Scientific article| Volume 44, ISSUE 4, P335.e1-335.e9, April 2019

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Mental and Physical Health Disparities in Patients With Carpal Tunnel Syndrome Living With High Levels of Social Deprivation


      Social, mental, and physical health have a complex interrelationship with each influencing individuals’ overall health experience. Social circumstances have been shown to influence symptom intensity and magnitude of disability for a variety of medical conditions. We tested the null hypothesis that social deprivation would not impact Patient-Reported Outcomes Measurement Information System (PROMIS) scores or objective health factors in patients presenting for treatment of carpal tunnel syndrome (CTS).


      This cross-sectional study analyzed data from 367 patients who presented for evaluation of CTS to 1 of 6 hand surgeons at a tertiary academic center between August 1, 2016, and June 30, 2017. Patients completed PROMIS Physical Function—v1.2, Pain Interference—v1.1, Depression—v1.0, and Anxiety—v1.0 Computer Adaptive Tests. The Area Deprivation Index was used to quantify social deprivation. Medical record review determined duration of symptoms, tobacco and opioid use, and the Charlson Comorbidity Index (CCI) for each patient. Sample demographics, PROMIS scores, and objective health measures were compared in groups defined by national quartiles of social deprivation.


      Patients with CTS living in the most deprived quartile had worse mean scores across all 4 PROMIS domains compared with those living in the least deprived quartile. A higher proportion of individuals from the most deprived quartile had a heightened level of anxiety than those in the least deprived quartile (37.3% vs 12.6%). The mean CCI was higher in the most deprived quartile, as was the proportion of individuals using tobacco. There were no differences in opioid use or symptom duration between patients from each deprivation quartile.


      Social deprivation is associated with worse patient-reported health measures in patients with CTS. Compared with those from the least deprived areas, patients from the most deprived areas also have a greater comorbidity burden and higher rates of tobacco use at presentation to a hand surgeon.

      Type of study/level of evidence

      Prognostic II.

