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Occupational Medicine Advance Access originally published online on November 11, 2005
Occupational Medicine 2006 56(1):46-50; doi:10.1093/occmed/kqi194
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© The Author 2005. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Time to return to work and surgeons' recommendations after carpal tunnel release

Navah Ratzon1, Tamara Schejter-Margalit2 and Paul Froom3

1 Department of Occupational Therapy, Tel Aviv University, PO Box 39040, Ramat Aviv, 69978 Tel Aviv, Israel
2 Formerly at: Department of Occupational Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
3 Department of Epidemiology and Preventive Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel

Correspondence to: Navah Ratzon, Department of Occupational Therapy, Tel Aviv University, PO Box 39040, Ramat Aviv, 69978 Tel Aviv, Israel. Tel: +972-3-6405443; fax: +972-3-6409933; e-mail: navah{at}post.tau.ac.il


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Time to return to work after carpal tunnel release is extremely variable suggesting that only a small proportion of total sick-leave is for medical reasons.

Aims To determine factors predicting a delayed return to work.

Methods Fifty consecutive employed patients undergoing carpal tunnel surgery were tested pre-operatively, and then at 1 month post-operatively using both questionnaires and objective testing. Further follow-up by telephone was carried out every 2 weeks up until 90 days.

Results Forty-nine of the 50 workers had returned to work by 3 months. Time to return to work was extremely variable ranging from 1 to 88 days in those who returned to work. Post-operative recommendations by the surgeon also varied widely from 1 to 36 days. The surgeons' recommendations were the strongest predictors of delayed return to work [odds ratio 30.5; 95% confidence interval (CI), 3.2–288], with physical work (odds ratio 27.7; 95% CI, 1.5–507) and lack of self-rated health (odds ratio 5.0; 95% CI, 1.11–100) adding significantly to the logistic regression model, which was highly predictive (area under the receiver–operator curve of 88%). Patient symptoms and objective findings of disability did not add significantly to a logistic regression model either predicting return to work or the surgeon's recommendations.

Conclusions Our study suggests that workers will return to work in less than 3 weeks if recommended by the surgeon. A randomized controlled trial is warranted to determine if a higher proportion of workers returning in less than 3 weeks can be obtained by standardizing surgeons' recommendations.

Keywords      Absenteeism; carpal tunnel release; occupational; surgeons' recommendations


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Time to return to work following carpal tunnel release is extremely variable with self-employed workers taking sick-leave of 4.3 days [1], and others reporting a significant number of subjects still absent from work after 3 months [2–4]. Some authors claim that the wide variability suggests that only a small proportion of total sick-leave is for medical reasons [5]. Predictors of delayed return to work include receipt of workers' compensation [2,4,6,7], female gender [6], ergonomic stresses at work [3,6], work absence pre-operatively and a poor mental health status [2], but explain only a small part of sick-leave variability.

The role of continued symptoms and poor functional status in delayed return to work after carpal tunnel release has not been studied extensively and the results are discordant. Atroshi et al. [8] reported that pre-operative variables including age, gender, symptoms and signs, activities of daily living, hand sensory measurements, hand strength measurements and distal motor latency of the median nerve did not predict the length of time until return to work after surgery. On the other hand other studies found that hand symptoms explained a small part of the variance of functional status [9] and that regaining hand function predicted early return to work [10].

In the following study we attempted to determine factors predicting a delayed return to work.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
We tested and followed up 50 employed patients consecutively referred for carpal tunnel surgery, hospitalized and operated on by five surgeons. Patients signed a form of consent, but no ethical approval was sought since it was thought that the testing represented good medical practice. One patient refused. Patients were discharged from the hospital within 24 h after surgery, and the surgeon's recommendation for sick-leave was written on the discharge summary. Functional status was determined pre-operatively and at 1 month post-operatively in order to adjust for physical disability. Further follow-up of symptom severity and whether or not the patient had returned to work was done by telephone every 2 weeks up until 90 days.

