Abstract
Purpose
Long-established patient-reported outcome measures (PROMs), such as the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) and the QuickDASH, have been used traditionally to measure baseline symptoms and treatment effects before and after carpal tunnel release (CTR), but more recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been used increasingly in the CTR patient population. We aimed to measure the correlation between legacy and PROMIS PROMs for baseline pain and function in a cohort of patients undergoing CTR for idiopathic carpal tunnel syndrome (CTS).
Methods
Baseline PROMs were collected prospectively in 86 patients with electrodiagnostically confirmed CTS treated with CTR at a single tertiary referral center. The legacy PROMs used were the BCTQ and the QuickDASH. The PROMIS instruments used were computer adaptive test versions of the PROMIS Pain Interference (PI), Upper Extremity (UE), and Physical Function (PF). Given normal distributions, correlation between PROMs was assessed using the Pearson correlation coefficient.
Results
The mean age of the cohort was 59.7 years, and 56% were women. When assessing pain, the BCTQ – Symptom Severity Scale (SSS) was correlated moderately with PROMIS – PI (ρ = 0.59). When assessing function, the BCTQ – Functional Status Scale (FSS) was strongly inversely correlated with PROMIS – UE (ρ = −0.71) and moderately inversely correlated with PROMIS – PF (ρ = −0.58). The QuickDASH was strongly inversely correlated with PROMIS – UE (ρ = −0.75) and moderately inversely correlated with PROMIS – PF (ρ = −0.62). Finally, when comparing the two legacy PROMs for function, the BCTQ – FSS was strongly correlated with QuickDASH (ρ = 0.88).
Conclusions
We demonstrated at least moderate correlation between legacy and PROMIS outcome measures of baseline pain and function in CTS patients.
Clinical Relevance
Our findings support the use of either legacy or PROMIS outcome measures for this patient population.
Key words: Boston carpal tunnel questionnaire, Carpal tunnel syndrome, Carpal tunnel release, Patient-reported outcome measure, PROMIS, QuickDASH
Patient-reported outcome measures (PROMs) are important tools in hand surgery clinical care and research. The PROMs allow clinicians and scientists to measure patients’ symptoms reliably and track these symptoms over time, thereby measuring treatment effects.1 The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health approximately 20 years ago as a general, validated PROM that can be applied and compared across health care specialties, with domains relevant to the physical, mental, and social aspects of health. The PROMIS has been standardized across domains and diseases and can be administered in a number of ways, including with computer adaptive tests.2
Carpal tunnel syndrome (CTS) is the most common upper-extremity compressive neuropathy, affecting between 3% and 5% of the general population.3,4 Carpal tunnel release (CTR) is a safe and effective surgical treatment option for CTS.5 Legacy PROMs have been used traditionally to measure baseline symptoms and treatment effects of CTR, but recently, PROMIS has been used increasingly in the CTR patient population.5, 6, 7, 8, 9 There are few direct comparisons of legacy and PROMIS outcome measures.10, 11, 12
With this rationale, we performed a single-institution prospective study of patients undergoing isolated, unilateral CTR for idiopathic CTS. Multiple legacy and PROMIS outcome measures were obtained before surgery to assess baseline pain and dysfunction. The objective of this study was to measure the correlation between legacy and PROMIS outcome measures for (1) pain and for (2) function in a CTR patient population. Based on prior literature,11,12 we hypothesized that moderate-to-strong correlations exist between legacy and PROMIS outcome measures for pain and function for this common hand pathology.
Methods
Cohort identification
Institutional review board approval was obtained for this study. Patients undergoing CTR for idiopathic CTS from January 2023 to October 2024 were identified before surgery and administered a battery of legacy and PROMIS outcome measures. Inclusion criteria were adult patients with electrodiagnostically confirmed idiopathic CTS who underwent isolated, unilateral mini-open CTR during the study period by 1 of 3 surgeons at a single tertiary referral institution. If patients underwent staged bilateral CTR during the study period, only the first side was included to maintain the assumption of independent events. Exclusion criteria included concomitant procedure, lack of electrodiagnostic confirmation, not completing the study questionnaires, or completing the study questionnaires but not proceeding with surgery.