      Key words

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        • Padua L.
        • Coraci D.
        • Erra C.
        • et al.
        Carpal tunnel syndrome: clinical features, diagnosis, and management.
        Lancet Neurol. 2016; 15: 1273-1284
        • Atroshi I.
        • Gummesson C.
        • Johnsson R.
        • Ornstein E.
        • Ranstam J.
        • Rosen I.
        Prevalence of carpal tunnel syndrome in a general population.
        JAMA. 1999; 282: 153-158
        • de Krom M.C.
        • Knipschild P.G.
        • Kester A.D.
        • Thijs C.T.
        • Boekkooi P.F.
        • Spaans F.
        Carpal tunnel syndrome: prevalence in the general population.
        J Clin Epidemiol. 1992; 45: 373-376
        • Atroshi I.
        • Gummesson C.
        • Johnsson R.
        • Sprinchorn A.
        Symptoms, disability, and quality of life in patients with carpal tunnel syndrome.
        J Hand Surg Am. 1999; 24: 398-404
        • Wilson d'Almeida K.
        • Godard C.
        • Leclerc A.
        • Lahon G.
        Sickness absence for upper limb disorders in a French company.
        Occup Med (Lond). 2008; 58: 506-508
        • Bekkelund S.I.
        • Pierre-Jerome C.
        • Torbergsen T.
        • Ingebrigtsen T.
        Impact of occupational variables in carpal tunnel syndrome.
        Acta Neurol Scand. 2001; 103: 193-197
        • Foley M.
        • Silverstein B.
        • Polissar N.
        The economic burden of carpal tunnel syndrome: long-term earnings of CTS claimants in Washington State.
        Am J Ind Med. 2007; 50: 155-172
        • Singh G.K.
        Area deprivation and widening inequalities in US mortality, 1969–1998.
        Am J Public Health. 2003; 93: 1137-1143
        • Kind A.J.
        • Jencks S.
        • Brock J.
        • et al.
        Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study.
        Ann Intern Med. 2014; 161: 765-774
        • Urwin M.
        • Symmons D.
        • Allison T.
        • et al.
        Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation.
        Ann Rheum Dis. 1998; 57: 649-655
        • Davis E.T.
        • Lingard E.A.
        • Schemitsch E.H.
        • Waddell J.P.
        Effects of socioeconomic status on patients' outcome after total knee arthroplasty.
        Int J Qual Health Care. 2008; 20: 40-46
        • Dy C.J.
        • Lane J.M.
        • Pan T.J.
        • Parks M.L.
        • Lyman S.
        Racial and socioeconomic disparities in hip fracture care.
        J Bone Joint Surg Am. 2016; 98: 858-865
        • Barnard J.
        • Grant S.W.
        • Hickey G.L.
        • Bridgewater B.
        Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry.
        BMJ Open. 2015; 5: e008287
      1. Capturing Social and Behavioral Domains in Electronic Health Records: Phase 1. Institute of Medicine, Washington, DC2014
        • Cella D.
        • Riley W.
        • Stone A.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Stone A.A.
        • Broderick J.E.
        • Junghaenel D.U.
        • Schneider S.
        • Schwartz J.E.
        PROMIS fatigue, pain intensity, pain interference, pain behavior, physical function, depression, anxiety, and anger scales demonstrate ecological validity.
        J Clin Epidemiol. 2016; 74: 194-206
        • Pilkonis P.A.
        • Choi S.W.
        • Reise S.P.
        • et al.
        Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS): depression, anxiety, and anger.
        Assessment. 2011; 18: 263-283
        • Amtmann D.
        • Cook K.F.
        • Jensen M.P.
        • et al.
        Development of a PROMIS item bank to measure pain interference.
        Pain. 2010; 150: 173-182
        • Doring A.C.
        • Nota S.P.
        • Hageman M.G.
        • Ring D.C.
        Measurement of upper extremity disability using the Patient-Reported Outcomes Measurement Information System.
        J Hand Surg Am. 2014; 39: 1160-1165
        • Hung M.
        • Stuart A.R.
        • Higgins T.F.
        • Saltzman C.L.
        • Kubiak E.N.
        Computerized adaptive testing using the PROMIS physical function item bank reduces test burden with less ceiling effects compared with the short musculoskeletal function assessment in orthopaedic trauma patients.
        J Orthop Trauma. 2014; 28: 439-443
        • Tyser A.R.
        • Beckmann J.
        • Franklin J.D.
        • et al.
        Evaluation of the PROMIS physical function computer adaptive test in the upper extremity.
        J Hand Surg Am. 2014; 39: 2047-2051 e2044
        • Graham B.
        • Peljovich A.E.
        • Afra R.
        • et al.
        The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on Management of Carpal Tunnel Syndrome.
        J Bone Joint Surg Am. 2016; 98: 1750-1754
        • Graham B.
        The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2008; 90: 2587-2593
        • Sears E.D.
        • Swiatek P.R.
        • Hou H.
        • Chung K.C.
        Utilization of preoperative electrodiagnostic studies for carpal tunnel syndrome: an analysis of national practice patterns.
        J Hand Surg Am. 2016; 41: 665-672.e1
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Fitzpatrick S.K.
        • Casemyr N.E.
        • Zurakowski D.
        • Day C.S.
        • Rozental T.D.
        The effect of osteoporosis on outcomes of operatively treated distal radius fractures.
        J Hand Surg Am. 2012; 37: 2027-2034
        • Voskuijl T.
        • Hageman M.
        • Ring D.
        Higher Charlson Comorbidity Index Scores are associated with readmission after orthopaedic surgery.
        Clin Orthop Relat Res. 2014; 472: 1638-1644
        • Bevans M.
        • Ross A.
        • Cella D.
        Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life.
        Nurs Outlook. 2014; 62: 339-345
        • Jenkins P.J.
        • Watts A.C.
        • Duckworth A.D.
        • McEachan J.E.
        Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome.
        J Hand Surg Eur Vol. 2012; 37: 123-129
        • Yost K.J.
        • Eton D.T.
        • Garcia S.F.
        • Cella D.
        Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients.
        J Clin Epidemiol. 2011; 64: 507-516
        • Amtmann D.
        • Kim J.
        • Chung H.
        • Askew R.L.
        • Park R.
        • Cook K.F.
        Minimally important differences for Patient-Reported Outcomes Measurement Information System pain interference for individuals with back pain.
        J Pain Res. 2016; 9: 251-255
        • Schalet B.D.
        • Cook K.F.
        • Choi S.W.
        • Cella D.
        Establishing a common metric for self-reported anxiety: linking the MASQ, PANAS, and GAD-7 to PROMIS Anxiety.
        J Anxiety Disord. 2014; 28: 88-96
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        • Monahan P.O.
        • Lowe B.
        Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
        Ann Intern Med. 2007; 146: 317-325
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Lowe B.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Choi S.W.
        • Schalet B.
        • Cook K.F.
        • Cella D.
        Establishing a common metric for depressive symptoms: linking the BDI-II, CES-D, and PHQ-9 to PROMIS depression.
        Psychol Assess. 2014; 26: 513-527
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Wolny T.
        • Linek P.
        • Saulicz E.
        Overall health status in patients with mild to moderate carpal tunnel syndrome: a case-control study.
        J Hand Ther. 2017; 30: 293-298
        • Nunez F.
        • Vranceanu A.M.
        • Ring D.
        Determinants of pain in patients with carpal tunnel syndrome.
        Clin Orthop Relat Res. 2010; 468: 3328-3332
        • Hobby J.L.
        • Venkatesh R.
        • Motkur P.
        The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome.
        J Bone Joint Surg Br. 2005; 87: 196-200
        • Bhattacharya A.
        Cost of occupational musculoskeletal disorders (MSDs) in the United States.
        Int J Ind Ergon. 2014; 44: 448-454
        • Enticott J.C.
        • Meadows G.N.
        • Shawyer F.
        • Inder B.
        • Patten S.
        Mental disorders and distress: associations with demographics, remoteness and socioeconomic deprivation of area of residence across Australia.
        Aust N Z J Psychiatry. 2016; 50: 1169-1179
        • Ostler K.
        • Thompson C.
        • Kinmonth A.L.
        • Peveler R.C.
        • Stevens L.
        • Stevens A.
        Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care: the Hampshire Depression Project.
        Br J Psychiatry. 2001; 178: 12-17
        • Lozano Calderon S.A.
        • Paiva A.
        • Ring D.
        Patient satisfaction after open carpal tunnel release correlates with depression.
        J Hand Surg Am. 2008; 33: 303-307
        • Peters S.
        • Johnston V.
        • Hines S.
        • Ross M.
        • Coppieters M.
        Prognostic factors for return-to-work following surgery for carpal tunnel syndrome: a systematic review.
        JBI Database System Rev Implement Rep. 2016; 14: 135-216
        • Katz J.N.
        • Lew R.A.
        • Bessette L.
        • et al.
        Prevalence and predictors of long-term work disability due to carpal tunnel syndrome.
        Am J Ind Med. 1998; 33: 543-550
        • Casalino L.P.
        • Elster A.
        • Eisenberg A.
        • Lewis E.
        • Montgomery J.
        • Ramos D.
        Will pay-for-performance and quality reporting affect health care disparities?.
        Health Aff (Millwood). 2007; 26: w405-w414
        • Moody A.
        • Cowley G.
        • Ng Fat L.
        • Mindell J.S.
        Social inequalities in prevalence of diagnosed and undiagnosed diabetes and impaired glucose regulation in participants in the Health Surveys for England series.
        BMJ Open. 2016; 6: e010155
        • Krieger N.
        • Waterman P.D.
        • Spasojevic J.
        • Li W.
        • Maduro G.
        • Van Wye G.
        Public health monitoring of privilege and deprivation with the index of concentration at the extremes.
        Am J Public Health. 2016; 106: 256-263
      2. Do Smoking rates vary between more and less advantaged areas? 2014. Available at: Accessed April 24, 2017.

