SCIENTIFIC ARTICLE

The Six-Item CTS Symptoms Scale and Palmar Pain

Scale in Carpal Tunnel Syndrome
Isam Atroshi, MD, PhD, Per-Erik Lyrén, PhD, Ewald Ornstein, MD, PhD, Christina Gummesson, PhD

Purpose To evaluate measurement properties of 2 brief outcome measures for carpal tunnel
syndrome: the 6-item carpal tunnel symptoms scale (CTS-6) and the 2-item palmar pain scale
(measuring severity of pain in the scar/palm and pain-related activity limitation). Our
hypothesis was that the CTS-6 is responsive to change in symptoms after surgical treatment
and the pain scale is a valid measure of surgery-related pain.
Methods This study followed 447 consecutive patients with carpal tunnel syndrome undergoing open
release; 308 completed the CTS-6 and the Disabilities of the Arm, Shoulder, and Hand–short form
(QuickDASH) before surgery and the CTS-6, QuickDASH, palmar pain scale, and 2 items regarding
global rating of change and treatment satisfaction once after surgery (range, 2–13 mo). The mean
scores for the CTS-6 (range, 1–5) and QuickDASH and palmar pain scales (range, 0–100) were
calculated (lower score is better). Responsiveness was assessed with the effect size (ES). We estimated
the CTS-6 score change indicating minimal clinically important difference based on scores for patients
with moderate self-rated improvement.
Results The mean baseline CTS-6 score was 3.16, mean change after surgery was ⫺1.54 (95%
confidence interval [CI], ⫺1.65 to ⫺1.44), and ES was 2.0. The ES was large (2.5) in patients with
the largest self-rated improvement and decreased with lower self-rated improvement. A score change
of 0.9 indicated a minimal clinically important difference. The mean change in QuickDASH score was
⫺25.4 (95% CI, ⫺27.8 to ⫺23.0), and ES was 1.25. The mean palmar pain score for patients with
time since surgery of less than 3 months was 38.5, at 3 to 6 months was 35.4, and greater than 6
months was 19.5; the mean score was significantly higher among patients with lower satisfaction.
Conclusions The CTS-6 is highly responsive to change in symptoms, and the palmar pain scale is a
valid measure of surgery-related pain. These brief scales can be appropriate primary and secondary
outcomes measures in clinical trials studying carpal tunnel syndrome. (J Hand Surg 2011;36A:788–
794. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Diagnostic I.
Key words Carpal tunnel syndrome, CTS-6 symptoms scale, patient-reported outcomes,
carpal tunnel release, QuickDASH.

treatment effects in carpal 8-item functional status scales, introduced in 19931 and

S
TUDIES THAT EVALUATE
tunnel syndrome (CTS) increasingly use patient- later translated to other languages2–5 have been used in
reported symptoms and disability as primary out- several clinical trials.6 – 8 However, these scales were
come measures. The 11-item symptom severity and initially developed without examining their item struc-
From the Department of Orthopedics, Hässleholm and Kristianstad Hospitals, Hässleholm; the Depart- No benefits in any form have been received or will be received related directly or indirectly to the
ment of Clinical Sciences Lund and the Department of Health Sciences, Division of Physiotherapy, Lund subject of this article.
University, Lund; and the Department of Applied Educational Science, Division of Educational Measure-
ment, Umeå University, Umeå, Sweden. Corresponding author: Isam Atroshi, MD, PhD, Department of Orthopedics, Hässleholm and Kris-
tianstad Hospitals, SE-28125 Hässleholm, Sweden; e-mail: isam.atroshi@skane.se.
Received for publication July 16, 2010; accepted in revised form February 19, 2011.
0363-5023/11/36A05-0003$36.00/0
Supported by Hässleholm Hospital and Umeå University, Sweden. doi:10.1016/j.jhsa.2011.02.021

