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Effects of Cognitive and Mental Health Factors on the Outcomes Following Carpal Tunnel Release: A Systematic Review and Meta-analysis

  • Rodrigo Núñez-Cortés
    Affiliations
    Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain

    Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile

    International Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
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  • Carlos Cruz-Montecinos
    Affiliations
    Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain

    Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile

    Division of Research, Devolvement and Innovation in Kinesiology, Kinesiology Unit, San José Hospital, Santiago, Chile
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  • Rodrigo Torres-Castro
    Affiliations
    Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile

    International Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
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  • Claudio Tapia
    Affiliations
    Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile
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  • Thomas A. Püschel
    Affiliations
    Ecology and Evolutionary Biology Division, School of Biological Sciences, University of Reading, Reading, United Kingdom

    Primate Models for Behavioural Evolution Lab, Institute of Cognitive and Evolutionary Anthropology, School of Anthropology, University of Oxford, Oxford, United Kingdom
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  • Sofía Pérez-Alenda
    Correspondence
    Corresponding author: Sofía Pérez-Alenda, PT, PhD, Department of Physiotherapy, University of Valencia, C/ Gascó Oliag N 5, 46010 Valencia, Spain.
    Affiliations
    Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain
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Open AccessPublished:November 29, 2021DOI:https://doi.org/10.1016/j.apmr.2021.10.026

      Abstract

      Objective

      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.

      Keywords

      List of abbreviations:

      BCTQ-F (Boston Carpal Tunnel Questionnaire score-function), BCTQ-S (Boston Carpal Tunnel Questionnaire score-symptoms), BDI-II (Beck Depression Inventory II), CES-D (Center of Epidemiologic Studies-Depression scale), CTS (Carpal tunnel syndrome), CTS-6 (6-item shortened Boston Carpal Tunnel Questionnaire), CTR (Carpal tunnel release), DASH (Disabilities of the Arm, Shoulder, and Hand), HADS (Hospital anxiety and depression scale), MHI-5 (5-item mental health index), PASS (Pain Anxiety Symptoms Scale), PCS (Pain Catastrophizing Scale), PHQ-4 (Patient Health Questionnaire-4), PEM (Patient evaluation measure), RCT (randomized controlled trial)

