J Orthop Sci (2007) 12:249–253
DOI 10.1007/s00776-007-1128-z

Original article
Comparison of responsiveness of the Japanese Society for Surgery of
the Hand version of the carpal tunnel syndrome instrument to surgicaltreatment with DASH, SF-36, and physical findings
S. Uchiyama1, T. Imaeda2, S. Toh3, K. Kusunose4, T. Sawaizumi5, T. Wada6, S. Okinaga7, J. Nishida8,
and S. Omokawa9, for the Clinical Outcomes Committee of the Japanese Orthopaedic Association and the
Impairment Evaluation Committee of the Japanese Society for Surgery of the Hand
1

Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
Department of Public Health, Fujita Health University School of Medicine, Toyoake, Japan3
Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
4
Department of Orthopaedic Surgery, Tokyo Rosai Hospital, Tokyo, Japan
5
Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
6
Department of Orthopaedic Surgery, School of Medicine, Sapporo Medical University, Sapporo, Japan
7
Department of Orthopaedic Surgery, Tokyo Teishin Hospital, Tokyo, Japan
8
Department of Orthopaedic Surgery, Iwate Medical University, Morioka, Japan
9
Department of Orthopaedic Surgery, Ishin-kai Yao General Hospital, Yao, Japan
2

Abstract
Background. The Japanese Society for Surgery of -the Hand
version of the Carpal Tunnel Syndrome Instrument (CTSIJSSH), which consists of two parts — one for symptom severity (CTSI-SS) and the other for functional status (CTSI-FS)— is a self-administered questionnaire specifically designed
for carpal tunnel syndrome. The responsiveness of the CTSIJSSH was compared with that of the JSSH version of the
Disability of Arm, Shoulder, and Hand questionnaire (DASH),
the official Japanese version of the 36-Item Short Form Health
Survey (SF-36, version 1.2), and physical examinations to elucidate the role of the CTSI-JSSH for evaluating patients withcarpal tunnel syndrome.
Methods. Preoperatively, a series of 60 patients with carpal
tunnel syndrome completed the CTSI-JSSH, DASH, and SF36. Results of physical examinations, including grip strength,
pulp pinch, and static two-point discrimination of the thumb,index, and long fingers, were recorded. Three months after
carpal tunnel release surgery the patients were asked to fillout the same questionnaires, and the physical examinations
were repeated. The responsiveness of all the instruments was
examined by calculating the standardized response mean
(SRM) and effect size (ES). Correlation coefficients were calculated between questionnaire change scores and patient satisfaction scores as well as between the CTSI change scores andthose of the DASH and SF-36.
Results. The largest responsiveness was observed in the CTSISS (SRM/ES: −1.00/−1.08) followed by the CTSI-FS (−0.76/−
0.63), and bodily pain subscale of SF-36 (SF-36-BP, 0.45/0.55),
and the DASH (−0.46/−0.47). Only the change scores of the
CTSI-SS had significant correlation with patient satisfaction

Offprint requests to: S. Uchiyama
Received: November 1, 2006 / Accepted: February 19, 2007

(r = 0.34, P < 0.01). An absolute value of Spearman’s correlation coefficient of >0.5 was observed between the change
scores of the CTSI-SS and the DASH, the CTSI-SS and the
SF-36-BP, the CTSI-FS and the DASH, and the DASH and
the SF-36-BP.
Conclusion. The CTSI-JSSH was proven to be more sensitive
to clinical changes after carpal tunnel release than the otheroutcome measures and should be used to evaluate patientswith carpal tunnel syndrome who speak Japanese as theirnative language.

Introduction
Although carpal tunnel syndrome is the most common
entrapment neuropathy in the human body, the operative indications are still not definitively determined.
Thus, many procedures, such as traditional open carpal
tunnel release, mini-open release, and endoscopic release, are performed based on the surgeon’s preference,
not on scientific data. It has been recognized that thedevelopment of disease-specific and patient-oriented
outcome measures is necessary to compare various
treatment modalities so the surgeons and patients canchoose the best treatment procedure.
Levine et al. developed a self-administered questionnaire, or Carpal Tunnel Syndrome Instrument (CTSI),
that is specific to carpal tunnel syndrome, and it has
been used widely.1 We developed a Japanese Society for
Surgery of the Hand version of the CTSI (CTSI-JSSH)
based on guidelines for cross-cultural adaptation processes recommended by Beaton et al.2 The CTSI-JSSH
is written in Japanese and consists of two sections: One