788 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 RESPONSIVENESS OF CTS-6 SCALE
ture with, for example, factor analysis. We recently
investigated the symptom severity and functional status
scales using modern measurement methodology in a
stepwise process that resulted in removal of 4 items that
did not fit well in the symptom severity scale and
merging of 2 other items in that scale.9 We developed
the 6-item CTS symptoms scale as a brief outcome
measure of symptoms in CTS (Appendix 1).9 (Appen-
dix 1 is available on the Journal’s Web site at www.
jhandsurg.org.) The 6-item CTS symptoms scale is
shorter than the 11-item symptom severity scale not
only because of fewer items but also because of a
different layout (the 6 items share horizontal item
response choices). The 6-item CTS symptoms scale
demonstrated good internal consistency, test-retest
reliability, and validity compared with the 11-item
symptom severity scale and did not exhibit differen-
tial item functioning with regard to gender (none of
the items performed differently in women than
men).9 The 6-item CTS symptoms scale can improve
the efficiency of outcome measurement in CTS but it
needs to be evaluated with regard to responsiveness.
After carpal tunnel release, pain in the scar or prox-
imal palm is common but varies in severity and dura-
tion.6,7,10 Several endoscopic or small-incision surgical
techniques were introduced, with the main proposed
benefit being decreased surgery-related morbidity.10
Consequently, measurement of postoperative pain that
is mainly related to the surgery itself would be impor-
tant in assessing the effectiveness of such techniques in
that respect. We developed a 2-item palmar pain scale
(Appendix 2) (Appendix 2 is available on the Journal’s
Web site at www.jhandsurg.org) and used it as a spe-
cific measure of surgery-related pain after carpal tunnel
release.7 The scale has not been evaluated in a large
cohort.
The purpose of this study was to evaluate measure-
ment properties of 2 brief outcomes measures for CTS:
the 6-item CTS symptoms scale (CTS-6) and the 2-item
palmar pain scale. Our hypothesis was the CTS-6 is
responsive to change in symptoms after surgical treat-
ment and the palmar pain scale is a valid measure of
surgery-related pain.
MATERIALS AND METHODS
Study sample
This study enrolled all adult patients with primary CTS
planned for open carpal tunnel release at 1 orthopedic
department over 15 months beginning January 2008. The
examining surgeon established the diagnosis through his-
tory, physical examination, and, if required, nerve conduc-
tion tests. All patients had failed treatment with wrist
JHS 䉬 Vol A, May 
789
splinting. After surgery a soft dressing was applied and
patients were given oral and written instructions on
postoperative exercises and gradual return to activi-
ties. Therapy was not routinely prescribed.
Measures and follow-up
The patients completed a questionnaire consisting of
the CTS-6 and the Disabilities of the Arm, Shoulder,
and Hand–short form (QuickDASH) in the preoperative
area on the day of surgery. A follow-up questionnaire
consisting of the CTS-6, QuickDASH, palmar pain
scale, and 2 separate items concerning global rating of
change in hand status after surgery and treatment sat-
isfaction, respectively, was sent by mail to all patients.
A reminder was sent when necessary. To evaluate re-
sponsiveness over a longer period, the follow-up ques-
tionnaire was mailed at a time ranging from 10 to 52
weeks postoperatively by a research assistant who had
no knowledge of the patients’ medical data except for
the date of surgery. Each patient completed the fol-
low-up questionnaire only once. We chose the fol-
low-up times based on findings from a randomized trial
of carpal tunnel release showing that major improve-
ment in the baseline CTS symptom severity scores
occurred by 6 weeks postoperatively, with only small
additional improvement observed at 12 and 52 weeks,
whereas postoperative pain gradually decreased up to 1
year.7 Two other randomized trials have shown near-
normal mean CTS symptom severity score at 12 weeks
postoperatively.11,12 Consequently, a responsive mea-
sure of CTS symptoms should be able to detect change
in CTS symptoms measured before surgery and at 10 to
52 weeks after surgery, and a measure of postoperative
pain should be able to detect differences in pain severity
measured at different time intervals during this postop-
erative period.
Six-item CTS symptoms scale: This scale consists of 6 items
that inquire about severity and frequency of night and
daytime numbness and tingling and pain (Appendix 1).
The CTS-6 was scored with conventional scoring (sim-
ilar to that used for the 11-item symptom severity
scale); each item was scored on a scale of 1 (no symp-
tom) to 5 (most severe symptom). For each patient, a
CTS-6 score was calculated as the mean of the items
answered by the patient, with only 1 missing item
response allowed, and would thus range from 1 (best) to
5 (worst).
QuickDASH: This scale is an 11-item measure of upper
extremity–related disability and has previously been
studied in patients with CTS.13 The QuickDASH score
may range from 0 (no disability) to 100 (most severe
disability).
790 RESPONSIVENESS OF CTS-6 SCALE