      Introduction

      Carpal tunnel syndrome (CTS) is the most prevalent compression neuropathy of the upper limb,
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      What symptoms are truly caused by median nerve compression in carpal tunnel syndrome?.
      characterized by pain, paresthesia, and a tingling sensation in the region of the median nerve.
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      • et al.
      American Academy of Orthopaedic Surgeons Clinical Practice Guideline on diagnosis of carpal tunnel syndrome.
      These symptoms cause significant functional impairment,
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      The impact of sensory, motor and pain impairments on patient-reported and performance based function in carpal tunnel syndrome.
      affecting the quality of life of the patient.
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      Carpal tunnel syndrome.
      The prevalence of CTS ranges between 6.3% and 11.7%,
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      • Hegmann KT
      • et al.
      Effects of varying case definition on carpal tunnel syndrome prevalence estimates in a pooled cohort.
      being more frequent in women than in men.
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      • Rempel D
      • et al.
      Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies.
      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.
      • Tadjerbashi K
      • Åkesson A
      • Atroshi I.
      Incidence of referred carpal tunnel syndrome and carpal tunnel release surgery in the general population: increase over time and regional variations.
      CTR is one of the most common operations performed on the upper limb, with a lifetime prevalence of 3.1%,
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      • Shiri R.
      Carpal tunnel release: lifetime prevalence, annual incidence, and risk factors.
      representing a considerable expense for healthcare systems.
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      • Mauck BM
      • Thompson NB
      • Calandruccio JH.
      Cost, value, and patient satisfaction in carpal tunnel surgery.
      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.
      • Urits I
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      Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review.
      While most patients improve after surgery,
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      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.
      approximately 5% of patients report persistent symptoms and require revision CTR within the first postoperative year.
      • Wessel LE
      • Gu A
      • Asadourian PA
      • Stepan JG
      • Fufa DT
      • Osei DA.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      The unfavorable outcome after CTR may also be because of pain related to the surgical scar, which may be affected by depressive symptoms.
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      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.
      • Chester R
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      • Lewis J
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      Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study.
      ,
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      • et al.
      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.
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      The fear-avoidance model of musculoskeletal pain: current state of scientific evidence.
      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.
      • Innocenti T
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      ,
      • Giusti EM
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      Psychological and psychosocial predictors of chronic postsurgical pain: a systematic review and meta-analysis.
      Previous systematic reviews have shown that these factors are associated with poorer postoperative outcomes in shoulder surgery,
      • Innocenti T
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      • Galantini P
      • Testa M
      • Bari MD.
      The influence of central pain modulation on postoperative outcomes after shoulder surgery: a systematic review.
      ,
      • Sheikhzadeh A
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      Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review.
      spine surgery,
      • Giusti EM
      • Lacerenza M
      • Manzoni GM
      • Castelnuovo G.
      Psychological and psychosocial predictors of chronic postsurgical pain: a systematic review and meta-analysis.
      ,
      • Celestin J
      • Edwards RR
      • Jamison RN.
      Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis.
      ,
      • Alodaibi FA
      • Minick KI
      • Fritz JM.
      Do preoperative fear avoidance model factors predict outcomes after lumbar disc herniation surgery? A systematic review.
      , and knee replacements.
      • Giusti EM
      • Lacerenza M
      • Manzoni GM
      • Castelnuovo G.
      Psychological and psychosocial predictors of chronic postsurgical pain: a systematic review and meta-analysis.
      ,
      • Khatib Y
      • Madan A
      • Naylor JM
      • Harris IA.
      Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review.
      ,
      • Lewis GN
      • Rice DA
      • McNair PJ
      • Kluger M.
      Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis.
      However, the relevance of cognitive and mental health factors as prognostic indicators of recovery to CTR is controversial.
      • Park JW
      • Gong HS
      • Rhee SH
      • Kim J
      • Lee YH
      • Baek GH.
      The effect of psychological factors on the outcomes of carpal tunnel release: a systematic review.
      There is a growing literature supporting the role of modifiable cognitive and mental health factors in CTR.
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      However, the assessment of these factors has not been taken into account in the recent clinical practice guidelines for patients with CTS
      • Erickson M
      • Lawrence M
      • Jansen CWS
      • Coker D
      • Amadio P
      • Cleary C.
      Hand pain and sensory deficits: carpal tunnel syndrome.
      when most of the patients may end up needing surgery.
      • Tadjerbashi K
      • Åkesson A
      • Atroshi I.
      Incidence of referred carpal tunnel syndrome and carpal tunnel release surgery in the general population: increase over time and regional variations.
      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.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • Altman DG
      • Group PRISMA
      Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.
      The meta-analysis was conducted according to the Meta-analysis of Observational Studies in Epidemiology.
      • Stroup DF
      • Berlin JA
      • Morton SC
      • et al.
      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
      • Sullivan MJL
      • Bishop SR
      • Pivik J.
      The Pain Catastrophizing Scale: development and validation.
      ; (2) kinesiophobia, measured by the Tampa Scale of Kinesiophobia
      • Tkachuk GA
      • Harris CA.
      Psychometric properties of the Tampa Scale for Kinesiophobia-11 (TSK-11).
      ; (3) self-efficacy, measured by Self-Efficacy Scale
      • Keefe FJ
      • Lefebvre JC
      • Maixner W
      • Salley Jr, AN
      • Caldwell DS.
      Self-efficacy for arthritis pain: relationship to perception of thermal laboratory pain stimuli.
      ; (4) fear avoidance, measured by Fear Avoidance and Beliefs Questionnaire
      • Waddell G
      • Newton M
      • Henderson I
      • Somerville D
      • Main CJ.
      A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
      ; (5) symptoms of anxiety, measured by the Hospital Anxiety and Depression Scale
      • Zigmond AS
      • Snaith RP.
      The Hospital Anxiety and Depression Scale.
      or the Pain Anxiety Symptoms Scale
      • Osman A
      • Barrios FX
      • Osman JR
      • Schneekloth R
      • Troutman JA.
      The Pain Anxiety Symptoms Scale: psychometric properties in a community sample.
      ; (6) symptoms of depression, measured by the Hospital Anxiety and Depression Scale,
      • Zigmond AS
      • Snaith RP.
      The Hospital Anxiety and Depression Scale.
      Center for Epidemiologic Studies Depression Scale,
      • Weissman MM
      • Sholomskas D
      • Pottenger M
      • Prusoff BA
      • Locke BZ.
      Assessing depressive symptoms in five psychiatric populations: a validation study.
      Beck Depression Inventory II,
      • Wang YP
      • Gorenstein C.
      Assessment of depression in medical patients: a systematic review of the utility of the Beck Depression Inventory-II.
      5-item Mental Health Inventory,
      • McHorney C
      • Ware JE
      • Raczek AE.
      The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.
      or Patient Health Questionnaire-4.
      • Kroenke K
      • Spitzer RL
      • Williams JBW
      • Löwe B.
      An ultra-brief screening scale for anxiety and depression: the PHQ-4.
      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
      • Levine DW
      • Simmons BP
      • Koris MJ
      • et al.
      A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome.
      or similar, 6-item shortened Boston Carpal Tunnel Questionnaire,
      • Atroshi I
      • Lyrén PE
      • Gummesson C.
      The 6-item CTS symptoms scale: a brief outcomes measure for carpal tunnel syndrome.
      Disabilities of the Arm, Shoulder, and Hand,
      • Hudak PL
      • Amadio PC
      • Bombardier C.
      Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
      Quick–Disabilities of the Arm, Shoulder, and Hand,
      • Gummesson C
      • Ward MM
      • Atroshi I.
      The shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH.
      and the Michigan Hand Questionnaire
      • Chung KC
      • Pillsbury MS
      • Walters MR
      • Hayward RA.
      Reliability and validity testing of the Michigan Hand Outcomes Questionnaire.
      ; (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.
      • Ouzzani M
      • Hammady H
      • Fedorowicz Z
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.

