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Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, SpainDepartment of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, ChileInternational Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, SpainDepartment of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, ChileDivision of Research, Devolvement and Innovation in Kinesiology, Kinesiology Unit, San José Hospital, Santiago, Chile
Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, ChileInternational Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
Ecology and Evolutionary Biology Division, School of Biological Sciences, University of Reading, Reading, United KingdomPrimate Models for Behavioural Evolution Lab, Institute of Cognitive and Evolutionary Anthropology, School of Anthropology, University of Oxford, Oxford, United Kingdom
To determine the effects of the cognitive and mental health factors on the outcomes after carpal tunnel release (CTR).
Data Sources
Embase, PubMed/MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials databases from inception to August 14, 2021.
Study Selection
Randomized controlled trials and observational studies of patients with CTR were included. The included studies aimed to determine the effect of the cognitive (catastrophic thinking, kinesiophobia, self-efficacy) or mental health factors (symptoms of anxiety and depression) on the outcomes at least 3 months post CTR.
Data Extraction
Two independent reviewers performed data extraction and assessed the risk of bias. Data were extracted using a standardized protocol and reporting forms. The risk of bias of the included studies was assessed using the Quality in Prognosis Studies risk-of-bias tool. Random-effects models were used for meta-analysis.
Data Synthesis
A total of 15 studies involving 2599 patients were included in this systematic review. The majority of studies indicate a significant association between the cognitive or mental health factors and outcomes after CTR. Quantitative analysis showed a moderate association of symptoms of depression on symptom severity (n=531; r=0.347; 95% CI, 0.205-0.475; P≤.0001), function (n=386; r=0.307; 95% CI, 0.132-0.464; P=.0008), and pain (n=344; r=0.431; 95% CI, 0.286-0.558; P≤.0001). In general, the risk of bias in the included studies was low.
Conclusions
This systematic review and meta-analysis showed that symptoms of depression have a moderate association with symptom severity, function, and pain after CTR. Symptoms of anxiety, catastrophic thinking, and self-efficacy are also important indicators of poor postsurgery outcomes. Physicians, physical therapists, and occupational therapists should consider evaluating these variables in patients undergoing CTR.
It is estimated that 65% of people diagnosed as having CTS eventually require surgery, and the incidence of carpal tunnel release (CTR) per 100,000 person-years is 151 in women and 65 in men.
CTR is indicated primarily in patients who do not respond to conservative treatment, in acute cases (eg, trauma), and in severe cases with persistent hypoesthesia of the median nerve region and motor impairment.
Comparison of the short-term and long-term effects of surgery and nonsurgical intervention in treating carpal tunnel syndrome: a systematic review and meta-analysis.
In musculoskeletal diseases, identified cognitive (catastrophic thinking, kinesiophobia, self-efficacy, fear avoidance) and mental health factors (symptoms of anxiety and depression) have been reported to be relevant to optimizing the postsurgical outcomes. For instance, the patient's cognitions and emotions may affect the recovery and response to treatment in patients with chronic musculoskeletal pain.
Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis.
In this context, the fear avoidance model proposes that patients with catastrophic cognitions about pain tend to interpret certain experiences as a threat, avoiding select activities and developing disuse, disability, and depression.
We can find a heterogeneous set of predictors related to emotions, cognitions, and coping strategies within the cognitive and mental health factors. Among them, catastrophizing, self-efficacy, fear related to pain, depression, and anxiety have taken on greater relevance in the last few decades because of their strong relationship with postsurgical pain and function.
Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
A better understanding of the association between cognitive and mental health factors and the surgery results could also help to provide more specialized interventions, including the expertise of psychologists, physical therapists, occupational therapists, and physicians in the perioperative and postoperative period. In addition, the economic costs associated with mental health disorders and postoperative pain reinforce the need to examine these risk factors closely with a rigorous narrative approach and a quantitative synthesis of the available evidence. This systematic review and meta-analysis aims to determine the effects of the chosen cognitive and mental health factors on the outcomes after CTR, 3 months after surgery, and beyond.
Methods
Protocols and registration
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines.
Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.
The protocol was previously registered on the International Prospective Register of Systematic Reviews PROSPERO (CRD42020181709) in July 2020.
