Title: Returning to employment after carpal tunnel release surgery (REACTS):Understanding current practice in order to develop evidence-based guidance for return to work following carpal tunnel release surgery
Funder: Department of Health and Social Care

Abstract: Background Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome, occurring when the median nerve becomes compressed as it passes through the volar wrist. Carpal tunnel release (CTR) surgery is recommended for more severe CTS, or when conservative management has failed. More than 51,000 CTR procedures are performed in England annually. Return to work post-CTR has been reported to vary widely, from three days to several months. In the UK, the costs of prolonged sickness absence are borne by employers, insurance companies, the government and employees themselves, but there is currently no evidence informing whether early return to work is harmful in some/all types of work.Aims and research questions The aim of this research is to inform best practice around safe return to work after CTR, with the following research questions: 1) What is currently known about when patients return to work? 2) What is currently known about the factors influencing return to work? 3) Is return to work affected by the advice provided by UK healthcare professionals? If so, what advice do they give and is this advice consistent? 4) When and how do patients in the UK return to work? 5) Is earlier return to work associated with poorer outcomes? Methods A mixed methods approach will be used to answer the above research questions across three phases. Phase 1. Review of evidenceA systematic review will be conducted to identify existing data reporting return to work timescales and outcomes for patients following CTR. The findings will be used iteratively to inform the development of subsequent sections of this research.Phase 2. Identification of current UK practice Hand surgeons and hand therapists will be surveyed about the advice they give to their patients concerning return to work after CTR, including to what extent clinicians tailor their advice for individual patients. Data will be analysed using descriptive statistics.Phase 3. Observational study of patient outcomesFour hundred working-aged patients undergoing CTR in the South of England will be recruited to a prospective observational study. Baseline data will be collected on clinical, occupational, functional and psychosocial factors. Follow-up data will be collected at six and 12 weeks post-operatively to explore when and how patients return to work, post-operative symptoms and complications. Data will be analysed using Cox regression to identify determinants of differences in return to work timescales and Poisson regression to assess the impact of earlier return to work. Focus groups will be conducted with a small sub-group of participants to explore the barriers and facilitators of returning to work after CTR and to identify key factors determining how patients return to work. Data will be analysed using the Framework method and will be used to shape the recommendations for the content, format and timescales of return to work advice for CTR patients.Potential benefits The creation of evidence-based return to work advice will provide clinicians with a reference point when discussing surgery with patients, leading to better informed, higher quality healthcare. It is anticipated that patients who are provided with relevant return to work advice will have realistic expectations, will be able to have an informed discussion with their employer about their likely work absence and any additional support they may require on returning to work, and will require fewer follow-up appointments with their surgeon or GP to discuss returning to work. With more than 51,000 CTR procedures in England annually, even one day of sick leave less per patient will bring about significant benefit to the economy and employers, including the NHS.

Lay abstract: Background Carpal tunnel syndrome (CTS) is a common condition affecting the hand/wrist. It occurs when a nerve (the median nerve) becomes compressed as it passes through the palm at the wrist. CTS causes pain and pins and needles in the thumb, index and middle fingers particularly at night, and can result in reduced thumb pinch strength. Mild CTS can be treated with splints or steroid injections, but if symptoms are severe, or fail to improve, carpal tunnel release surgery (CTR) is recommended. CTR involves making an incision through the wrist ligament (transverse carpal ligament) to release the pressure on the median nerve. This relatively straightforward procedure is usually done as a day case and the wound is sutured and kept dry with a dressing. More than 51,000 CTR procedures are carried out in England annually. Many of those having CTR surgery are of working age and yet there is currently no evidence informing when it is safe to return to different types of work after the operation. Sick leave after CTR currently varies widely from three days to several months. In the UK, the costs of sick leave are borne by employers, the government, insurance companies and employees themselves. Research plan The aim of this research is to inform best practice around safe return to work after CTR, with the following research questions: 1) What is currently known about when patients return to work? 2) What is currently known about the factors influencing return to work? 3) Is return to work affected by the advice provided by healthcare professionals in the UK? If so, what advice do they give and is this advice consistent? 4) When and how do UK patients return to work? 5) Is earlier return to work associated with poorer outcomes? Methods This research programme involves three phases with different types of research methods: Phase 1. Review of evidenceThe existing literature will be reviewed systematically to identify studies reporting return to work timescales and outcomes for patients following CTR. The findings will be used to inform the development of subsequent sections of this research. Phase 2. Identification of current UK practice Through their professional bodies, UK hand surgeons and hand therapists will be surveyed about the advice they give to their patients concerning return to work after CTR, including to what extent clinicians tailor their advice for individual patients.Phase 3. Observational study of patient outcomes Four hundred working-aged patients undergoing CTR in the South of England will be recruited prior to their operation. We will collect information about their symptoms, occupation and other relevant factors at baseline by questionnaire. Six weeks and 12 weeks later we will send further questionnaires enquiring about when and how they return to work and their symptoms and/or complications. We will use their responses to inform us about factors which determine when they returned to work and whether early return to work produced poorer outcomes in terms of symptoms or complications. We will also carry out focus groups with a small sub-group of participants to explore the barriers and facilitators of returning to work after CTR and to identify key factors that influence how patients return to work. These results will be used to shape the recommendations for the content, format and timescales of return to work advice for CTR patients.Potential benefits We will use the evidence to create new guidance about return to work after CTR which will provide clinicians with a reference point when discussing surgery with patients, leading to better informed, higher quality healthcare. It is anticipated that patients who are provided with relevant return to work advice will have realistic expectations, will be able to have an informed discussion with their employer about their likely work absence and any additional support they may require on returning to work, and will require fewer follow-up appointments with their surgeon or GP to discuss returning to work. With more than 51,000 CTR procedures in England annually, even one day of sick leave less per patient will bring about significant benefit to the economy and employers, including the NHS.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: NEUROLOGICAL