During the study period, 101 patients completed the full battery of preoperative outcome measures. Of these 101 patients, 15 were excluded (5 patients underwent a separate concomitant procedure at the time of CTR, five lacked preoperative confirmatory electrodiagnostic studies, two lacked an electrodiagnostic study report, two did not proceed with surgery, and one had a normal electrodiagnostic study). The remaining 86 patients comprised our final study cohort.
PROMs
The legacy PROMs were the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), which is subdivided into the Symptom Severity Scale (SSS) and Functional Status Scale (FSS), and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). The PROMIS instruments were computer adaptive test versions of the PROMIS Bank v1.1 Pain Interference (PROMIS – PI), the PROMIS Bank v2.0 - Upper Extremity (PROMIS – UE), and the PROMIS Bank v2.0 - Physical Function (PROMIS – PF). All PROMs were collected before surgery, after confirmatory electrodiagnostic studies and before surgery.
Additionally, the following variables were collected from the electronic medical record: age, sex, dominant hand surgery, comorbid diabetes mellitus, current smoking, and electrodiagnostic disease severity (mild, moderate, or severe) by the Werner and Andary criteria.13
Statistical analysis
Descriptive statistics were calculated. All data sets were complete. The parametricity of continuous variables was tested and all were normal (|skewness| < 0.5). Given normal distributions, correlation between PROMs was assessed using the Pearson correlation coefficient. Strength of correlation was defined as follows: ρ < 0.19, very weak; ρ = 0.2–0.39, weak; ρ = 0.40–0.59, moderate; ρ = 0.6–0.79, strong; and ρ > 0.8, very strong.14 The standard significance criterion of α = 0.05 was used. Our power analysis showed that a sample size of 47 subjects is sufficient to yield >80% power to detect a significant association between PROMs, conservatively assuming a weak correlation effect (ρ = 0.40).
Results
Cohort characteristics
Our study cohort comprised 86 patients who underwent isolated CTR for idiopathic CTS. The mean age of the cohort was 59.7 years, and 56% were women. Fifteen percent had diabetes mellitus, and 6% were active smokers. Preoperative confirmatory electrodiagnostic studies demonstrated mild CTS in 21% of patients, moderate in 60% of patients, and severe in 19% of patients (the Table).
Table.
Characteristics of the study cohort
| Patients (n = 86) | |
|---|---|
| Mean (SD) | |
| Age (y) | 59.7 (13.1) |
| BCTQ – SSS | 3.0 (0.7) |
| BCTQ – FSS | 2.3 (0.8) |
| QuickDASH | 61.4 (20.2) |
| PROMIS – PI | 57.4 (7.4) |
| PROMIS – UE | 37.1 (8.9) |
| PROMIS – PF | 45.5 (8.6) |
| n (%) | |
| Female sex | 48 (56) |
| Caucasian race | 84 (98) |
| Dominant hand | 52 (60) |
| Diabetes mellitus | 13 (15) |
| Current smoking | 5 (6) |
| EDS severity | |
| Mild | 18 (21) |
| Moderate | 52 (60) |
| Severe | 16 (19) |
EDS, electrodiagnostic study.
PROMs
Preoperative pain was assessed using the BCTQ – SSS and PROMIS – PI. The mean BCTQ – SSS was 3.0. The mean PROMIS – PI was 57.4.
Preoperative function was assessed using the QuickDASH, PROMIS – UE, and PROMIS – PF. The mean QuickDASH was 61.4. The mean PROMIS – UE was 37.1. The mean PROMIS – PF was 45.5 (the Table).
Correlation between PROMIS and legacy PROMs
When assessing patient-reported measures of pain, the BCTQ – SSS was moderately correlated with PROMIS – PI (ρ = 0.59, P < .05; Fig. 1).
Figure 1.
Scatter plot with trend line depicting the relationship between BCTQ-SSS and PROMIS – PI.
When assessing patient-reported measures of function, the BCTQ – FSS was strongly negatively correlated with PROMIS – UE (ρ = −0.71, P < .05; fig. 2) and moderately negatively correlated with PROMIS – PF (ρ = −0.58, P < .05; fig. 3). The QuickDASH was strongly negatively correlated with PROMIS – UE (ρ = −0.75, P < .05; fig. 4) and moderately negatively correlated with PROMIS – PF (ρ = −0.62, P < .05; fig. 5). Finally, when comparing the two legacy PROMs for function, the BCTQ – FSS was strongly correlated with QuickDASH (ρ = 0.88, P < .05; fig. 6).