       Reviewing procedure and data extraction

      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.
      • Hayden JA
      • van der Windt DA
      • Cartwright JL
      • Côté P
      • Bombardier C.
      Assessing bias in studies of prognostic factors.
      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
      • McGuinness LA
      • Higgins JPT.
      Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments.
      was used to create risk of bias assessment plots.

       Quantitative synthesis

      The meta-analyses were performed in R v. 4.0.2.
      R Core Team
      2017 R: a language and environment for statistical computing.
      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.
      • Borenstein M
      • Hedges LV
      • Higgins JPT
      • Rothstein HR.
      Chapter 7: converting among effect sizes. Introduction to meta-analysis.
      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.
      • Viechtbauer W.
      Conducting meta-analyses in R with the metafor 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.
      • Borenstein M
      • Hedges LV
      • Higgins JPT
      • Rothstein HR.
      A basic introduction to fixed-effect and random-effects models for meta-analysis.
      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.
      • Cohen J.
      A power primer.
      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%).
      • Higgins JPT
      • Thomas J.
      Cochrane handbook for systematic reviews of interventions.
      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).
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      ,
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      We observed a very high concordance between the reviewers when selecting the studies (kappa=0.942, P<.001).
      Fig 1
      Fig 1Study selection process. Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to Nursing and Allied Health.

       Study characteristics

      The studies were conducted in the United States (6 studies),
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      South Korea (3),
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      ,
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      the United Kingdom (2),
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      ,
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      the Netherlands (2),
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      Spain (1),
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      and Denmark (1).
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      All of the included studies were written in English. Seven studies (47%) were published less than 5 years ago (after 2016).
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      The designs of the studies included 1 randomized controlled trial,
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      12 prospectives,
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      ,
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      ,
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      ,
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      and 2 retrospectives.
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      ,
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      The sample sizes varied between 60 participants
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      and 455 participants.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      A total of 2599 patients were included, with a mean age that varied between 46±9 and 62±12 years. Eight studies included open CTR,
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      ,
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      ,
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      ,
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      and 5 studies included open and endoscopic CTR,
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      ,
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      ,
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      while 2 studies did not report the type of surgery.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      ,
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      The total time of the follow-up ranged from 3 months
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      ,
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      after CTR to 2 years.
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      Table 1 is the descriptive summary of the included studies.
      Table 1Description of included articles
      AuthorCountryDesignN(M/F)Age (y)Type of SurgeryFollow-up(N)Prognostic

      Factor
      Postoperative

      Outcomes
      Significant Result

      of Univariate

      Analysis
      Significant Result

      of Multivariate

      Analysis
      Overall

      Risk of

      Bias(QUIPS)
      Katz et al
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      USAProspective241

      (82/159)
      44.6±11.5Open or

      endoscopic

      CTR
      18 mo

      (188)
      MHI-5BCTQ-S

      BCTQ-F

      Satisfaction
      Yes

      Yes

      Yes
      Yes

      Yes

      Yes
      Low
      Amick et al
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      USAProspective197