Criteria for considering studies in this review
Randomized controlled trials and observational studies (cross-sectional, longitudinal, case-control, cohort) of patients with CTR (open or endoscopic surgery) were included. The included studies aimed to determine the effect of the chosen cognitive or mental health factors on the outcomes at least 3 months post CTR. The cognitive factors related to pain (ie, catastrophic thinking, kinesiophobia, self-efficacy, fear avoidance) and mental health factors (ie, symptoms of anxiety and depression) should have been assessed using an objective measure. Therefore, we included studies with at least 1 of the following prognostic factors: (1) catastrophic thinking, measured by the Pain Catastrophizing Scale
On the other hand, studies with at least one of the following outcomes after surgery were included: (1) functional limitations and symptoms, measured by a patient-reported scoring systems such as the Boston Carpal Tunnel Questionnaire
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
The shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH.
; (2) pain intensity, measured by a visual analog scale, numeric rating scale, or another numeric ordinal rating scale; (3) patient satisfaction, measured by a satisfaction score (Likert scale or by categorical grading); (4) work participation, measured as return to work, absenteeism, or time on benefits; and (5) physical measures of recovery, including grip and pinch strengths and range of motion. We included studies in any language published between January 1950 and August 2021. All editorials, letters to the editor, review articles, systematic reviews, meta-analyses, and in vivo and in vitro studies were excluded.
Search strategy
A systematic review of the literature was conducted to identify the studies that investigate the effect of the chosen cognitive and mental health factors on the outcomes after CTR. We reviewed the Embase, PubMed/MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials databases from inception to August 14, 2021. Manual searches with the followings terms were performed: (1) for population: carpal tunnel release OR carpal tunnel decompression OR ([carpal tunnel syndrome OR median neuropathy] AND [surgery OR postoperative OR post-operative OR postsurgical OR post-surgical]); (2) for exposition: psychological OR anxiety OR fear OR avoidance OR depression OR depress* OR mood OR catastrophizing OR catastrophic thinking OR self-efficacy OR kinesiophobia OR emotional OR coping; (3) for condition: association* OR predict* OR "risk factor*" OR determinant* OR prognos*; and (4) for main outcome: symptom severity OR disability OR pain OR patient reported outcome measures OR recovery of function OR range of motion, articular OR hand strength OR hand grip OR patient satisfaction OR return to work. The terms selected were combined using Boolean logical operators (OR, AND, NOT). We supplemented our search with the reference lists of all included studies to identify potentially relevant articles from other sources. All references were analyzed using the Rayyan web software.
First, the titles and abstracts of all identified studies were reviewed by 2 investigators (R.N.C., C.C.M.). The irrelevant references were removed. Any disagreements were solved by consensus. Second, the full-text versions of the articles selected in the first stage were read and checked against the eligibility criteria (R.N.C., C.C.M.). Any disagreements were solved by a third reviewer (R.T.C.).
Then, 2 investigators (R.N.C., C.T.) extracted the data independently using a standardized protocol and reporting forms. The following information was extracted from each included study: design, population characteristics, type of surgery, follow-up time, prognostic factor, postoperative outcomes, results of univariate analysis, and results of multivariate analysis. The authors were contacted to obtain the information if some relevant data were not included in the study.
Methodological quality assessment
The risk of bias in the included studies was assessed using the Quality in Prognosis Studies risk-of-bias tool.
We classified the studies as high, moderate, or low risk in relation to the domains of study participation, study attrition, prognostic factor measurement, outcome measurement, study confounding, and statistical analysis and reporting. The low risk of bias was assigned only if the majority (≥75%) of the prompting items were satisfied, moderate risk of bias if 50%-74% of the prompting items were satisfied, and a high risk of bias if ≤50% of the prompting items were satisfied. Two authors carried out this evaluation independently (R.N.C., R.T.C.), and discrepancies were resolved by consensus. The concordance was calculated using Cohen's kappa coefficient. The Robvis tool
For the quantitative synthesis, the prognostic factors that were evaluated by 3 or more studies were considered to avoid performing low-power analyses. Studies that operationalized the risk factor in a markedly different way than most other studies were excluded from the estimate. The quantitative synthesis was carried out in the following steps: (1) The original data (eg, correlations, regression coefficients, odds ratios) were converted to Pearson r using standard formulas.
To maintain consistency, the associations were recalculated so that they were in the same direction. (2) The data were converted into Fisher z using the escalc() function from the “metafor” v. 3.0-2 R package.