Palmar pain scale: This scale consists of 2 items that in-
quire about the severity of postoperative pain in the scar
and/or proximal palm (5 response choices) and the
degree of activity limitation because of the pain (6
response choices) (Appendix 2). The scale is scored on
a scale ranging from 0 (no palmar pain or related
activity limitation) to 100 (most severe); the scoring is
similar to the 2-item bodily pain scale of the Short
Form–36 (because it has similar response choices)14 but
with the final score reversed.
Global rating of change item: This item asked the patient to
rate the hand problem compared with before surgery.
The 5 categorical response choices were much better,
somewhat better, rather the same, somewhat worse, and
much worse.
Treatment satisfaction item: This item asked the patient to
rate satisfaction with the results of surgery. The 5 cat-
egorical response choices were completely satisfied,
very satisfied, rather satisfied, dissatisfied, and very
dissatisfied.
Participants
Of 447 consecutive patients, 308 patients had complete
responses to all the outcome measures at baseline and at
follow-up, and these were included in the analyses. The
mean age was 55 years (SD 16 y) and 214 were women.
The right hand was operated on in 205 patients. Surgery
was done under local anesthesia in all except 11 pa-
tients. The median time from surgery to completion of
the follow-up outcome measures was 105 days (range,
71–388 d). Eighteen patients returned the question-
naires after 365 days postoperatively. Of the 139 non-
participants who were excluded because they did not
respond or had missing item responses precluding scor-
ing on 1 or more of the outcome measures, 91 were
women and the mean age was 58 years.
Statistical analysis
We calculated the mean baseline and follow-up scores
for the CTS-6 and QuickDASH. The effect size (mean
change in scores from baseline to after surgery divided
by the standard deviation of the baseline scores) was
used as a measure of responsiveness. An effect size of
0.2 is considered to be small, 0.5 is moderate, and 0.8 or
greater is large.15 We calculated the effect size in sub-
groups of patients who experienced improvement or
worsening defined according to 2 indicators.16 The first
indicator was the item regarding global rating of the
hand problem compared with before surgery. The re-
sponses of much better, somewhat better, rather the
same, and somewhat worse or much worse (combined
JHS 䉬 Vol A, May 
because of the small number of patients) were analyzed
as indicating 4 categories of self-perceived change. The
second indicator was treatment satisfaction, with the
satisfaction item responses categorized into 3 groups:
completely satisfied or very satisfied considered as high
treatment satisfaction, rather satisfied as moderate sat-
isfaction, and dissatisfied or very dissatisfied as low
satisfaction. We measured the effect size for each of
these subgroups, hypothesizing that the effect size
would be higher with higher level of self-rated per-
ceived change or satisfaction. The correlation between
the global change and treatment satisfaction items was
assessed with the Spearman correlation coefficient (rs).
We also estimated the CTS-6 score change indicat-
ing a minimal clinically important difference. The esti-
mate was based on 2 criteria16: the magnitude of CTS-6
score improvement in patients reporting being some-
what better or rather satisfied, and the difference in
CTS-6 score change between the subgroup of patients
reporting being somewhat better and those reporting
being rather the same. In determining the minimal clin-
ically important difference or change, we took into
consideration the limits of the 95% confidence intervals
(CIs) for the mean differences.
We further analyzed the CTS-6 by doing a linear
regression with the CTS-6 score change as the depen-
dent variable and age, gender, side on which surgery
was done, baseline CTS-6 score, and days since surgery
(continuous variable) as independent variables.
Reliability (internal consistency) of the palmar pain
scale was assessed with Cronbach alpha coefficient.
Validity was assessed by determining the correlations
with the QuickDASH and the CTS-6 scores and com-
paring the pain scores according to degree of treatment
satisfaction and time since surgery.17 We hypothesized
that the palmar pain scores would correlate at least
moderately (⬎0.50) with the QuickDASH scores and
less with the CTS-6 score, and that the palmar pain
scores would be lower (better) with higher treatment
satisfaction and with longer time since surgery. We
used the Pearson correlation coefficient (r) for the anal-
yses of correlation between scores. The analysis of
variance was used to compare the mean pain scores
among the 3 treatment satisfaction categories. Analysis
of the relationship between pain scores and days since
surgery was done using a linear regression with the pain
score as the dependent variable and age, gender, side on
which surgery was done, and days since surgery (con-
tinuous variable) as independent variables. We also
classified time since surgery into shorter than 3 months,
3 to 6 months, and greater than 6 months, which are
follow-up intervals commonly used in clinical stud-
 RESPONSIVENESS OF CTS-6 SCALE 791