      (NR)
      NROpen or

      endoscopic

      CTR
      6 months

      (122)
      MHI-5

      Self-efficacy

      (4-item scale)
      Return to work

      Return to work
      Yes

      Yes
      Yes

      Yes
      Low
      Hobby et al
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      UKProspective97

      (22/75)
      53.4 (21 - 85)NR6 mo

      (86)
      HADS

      (depression)

      HADS

      (anxiety)
      PEM

      BCTQ-S

      BCTQ-F

      Satisfaction

      PEM

      BCTQ-S

      BCTQ-F

      Satisfaction
      No

      No

      No

      No

      No

      No

      No

      Yes
      High
      Katz et al
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      USAProspective181

      (76/105)
      45.7±9.4Open or

      endoscopic

      CTR
      6 and 12 mo

      (158, 157)
      MHI-5

      Self-efficacy

      (4-item scale)
      Work status

      Work status
      No, no

      Yes, yes
      No

      Yes
      Low
      Lozano et al
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      USARetrospective82

      (29/53)
      61±12.8Open CTR

      2 y

      (82)
      CES-D

      PASS

      PCS
      DASH

      Satisfaction

      DASH

      Satisfaction

      DASH

      Satisfaction
      Yes

      Yes

      No

      No

      Yes

      Yes
      Yes

      Yes

      No

      No

      Yes

      No
      Low
      Kim et al
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      South KoreaProspective83

      (10/73)
      54±10.4Open CTR

      3 mo

      (83)
      CES-D

      PASS

      Scar pain

      (ordinal scale)

      Scar pain

      (ordinal scale)
      Yes

      No
      Yes

      No
      Low
      Becker et al
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      USAProspective66

      (17/49)
      50±11Open CTR6±5 mo

      (66)
      CES-D

      PASS

      PCS
      DASH

      Satisfaction

      DASH

      Satisfaction

      DASH

      Satisfaction
      No

      No

      No

      No

      No

      No
      No

      No

      No

      No

      Yes

      No
      Low
      Cowan et al
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      USAProspective66

      (17/49)
      49.7±11.3Open CTR2-4 mo

      (66)
      CES-D

      PASS

      PCS
      Return to work

      Return to work

      Return to work
      No

      Yes

      Yes
      No

      Yes

      Yes
      Low
      Datema et al
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      NetherlandsProspective227

      (60/167)
      58 (49-73)Open CTR12 mo

      (227)
      CES-DBCTQ

      Palmar pain scale (0-9)
      Yes

      Yes

      No

      Yes
      Low
      Bae et al
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      South KoreaRetrospective60

      (7/53)
      55 (36-80)Open CTR3 mo

      (60)
      CES-D

      PASS

      Satisfaction

      Satisfaction
      Yes

      No
      Yes

      No
      Low
      Shin et al
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.


      South Korea
      Prospective60

      (7/53)
      55 (36-80)Open CTR3 mo

      (60)
      CES-D

      PASS
      BCTQ-S

      BCTQ-F

      BCTQ-S

      BCTQ-F
      Yes

      No

      Yes

      No
      Yes

      No

      Yes

      No
      Low
      Fernandez-de-Las-

      Peñaz et al
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      SpainRCT60

      (0/60)
      46±9Open or

      endoscopic CTR
      6 and 12 mo

      (60,56)
      BDI-IIPain (0-10)

      BCTQ-S

      BCTQ-F
      Yes, yes

      Yes, yes

      Yes, yes
      Low
      Jerosch-

      Herold et al
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      UKProspective455

      (293/162)
      62±12NR18 mo

      (455)
      HADS

      (depression)

      HADS

      (anxiety)
      CTS-6

      GROC

      CTS-6

      GROC


      Yes

      Yes
      No

      Yes

      Yes

      Yes
      Low
      Mosegaard

      et al
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      DenmarkProspective417

      (148/269)

      58 (18-92)Open or

      endoscopic CTR
      12 mo

      (417)
      PCSSatisfactionYesYesLow
      Sun et al
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      NetherlandsProspective307

      (91/216)
      56Open CTR6 mo

      (307)
      PHQ-4

      PCS
      BCTQ

      BCTQ
      No

      Yes
      Yes

      Yes
      High
      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.