Figure 2.
Scatter plot with trend line depicting the relationship between BCTQ-FSS and PROMIS – UE.
Figure 3.
Scatter plot with trend line depicting the relationship between BCTQ-FSS and PROMIS – PF.
Figure 4.
Scatter plot with trend line depicting the relationship between QuickDASH and PROMIS – UE.
Figure 5.
Scatter plot with trend line depicting the relationship between QuickDASH and PROMIS – PF.
Figure 6.
Scatter plot with trend line depicting the relationship between BCTQ-FSS and QuickDASH.
Discussion
Carpal tunnel release is a common, safe, and effective surgical treatment for CTS.15,16 A number of options exist for PROMs when measuring baseline symptoms and treatment effect in the CTR patient population, with a recent shift toward PROMIS and away from legacy PROMs.2,10 In this study, we assessed multiple PROMs to measure the correlation between legacy and PROMIS outcome measures for pain and dysfunction in a CTR patient population. We found at least moderate correlations in measures of pain and function between legacy and PROMIS outcome measures in this population.
Our findings support the prior published literature on the relationship between legacy and PROMIS outcome measures in CTS. Kortlever et al.11 compared nerve-specific (Impact of Hand Disorders), condition-specific (BCTQ and/or Patient-Rated Ulnar Nerve Evaluation), and upper extremity-specific (PROMIS PF-UE-7) PROMs in 150 patients with upper-extremity compressive neuropathies, finding moderate-to-strong correlations between PROMs. Phillips et al.12 studied baseline PROMs in 51 patients with electrodiagnostically confirmed CTS and found excellent (ρ = −0.76) correlation between PROMIS – UE and QuickDASH and good (ρ = −0.58) correlation between PROMIS – UE and BCTQ. They used a smaller sample size and did not subdivide BCTQ into symptom and function subdomains. By subdividing the BCTQ into respective domains, we were able to compare PROMs aimed specifically at patient function with one another. In our study, by specifically correlating BCTQ – FSS with PROMIS – UE, we found a stronger correlation (ρ = −0.71). Finally, Cizik et al.10 studied 18,944 non-shoulder hand and upper-extremity patients and developed crosswalk tables between PROMIS – UE and QuickDASH. They found strong (ρ < −0.80) linear relationships between PROMIS – UE and QuickDASH, but of note, their findings were not specific to CTS.
There are several considerations when choosing between PROMs for a condition such as CTS, as each outcome measure has advantages and disadvantages. First, the questionnaire must be comprehensible by patients to measure the intended effect. A qualitative study by Azad et al.17 highlighted common difficulties patients encountered when interpreting the questions on PROMIS – UE, although this issue is unlikely to be isolated to PROMIS – UE. Second, it is important that the outcome measure reflects patients’ symptoms and complaints.18,19 A prospective study of 133 hand surgery patients on the applicability of QuickDASH questions to their upper-extremity condition and daily life found that QuickDASH may not optimally evaluate patients with mild disability and low pain interference.19 Lastly, it is important that the outcome measure accurately reflects treatment effect. Bernstein et al.6 reported on 156 patients who underwent CTR and found that while 74% reported symptomatic improvement by the first postoperative visit, this improvement was not captured by PROMIS. Rather, PROMIS – UE, PROMIS – PF, and PROMIS – PI all remained worse than before surgery, although not to a clinically significant degree.
Our findings should be interpreted in the context of several limitations. First, while we have studied multiple common legacy and PROMIS outcome measures for CTS, there are others that we did not include. These include the visual analog scale for pain, the Michigan Hand Outcomes Questionnaire, and the Patient-Rated Wrist/Hand Evaluation.20 Second, our study was performed at a single metropolitan tertiary referral center. Our cohort exhibited relatively poor baseline functional scores compared to prior publications.21,22 This may limit the generalizability of our findings to other practice settings. Third, we did not exclude patients for the existence of other symptomatic upper-extremity pathologies, which may have influenced PROMs. Finally, we did not specifically study the effects of socioeconomic well-being or mental health on PROMs. Although we do not expect this information to change the correlations that we found, it is possible that the correlation between legacy and PROMIS outcome measures is moderated by mental health or social deprivation.11,23, 24, 25 Future studies of the responsiveness of these instruments in a population undergoing CTR would be beneficial to guide PROM selection.