        • Lakshman R.
        • McConville A.
        • How S.
        • Flowers J.
        • Wareham N.
        • Cosford P.
        Association between area-level socioeconomic deprivation and a cluster of behavioural risk factors: cross-sectional, population-based study.
        J Public Health (Oxf). 2011; 33: 234-245
        • Cagle Jr., P.J.
        • Reams M.
        • Agel J.
        • Bohn D.
        An outcomes protocol for carpal tunnel release: a comparison of outcomes in patients with and without medical comorbidities.
        J Hand Surg Am. 2014; 39: 2175-2180
        • Johnson S.P.
        • Chung K.C.
        • Zhong L.
        • et al.
        Risk of prolonged opioid use among opioid-naive patients following common hand surgery procedures.
        J Hand Surg Am. 2016; 41: 947-957 e943
        • Brummett C.M.
        • Waljee J.F.
        • Goesling J.
        • et al.
        New persistent opioid use after minor and major surgical procedures in US adults.
        JAMA Surg. 2017; 152: e170504
        • Titchener A.G.
        • Fakis A.
        • Tambe A.A.
        • Smith C.
        • Hubbard R.B.
        • Clark D.I.
        Risk factors in lateral epicondylitis (tennis elbow): a case-control study.
        J Hand Surg Eur Vol. 2013; 38: 159-164