A questionnaire was administered by one of the authors to the patients pre-operatively. The questionnaire included age, gender, body mass index (BMI, weight in kilograms divided by height in square meters), current smoking status (yes/no), completion of a high school education (yes/no), any regular leisure physical activity (at least once a week, yes/no), chronic disease (any long-term symptomatic disease, or chronic use of medications such as for diabetes mellitus or ischemic heart disease), whether or not early return to work will damage one's health (yes/no) and self-rated health (poor, fair, good, very good or excellent). Operation of the dominant hand was also recorded (yes/no). The severity of hand symptoms was evaluated by the symptom severity scale [11] pre-operatively, at one month and on every follow-up telephone call.

Work place variables included patient's job satisfaction, evaluated by the standard job description index with a higher score representing a higher degree of job satisfaction [12,13]. Self-reported evaluation of physical demands at work included a general question on the overall degree of physical activity (none/easy/intermediate/hard), and a standard questionnaire on occupational hand use (five questions with answers for each question: not agree at all/not agree/neutral/agree/highly agree) [14]. The five questions about requirements at work included typing over 4 h/day, heavy lifting, the need for a high degree of hand strength and frequent and fast hand movements. The answers were divided into yes (agree or highly agree) and no (all the other answers).

The results of pre-operative electromyographic motor and sensory conduction (milliseconds) were recorded. Functional testing was done, pre-operatively and 1 month post-operatively and included grip strength, and pinch grip (tip pinch, palmar pinch and lateral pinch) executed in the standard position recommended by the American Society of Hand Therapists [15,16]. The functional assessment of the hand was measured with the Purdue pegboard test (PPT), measuring gross movements of hands, fingers and arms and fingertip dexterity (completed tasks in 30–60 s) [17].

Analyses were performed with the statistical package Statistix for Windows 2.0 (Analytical Software).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Patients were aged between 28 and 65 years with 74% aged between 35 and 54 years. Forty-four (88%) were females. They generally had manual or clerical occupations including health service (n = 11), cleaning (n = 6), typing in desk jobs (n = 12, 9 of 12 typed for at least 4 h/day), catering (n = 5) and factory work (n = 16). Of those who did not have desk jobs, 32 of 35 claimed to use a high degree of hand force at work. Eighty-four percent (42/50) underwent operations on their dominant hand. Forty-nine of the 50 workers had returned to work by 3 months. Time to return to work (days of absenteeism) ranged from 1 to 88 days. We divided the workers into two groups, those with early return to work (≤21 days, n = 26), and the others who either returned to work after 21 days (n = 23) or did not return to work by the end of the follow-up period (n = 1) (Tables 1 and 2).


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  		Table 1. Predictors of delayed return to work after carpal tunnel surgery (>21 days) (continuous variables)

 

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  		Table 2. Predictors of delayed return to work after carpal tunnel surgery (>21 days) (non-parametric variables)

 
Post-operative surgeon recommendations varied widely from 1 to 36 days. The median recommendation was 21 days, with first and fourth quartile range of 14–30 days. The patients did not always follow the surgeons' advice, with 6% returning at least a week earlier and 28% returning at least a week later than advised.

On univariate analysis in predicting a delayed return to work there was no significant difference between age (years), sex (female: yes/no), BMI (kg/m2), current smoking (yes/no) and education (not completing high school: yes/no) (Tables 1 and 2). There was a trend for more chronic diseases and a significantly lower self-rated health in the delayed return to work group. Physical leisure activity was more common in those who returned earlier to work. Pre-operative functional status was nearly identical and not significantly different in the two groups (daily activities, psychological function, social function and interaction and function at work; results not shown, P > 0.10 in all cases). Also nerve conduction velocity study findings and objective functional tests were not significantly different except for the test for dexterity (PPT) which was higher in those who returned to work earlier. Job characteristics were associated with delayed return to work (Table 3), and included hard physical work, and that requiring heavy lifting.