       Methodological quality assessment

      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.
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      ,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      ,
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      Figure 3 shows the summary of each Risk of Bias domain.
      Fig 2
      Fig 2Summary of the risk of bias assessment using the Quality in Prognosis Studies tool.
      Fig 3
      Fig 3Proportion of included studies with low, high, or moderate risk of bias using the Quality in Prognosis Studies tool.

       Narrative synthesis

      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.
      Table 2Summary findings
      AuthorFollow-up(N)ResultsConclusion
      Katz et al
      • Katz JN
      • Losina E
      • Amick 3rd, BC
      • Fossel AH
      • Bessette L
      • Keller RB.
      Predictors of outcomes of carpal tunnel release.
      18 mo

      (188)
      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.
      Amick et al
      • Amick 3rd, BC
      • Habeck RV
      • Ossmann J
      • Fossel AH
      • Keller R
      • Katz JN
      Predictors of successful work role functioning after carpal tunnel release surgery.
      6 mo

      (122)
      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.
      Hobby et al
      • Hobby JL
      • Venkatesh R
      • Motkur P.
      The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
      6 moThere 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.
      Katz et al
      • Katz JN
      • Amick 3rd, BC
      • Keller R
      • et al.
      Determinants of work absence following surgery for carpal tunnel syndrome.
      6 and12 mo

      (158, 157)
      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.
      Lozano et al
      • Lozano Calderón SA
      • Paiva A
      • Ring D.
      Patient satisfaction after open carpal tunnel release correlates with depression.
      2 ye

      (82)
      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.
      Kim et al
      • Kim JK
      • Kim YK.
      Predictors of scar pain after open carpal tunnel release.
      3 mo

      (83)
      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.
      Becker et al
      • Becker SJE
      • Makanji HS
      • Ring D.
      Expected and actual improvement of symptoms with carpal tunnel release.
      6±5 mo

      (66)
      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.
      Cowan et al
      • Cowan J
      • Makanji H
      • Mudgal C
      • Jupiter J
      • Ring D.
      Determinants of return to work after carpal tunnel release.
      2-4 mo

      (66)
      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.
      Datema et al
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      12 mo

      (227)
      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.
      Bae et al
      • Bae JY
      • Kim JK
      • Yoon JO
      • Kim JH
      • Ho BC.
      Preoperative predictors of patient satisfaction after carpal tunnel release.
      3 mo

      (60)
      Univariate analyses demonstrated significant correlations of patient satisfaction with preoperative CES-D: OR, 0.923; 95% CI. 0.880-0.968; P=.001. Multivariate analyses showed that preoperative CES-D were significantly correlated with patient satisfaction. OR, 0.938; 95% CI, 0.895-0.982; P=.007. Age adjusted: OR, 0.922; 95% CI, 0.877-0.969; P=.001Age and depression level were preoperative predictors influencing satisfaction after CTR.
      Shin et al
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      3 mo

      (60)
      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.
      Fernandez-de-Las-Peñaz et al
      • Fernández-de-Las-Peñas C
      • de-la-Llave-Rincón AI
      • Cescon C
      • Barbero M
      • Arias-Buría JL
      • Falla D.
      Influence of clinical, psychological, and psychophysical variables on long-term treatment outcomes in carpal tunnel syndrome: evidence from a randomized clinical trial.
      6 and 12 mo

      (60, 56)
      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,
      Jerosch-Herold et al
      • Jerosch-Herold C
      • Shepstone L
      • Houghton J
      • Wilson ECF
      • Blake J.
      Prognostic factors for response to treatment by corticosteroid injection or surgery in carpal tunnel syndrome (palms study): a prospective multicenter cohort study.
      18 mo

      (455)
      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.
      Mosegaard et al
      • Mosegaard SB
      • Stilling M
      • Hansen TB.
      Higher preoperative pain catastrophizing increases the risk of low patient reported satisfaction after carpal tunnel release: a prospective study.
      12 mo

      (417)
      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.
      Sun et al
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      6 mo

      (307)
      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 (%)

       Quantitative synthesis (meta-analyses)

      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 4
      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.

       Symptoms of depression and function

      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 5
      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.

       Symptoms of depression and pain

      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 6
      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.

       Symptoms of depression and satisfaction

      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 7
      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.

