients from the most- and least-deprived quartiles who presented to the subspecialties of spine (physical function, mean 35+/-7 versus 35+/-7; p = 0.872; pain interference, 67+/-7 versus 66+/-7; p = 0.562; depression, 54+/-12 versus 51 +/-10; p = 0.085; and anxiety, 60+/-11 versus 58 +/-9; p = 0.163), oncology (physical function, mean 33+/-9 versus 38 +/-13; p = 0.105; pain interference, 68+/-9 versus 64+/-10; p = 0.144; depression, 51+/-10 versus 52+/-13; p = 0.832; anxiety, 59+/-11 versus 59+/-10 p = 0.947); and trauma (physical function, 35+/-11 versus 32+/-10; p = 0.268; pain interference, 66+/-7 versus 67+/-6; p = 0.566; depression, 52+/-12 versus 53+/-11; p = 0.637; and anxiety, 59+/-12 versus 60+/-9 versus; p = 0.800). The social deprivation-based differences in all PROMIS domains remained for the subspecialties of foot/ankle, where mean differences ranged from 3 to 6 points on the PROMIS domains (p < 0.001 for all four domains), joint reconstruction where mean differences ranged from 4 to 7 points on the PROMIS domains (p < 0.001 for all four domains), sports medicine where mean differences in PROMIS scores ranged from 3 to 5 between quartiles (p < 0.001 for all four domains), and finally upper extremity where mean differences in PROMIS scores between the most- and least-deprived quartiles were five points for each PROMIS domain (p < 0.001 for all four domains). The proportion of individuals from the most- and least-deprived quartiles was distinct when looking across all seven subspecialty categories; only 11% of patients presenting to sports medicine providers and 17% of patients presenting to upper extremity providers were from the most-deprived quartile, while 39% of trauma patients were from the most-deprived quartile (p < 0.001).

CONCLUSIONS

Orthopaedic patients must be considered within the context of their social environment because it influences patient-reported physical and mental health as well as has potential implications for treatment and prognosis. Social deprivation may need to be considered when using patient-reported outcomes to judge the value of care delivered between practices or across specialties. Further studies should examine potential interventions to improve the perceived health of patients residing in communities with greater social deprivation and to determine how social health influences ultimate orthopaedic treatment outcomes.

LEVEL OF EVIDENCE

Level II, prognostic study.

Mental and Physical Health Disparities in Patients With Carpal Tunnel Syndrome Living With High Levels of Social Deprivation

PURPOSE

Social, mental, and physical health have a complex interrelationship with each influencing individuals' overall health experience. Social circumstances have been shown to influence symptom intensity and magnitude of disability for a variety of medical conditions. We tested the null hypothesis that social deprivation would not impact Patient-Reported Outcomes Measurement Information System (PROMIS) scores or objective health factors in patients presenting for treatment of carpal tunnel syndrome (CTS).

METHODS

This cross-sectional study analyzed data from 367 patients who presented for evaluation of CTS to 1 of 6 hand surgeons at a tertiary academic center between August 1, 2016, and June 30, 2017. Patients completed PROMIS Physical Function-v1.2, Pain Interference-v1.1, Depression-v1.0, and Anxiety-v1.0 Computer Adaptive Tests. The Area Deprivation Index was used to quantify social deprivation. Medical record review determined duration of symptoms, tobacco and opioid use, and the Charlson Comorbidity Index (CCI) for each patient. Sample demographics, PROMIS scores, and objective health measures were compared in groups defined by national quartiles of social deprivation.

RESULTS

Patients with CTS living in the most deprived quartile had worse mean scores across all 4 PROMIS domains compared with those living in the least deprived quartile. A higher proportion of individuals from the most deprived quartile had a heightened level of anxiety than those in the least deprived quartile (37.3% vs 12.6%). The mean CCI was higher in the most deprived quartile, as was the proportion of individuals using tobacco. There were no differences in opioid use or symptom duration between patients from each deprivation quartile.

CONCLUSIONS

Social deprivation is associated with worse patient-reported health measures in patients with CTS. Compared with those from the least deprived areas, patients from the most deprived areas also have a greater comorbidity burden and higher rates of tobacco use at presentation to a hand surgeon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

PURPOSE

Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures.

METHODS

This cross-sectional evaluation analyzed data from 975 new pediatric patients (8-17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population.

RESULTS

A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles.

CONCLUSIONS

Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Predicting surgical intervention in patients presenting with carpal tunnel syndrome in primary care

Purpose

Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve. This study investigated the value of candidate prognostic factors (PFs) in predicting carpal tunnel release surgery.