(3) Four different random-effects models were fitted to synthesize the quantitative results of the published studies for each one the effect sizes under study (ie, correlational data on prognostic factors and postoperative results). This kind of model was preferred because it accounts for study heterogeneity and does not assume that all studies come from a single common population that were tested under identical or quite similar conditions.
These models were computed using the rma() function from the same package (ie, “ metafor” v. 3.0-2). (4) The result of each meta-analysis was transformed back into Pearson r for final interpretation. The effect size magnitude of r can be interpreted as follows: r=0.1, small; r=0.3, moderate; and r=0.5, large.
Statistical heterogeneity was assessed using I2 and classified as might not be important (I2=0%-40%), moderate (I2=30%-60%), substantial (I2=50%-90%), or considerable (I2=75%-100%).
Forest plots were generated as a way to visualize the effect sizes and CIs from the considered studies, along with the computed summary effect size. These plots were produced using the forest() function also available as part of the “ metafor” v. 3.0-2 R package.
Results
The initial search identified 247 potential studies through electronic databases. In addition, 466 potential studies were identified by reference screening. In total, 251 duplicate studies were eliminated, and 429 were excluded in the screening stage by their title and abstract. Thirty-three studies were assessed as full texts. Of these, 10 studies were excluded for having the wrong study design, 3 for being the wrong publication type, 2 for involving the wrong population, and 3 for having the wrong outcome. Finally, 15 studies were included in this review (fig 1).
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
We observed a very high concordance between the reviewers when selecting the studies (kappa=0.942, P<.001).
Fig 1Study selection process. Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to Nursing and Allied Health.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
NOTE. Data are shown as mean ± SD, median (IQR), n (%)
Abbreviations: F, Female; GROC, global rating of change; M, Male; NR, not reported; QUIPS, Quality in Prognosis Studies; UK United Kingdom; US, United States.
We assessed the risk of bias across 6 domains using the Quality in Prognosis Studies tool for the included studies (fig 2). A very high concordance between the reviewers in the quality assessment was observed (kappa=0.875, P<.05). In general, the risk of bias in the included studies was low. We assessed 13 studies (87%) as having a low overall risk of bias.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Estimates of the association between prognostic factors and outcomes after CTR are shown in table 1. Most of the predictors were associated with the symptom severity, function, pain, satisfaction or return to work after CTR, both in the bivariate and multivariate analysis.
Regarding the severity of symptoms, symptoms of depression were associated with higher severity of symptoms in 71% of the studies that considered this prognostic factor, followed by symptoms of anxiety (66%). Regarding the function, pain catastrophizing was associated with higher functional impairment in 100% of the studies that considered this prognostic factor, followed by symptoms of depression (57%) and symptoms of anxiety (0%). Regarding pain, symptoms of depression were associated with higher pain intensity in 100% of the studies that considered this prognostic factor, followed by symptoms of anxiety (0%). Regarding patient satisfaction, symptoms of depression were associated with higher satisfaction in 60% of the studies that considered this prognostic factor, followed by pain catastrophizing (33%) and symptoms of anxiety (25%). Regarding return to work, lower pain catastrophizing was associated with early return to work in 100% of the studies that considered this prognostic factor, followed by symptoms of anxiety (100%) and symptoms of depression (33%). Table 2 summarizes the results and conclusions of the included studies.
Worse mental health status (MHI-5) was significantly associated with more severe symptoms (r=−0.23, P<.005), functional limitation (r=−0.22, P<.005), and lower satisfaction (r=−0.24, P<.005).
Clinicians should carefully evaluate patients’ functional status, mental health status, health habits, and attorney involvement prior to performing carpal tunnel release.
Greater likelihood of transition to successful work role functioning was related to self-efficacy improvement (χ2=26.24, P<.001). Univariate models (self-efficacy): OR, 10.44; 95% CI, 4.17-26.17; P<.001; univariate models (depression): OR, 0.34; 95% CI, 0.17- 0.72; P=.004. In logistic regression model, only improved self-efficacy post surgery and a supportive work organization significantly predict successful work role functioning.
Significance of improved self-efficacy at 6 mo and depression at 2 mo post surgery highlights the importance of psychosocial management of musculoskeletal disorders.