ies,10 and compared mean pain scores according to

1.25
1.61
0.86
0.45
⫺0.22
these intervals with analysis of variance.

ES
In each analysis, we used assessments from 1 hand
per patient. In the 28 patients who had bilateral surgery

Mean Change (95% CI)

⫺16.7 (⫺21.6, ⫺11.8)

⫺25.4 (⫺27.8, ⫺23.0)
⫺31.8 (⫺34.3, ⫺29.4)
during the study period, only the first-operated hand

⫺8.9 (⫺18.1, 0.43)

5.0 (⫺7.6, 17.5)
was included. All statistical tests were 2-sided and a p
value less than .05 was considered to indicate statistical
significance. The local ethics committee approved the
study.

QuickDASH
RESULTS
The 6-item CTS symptoms scale

(Mean [SD])

38.0 (19.6)
51.2 (19.8)
60.4 (18.4)
23.7 (22.1)
14.4 (14.8)
The mean CTS-6 score for the whole sample improved

After
with a mean change of ⫺1.5 (p ⬍ .001), yielding an
effect size of 2.0 (Table 1). At follow-up, we recorded
a best possible score in 107 of the 308 patients (35%).
The change in the CTS-6 reflected patients’ perceived

(Mean [SD])

55.5 (22.3)
49.1 (20.3)
46.1 (19.7)
54.6 (19.4)
60.1 (20.0)
improvement; those with highest perceived improve-

Before
ment had the largest change in the CTS-6 score and the
largest effect size (Table 1). The mean changes in
CTS-6 scores and the effect sizes for the 3 levels of
treatment satisfaction were similar to those for self-

1.32
0.62
0.23
2.03
2.53
The CTS-6 and QuickDASH Scores According to Self-rated Global Change

ES
rated change item (data not shown); these 2 items
correlated strongly with each other (rs ⫽ 0.75).
Among patients who responded somewhat better to

The score range for the CTS-6 is 1 to 5, and for the QuickDASH it is 0 to 100 (a lower score is better).
Mean Change (95% CI)

⫺0.54 (⫺0.99, ⫺0.09)

⫺1.54 (⫺1.65, ⫺1.44)
⫺1.87 (⫺1.97, ⫺1.77)
⫺1.08 (⫺1.27, ⫺0.90)
the self-rated global change item, the 95% confidence

⫺0.17 (⫺0.69, 0.35)

limit for the mean change in CTS-6 score was ⫺0.90
(Table 1). Among patients who responded being rather
satisfied to the item regarding satisfaction, the mean
CTS-6 score change was ⫺1.14 (95% confidence limit,
⫺0.93). The mean difference in CTS-6 score change
CTS-6

between patients who responded somewhat better and

those who responded rather the same was ⫺0.54 (95%
(Mean [SD])

CI, ⫺0.95 to ⫺0.14). Thus, based on the 95% confi-

2.59 (0.86)
3.07 (0.91)
1.62 (0.79)
1.27 (0.41)
2.11 (0.74)
After

dence limits for the mean preoperative to postoperative

score changes in patients with some self-rated improve-
ES, effect size (mean change score divided by baseline SD).

ment or moderate satisfaction and for the mean score

differences between these patients and patients rating
(Mean [SD])

themselves as not improved, a score change of 0.9

3.13 (0.87)
3.24 (0.74)
3.16 (0.76)
3.15 (0.74)
3.21 (0.82)
Before

could be considered a minimal clinically important

change. Among the 11 patients with the response
“much worse,” the mean CTS-6 score worsened from
3.05 (SD, 0.75) preoperatively to 3.33 (SD, 0.82) at
follow-up.
19
18
308
214
57
N

The mean CTS-6 score in patients with time since

surgery of 71 to 90 days was 1.58 (SD, 0.75), 91 to 180
Large improvement
Some improvement
Self-Rated Global

days was 1.70 (SD, 0.83), and 181 to 388 days was 1.59
(SD, 0.79); the effect size was 2.1, 1.9, and 2.0, respec-
Change

All patients

tively (Fig. 1). Adjusting for baseline CTS-6 scores, we

TABLE 1.

Worsening
No change

found no significant relationship between change in

CTS-6 score and gender (p ⫽ .13), age (p ⫽ .67), or
time since surgery (p ⫽ .92).

JHS 䉬 Vol A, May 

792 RESPONSIVENESS OF CTS-6 SCALE

FIGURE 1: Preoperative and postoperative scores (mean and 95% CIs) according to time since surgery. The CTS-6 is transformed
to a scale of 0 to 100 for comparability with the other 2 scales.