Patients and methods

This is a retrospective cohort study set in the Clinical Practice Research Datalink. Patients ≥18 years presenting with an incident episode of CTS were identified between 1989 and 2013. Candidate PF’s defined in coded electronic patient records were identified following literature review and consultation with clinicians. Time to first carpal tunnel release surgery was the primary end point. A manual backward stepwise selection procedure was used to obtain an optimal prediction model, which included all the significant PFs.

Results

In total, 91,412 patients were included in the cohort. The following PFs were included in an optimal model (C-statistic: 0.588 [95% CI 0.584–0.592]) for predicting surgical intervention: geographical region; deprivation status; age hazard ratio (HR 1.02 per year, 95% CI 1.01–1.02); obesity (HR 1.23, 95% CI 1.19–1.27); alcohol drinker (HR 1.05, 95% CI 1.00–1.10); smoker (HR 1.06, 95% 1.03–1.10); inflammatory condition (HR 1.13, 95% CI 0.98–1.29); neck condition (HR 1.13, 95% CI 1.03–1.23); and multisite pain (HR 1.10, 95% CI 1.05–1.15). Although not included in the multivariable model, pregnancy (if gender female) within 1 year of the index consultation, reduced the risk of surgery (HR 0.24, 95% CI 0.21–0.28).

Conclusion

This study shows that patients who are older and who have comorbidities including other pain conditions are more likely to have surgery, whereas patients presenting with CTS during or within a year of pregnancy are less likely to have surgery. This information can help to inform clinicians and patients about the likely outcome of treatment and to be aware of which patients may be less responsive to primary care interventions.

Trends in the prevalence, incidence and surgical management of carpal tunnel syndrome between 1993 and 2013: an observational analysis of UK primary care records

OBJECTIVES

To describe the prevalence, incidence and surgical management of carpal tunnel syndrome (CTS), between 1993 and 2013, as recorded in the Clinical Practice Research Datalink (CPRD).

DESIGN

We completed a series of cross-sectional epidemiological analyses to observe trends over time.

SETTING

Primary care data collected between 1993 and 2013, stored in the CPRD.

POPULATION

Individuals aged ≥18 years were selected. Prevalent and incident episodes of CTS and episodes of surgical intervention were identified using a list of preidentified Read codes.

ANALYSIS

We defined incident episodes as those with no preceding diagnostic code for CTS in the past 2 years of data. Episodes of surgery were expressed as a percentage of the prevalent population during the same calendar year. Joinpoint regression was used to determine significant changes in the underlying trend.

RESULTS

The prevalence of CTS increased over the study period, with a particular incline between 2000 and 2004 (annual percentage change 7.81). The female-to-male prevalence ratio reduced over time from 2.74 in 1993 to 1.93 in 2013. The median age of females and males with CTS were noted to increase from 49 and 53 years, respectively in 1993 to 54 and 59 years, respectively in 2013. Incidence was also noted to increase over time. After an initial increase between 1993 and 2007, the percentage of prevalent patients with a coded surgical episode began to decrease after 2007 to 27.41% in 2013 (annual percentage change -1.7).

CONCLUSION

This study has demonstrated that the prevalence and incidence of CTS increased over the study period between 1993 and 2013. Rates of surgery for CTS also increased over the study period; however after 2007, the per cent of patients receiving surgery showed a statistically significant decline back to the rate seen in 2004.

The Effect of Carpal Tunnel Release on Neuropathic Pain in Carpal Tunnel Syndrome

Purpose

The aim of this study was to determine the risk factors of neuropathic pain (NP) in the patient with carpal tunnel syndrome (CTS) before and after the carpal tunnel release.

Materials and Methods

One hundred and two CTS patients were enrolled in the study. The pain score was measured by the visual analogue score. NP was determined by the painDETECT (PD) questionnaire. All subjects were divided into 3 groups at 12 weeks after surgery: an Improved, Unchanged, and Worsened group. The risk factors of worsening NP after surgery were evaluated.

Results

We found that 36% and 18% of patients with CTS had neuropathic pain before and 12 weeks after surgery, respectively, and pain was significantly stronger than in those without NP. The PD score of eight hands worsened after surgery. In the “Improved group,” the average age at the surgery was younger and the pain score was lower than in the “Unchanged group.” Conclusions. The surgery was very effective on NP of CTS; however, the PD in 7% of hands worsened after surgery. Risk factors before surgery that predicted worse NP after surgery were found to be a younger age, weaker pain, and the absence of night pain.

