340
improved scores have been reported for both DASH domains at 3 months [ 56 ] and
at 6 months follow-up post-CT decompression surgery [ 57 ]. In another study, which
included 40 patients undergoing carpal tunnel decompression surgery, Gay et al.
[ 32 ] found DASH to have greater responsiveness than the Short Form Health Survey
36 (SF-36) but not BCTQ. In another study, Kotsis et al. [ 43 ] reported moderate
responsiveness for DASH after carpal tunnel release surgery. However, two dimen-
sions of the Michigan Hand Outcome questionnaire (Pain and Satisfactions) were
found to be more responsive than the DASH. In contrast, Heebner and Roddey [ 58 ],
in a randomized controlled trial of CTS patients, recorded that the DASH was not
able to detect any signifi cant changes between the standard treatment group and the
intervention group. However, this could be as a result of the effectiveness of the
intervention, rather than the responsiveness of the DASH.
Patient Reported Outcome Measures and Quality of Care
in Carpal Tunnel Syndrome Management
Patient-reported outcomes measures are a critical component of assessing whether
the patients’ health is improving in response to management provided by health care
professionals. In contrast to standard process measures, which capture the clini-
cian’s productivity and adherence to the guidelines of recommended care, or patient
experience measures, which focus on the patients’ journey and aspects of care deliv-
ery, PROMs attempt to capture whether the services provided actually improved
patients’ health and sense of well-being. Figure 13.1 shows aspects where PROMs
can play a role in the management of CTS patients. This includes:
PROMs as Predictors of CTS Underlying Pathology
The diagnosis of CTS is based primarily on clinical manifestations elicited on both
taking history and physical examination. The commonest symptom is paresthesia in
the median nerve distribution (mainly lateral fi ngers of the hand). Other symptoms
include clumsiness and weakness in the affected hand, which tend to get worse with
activity. However, symptoms may vary according to the underlying pathology.
Proximal radiation of pain or paresthesia to the elbow usually indicates tenosynovi-
tis of the fl exors of the hand (Fig. 13.2 ). This usually occurs in combination with
worsening of pain and paresthesia at night, which may wake up the patient from
sleep. These symptoms refl ect the state of engorgement and relative venostasis in
the small blood vessels within the fl exor tendons synovial sheath, producing swell-
ing, and further compression on the nerve within the tunnel (Fig. 13.3 ) [ 1 , 21 ].
Active movement of the fi ngers and wrist or shaking the hands decreases venous
engorgement and relieves pain, a phenomenon commonly reported in several
Y. El Miedany