There was no association between the preoperative HADS and the mean score of PEM (depression: P=.2; anxiety: P=.58), BCTQ-S (depression: P=.9; anxiety: P=.79), and BCTQ-F (depression: P=.18; anxiety: P=.77). There was no difference in patient satisfaction between patients with and without depression (1.93 vs 1.53, P=.63). Patients with anxiety were less satisfied than patients without anxiety (2.05 vs 1.28, P=.005).
There was no significant difference in the outcome of CTR between patient with and without psychological disturbance.
Change in self-efficacy between baseline and 2 mo was also strongly associated with work absence at 6 mo (same or better was 89% vs 11% in working vs not working respectively, P<.001). In logistic regression model, having the same or worse self-efficacy was associated with work absence at 6 mo (adjusted OR, 4.4; 95% CI, 1.4-14).
Factors associated with work absence at 6 and 12 mo after CTR included preoperative physical functional status, lower self-efficacy, workers’ compensation, and less supportive organizational policies and practices.
Significant association between satisfaction and the CES-D score (r=−0.24, P<.05). Significant association between the DASH score and the CES-D (r=0.46, P<.01) and PCS scores (r=0.35, P<.01).
Dissatisfaction and perceived disability after CTR is predicted primarily by depression and ineffective coping skills and to a lesser degree by clinical or electrophysiologic evidence of advanced nerve damage.
CES-D score (r=0.47, P=.001) was significantly correlated with scar pain intensity. Stepwise multivariable linear regression analysis showed that CES-D score (β=0.44, P<.001) and postoperative BCTQ-S (β=0.38, P<.01) best predicted scar pain intensity.
Depression score and postoperative symptoms predicted scar pain intensity after open CTR. However, the most important contributor to scar pain intensity variance remains unidentified.
The PASS score was the only correlate of actual improvement of tingling after surgery (r=0.33, P=.009). There was no significant association between the CES-D and PASS with satisfaction with surgery and DASH scores. The best regression model for lower postoperative DASH score included men, lower PCS, and actual improvement of weakness (adjusted R2=0.32, P<.001).
Actual relief of symptoms with CTR matched patients’ expectations. Satisfaction with treatment correlated with relief of symptoms.
Earlier return to full work duty was associated with a lower PCS score (P=.028) and a lower PASS score (P=.005). CES-D was not associated with earlier return to full work duty (P=.380).
The most important determinant of return to full duty work CTR is job type, but psychological factors such as patient expectations, catastrophic thinking, and anxiety in response to pain also have a role.
Patients with a depression had significantly less favorable outcomes than patients without depression: BCTQ: 1.1 (1.0-1.6) vs 1.4 (1.2-2.1), P<.05; and Palmar pain score=0: 58.4% vs 27.3%, P<.05. Multivariable analyses showed that preoperative CES-D had a small but statistically significant influence on palmar pain (β=0.075, P<.05) but not on postoperative BCTQ (β=0.005, P=.44).
Depression is not an independent predictor of residual CTS symptoms 1 y after CTR. Patients with CTS and depression may expect a somewhat higher degree of palmar pain after CTR, the clinical relevance of which is small.
Postoperative CES-D (r=0.48, P<.05) and PASS (r=0.27, P<.05) were significantly correlated with postoperative BCTQ-S. In a multivariable linear regression model, the CES-D (β=6.679; 95% CI, 3.462-9.895; P<.05) and PASS (β=6.300; 95% CI, 0.404-12.195; P<.05) were significantly associated with the postoperative BCTQ-S.
Depression level and pain anxiety of patients with CTS are associated with the symptom severity of CTS in both the preoperative and the postoperative period.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Depressive symptoms (BDI-II) were significantly and negatively correlated with pain intensity, BCTQ-S and BCTQ-F at 6 and 12 mo (all P<.001). Higher depressive symptoms at baseline contributed to poorer outcomes post intervention (from 5%-15% of the variance).
Baseline localized pressure pain sensitivity and depression were predictive of long-term clinical outcomes in women with CTS after surgery,
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
A general linear model identified that lower anxiety is associated with lower symptom severity in CTS-6 (β=−0.02; 95% CI, 0.01-0.04; P<.001).
Multivariable modeling identified, independent of symptom severity at outset, higher health utility, fewer comorbidities, and lower anxiety as significant predictors of better outcome from CTR.