[An effect of ipidacrine (neuromidin) on electroneuromyographic parameters in the conditions of artificial decompression (a clinical/instrumental study)]

AIM

To study an effect of neuromidin on the changes in electroneuromyographic (ENMG) parameters in patients with carpal tunnel syndrome in the conditions of artificial decompression of a forearm.

MATERIAL AND METHODS

Sixty-four 64 patients, 46 women and 18 men, mean age 50,7±4,5years, matched for disease severity were studied. The patients were randomized into neuromidin group and control group. Neuromidin was introduced using subcutaneous local perineural injections. Characteristics of neuromidin effect on the changes in ENMG parameters of the median nerve were studied in a model of additional artificial decompression of the median nerve.

RESULTS AND CONCLUSION

There was the significant depression of the nerve function and worsening of ENMG parameters during the additional decompression as well as the aggravation of conduction block along nerve fibers (motor and sensory). In patients treated with ipidacrine, there was an increase in the amplitude of sensory and (to a less extent) of M-response that indicated the activation of axonal transport and reservation of functioning of the compressed nerve.

[Electroneurographic monitoring during the test of artificial compression as a method of early diagnosis of carpal tunnel syndrome]

AIM

To develop the algorithm of early diagnosis of carpal tunnel syndrome (CTS) at the stage of functional neurological disturbances by expanding diagnostic possibilities of electroneuromyography using artificial compression test.

MATERIAL AND METHODS

Parameters of conductivity of the median nerve in 54 patients with finger numbness were analyzed during 3 months before and after compression of the forearm (blood pressure was measured for 1 min).

RESULTS AND CONCLUSION

An increase in the latency in motor fibers and a decrease in the amplitude of sensory response were identified in patients with CTS signs and normal electroneuromyographical parameters at baseline. The use of additional electroneuromyographical monitoring during the provocative artificial compression test expands the possibilities of this method and improves early diagnosis of CTS.

The influence of education and income on responses to the QuickDASH questionnaire

We studied the influence of levels of income and education on QuickDASH scores. The scores were collected in a random sample of 1376 residents of Norway. The level of income was divided into four bands and level of education into five bands. The mean QuickDASH score for both men and women fell with every increase in education and income level. For women the mean score was 30 for those with the shortest education and 9 for those with the longest (p < 0.001). The corresponding figures for men were 19 and 7 (p < 0.01). The women with the lowest level of income had a mean score of 23, compared with 8 for women with the highest income level (p < 0.001). For men the corresponding mean scores were 20 and 5 (p < 0.001). Analysis of variance showed that age alone accounted for 16% of the variability of the scores among women and 7% among men. When levels of education and income were added to the analysis, these three factors accounted for 21% of the variability among women and 13% among men. We conclude that socioeconomic factors significantly influence QuickDASH scores.

LEVEL OF EVIDENCE

3.

Outcome of carpal tunnel release--correlation with wrist and wrist-palm anthropomorphic measurements

Wrist and wrist-palm measurements have been associated with the diagnosis of carpal tunnel syndrome. We found no reported study about how this correlation affects the outcome after surgery. We investigated the role of the measurements in predicting outcome after open carpal tunnel release. A total of 131 patients (88 female, 43 male) responded to our postal questionnaire using the Boston Carpal Tunnel assessment (65% response rate) at a minimum of 9 months post-operatively. Symptom and functional scores showed a strong correlation. There was no statistical difference in the outcome between wrist ratio (≥0.7 vs <0.7), wrist-palm ratio (≥0.41 vs <0.41) and gender, but a better functional score was very weakly correlated with a higher wrist ratio. A very large study would be needed to show any statistical correlation between both measurement and outcome.

Median nerve superficial to the transverse carpal ligament

Recurrent carpal tunnel syndrome occurs in up to 12% of cases after carpal tunnel release. Recurrent carpal tunnel syndrome is defined as recurrence of classic symptoms confirmed by electrodiagnostic studies after a symptom-free interval of a minimum of 6 months, as opposed to persistent carpal tunnel syndrome, where a symptom-free interval never occurs after carpal tunnel release, which is attributed to incomplete release of the transverse carpal ligament. The most common causes of recurrent carpal tunnel syndrome requiring reoperation are incomplete release of the transverse carpal ligament and scarring of the median nerve to the surrounding structures. Surgical exploration, release of the reconstituted transverse carpal ligament, and freeing of the median nerve from constricting scar will usually result in symptom relief. The authors describe an unusual presentation of recurrent carpal tunnel syndrome with healing of the transverse carpal ligament dorsal to the median nerve, trapping the median nerve in the subcutaneous tissue. Hand surgeons must be aware of this anomalous location when performing revision carpal tunnel release. The surgeon must locate the median nerve proximally in normal tissue before proceeding distally to avoid iatrogenic injury during revision carpal tunnel release.