In a cohort of patients undergoing CTR for electrodiagnostically confirmed idiopathic CTS, we have demonstrated at least moderate correlation between legacy and PROMIS outcome measures of baseline pain and function. We found moderate correlations between BCTQ – SSS and PROMIS – PI, BCTQ – FSS and PROMIS – PF, and QuickDASH and PROMIS – PF. We found strong correlations between BCTQ – FSS and PROMIS – UE as well as QuickDASH and PROMIS – UE. Our findings support the use of either set of PROMs for a CTR patient population based on preference.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.”
Acknowledgments
The work was funded by AFSH Clinical Research Grant Award #3956. No portion of this work has been previously presented or published.
References
- 1.Kane L.T., Abboud J.A., Plummer O.R., Beredjiklian P.T. Improving efficiency of patient-reported outcome collection: application of computerized adaptive testing to DASH and QuickDASH outcome scores. J Hand Surg Am. 2021;46(4):278–286. doi: 10.1016/j.jhsa.2020.10.021. [DOI] [PubMed] [Google Scholar]
- 2.Hammert W.C., Calfee R.P. Understanding PROMIS. J Hand Surg Am. 2020;45(7):650–654. doi: 10.1016/j.jhsa.2020.03.016. [DOI] [PubMed] [Google Scholar]
- 3.Atroshi I., Gummesson C., Johnsson R., Ornstein E., Ranstam J., Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158. doi: 10.1001/jama.282.2.153. [DOI] [PubMed] [Google Scholar]
- 4.Gelfman R., Melton, Yawn B.P., Wollan P.C., Amadio P.C., Stevens J.C. Long-term trends in carpal tunnel syndrome. Neurology. 2009;72(1):33–41. doi: 10.1212/01.wnl.0000338533.88960.b9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Louie D.L., Earp B.E., Collins J.E., et al. Outcomes of open carpal tunnel release at a minimum of ten years. J Bone Joint Surg Am. 2013;95(12):1067–1073. doi: 10.2106/JBJS.L.00903. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Bernstein D.N., Englert C.H., Hammert W.C. Evaluation of PROMIS' ability to detect immediate postoperative symptom improvement following carpal tunnel release. J Hand Surg Am. 2021;46(6):445–453. doi: 10.1016/j.jhsa.2021.02.011. [DOI] [PubMed] [Google Scholar]
- 7.Levine D.W., Simmons B.P., Koris M.J., et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75(11) doi: 10.2106/00004623-199311000-00002. 1585–1192. [DOI] [PubMed] [Google Scholar]
- 8.Zhang D., Blazar P., Earp B.E. The effect of socioeconomic disparity on improvement in QuickDASH at 3 months after carpal tunnel release. Plast Reconstr Surg Glob Open. 2023;11(3) doi: 10.1097/GOX.0000000000004878. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Zhang D., Earp B.E., Blazar P. Carpal tunnel syndrome electrodiagnostic severity is not associated with PROMIS upper extremity, PROMIS pain interference and PROMIS pain intensity. J Hand Surg Asian Pac Vol. 2024;29(1):17–23. doi: 10.1142/S2424835524500036. [DOI] [PubMed] [Google Scholar]
- 10.Cizik A.M., Zhang C., Presson A.P., Randall D., Kazmers N.H. Linking QuickDASH and PROMIS upper-extremity computer-adaptive test scores in hand surgery: a crosswalk study. J Hand Surg Am. 2024;49(7):664–674. doi: 10.1016/j.jhsa.2024.04.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kortlever J.T.P., Somogyi J.R., Ring D., Reichel L.M., Vagner G.A. A comparison of nerve-specific, condition-specific, and upper extremity-specific patient-reported outcome measures in patients with carpal and cubital tunnel syndrome. J Hand Surg Am. 2022;47(8):791.e1–791.e10. doi: 10.1016/j.jhsa.2021.07.013. [DOI] [PubMed] [Google Scholar]
