Occupational Medicine Advance Access originally published online on March 28, 2008
Occupational Medicine 2008 58(3):187-190; doi:10.1093/occmed/kqn034
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Factors influencing return to work after surgical treatment for carpal tunnel syndrome
Department of Orthopedic Surgery, U.Z. Pellenberg, Weligerveld 1, B-3212 Lubbeek (Pellenberg), Belgium
Correspondence to: L. De Smet, Department of Orthopedic Surgery, U.Z. Pellenberg, Weligerveld 1, B-3212 Lubbeek (Pellenberg), Belgium. Tel: +32 016 338800; fax: +32 016 338803; e-mail: luc.desmet{at}uz.kuleuven.ac.be
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Abstract |
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Background Controversy exists regarding the factors influencing the duration of work incapacity after surgically treated carpal tunnel syndrome (CTS).
Aim To determine relevant factors related to return to work.
Methods Surgical technique, clinical factors, demographic factors, other medical problems, psychosocial factors, work-related and economical factors were reviewed in patients operated on for CTS. Statistical multivariate analyses were performed to identify the baseline factors influencing the work incapacity period.
Results A total of 107 cases were reviewed. Professional exposure to repetitive movements and heavy manual handling activity were associated with a longer return-to-work interval. The duration of work incapacity period was not significantly related to the socioprofessional category of the patient (self-employed or employee) or to the type of the procedure (open versus endoscopic surgery).
Conclusion Work-related features have a more important influence on return to work than personal, pathological or surgical features.
Keywords Carpal tunnel; disability; return to work
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Introduction |
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Carpal tunnel syndrome (CTS) is the most common compression neuropathy. Different risk factors for CTS have been mentioned in the literature. Some studies have demonstrated a clear correlation between work and CTS [1–3], while other studies have concluded that there is no such correlation [4]. The work incapacity period after a carpal tunnel release is a heavy burden on the health insurance and the social security budget [5]. Physical, psychological and social features of the worker, economic incentives to return to work, the organization and social environment of the workplace and the surgical technique have been correlated with length of work absence [6–8]. Our aim was to investigate factors affecting duration of work incapacity after surgical treatment of CTS.
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Methods |
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Data for this retrospective study were obtained from the medical records and from a questionnaire, sent in May 2005 to all patients who were operated on for CTS between January 2004 and March 2005 and in whom the treatment was considered complete. All patients were seen in one medical centre. Surgery was performed by several residents and fellows, under the direct supervision of two qualified hand surgeons. We restricted this study to persons who were professionally active at the time of enrolment into the study. Students, full-time homemakers and retired or disabled persons were excluded. Other exclusion criteria for this survey were patients younger than 18 years and older than 65 years of age, pregnancy, revision carpal tunnel decompression and patients with additional upper limb pathology.
The diagnosis was mainly based on clinical features and results of electrophysiological tests. The duration of the symptoms before the carpal tunnel release was at least 1 month. The operative technique was the classic open or the one-incision endoscopic carpal tunnel decompression. The choice of operative technique was not randomized but was decided by the surgeon in mutual agreement with the patient. The procedure was performed in a day-case clinic. Post-operatively a compressive bandage was given for 6 days but immediate mobilization of the wrist and fingers was encouraged.
Demographic variables included age, sex, marital status, number of children, body mass index (BMI), smoking habits, alcohol consumption, diabetes, previous wrist trauma and wrist arthritis. Economic variables included whether patients were self-employed or employees, whether they were on sick leave because of CTS preoperatively and whether they obtained an income replacement or a social security benefit during the work incapacity period. The patient's job at the time of enrolment was obtained by questionnaire and categorized into three groups: non-manual work (i.e. delegates, teachers and salesmen), light manual work (i.e. nurses and hairdressers) and heavy manual work (i.e. technicians and farmers). Working conditions such as exposure to vibration, manual handling repetitive movements and extreme temperature conditions were also noted. General questions to determine if patients liked their job and their job environment were also asked. The form of health insurance was not taken into consideration since all patients (in Belgium), for non-work-related pathology, are covered by a similar national insurance system. The disabilities of the arm, shoulder and hand (DASH) score [9] was recorded pre- and post-operatively. We also asked if the patients would advise a carpal tunnel release to their friends or family and if they would have the same operation again. There were also some questions on wrist mobility, gripping force and scar sensitivity. The primary outcome variable was the duration of work incapacity period after carpal tunnel decompression. Where individuals had had bilateral carpal tunnel releases, each release was described in this project as a separate case. The rationale for doing this was that in these cases, the surgery was performed at separate times and at the time of enrolment into the study, we did not know that these individuals had had a previous carpal tunnel release.
Comparative statistical analysis was performed to assess any correlation between duration of work incapacity and the above variables. Univariate correlates of work incapacity due to carpal tunnel decompression were assessed with the chi-square test for categorical predictor variables. The univariate statistical analysis was performed with the student's t-test and the analysis of variance procedure. The SAS statistical package [10] was used for the multivariate stepwise regression (backwards) statistical procedures. This allows after elimination of non-significant correlations to detect the most powerful associations between variables. Significance was set at P < 0.05.