The influence of vitamin C on the outcome of distal radial fractures: a double-blind, randomized controlled trial

BACKGROUND

Vitamin C has been proposed to improve outcomes after a distal radial fracture by promotion of bone and soft-tissue healing and reduction of the prevalence of complex regional pain syndrome (CRPS). Our primary aim was to examine the effect of vitamin C on functional outcome after a distal radial fracture.

METHODS

A total of 336 adult patients with an acute fracture of the distal aspect of the radius were recruited over a one-year period and randomized to receive 500 mg of vitamin C or placebo daily for fifty days after the fracture. The primary outcomes were the DASH (Disabilities of the Arm, Shoulder and Hand) score at six weeks and at one year. Secondary variables included complications, wrist and finger motion, grip and pinch strength, pain, and a CRPS score.

RESULTS

There were no significant differences in patient or fracture characteristics between the treatment groups. There was no significant effect of vitamin C on the DASH score throughout the study period. At six weeks, patients in the vitamin C group with a nondisplaced fracture had a significantly greater wrist flexion deficit (p = 0.008) and pinch strength deficit (p = 0.020) and a greater rate of CRPS (p = 0.022), but there was no difference in the CRPS rate at any other time point. At twenty-six weeks, there was a higher rate of complications (p = 0.043) and greater pain with use (p = 0.045) in the patients with a displaced fracture treated with vitamin C. There was no significant difference in the time to fracture-healing.

CONCLUSIONS

This study demonstrated no significant difference at one year in the DASH score, other functional outcomes, the rate of CRPS, or osseous healing of nondisplaced or displaced distal radial fractures treated with vitamin C compared with placebo. We conclude that administration of vitamin C confers no benefit to patients with a displaced or nondisplaced fracture of the distal aspect of the radius.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Carpal tunnel release surgery and venous hypertension in early hemodialysis patients without amyloid deposits

AIM

Carpal tunnel syndrome (CTS) is one of the frequent problems of the patients who underwent hemodialysis (HD). The role of venous hypertension due to arteriovenous fistula (AVF) has not been clarified completely; therefore, we aimed to investigate the role of venous hypertension due to AVF in hemodialysis patients who had CTS.

PATIENTS AND METHODS

We included 12 patients who had been receiving HD treatment for less than 8 years and the newly diagnosed CTS patients with the same arm of AVF. All patients were diagnosed clinically and the results were confirmed by both nerve conduction studies and electromyography. Open carpal tunnel release surgery was performed on all of them. Venous pressure was measured in all patients before and after two weeks of surgery.

RESULTS

There were significant differences before and after the surgery with regard to pressures (P > 0.05). After the surgery, all carpal ligament specimens of the patients were not stained with Congo red for the presence of amyloid deposition.

CONCLUSION

Increased venous pressure on the same arm with AVF could be responsible for CTS in hemodialysis patients. Carpal tunnel release surgery is the main treatment of this disease by reducing the compression on the nerve.

Pain and carpal tunnel syndrome

PURPOSE

Pain is not a classical symptom of carpal tunnel syndrome (CTS), with the exception of numbness that is so intense that it is described by patients as painful. The primary aim of our study was to determine which factors correlated with pain for patients diagnosed with CTS.

METHODS

We prospectively assessed all patients diagnosed with CTS in our unit over a 1-year period. We recorded demographic details for all patients, including past medical history, body mass index, smoking, and occupation. The diagnosis and severity of carpal tunnel syndrome were established through a combination of history, clinical assessment, and nerve conduction studies. Of 275 patients diagnosed and treated for CTS, 183 were women (67%), the mean age was 55 years (range, 22-87 y), and 166 cases were bilateral (60%). The mean body mass index was 29.5 kg/m2 (range, 17-48 kg/m2), and 81 patients smoked (30%). Patients completed a Short Form-McGill pain questionnaire (SF-MPQ) as a measure of pain at initial presentation. We assessed outcome 1 year after intervention using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.

