CORR Insights®: Which Psychological and Electrodiagnostic Factors Are Associated With Limb Disability in Patients With Carpal Tunnel Syndrome?

Where Are We Now?

Unfortunately, we live in a society that undervalues mental and behavioral healthcare. Fewer than half of Americans with mental illness received treatment for it in 2020, and 55% of US counties have no psychiatrist practicing in them, meaning that 134 million Americans live in a designated Mental Health Professional Shortage Area [6].

Less well known, though increasingly so in more-recent years, is how emotional stress affects patient outcomes after various orthopaedic surgical procedures. In the current study, Daliri B.O. et al. [2] examine the state of our patients’ mental health and the outcome that is to be expected after carpal tunnel release. The authors found that patient scores on psychological questionnaires— the Hospital Anxiety and Depression Score and Pain Catastrophizing Scale— correlated with surgical outcomes as measured by DASH scores, while there was no correlation between electromyography and nerve conduction studies and DASH scores.

Where Do We Need To Go?

In my experience, orthopaedic surgeons pay little attention to our patients’ mental health and do a poor job of talking with them about it. Patients need to feel comfortable talking with their orthopaedic surgeon about problems other than those involving the musculoskeletal system. We delay surgery for patients with diabetes and elevated A1c levels, why not treat poor scores on questionnaires evaluating anxiety and depression as though they carry the same importance [3]?

Surgeons today still operate on patients without having a high enough index of suspicion that a problem may be factitious. Unfortunately, the diagnosis often becomes one of exclusion when surgery is unsuccessful. Why don’t we screen our patients for psychological factors, which may play a potential role in persistent pain from musculoskeletal injury or other condition? Why is this not a part of the core curriculum of most residency programs?

The authors of the current study [2] did not use the Brigham Carpal Tunnel Questionnaire because it has not been validated in the Persian language. Researchers should perform a similar study using the Brigham Carpal Tunnel Questionnaire because it is a better tool to evaluate carpal tunnel syndrome. I believe this type of study would show still worse results in patients with depression and anxiety. The more specific study to carpal tunnel would yield even worse outcomes for patients with depression and anxiety. Additionally, more articles that focus on the psychological factors like those by Lozano Calderón et al. [4], Shin et al. [7], and Vranceanu et al. [9] would be a step in the right direction as well.

Even as we look after our patients, it is important that we look after our-selves, as well as the surgical learners whose educations with which we are charged. Although the Accreditation Council for Graduate Medical Education requires residency programs to provide counseling and mental healthcare to trainees, in my experience, it is rare for residents or fellows to request any type of mental health counseling, presumably because of the stigma associated with seeing any type of counselor, psychologist, psychiatrist, or even a life coach. There remains a perception, particularly among surgical residents, that seeking any type of support for mental health is somehow a sign of weakness. Some strides have been made in terms of destigmatizing the issue of emotional distress in the eyes of the public [1, 8]; it seems to me we have not done as well within our own profession, and we ought to do so.

How Do We Get There?

Symposia and interactive sessions at international annual meetings as well as integration of communication skills into the curriculum of residency programs around the country can help orthopaedic surgeons improve their ability to recognize psychological issues with their patients.

Beyond communication, orthopaedic surgeons should be trained on how to become mentors and conduct workshops at local and regional meetings as well as in residency programs for the benefit of residents and teaching faculty. A similar approach should be taken so orthopaedic surgeons become more comfortable discussing mental health and screening for mental health issues as part of our routine history and physical exams.

One of the main barriers of screening for psychological factors like depression, anxiety, catastrophic beliefs about pain, and heightened levels of distress is that most orthopaedic surgeons feel as though such work is beyond their expertise. A recent study published in CORR [5] described a new scale, the Traumatic Injuries Distress Scale (TIDS), which predicted pain-related outcomes after acute musculoskeletal injuries. The TIDS questionnaire takes patients less than 3 minutes to complete, and the authors found that it reliably anticipated which patients who presented with noncatastrophic orthopaedic injuries were more likely still to have pain a year later [5]. Importantly, the TIDS questionnaire focuses on patients’ self-perceived relationships to pain, as well as issues of affect, intrusive thoughts, and hyperarousal [5]. While more research is needed, this type of questionnaire may remove a key barrier for orthopaedic surgeons—the feeling among orthopaedic surgeons that discussions pertaining to our patients’ mental health is beyond our expertise or scope of practice.