QuickDASH TABLE 2. Palmar Pain Scores According to

The mean change in QuickDASH score was ⫺25.4 and Treatment Satisfaction
the effect size was 1.25 (Table 1). The effect size was
Treatment Pain Score Difference
generally smaller than that for the CTS-6 scale but Satisfaction N (Mean [SD])* (Mean [95% CI])
followed the same pattern of lower effect size with
smaller perceived change. Similar findings were shown All patients 308 30.4 (23.9)
for the analysis of treatment satisfaction (data not High 217 22.5 (19.0) Referent category
shown). A large improvement in QuickDASH scores Moderate 58 48.2 (17.3) 25.7 (19.5, 31.9)†
was recorded among patients with time since surgery of Low 33 51.4 (32.6) 28.9 (14.7, 43.2)†
90 days or less, and the improvement was somewhat
*The score range is 0 to 100 (a lower score is better).
larger among those with follow-up of 181 days or more †Welch F (2, 67.4) ⫽ 55.3, p ⬍ .001 compared with referent
(Fig. 1). category (Games-Howell post hoc test).

Palmar pain scale

Internal consistency was high (Cronbach alpha, 0.88).
The correlation between the palmar pain score and the
QuickDASH was moderate to strong (r ⫽ 0.61), and the
CTS-6 score was moderate (r ⫽ 0.52). The pain score
was significantly lower (less pain) in the subgroup with
high treatment satisfaction than in the subgroups with
moderate or low satisfaction (Table 2). In the linear
regression analysis, the palmar pain score was signifi-
cantly associated with time since surgery (number of
days as continuous variable), with pain decreasing for
longer time since surgery (regression coefficient,
⫺0.08; 95% CI, ⫺0.1 to ⫺0.06; p ⬍ .001). The other
variables in the model (gender, age, and side of surgery)
were not significant predictors of severity of postoper-
ative pain (p ⫽ .59, p ⫽ .76, and p ⫽ .77, respectively;
model’s R2, 0.123). The mean pain score for the pa-
tients with time since surgery of 71 to 90 days was 38.5
(SD, 21.9), 91 to 180 days was 35.4 (SD, 22.7), and 181
to 388 days was 19.5 (SD, 22.6). The lower score in the
group with longest time since surgery was statistically
significant (F[2, 305] ⫽ 22.62; p ⬍ .001, Tukey post-
hoc test] (Fig. 1).
Nonparticipant analysis
Among the excluded patients, the mean baseline CTS-6
score (n ⫽ 65) was 3.13 (SD, 0.77), the mean follow-up
CTS-6 score (n ⫽ 82) was 1.71 (SD, 0.83), and the
mean palmar pain score (n ⫽ 85) was 33.9 (SD, 25.9).
None of these scores were significantly different from
the corresponding scores for the participants (t-test, p ⬎
.2 for all analyses).