RESULTS

We found no association between pain according to the SF-MPQ and the positive clinical signs of CTS or positive nerve conduction studies. Multivariate analysis demonstrated that smoking and bilateral disease independently correlated with the overall SF-MPQ, with similar findings on subanalysis. Independent factors associated with an increased improvement in the QuickDASH at 1 year were the presentation QuickDASH score, positive nerve conduction studies, and smoking.

CONCLUSIONS

The only independent factors that correlated with pain at presentation of CTS were smoking and bilateral disease. Pain according to the SF-MPQ was not associated with classical clinical findings of the disease or with positive findings on nerve conduction testing.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

The effect of informed consent on results of a standard upper extremity intake questionnaire

PURPOSE

The trend toward requiring explicit consent from patients participating in observational research introduces the potential for consent bias, either through selection bias or through the Hawthorne effect. In the Hawthorne effect, patients may alter responses based on awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that study subjects' awareness of participation in an observational study by informed consent would alter responses to a standard upper extremity questionnaire in a statistically and clinically meaningful way compared with patients who filled out the questionnaire as a quality control measure.

METHODS

We retrospectively reviewed data on 39 patients who underwent isolated carpal tunnel release, who had completed preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) forms without providing consent for study participation. Next, we approached 35 patients scheduled to undergo isolated carpal tunnel release who completed the intake questionnaire on the day of surgery, for consent to participate in the study. After obtaining consent but before surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire at a mean of 8 weeks postoperatively.

RESULTS

There were no significant differences in age, sex, insurance status, symptom duration, nerve conduction study and electromyography results, or disease severity between groups. We identified no statistically significant difference in preoperative or postoperative Quick DASH score between the retrospective and prospective cohorts (40 ± 23 vs 40 ± 19 preoperatively; 27 ± 25 vs 19 ± 13 postoperatively) or within the prospective cohort before and after obtaining informed consent.

CONCLUSIONS

Informed consent did not significantly alter patients' responses to the Quick DASH questionnaire. These results suggest that both opt-in and opt-out approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice.

CLINICAL RELEVANCE

This study provides evidence that will inform the interpretation of observational research findings in hand surgery.

Evaluation and treatment of failed carpal tunnel release

Treatment failure and complications are encountered in 1% to 25% of all carpal tunnel releases. Besides hematoma, infection, skin necrosis, and intraoperative iatrogenic injuries, persistence and recurrence should be included in this discussion. Persistence is often related to incomplete release. Similar symptoms recurring after a symptom-free interval of 6 months are considered recurrent and may be caused by intraneural or perineural scarring. Adequate diagnosis and treatment of these failures can be challenging. Operative release is the main treatment consisting of complete decompression of the median nerve. In some circumstances, coverage of the median nerve may be necessary.

Follow-up investigation of open trigger digit release

PURPOSE

The purpose of this retrospective study was to identify the postoperative complications and disorders associated with open trigger finger release. Factors that were investigated by this study included demographic details, the number of digits affected, BMI, level of manual strain, trauma, received systemic medication, hand dominance, pre-treatment with steroid injection, and concomitant diseases.

METHODS

One hundred and three patients, who underwent open release surgery for 117 trigger fingers and thumbs, were followed up until complete resolution of all complaints. Patients' age, BMI, hand dominance, occupational manual strain, and previous medical history regarding trigger finger or thumb were obtained. Associated conditions and medical treatment, trauma, and previous hand surgical interventions were included as well. Details regarding duration of complaints, ROM, visual analogue pain scale, swelling, recurrence of the disease following previous surgical release, and persistence of complaints following corticosteroid injection were examined.

RESULTS

The dominant hand was not significantly more frequently affected than the non-dominant hand. Occupation also did not influence the incidence of trigger digit. Patients with systemic steroid therapy had a significantly shorter duration of postoperative symptoms with a mean duration of 29.3 days (range, 28-31 days ± 1.3). Significantly less postoperative swelling was noticed in patients with a pre-surgical steroid injection. The mean duration of symptoms before and after surgery was significantly shorter for a trigger thumb than for trigger finger.

DISCUSSION

Open trigger digit release constitutes an adequate low-risk surgical procedure for treatment of trigger digit. In this study, we could show that the incidence of this disease is not significantly correlated with the manual strain, trauma, BMI, hand dominance or concomitant diseases like diabetes mellitus, rheumatoid arthritis, renal insufficiency, and hypothyroidism. Additionally, this study illustrates the importance of a careful postoperative follow-up treatment to avoid potential persistent functional limitations.