- 12.Phillips J.L.H., Freedman M.K., Simon J.I., Beredjiklian P.K. The PROMIS upper extremity computer adaptive test correlates with previously validated metrics in patients with carpal tunnel syndrome. Hand (N Y) 2021;16(2):164–169. doi: 10.1177/1558944719851182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Werner R.A., Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve. 2011;44(4):597–607. doi: 10.1002/mus.22208. [DOI] [PubMed] [Google Scholar]
- 14.BMJ Correlation and regression. The BMJ. https://www.bmj.com/about-bmj/resources-readers/publications/statistics-square-one/11-correlation-and-regression available at:
- 15.Atroshi I., Hofer M., Larsson G.U., Ranstam J., Bertelsmann F.W., de Krom M.C.T.F.M., Bouter L.M. Extended follow-up of a randomized clinical trial of open vs endoscopic release surgery for carpal tunnel syndrome. JAMA. 2015;314(13):1399–1401. doi: 10.1001/jama.2015.12208. [DOI] [PubMed] [Google Scholar]
- 16.Gerritsen A.A.M., de Vet H.C.W., Scholten R.J.P.M., et al. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA. 2002;288(10):1245–1251. doi: 10.1001/jama.288.10.1245. [DOI] [PubMed] [Google Scholar]
- 17.Azad C.L., Beres L.K., Wu A.W., Giladi A.M. Patient interpretations vary for questions in the Patient-Reported Outcomes Measurement Information System Upper Extremity. J Hand Surg Eur Vol. 2023;48(7):654–660. doi: 10.1177/17531934231162738. [DOI] [PubMed] [Google Scholar]
- 18.Brodke D.J., Zhang C., Shaw J.D., Cizik A.M., Saltzman C.L., Brodke D.S. How Do PROMIS scores correspond to common physical abilities? Clin Orthop Relat Res. 2022;480(5):996–1007. doi: 10.1097/CORR.0000000000002046. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Siebert M.J., Roca H., Maughan G., et al. Evaluating factors associated with patient-perceived applicability of the QuickDASH survey in reflecting their goals of care before hand surgery. J Hand Surg Am. 2024 Jan;49(1):35–41. doi: 10.1016/j.jhsa.2023.09.013. Erratum in: J Hand Surg Am. 2024;49(3):283. [DOI] [PubMed] [Google Scholar]
- 20.Hoogendam L., Koopman J.E., van Kooij Y.E., et al. the Hand-Wrist Study Group What are the minimally important changes of four commonly used patient-reported outcome measures for 36 hand and wrist condition-treatment combinations? Clin Orthop Relat Res. 2022;480(6):1152–1166. doi: 10.1097/CORR.0000000000002094. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hubbard J., Rogers M.J., Cizik A.M., Zhang C., Presson A.P., Kazmers N.H. Establishing the patient acceptable symptom state in a nonshoulder hand and upper extremity population for the QuickDASH and PROMIS UE computer adaptive tests. J Hand Surg Am. 2024;49(3):282.e1–282.e212. doi: 10.1016/j.jhsa.2022.07.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hubbard J.C., Zhang Y., Qiu Y., et al. Establishing the substantial clinical benefit in a non-shoulder hand and upper extremity population for the QuickDASH and PROMIS upper extremity and physical function computer adaptive tests. J Hand Surg Am. 2022;47(4):358–369.e3. doi: 10.1016/j.jhsa.2021.12.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Bernstein D.N., Kurucan E., Fear K., Hammert W.C. Evaluating the impact of patient social deprivation on the level of symptom severity at carpal tunnel syndrome presentation. Hand (N Y) 2022;17(2):339–345. doi: 10.1177/1558944720928487. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Zhang D., Earp B.E., Blazar P. Association of economic well-being with comorbid conditions in patients undergoing carpal tunnel release. J Hand Surg Am. 2022;47(12):1228.e1–1228.e7. doi: 10.1016/j.jhsa.2021.09.012. [DOI] [PubMed] [Google Scholar]
- 25.Zimmerman M., Hall E., Carlsson K.S., Nyman E., Dahlin L.B. Socioeconomic factors predicting outcome in surgically treated carpal tunnel syndrome: a national registry-based study. Sci Rep. 2021;11(1):2581. doi: 10.1038/s41598-021-82012-x. [DOI] [PMC free article] [PubMed] [Google Scholar]