      Discussion

      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.
      • Sobol-Kwapinska M
      • Bąbel P
      • Plotek W
      • Stelcer B.
      Psychological correlates of acute postsurgical pain: a systematic review and meta-analysis.
      ,
      • Theunissen M
      • Peters ML
      • Bruce J
      • Gramke HF
      • Marcus MA.
      Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain.
      For example, symptoms of depression, anxiety, and pain catastrophizing can predict poor outcomes in patients undergoing shoulder surgery,
      • Innocenti T
      • Ristori D
      • Galantini P
      • Testa M
      • Bari MD.
      The influence of central pain modulation on postoperative outcomes after shoulder surgery: a systematic review.
      ,
      • Sheikhzadeh A
      • Wertli MM
      • Weiner SS
      • Rasmussen-Barr E
      • Weiser S.
      Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review.
      spine surgery,
      • Celestin J
      • Edwards RR
      • Jamison RN.
      Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis.
      ,
      • Alodaibi FA
      • Minick KI
      • Fritz JM.
      Do preoperative fear avoidance model factors predict outcomes after lumbar disc herniation surgery? A systematic review.
      and knee replacement.
      • Khatib Y
      • Madan A
      • Naylor JM
      • Harris IA.
      Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review.
      ,
      • Lewis GN
      • Rice DA
      • McNair PJ
      • Kluger M.
      Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis.
      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.
      • Gong HS
      • Baek GH
      • Oh JH
      • Lee YH
      • Jeon SH
      • Chung MS.
      Factors affecting willingness to undergo carpal tunnel release.
      Postoperative pain control is an essential goal in rehabilitation because of the possibility of reducing the costs associated with the use of opioids.
      • Ingram J
      • Mauck BM
      • Thompson NB
      • Calandruccio JH.
      Cost, value, and patient satisfaction in carpal tunnel 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.
      • Loisel P
      • Durand MJ
      • Berthelette D
      • et al.
      Disability prevention.

       Study strengths and limitations

      This systematic review has several strengths. We used the current guidelines to develop the systematic review.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • Altman DG
      • Group PRISMA
      Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.
      ,
      • Stroup DF
      • Berlin JA
      • Morton SC
      • et al.
      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,
      • Das De S
      • Vranceanu AM
      • Ring DC.
      Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability.
      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.
      • Erickson M
      • Lawrence M
      • Jansen CWS
      • Coker D
      • Amadio P
      • Cleary C.
      Hand pain and sensory deficits: carpal tunnel syndrome.
      ,
      • Núñez-Cortés R
      • Cruz-Montecinos C
      • Antúnez-Riveros MA
      • Pérez-Alenda S.
      Does the educational level of women influence hand grip and pinch strength in carpal tunnel syndrome?.
      In addition, peripheral nerve injury triggers changes in the central nervous system. These changes include central sensitization and changes in the cortical representation.
      • Schmid AB
      • Fundaun J
      • Tampin B.
      Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management.
      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,
      • Datema M
      • Tannemaat MR
      • Hoitsma E
      • et al.
      Outcome of carpal tunnel release and the relation with depression.
      ,
      • Shin YH
      • Yoon JO
      • Kim YK
      • Kim JK.
      Psychological status is associated with symptom severity in patients with carpal tunnel syndrome.
      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.
      • Schwartz AM
      • Wilson JM
      • Farley KX
      • Roberson JR
      • Guild GN
      • Bradbury TL.
      Modifiability of depression's impact on early revision, narcotic usage, and outcomes after total hip arthroplasty: the impact of 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.
      • Wang L
      • Chang Y
      • Kennedy SA
      • et al.
      Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials.
      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.
      • Patel A
      • Culbertson MD
      • Patel A
      • et al.
      The negative effect of carpal tunnel syndrome on 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.
      • Kadzielski J
      • Malhotra LR
      • Zurakowski D
      • Lee SGP
      • Jupiter JB
      • Ring D.
      Evaluation of preoperative expectations and patient satisfaction after carpal tunnel release.
      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).
      • Núñez-Cortés R
      • Espinoza-Ordóñez C
      • Pommer PP
      • Horment-Lara G
      • Pérez-Alenda S
      • Cruz-Montecinos C
      A single preoperative pain neuroscience education: is it an effective strategy for patients with carpal tunnel syndrome?.
      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.
      • Sun PO
      • Walbeehm ET
      • Selles RW
      • et al.
      Patient mindset and the success of carpal tunnel release.
      Similarly, the efficacy of treatments after CTR should focus on more favorable outcomes such as quality of life.
      • Peters S
      • Page MJ
      • Coppieters MW
      • Ross M
      • Johnston V.
      Rehabilitation following carpal tunnel release.
      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.

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