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  		Table 3. Logistic regression and the odds of delayed return to work

 
The surgeons' recommendations were the strongest predictor of delayed return to work. Heavy physical demands and a lower self-rated health significantly added to the logistic regression model, which was highly predictive with the area under the receiver–operator curve of 88%. Patient's hand function and symptoms did not add significantly to the model.

We found that the use of considerable hand force at work, repetitive jobs and regular leisure sports activity added significantly to a logistic regression model, predicting a surgeon's recommendation for a delayed return to work [odds ratios (95% confidence interval, CI): 16.6 (1.5–180), 0.09 (0.01–0.87) and 0.20 (0.05–0.81), respectively]. Patient symptoms and objective findings did not add significantly to this model, and the area under the receiver–operator curve was 77%.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The major finding of our study was that surgeons' recommendations had a strong influence on the period of absenteeism and was not correlated with objective findings. The length of sick-leave was extremely variable and was not influenced by subjective or objective findings, either pre-operatively or 1 month post-operatively, suggesting that a great deal of the sick-leave is unnecessary. There were a few patients who returned to work earlier than recommended and nearly a quarter returned to work more than 7 days after the recommended sick-leave. Although surgeons might have taken into account characteristics of the patients' jobs, the logistic regression model was not highly predictive of the surgeons' recommendations, and the basis for the wide variation in the length of sick-leave remains unclear. It may be that the advice is not based on the physiology or the other parameters measured but other more subjective information. It is possible but unlikely that patient preferences influenced the surgeon's decision since the recommendations are written in the discharge summary usually without any face-to-face discussion.

Objective and subjective findings did not predict delayed return to work. We found that there was no difference in pinch, power and static grasp function in those who returned to work early or late. This is not consistent with the study by Braun and Jackson [10] who found that return to work times correlated well with measured functional recovery to pre-operative levels, but in their study most only returned to work after they had regained full function. At 30 days 72% of our patients had returned to work, whereas only 16% had regained full pre-operative function with regard to grip strength. Thus, our study has demonstrated that early return to physical work is possible despite the lack of complete post-operative functional recovery. Others have also reported that grip strength was reduced at 6 weeks post-operatively at a time when 50% of the patients had returned to work [18]. The association of low self-reported health with delayed return to work also suggests that factors other than the actual hand disability influence the length of sick-leave.

Self-reported physical work rather than heavy lifting or the need for a high degree of hand strength added significantly to the logistic regression model prediction of a delayed return to work. We are unaware of the results of previous studies regarding the effect of physical work on the length of sick-leave after carpal tunnel release. However, Carmona et al. [6] reported that patients exposed to higher levels of bending and twisting of their hands and wrists were slower to return to work after carpal tunnel release surgery.

We found only a statistically insignificant trend for an association between job satisfaction and delayed return to work. This is in contrast to our earlier report using identical methodology in patients undergoing cholecystecomy where those with a low job description index [13] (low job satisfaction) had nearly 13-fold increased odds of delayed return to work independent of physical work. It is logical that those who are satisfied with their job will be more likely to return earlier than those who do not like their jobs. The reason for our findings is uncertain but might be due to socio-economic differences. Those undergoing cholecystecomy had a wide range of jobs, whereas nearly all those in this study had less desirable non-professional jobs. In such workers, job satisfaction might have less meaning since they have less job choices and expectations.

Extrapolation of our results to other settings should be done with caution. Most of our subjects were female, and included predominantly office work, cleaning, catering and care work. We enrolled consecutive patients, and the female predominance in our study has been reported in other settings [19]. Also since surgery is freely available through health maintenance organizations we feel that a socio-economic selection bias is unlikely. However, disability payments in Israel are not a good alternative to employment (workers lose money), explaining the high proportion of workers who returned to work (96%) by 90 days. Thus, our results might not apply to other settings with more generous disability coverage. Also, our study used the standard open carpal tunnel release that might differ in relief of symptoms and sick-leave than alternative operations such as endoscopic carpal tunnel release. However, a systematic review of randomized clinical trials did not find any better relief of symptoms and found conflicting evidence with regard to the time to return to work and activities of daily living when comparing the various procedures [20].