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Results |
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A total of 275 patients, 209 women (76%) and 66 men (24%), were operatively treated for CTS during the study period. In all, 332 procedures were performed. In total, 208 patients (76%) with 252 operations completed the questionnaire. A total of 107 carpal tunnel procedures fulfilled the inclusion criteria and were analysed. These procedures involved 68 women and 20 men aged between 23 and 60 (average age: 48 years, SD = 8).
Statistically significant findings with reference to the relationship between variables and the duration of work absence are summarized in Table 1. Gender, BMI, marital status, number of children, involved side, smoking, alcohol intake, wrist fracture, wrist arthritis, operative procedure, exposure to vibration, job satisfaction and job environment satisfaction were not significantly correlated with the duration of work absence. General clinical outcomes and post-operative symptoms are summarized in Table 2. Ninety-two per cent of patients stated that they would have the same operation again and would recommend carpal tunnel release to their family and friends. The overall duration of work incapacity was 34 days (SD = 24). The average DASH score preoperatively was 36 and the average DASH score post-operatively was 18. The mean decrease of the DASH score was 15 (P < 0.05). The results of the multivariate statistical analysis showed a non-significant correlation between duration of work absence and the technique of decompression (open versus endoscopic), involved side, smoking, drinking habits, diabetes, BMI, arthritis, wrist fracture, marital status, number of children, duration of the symptoms preoperatively, self-employed versus employed, duration of the last job, job satisfaction and job environment satisfaction. The variables which proved significant for duration of work incapacity after the multivariate stepwise regression analysis are shown in Table 3. The strongest significant correlation is found between the duration of work incapacity and job classification (non-manual, light manual and heavy manual job) (P < 0.01). Other significant correlations were gender (shorter time off work for women), exposure to vibrations, repetitive movements (P <0.05) and persistence of scar tenderness (P < 0.05).
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Discussion |
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In this survey, we found that a longer duration of work incapacity was significantly related to patients performing manual work, patients with professional exposure to repetitive movements, scar tenderness and gender. Exposure to vibration was not related to a longer work incapacity (Table 3). Our results support the thesis that the duration of work incapacity after carpal tunnel decompression is multifactorial, mostly based on job requirements.
The strengths of the study are the unbiased community-based recruitment patient group and the relatively large sample group. The weaknesses in this study are the possibility of selection bias based in the way that cases were chosen. However, we did try to apply strict and rigid selection criteria to mitigate against this. Job strain was poorly defined and the timing of follow-up was variable. Further studies with better definitions of the cohort, the job type and strain and an evaluation at a fixed time post-operatively may be helpful.
The meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression of Thoma et al. [11] concluded that the data are inconclusive, relating to symptom relief and return to work. Endoscopic treatment is proposed on the belief that this technique will give a less sensitive scar and a shorter work incapacity period. Our study could not find a statistically significant difference between the performed operative technique and the duration of return-to-work interval.
Nathan and Keniston [6] showed that the most important factor from the point of view of the return-to-work interval after surgery was the quality of the post-operative rehabilitation, and in this study, the author demonstrated a direct link with the patient's motivation. In our study, the correlation between the duration of work incapacity and job satisfaction or job environmental situation was not significant. Another important factor in the study of Nathan and Keniston [6], Chaise et al. [5] and Carmona et al. [7] was the patient's type of social insurance compensation. Patients covered by workers compensation returned to work much later than those with a private insurance. In this survey, we were unable to investigate this as the social security system was similar for all workers.
In other studies on CTS, Cheadle et al. [8] found a statistically significant correlation with scar tenderness, period of preoperative work incapacity and symptom severity score preoperatively. Butterfield et al. [4] analysed predictors of return to work following carpal tunnel release in 196 workers in sickness benefit compensation. The most important predictors for length of work absence included the patient's perception that their income was inadequate, involvement of an attorney, lower education and bilateral surgery. Greater occupational exposure to repetitive motion and forceful exertions had a borderline significant risk (<0.01). In this survey, reduced force and stiffness post-operatively, personal factors (BMI, health status, marital status and number of children), duration of the symptoms preoperatively and psychological factors (job satisfaction and job environmental satisfaction) were not correlated to the duration of work incapacity. Dias et al. [1] concluded that even if work does not cause the CTS, its effect on workers may be profound and that there was no clear association between CTS and work. Amick et al. [12] studied successful work role functioning after CTS surgery. At 2 months, post-operatively patient's depression and workmen's compensation were predictors of prolonged sick leave and at 6 months, improved self-efficacy and a supportive work organization were positive predictors.
In our results, working conditions and the type of work are more important than surgical technique, individual patient characteristics (except gender) and severity of the neurocompression. The implication for clinicians and policymakers are straightforward. Return to work is influenced by working conditions rather than the medical situation. Efforts to shorten the post-operative period of absence should concentrate on adapting the work environment and resettling individuals back to work progressively.
Key points
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None declared.
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References |
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