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CORR Insights®: Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability

2022; Lippincott Williams & Wilkins; Volume: 480; Issue: 6 Linguagem: Inglês

10.1097/corr.0000000000002162

1528-1132

Kalpit N. Shah,

Nerve Injury and Rehabilitation

Where Are We Now? As the most common peripheral compression neuropathy, affecting roughly 5% to 7% of the adult population, carpal tunnel syndrome is a household term that most adults in the United States have likely heard about [1]. I remember being a medical student and later a junior resident learning about the pathophysiology, treatment options, and surgical technique for the release—everything just made sense. I was fascinated by the degree to which surgeons had this entity figured out. Later, as I progressed to being a senior resident and then a hand surgery fellow, I learned of the nuances associated with the differences between disease and the severity of patient symptoms. The more recent focus on understanding the interplay between pathology and factors such as mental and psychosocial health has improved our understanding of these nuances [3, 4, 7]. The diagnosis of carpal tunnel syndrome, particularly severe neuropathy, is often made clinically without electrodiagnostic testing [2]. As such, it is important to understand the factors clinicians rely on to make the diagnosis and assess the role those subjective complaints of incapability play in the diagnosis. The rationale is that if these complaints are interpreted as indicating severe dysfunction of the median nerve, then these patients might be offered carpal tunnel release without potential benefit. Sarwar et al. [5] surveyed 93 surgeons and asked them to rate the severity of idiopathic carpal tunnel syndrome in seven fictitious patients with randomized findings including objective examination findings and subjective incapability, defined as the presence or absence of perceived limitations to daily activities. The authors reported that surgeons use specific signs and symptoms (namely, palmar abduction weakness, longer duration of symptoms, splint that no longer relieves symptoms, constant numbness, provocative physical examination test with a positive result, and older age) to rate the severity of carpal tunnel syndrome in these vignettes but not the presence or absence of incapability. The authors concluded that surgeons use objective findings to rate the severity of idiopathic carpal tunnel syndrome and are not distracted by the incapability the patients may express. In line with what this study suggests, surgeons should continue devising treatment strategies for carpal tunnel syndrome based on the patient’s objective findings, but careful thought must also be given to addressing the psychosocial elements of the patient’s presentation. Some strategies for the latter might include active listening, offering empathy, and perhaps tactfully suggesting a referral to mental and social health resources if the patient is open to the suggestion. Where Do We Need to Go? The authors [5] should be commended for their efforts to better understand the nuances of tying objective findings to subjective patient complaints to form a clinical assessment. It was reassuring to see that the group of surgeons included in the study considered the factors we have all been taught to focus on as the ones that are the most valuable in assessing severity. However, the Hawthorne effect should be considered when interpreting the results of this study. The Hawthorne effect is defined as a change in behavior that stems from the fact that the subject is being observed [6]. The name is derived from a study at the Hawthorne Plant of the Western Electric Company in Cicero, Illinois, in the 1920s. Workers at the plant increased their productivity when they were being observed during the study, but productivity declined when the study finished [6]. In the study by Sarwar et al. [5] in this month’s Clinical Orthopaedics and Related Research®, the Hawthorne effect may particularly be in play because the group of surgeons was surveyed on their assessment of disease severity under the premise of studying the non-objective methods influencing patient evaluation and its effect on the surgeon’s decision-making process. In the current study [5], incapability, defined as the presence or absence of physical activity, was a small portion of the patient vignettes. But from clinical experience, we know that the said incapability often dominates the conversation in patients with potential mental and social health issues that need attention. Understanding the mechanisms of severity assessment in a clinical, real-world context may provide further validation of this study or perhaps point to areas that we, as clinicians, need to focus our efforts on in order to remain objective. This study brought forth another issue that warrants further exploration. Even if the clinicians who took the survey did not use physical incapability in their personal formula of severity assessment, they are still entrusted to care for patients who are incapacitated by carpal tunnel syndrome. Patients seek counsel for their issues, without necessarily appreciating which portions are objective and which are subjective. How do we help those who are not as resilient, easily overwhelmed, and quick to become incapacitated? Strategies to help surgeons demonstrate empathy without offering invasive solutions are not explicitly taught in our current surgical training, but that ability is as important to master as dividing the transverse carpal ligament. How Do We Get There? Although it would be substantially more resource-intensive, a simulated or real patient encounter where the surgeon is blinded to which patient is being studied may be another way to answer these authors’ questions and confirm the findings in this experimental study with some observations in a clinical setting. This may uncover ways in which clinicians assess symptom severity when treating patients with underlying mental and social health issues that thwart the use of adequate coping mechanisms. Arming clinicians with strategies for treating patients with psychosocial and mental health issues may provide major benefits in treating not only the carpal tunnel syndrome but also the “whole” patient. Seminars with mental health professionals or short courses on helping these patients would help the clinician acquire that skillset. Observational studies before and after such courses and seminars, using validated assessment tools, would be necessary to quantify the benefits gained from such clinician-directed interventions. Patient-reported outcomes that are focused on patient satisfaction from clinical visits before and after the above-mentioned interventions might further help assess their utility. Finally, ensuring that clinicians are aware of institutional or community resources to help those with psychosocial and mental health issues would help us provide wholistic patient care.