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S. Uchiyama et al.: Comparison of responsiveness of the Japanese Society

assesses pain and paresthesia, or symptom severity(CTSI-SS); and the other assesses functional status(CTSI-FS). It is now available in Charts for Functional
Evaluation of the Hand (4th edition).3 Validity, reliability, and responsiveness of the Japanese versions of both
the CTSI-SS and CTSI-FS were found to be good.4
In this study, the responsiveness of the CTSI-JSSH
was compared with that of the Japanese Society for
Surgery of the Hand version of the Disability of Arm,
Shoulder, and Hand questionnaire (DASH-JSSH),5,6
the official Japanese version of the 36-Item Short Form
Health Survey (SF-36; version 1.2),7,8 and physical examinations to elucidate the role of the CTSI-JSSH for
evaluating patients with carpal tunnel syndrome.

Materials and methods
We prospectively recruited 65 patients who had been
diagnosed with carpal tunnel syndrome and who gave
written informed consent. This was a multicenter study,
and the ethics committee of each institution approved
the study protocol. One female patient who was unable
to fill out the forms by herself because of poor eyesightwas not recruited. The diagnosis of carpal tunnel syndrome was based on the clinical history and physicalexaminations, such as Phalen’s test, Tinel’s sign at the
carpal tunnel, sensory disturbance over the median
nerve distribution area, and nerve conduction velocities
measured across the wrist. Based on nerve conduction
studies, the severity of preoperative carpal tunnel syndrome was determined as mild, moderate, severe, or
extremely severe.9
Preoperatively, the patients were asked to fill out the
CTSI-JSSH, DASH, and SF-36. Pain severity was assessed using the Visual Analog Scale (VAS). Results ofphysical examinations, including grip strength, pulp
pinch, and static two-point discrimination (s-2PD) of
the thumb, index, and long fingers, were recorded. A
total of 43 patients underwent endoscopic carpal tunnel
release surgery, and 22 underwent open carpal tunnel
release. Six patients had bilateral surgeries on the sameday. One patient had diabetes, two were undergoinghemodialysis, two had had distal radial fractures, andone had a ganglion in the carpal tunnel. Six patients had
release of the A1 pulley or synovectomy for trigger
digit, and two patients has tendon transfer to restore
thumb opposition followed by 3 weeks of immobilization of the wrist and thumb. Because the prime purposeof this study was to assess the responsiveness of the
CTSI-JSSH and not to report the results of carpal tunnel release surgery, the two patients who had undergone tendon transfer were included.
Three months after surgery, the patients were asked
to fill out the same questionnaires, and the physicalexaminations were repeated. This time each patient
rated his or her satisfaction with the surgery into four
categories: very satisfied, satisfied, neither satisfied nor
unsatisfied, unsatisfied.
Grip strength was measured using a Jamar dynamometer (Sammons Preston Rolyan, IL, USA) or a Smedley’s hand dynamometer (Igarashi Ikakougyou, Tokyo,
Japan), and pinch strength was measured using a Jamar
pinch meter (Sammons Preston Rolyan) or a Pinch
gauge (Fuji Seiko, Nagoya, Japan). They were measured three times each, and the average was used foranalysis. The values of s-2PD of the thumb, index, andlong fingers were summed, and the average was used foranalysis. The patients rated their degree of pain using
a VAS range from 0 to 10 (0, no pain → 10, the most
severe pain ever experienced).
The responsiveness of all the instruments was
examined by calculating the standardized response mean
(SRM; mean change/SD) and effect size (ES; meanchange/SD of the baseline value). SRM > 0.8 indicatedlarge change, 0.5 indicated moderate change, and <0.2
indicated small change. Correlation coefficients were
calculated between questionnaire change scores and patients’ satisfaction scores, and between the CTSI change
scores and those of the DASH and SF-36.
All statistical analyses were conducted using Statistical Package for Social Science (SPSS) version 14.0 J
software. As some of the instrument values were notnormally distributed, correlations between the instruments and patient satisfaction were assessed using a
nonparametric test (Spearmen’s correlation). Statisticalsignificance was set at P < 0.05.

