CORR Insights®: Which Psychological Variables Are Associated With Pain and Function Before Surgery for de Quervain’s Tenosynovitis? A Cross-sectional Study

Where Are We Now?

Blackburn and colleagues [2] studied patients who chose surgery for de Quervain tendinopathy and confirmed that unhealthy thoughts increase symptom intensity and the magnitude of limitations [5, 12]. Cognitive errors and cognitive biases, such as: “The pain means I’m injured”, “It’s taking too long …”, “I’m making it worse …”, and “It won’t get better without surgery …” make people feel worse. Indeed, other studies have shown that these cognitive errors and biases may increase the number of visits [4] and the likelihood of choosing surgery [3].

It’s my impression that surgeons approach this condition with a set of biases. First among them is that this condition is permanent; in fact, it may be self-limiting [9, 13]. Second, that non-surgical treatment is somehow disease-modifying; this may not be true [8] and in fact, some kinds of non-surgical treatment (in particular, injections) are associated with a higher likelihood of a patient progressing to surgery [9]. Finally, and most importantly, that a large proportion of patients who have this condition will benefit from surgery; in our study [9], we found that the large majority of patients can be managed quite well without any surgery, provided that the patients were counseled adequately up front about the disease’s trajectory. This approach resulted in a much lower likelihood that a patient would have surgery [9, 13].

Where Do We Need To Go?

People with de Quervain tendinopathy stand to benefit from more data on the natural history of this disease and the ability of treatments to alleviate symptoms (palliative treatments) or alter the natural history (disease-modifying treatments) better than placebo treatment. Non-specific effects such as regression to the mean and the placebo effect seem to have a particularly strong influence on the perceived effectiveness of treatments for self-limiting conditions. In other words, it’s easy to believe, but difficult to prove, that a treatment for a self-limiting disease is palliative or disease-modifying. In my opinion, lacking solid evidence to the contrary, it may be wise to move forward with the principle that de Quervain tendinopathy resolves on its own in order to limit both false hope and reinforcement of cognitive error and bias.

If evidence continues to suggest that de Quervain tendinopathy is a self-limited condition [9, 13], lasting about a year on average, and with no disease-modifying treatments other than surgery available, both people seeking and people providing care will need to address the cognitive errors and biases common to atraumatic painful conditions. Based on my experience and research, if a problem resolves on its own, most people will choose to wait it out, even if it takes a year or so [8-10, 13, 14]. For self-limiting diseases, a person can choose to limit activity or continue as usual—it all depends on their desired balance between comfort and activity. The same goes for splints. To keep active and comfortable while waiting for this condition to resolve, people will benefit from an adeptness at being curious and reflective about the mind’s initial reactions to the pain of de Quervain tendinopathy. These initial thoughts can be described as gut feelings, intuition, or gestalt. Daniel Kahneman, in his book, Thinking, Fast and Slow, describes it as system 1 (automatic thought) [11]. I like thinking about it as my mind’s “first draft.” People who approach their initial response to a painful condition as a first draft, anticipating some changes in an inquisitive and thoughtful editing process, tend to have less pain and fewer limitations. As with most skills, an adeptness at the “editing” process improves with training and practice.

How Do We Get There?

The evidence from the current study and other ones suggests that a healthy inner narrative about de Quervain can alleviate symptoms and limitations [1, 6, 7, 15]. Surgery can be a reasonable choice at any time no matter the stress level. What we need to limit is a choice for surgery based on misconceptions rather than on what matters most to a person (his or her values). A choice for surgery can represent under-diagnosis and under-treatment of mental and social health opportunities that are associated with biased or erroneous thoughts leading to decisions not consistent with one’s values.

Anticipating that such errors and biases are a basic element of the human mind’s response to pain, we can help reorient people to a more-balanced and calm understanding of the problem while avoiding reinforcing the mind’s most-common misconceptions. We can anticipate that people in pain will feel somewhat injured, vulnerable, and action-oriented. Our treatment strategies can be planned and scripted to address these biases and errors. We can make sure that publicly available expertise about de Quervain tendinopathy is available to potentially “edit” each person’s inner narrative. We can provide people with decision aids intended to establish trust, restore hope, provide balanced information, and correct common misconceptions. It might also help to encourage front-line clinicians to avoid reinforcement of common misconceptions with their language such as “tear”, “injury”, “over-use”, or “failed” and habits (unhelpful tests and treatments). In addition, we can incrementalize care so that neither we nor the people seeking our care feel pressured to make all the decisions about management in a single, brief, specialty visit.