Risk of low patient-reported satisfaction for patients with preoperative PCS>30 compared with patients with PCS≤30 was unadjusted: OR, 2.24; 95% CI, 1.27-3.96; P=.005; adjusted for demographics: OR, 2.56; 95% CI, 1.38-4.74; P=.003).
Higher preoperative PCS seems to have a negative effect on postoperative patient-reported satisfaction after CTR.
Association between BCTQ total score post surgery and baseline pain catastrophizing was statistically significant (β=0.008; 95% CI, 0-0.01). In multivariable linear regression model, only before adding illness perceptions and expectations to the model, pain catastrophizing was significantly associated with outcome.
Effects of pain catastrophizing on CTR outcome may be captured by the mindset about the efficacy of CTS and the mindset regarding CTS.
NOTE. Data are shown as mean ± SD, median (IQR), n (%)
The meta-analyses included estimates of the predictive role of symptoms of depression on symptom severity, function, pain, and satisfaction. We decided not to pool data from studies evaluating symptoms of anxiety, self-efficacy, and pain catastrophizing. In all these variables, there were not enough articles to analyze their operationalizations separately.
Symptoms of depression and symptom severity
Four studies reported estimates of the depressive symptoms on symptom severity (n=531). The overall result of the random-effects model was r=0.347 (95% CI, 0.205-0.475; P ≤.0001) (fig 4). Heterogeneity between studies was substantial (I2=63.13%).
Fig 4Forest plot of the relationship between symptoms of depression and symptom severity. Each study considered in the meta-analysis corresponds to a point estimate, which is bounded by a 95% CI. The polygon at the bottom of the plot corresponds to the summary effect, and its width represents its 95% CI. Studies with larger squares have contributed more to the summary effect size than other studies.
Four studies reported estimates of the depressive symptoms on function (n=386). The overall result of the random-effects model was r=0.307 (95% CI, 0.132-0.464; P=.0008) (fig 5). Heterogeneity between studies was substantial (I2=65.51%).
Fig 5Forest plot of the relationship between symptoms of depression and function. Each study considered in the meta-analysis corresponds to a point estimate, which is bounded by a 95% CI. The polygon at the bottom of the plot corresponds to the summary effect, and its width represents its 95% CI. Studies with larger squares have contributed more to the summary effect size than other studies.
Three studies reported estimates of the depressive symptoms on pain intensity (n=344). The overall result of the random-effects model was r=0.431 (95% CI, 0.286-0.558; P≤.0001) (fig 6). Heterogeneity between studies was moderate (I2=51.29%).
Fig 6Forest plot of the relationship between symptoms of depression and pain. Each study considered in the meta-analysis corresponds to a point estimate, which is bounded by a 95% CI. The polygon at the bottom of the plot corresponds to the summary effect, and its width represents its 95% CI. Studies with larger squares have contributed more to the summary effect size than other studies.
Three studies reported estimates of the depressive symptoms on satisfaction (n=330). The overall result of the random-effects model was r=0.202 (95% CI, 0.096-0.305; P=.0002) (fig 7). Heterogeneity between studies was extremely low (I2= 0.01%).
Fig 7Forest plot of the relationship between symptoms of depression and dissatisfaction. Each study considered in the meta-analysis corresponds to a point estimate, which is bounded by a 95% CI. The polygon at the bottom of the plot corresponds to the summary effect, and its width represents its 95% CI. Studies with larger squares have contributed more to the summary effect size than other studies.
This systematic review and meta-analysis provides updated evidence on the association between cognitive and mental health factors with self-reported outcomes in patients with CTS who undergo surgery. The majority of studies indicate a significant association between the cognitive or mental health factors and the outcomes after CTR. In general, the risk of bias in the included studies was low. Despite the heterogeneity of the available evidence, the results were consistent in the quantitative analysis regarding the effect of the symptoms of depression on symptom severity, function, and pain after CTR, 3 months after surgery, and beyond.
This evidence agrees with the other systematic reviews that emphasize the potential effect of the cognitive and mental health factors on postsurgical outcomes in individuals with chronic musculoskeletal pain.
Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis.
Therefore, physicians, physical therapists, and occupational therapists should consider evaluating the cognitive and mental health factors in patients undergoing hand surgery.
An interesting finding is that most of the studies found that the level of the symptoms of depression was associated more with the severity of the symptoms and postoperative pain than with functional impairment. This seems relevant because the severity of the symptoms is the most important reason for the patients undergoing surgery.