Results
Five patients were excluded from the study because
their second data acquisition was done more than 15
weeks after surgery, leaving 60 patients eligible foranalysis. There were 11 men and 49 women whose ages
ranged from 21 to 86 years (average 60 years). The duration of the symptoms before their first visit to thehospital ranged from 2 to 360 months (average 60
months). Preoperative severity of the disease determined by nerve conduction studies was as follows: normal 1 patient, mild 0, moderate 9, severe 40, extremely
severe 9, not available 1. All the surgeries were correctly performed because complete release of the transverse carpal ligament was confirmed intraoperatively,
and no postoperative complications such as infection,
nerve/tendon injuries, or aggravation of numbness werenoted. Nine patients developed a trigger digit within 3months after surgery.
The average pre- and postoperative values of each
instrument and the SRM and ES are summarized inS. Uchiyama et al.: Comparison of responsiveness of the Japanese Society

251

Table 1. Responsiveness of each instrument
Preoperative

Postoperative − preoperative

Postoperative

ResponsivenessInstrument

Mean

SD

Mean

SD

Mean

Median

SD

SRM

ES

CTSI-SS (60)***CTSI-FS (59)**
DASH-DS (55)***SF-36-PF (60)
SF-36-RP (58)
SF-36-BP (60)***SF-36-GH (59)SF-36-VT (59)SF-36-SF (60)
SF-36-RE (56)
SF-36-MH (58)
VAS (57)*

2.59
2.28
33.3
72.2
54.0
46.3
57.5
56.3
77.9
66.1
67.4
3.3

0.72
0.87
19.6
24.1
41.0
22.2
18.3
21.3
24.4
42.9
18.8
3.1

1.81
1.71
23.8
71.8
56.8
58.4
59.1
60.2
82.9
63.2
70.1
2.3

0.67
0.64
18.5
26.6
42.3
24.1
16.3
22.6
21.5
42.2
19.8
2.4

−0.77
−0.55
−9.14
−0.43
2.44
12.1
1.57
4.07
5.00
−2.98
2.98
−1.0

−0.80
−0.50
−9.17
0
0
11.5
0
5
0
0
4
−0.5

0.78
0.72
19.7
22.8
41.9
27.2
15.0
21.7
21.1
46.4
19.7
3.6

−1.00
−0.76
−0.46
−0.02
0.06
0.45
0.10
0.19
0.24
−0.06
0.15
−0.29

−1.08
−0.63
−0.47
−0.02
0.06
0.55
0.09
0.19
0.20
−0.07
0.16
−0.34

Numbers in parentheses indicate the number of tests performed
SRM, standardized response mean; ES, effect size; CTSI-JSSH-SS, Symptom Severity scale of the Japanese Society for Surgery of the Hand
Version of Carpal Tunnel Syndrome Instrument (CTSI-JSSH); CTSI-JSSH-FS, Functional Status scale of CTSI-JSSH; DASH-JSSH, Disability/
Symptom scale of the Japanese version of DASH; SF-36-PF, physical functioning subscale of the 36-Item Short-Form Health Survey (SF-36);
SF-36-RP, role-physical subscale of SF-36; SF-36-BP, bodily pain subscale of SF-36; SF-36-GH, general health subscale of SF-36; SF-36-VT, vitality subscale of SF-36; SF-36-SF, social functioning subscale of SF-36; SF-36-RE, role-emotional subscale of SF-36-MH, mental health subscaleof SF-36; VAS [0–10], Visual Analog Scale for pain [0–10 scale]* Significant difference between preoperative and postoperative median value (P < 0.05)** Significant difference between preoperative and postoperative median value (P < 0.01)*** Significant difference between preoperative and postoperative median value (P < 0.001)

Table 2. Responsiveness of grip strength, pinch strength, and s-2PD
Preoperative

Postoperative

Postoperative − preoperative

ResponsivenessInstrument

Mean

SD

Mean

SD

Mean

Median

SD

SRM

ES

Grip strength (66)*
Pinch (66)s-2PD (59)**

16.38
5.52
8.45

9.37
2.55
4.18

14.81
5.65
7.09

7.29
2.72
3.31

−1.57
0.13
−1.40

−1.17
−0.13
−0.67

6.04
1.42
3.25

−0.26
0.09
−0.43

−0.17
0.05
−0.33

Numbers in parentheses indicate the number of tests performeds-2PD, static two-point discrimination* Significant difference between the preoperative and postoperative median values (P < 0.05)** Significant difference between the preoperative and postoperative median values (P < 0.01)