We conclude that surgeon's recommendations strongly predict a delayed return to work, but that hand function is similar in those who return early or late to work. In our setting workers return to physically demanding work before full hand function is recovered. Since no negative effects of work on recovery from carpal tunnel release have been found, our study suggests that workers will return to work in less than 3 weeks if recommended to do so by their surgeon. Randomized controlled trials are warranted to determine if a higher proportion of workers returning in less than 3 weeks can be obtained by standardizing surgeons' recommendations.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. Vogt T, Scholz J. Clinical outcome and predictive value of electrodiagnostics in endoscopic carpal tunnel surgery. Neurosurg Rev 2002;25:218–221.[CrossRef][ISI][Medline]

  2. Katz HN, Keller RB, Fossel AH et al. Predictors of return to work following carpal tunnel release. Am J Ind Med 1997;31:85–91.[CrossRef][ISI][Medline]

  3. Nancollas MP, Peimer CA, Wheeler DR, Sherwin FS. Long-term results of carpal tunnel release. J Hand Surg [Br] 1995;20:470–474.[CrossRef][Medline]

  4. Adams ML, Franklin GM, Barnhart S. Outcome of carpal tunnel surgery in Washington State workers' compensation. Am J Ind Med 1994;25:527–536.[ISI][Medline]

  5. McEwan IM. Absenteeism and sickness absence. Postgrad Med J 1991;67:1067–1071.[Abstract]

  6. Carmona L, Faucett J, Blanc PD, Yelin E. Predictors of rate of return to work after surgery for carpal tunnel syndrome. Arthritis Care 1998;11:298–305.

  7. Chow JC, Hantes ME. Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique. J Hand Surg [Am] 2002;27:1011–1018.[CrossRef][Medline]

  8. Atroshi I, Johnsson R, Ornstein E. Patient satisfaction and return to work after endoscopic carpal tunnel surgery. J Hand Surg [Am] 1998;23:58–65.[Medline]

  9. Bessette L, Keller RB, Lew RA et al. Prognostic value of a hand symptom diagram in surgery for carpal tunnel syndrome. J Rheumatol 1997;24:726–734.[ISI][Medline]

  10. Braun RM, Jackson WJ. Electrical studies as a prognostic factor in the surgical treatment of carpal tunnel syndrome. J Hand Surg [Am] 1994;19:893–900.[Medline]

  11. 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. J Bone Joint Surg 1993;75A:1585–1592.[Abstract/Free Full Text]

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  13. Froom P, Melamed S, Nativ T, Gofer D, Froom J. Low job satisfaction predicts delayed return to work after laparoscopic cholecystectomy. J Occup Environ Med 2001;43:657–662.[ISI][Medline]

  14. Nathan PA, Keniston RC, Meadows KD, Lockwood RS. Validation of occupational hand use categories. Occup Med 1993;35:1034–1042.

  15. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers S. Grip and Pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69–74.[ISI][Medline]

  16. Fess EE. Documentation: essential elements of an upper extremity assessment battery. In: Hunter JM, Schneider LH, Mackin EJ, Callahan AD, eds. Rehabilitation of the Hand. St. Louis, MO: CV Mosby, 1984; 49–78.

  17. Tiffin J. Purdue Pegboard Examiner's Manual. Chicago, IL: Science Research Associates, 1987.

  18. Finsen V, Andersen K, Russwurm H. No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand 1999;70:288–292.[ISI][Medline]

  19. Tanaka S, Wild DK, Seligman PJ, Halperin WE, Behrens VJ, Putz-Anderson V. Prevalence and work-relatedness of self-reported carpal tunnel syndrome among U.S. workers: analysis of the Occupational Health Supplement data of 1988 National Health Interview Surgery. Am J Ind Med 1995;27:451–470.[ISI][Medline]

  20. Gerritsen AA, Uitdehaag BM, van Geldere D, Scholten RJ, de Vet HC, Bouter LM. Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome. Br J Surg 2001;88:1285–1295.[CrossRef][ISI][Medline]


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