On the other hand, although a quantitative analysis was not possible, the symptoms of depression with self-efficacy showed a significant association with a late return to work. The early identification of patients at a greater risk of a delayed return to work could prevent a prolonged absence from work or suboptimal performance at work.
Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.
We conducted a comprehensive search of 5 databases and additional sources to identify the relevant studies. Rigorous narrative approaches and a meta-analysis were considered to synthesize the available evidence. Most of the included studies were of high methodological quality and carried out a long-term follow-up (3-24 months). In contrast, a limitation of this review was the lack of measurement of the cognitive and mental health factors that may influence the CTR outcomes beyond those identified in the available studies. This limited the possibility of performing a quantitative synthesis of the data (meta-analysis) for all of the prognostic factors considered (ie, symptoms of anxiety, catastrophic thinking, self-efficacy). In addition, we did not find any studies that evaluated some of the psychosocial factors that we included in our search strategy (ie, fear avoidance or kinesiophobia). Although kinesiophobia, for example, has been shown to be an important predictor of upper extremity–specific disability in patients with CTS,
its prognostic value in postoperative outcomes has not yet been considered; therefore, future studies should evaluate this aspect. Another limitation was that we focused on evaluating the cognitive and mental health factors, while we know that many variables can modulate the symptoms in patients with CTS. For example, education level, intrinsic risk factors such as obesity, age, and sex, and occupational risk factors such as exposure to higher manual forces play a part.
In addition, peripheral nerve injury triggers changes in the central nervous system. These changes include central sensitization and changes in the cortical representation.
A comprehensive assessment that considers all of these aspects will allow clinicians to make more appropriate decisions and deliver greater benefits to their patients.
Directions for future studies
While some patients may experience an improvement in their depressive symptoms after CTR,
the effect of treating the depressive symptoms before surgery has been little studied. In other musculoskeletal pain conditions, it has been observed that depressed patients who received preoperative psychotherapy (eg, cognitive behavioral therapy) had fewer medical complications and less resource utilization than those who did not receive psychotherapy.
In addition, perioperative psychotherapy has been shown to be effective at reducing the level of postoperative pain and functional impairment in patients who undergo orthopedic surgery.
Future studies should therefore evaluate the efficacy of similar interventions in patients with CTS undergoing surgery, incorporating the approach to other aspects that negatively influence depressive symptoms, such as sleep quality.
On the other hand, it is not just about identifying those at risk of a poor outcome but also providing evidence to support that having more positive emotional and cognitive responses can benefit the patient and their outcomes. For example, expectations and resilience measures (eg, optimism) have been shown to be strong predictors of postoperative functionality.
Therefore, implementing strategies early on that reinforce these more positive beliefs, attitudes, and behaviors could positively influence their current and future pain experience (eg, educational program).
In addition, educating patients on the expectations and beliefs that they hold before surgery may help them to increase their participation in the shared decision-making process while setting realistic expectations regarding the postoperative outcomes.
Future studies should consider this point to reframe the conversation about how more positive cognitive and emotional responses can lead to better rehabilitation outcomes. For this reason, addressing the patient's emotional state and coping strategies could be an essential treatment opportunity that results in the improvement of the health of patients undergoing CTR.
Conclusions
This systematic review and meta-analysis showed that symptoms of depression have a moderate association with symptom severity, function, and pain after CTR. Symptoms of anxiety, catastrophic thinking, and self-efficacy are also important indicators of poor postsurgery outcomes and should be considered. Therefore, a preoperative evaluation of this variable could help to identify patients at risk for unfavorable surgical outcomes and provide timely treatment. As more is learned about the role of the cognitive and mental health factors and their potential effect on CTR, clinicians will be able to use these findings to approach patients more effectively.
References
Nora DB
Becker J
Ehlers JA
Gomes I.
What symptoms are truly caused by median nerve compression in carpal tunnel syndrome?.
Comparison of the short-term and long-term effects of surgery and nonsurgical intervention in treating carpal tunnel syndrome: a systematic review and meta-analysis.
Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis.
Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis.
Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
The shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH.
Disclosures: R. Núñez-Cortés is funded by a grant from the National Agency for Research and Development (ANID)/Scholarship Program/DOCTORADO BECAS CHILE/2020–72210026. The other authors have nothing to disclose.
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