JHS 䉬 Vol A, May 

 RESPONSIVENESS OF CTS-6 SCALE
DISCUSSION
Our results show that the 6-item CTS symptoms scale
was highly responsive to change in symptoms of CTS
after surgical treatment, with a large overall effect size
of 2.0 and with good discrimination between patient
groups that differed in level of perceived change. The
effects size shown for the CTS-6 in this study is similar
to the effect size of 2.1 shown for the 11-item symptom
severity scale in a previous study of 102 patients mea-
sured before and 3 months after endoscopic carpal
tunnel release.2 Because the CTS-6 has previously
shown good agreement with the 11-item symptom se-
verity score9 and is scored on similar scale, it can be
used as an alternative to the 11-item symptom severity
scale. The CTS-6 is shorter and has an improved layout.
We have also estimated a score change of 0.9 as a
minimal clinically important difference. This would be
helpful in designing treatment efficacy studies. Because
the minimally important difference depends on the sam-
ple and treatment, this value should be considered
within a possible small range of values and needs future
confirmation.16
The results showed that even among patients with no
perceived improvement and low treatment satisfaction,
the mean CTS-6 (and QuickDASH) scores still had
improved with effect sizes suggesting moderate im-
provement. Traditionally, treatments with effect size of
0.5 are considered moderately effective.15 The tradi-
tional effect size cutoffs may need to be interpreted
differently for disease-specific measures and particu-
larly for treatments that produce large effect sizes. For
example, if a nonsurgical treatment for CTS is found to
have an effect size in the range of 0.5 to 0.7 on the
CTS-6, it would be reasonable to interpret it as a small
effect compared with that of surgery rather than the
traditional interpretation of a moderate-to-large effect.
A factor that may have influenced patients’ self-rated
improvement is the severity of surgery-related pain and
morbidity that may overshadow small or moderate im-
provements in CTS symptoms, as suggested by the
higher mean palmar pain scores in patients with lower
satisfaction. Another possible explanation for the appar-
ent discordance between score change and self-rated
improvement among the unimproved is the response shift,
a phenomenon recognized as a potentially important factor
to consider when interpreting the change scores for pa-
tient-reported outcome measures.18,19 According to re-
sponse shift theory, health changes that occur in a respon-
dent after the baseline measurement (for example, owing
to treatment) lead to shifts in the respondent’s internal
standards of measurement and values (such as the relative
importance of the health aspects being measured). These
JHS 䉬 Vol A, May 
793
changes may influence the way some patients rate the
severity of their symptoms and disabilities, which may
explain apparent inconsistencies.15
Although the CTS-6 scale is intended to measure the
symptoms of CTS including pain, patients may not
separate the pain caused by nerve compression from
that caused by surgery in their responses. The moderate
correlation between the 6-item CTS symptoms score
and the palmar pain score suggests that these 2 scales
may be measuring a common symptom. When com-
paring 2 surgical treatments that are not expected to
differ in their efficacy but that potentially differ in the
degree of postoperative pain and activity limitations, the
CTS palmar pain scale would be more appropriate as
the primary outcome measure. In such comparisons, the
CTS-6 can be used as a secondary outcome measure
with regard to the efficacy of the treatments in relieving
CTS symptoms.
Self-perceived worsening translated only into small
effect size as measured with the CTS-6 and the Quick-
DASH. This is not caused by limitation of the scales
because the mean preoperative CTS-6 score was 3.2 of
a possible worst score of 5.0, allowing for larger mea-
surable deterioration. A likely explanation is that al-
though surgery might not be effective in some patients,
it seldom results in substantial worsening of symptoms.
The patients who reported low self-rated improvement
had a substantially worse mean preoperative Quick-
DASH score (sometimes by more than 10) than patients
with higher self-rated improvement. Because there
were no such differences in preoperative CTS symp-
toms (CTS-6 scores), the higher preoperative Quick-
DASH scores in patients with low self-rated change
might suggest the presence of upper extremity comor-
bidities or inaccurate diagnosis in some patients.
The CTS-6 scores for the 3 subgroups classified
according to time since surgery were similar. This find-
ing further supports that the rapid large symptom relief
after surgery is stable compared with the often tempo-
rary improvement after nonsurgical treatment.20 Al-
though the results are not based on repeated measures
on the same patients, they are in agreement with a
randomized trial that used the 11-item symptom sever-
ity scale in a repeated measures design.7 That trial
showed major improvement of the baseline scores at 6
weeks postoperatively, with only small additional im-
provement measured at 12 and 52 weeks.7 A best
possible CTS-6 score was recorded in 35% of the
patients within 13 months after surgery, which can be
compared with the 11-item symptom severity scale that
in a previous study showed a best possible score in 37%
794 RESPONSIVENESS OF CTS-6 SCALE
of patients 5 years after surgery.21 This supports long-
term stability of surgery outcomes.
As expected, the QuickDASH was less responsive
than the CTS-6. The QuickDASH is a measure of
disability, and the 2 scales are not directly comparable
because they measure different outcomes. Although the
mean preoperative QuickDASH score had improved
significantly in patients measured up to 3 months after
surgery, the mean score still was relatively high (ex-
ceeding 20) in patients measured after 6 months, sug-
gesting persistent moderate disability up to 1 year. In a
previous study that used the DASH in 50 patients be-
fore and after carpal tunnel release, the mean DASH
score at 6 months was 20.6,22 and it is known that the
QuickDASH usually produces somewhat higher scores
than the DASH.13 Coexisting upper extremity condi-
tions may also account for some of the residual disabil-
ity. Our findings confirm the more rapid improvement
in symptoms than in disability and the importance of
using a disease-specific symptoms measure such as the
CTS-6 as a primary outcome when assessing treatment
efficacy. A disability measure would not be sufficient as
the only outcome measure for upper extremity condi-
tions.
The results support the reliability and validity of the
CTS palmar pain scale as a measure of pain after carpal
tunnel release. Surgery-related pain among patients
measured up to 3 months after surgery was only slightly
higher than that among patients measured at 3 to 6
months. However, pain was substantially lower among
patients measured between 6 and 13 months. These
findings could be useful when discussing expected sur-
gery outcomes with patients. For further assessment of
the responsiveness of the palmar pain scale, a repeated
measures design on the same patients at standard times
from the early postoperative period would be needed.
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