Tables 1 and 2. Significant improvement was observedin the CTSI-SS, CTSI-FS, DASH, bodily pain subscaleof SF-36 (SF-36-BP), VAS, and s-2PD (P < 0.01). Grip
strength decreased significantly after 3 months postoperatively (P < 0.05). The largest responsiveness wasobserved in the CTSI-SS (SRM/ES: −1.00/−1.08), followed by the CTSI-FS (−0.76/−0.63), SF-36-BP(0.45/0.55), and DASH (−0.46/−0.47). Only the change
scores of the CTSI-SS had a significant correlation withpatient satisfaction (r = 0.34, P < 0.01) (Table 3).
An absolute value of Spearman’s correlation coefficient of >0.5 was observed between the change scoresof the CTSI-SS and the DASH, the CTSI-SS and the
SF-36-BP, the CTSI-FS and the DASH, and the DASH
and the SF-36-BP (Table 3).
Sixteen patients had worse scores in the DASH or
CTSI-SS 3 months after surgery. Eight patients had

worse scores in the DASH, whereas the CTSI-SS was
improved. Six patients had worsening of both the DASH
and the CTSI-SS, and two patients had worsening of
only the CTSI-SS. Although statistical analysis was not
performed owing to the small sample size, the patientswith worsening of the DASH score tended to have along duration of symptoms, severe stage of the disease,and development of trigger digit, as well as pain over
and around the wound.

Discussion
The responsiveness of the CTSI-SS and the CTSI-FS
was found to be greater than that of the DASH, thesubscales of SF-36, VAS, and the physical findings 3months after surgery. This was consistent with previous

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S. Uchiyama et al.: Comparison of responsiveness of the Japanese Society

Table 3. Correlation of change scores of each instrument
Correlation with
Instrument scale

CTSI-SSCTSI-FS

DASH

Satisfaction (n = 58)

CTSI-SS (60)
CTSI-FS (59)DASH (55)
SF-36-PF (60)
SF-36-RP (58)
SF-36-BP (60)
SF-36-GH (59)SF-36-VT (59)SF-36-SF (60)
SF-36-RE (56)
SF-36-MH (58)
VAH (57)
Grip strength (66)
Pinch (66)s-2PD (60)—0.467**
0.665**−0.318*−0.358**−0.580**0.318*−0.412**−0.186−0.437**−0.267*0.355**−0.181−0.1830.003——
0.641**−0.371**−0.291*−0.397**−0.145−0.421**−0.350**−0.264−0.474**−0.1860.064−0.1470.013———−0.485**−0.410**−0.621**−0.292*−0.392**−0.324**−0.420**−0.449**−0.393**−0.142−0.0560.026

0.337**
0.175
0.196−0.2360.051−0.254−0.252−0.188−0.028−0.06−0.102−0.1080.002−0.174−0.03* P < 0.05, ** P < 0.01; Spearman’s correlations (rs)Boldface results indicate a significant correlation, when P < 0.05 and |rs| > 0.5

Table 4. Correlation of instrument scale with grip strengthand pinch
Instrument scale

Correlation
with grip strength

Correlation
with pinch

Grip strength (66)
Pinch (66)s-2PD (60)—0.345**
0.001——−0.204** P < 0.01, Spearman’s correlation (rs)reports.10–12 Gay et al. found the CTSI was most sensitive to clinical changes after carpal tunnel release(ES/SRM: 1.77/1.66), followed by the DASH (1.01/1.13),
the SF-36-BP (0.57/0.52), and the role-physical subscaleof SF-36 (0.39/0.39).11 Greenslade et al. reported
that SRMs of the CTSI-SS, CTSI-FS, and DASH were
1.07, 0.62, and 0.66, respectively 3 months after open
carpal tunnel release.12 Atroshi et al. reported a good
response of the CTSI-SS (1.4–1.9), CTS-FS (0.8–1.1),
and SF-36 (1.0) 3 months after endoscopic carpal tunnel
release.
Although the CTSI is sensitive to clinical changes after carpal tunnel release, more generic instruments suchas the DASH or the SF-36 may be useful if the relative
impact of carpal tunnel syndrome on the entire upper
extremities or the body is evaluated. Patients with carpal tunnel syndrome scored low on the SF-36, but 3
months after surgery only bodily pain was alleviatedsignificantly. It is unclear whether carpal tunnel releaseaffected the patients’ general health status within the
3-month follow-up.
Carpal tunnel release surgery does not always relieve
the symptoms completely or immediately. After sur-gery, patients experience pain over the wound or thestumps of the transverse carpal ligament that could
last several months.13 During the 3 months after surgery,
numbness in the contralateral side of the hand is sometimes aggravated, and trigger digit can also develop.
Furthermore, patients with an extremely severe stageof the disease, especially those with diabetes, might not
feel significant alleviation of numbness with in a shortfollow-up period. These factors may explain the factthat grip strength decreased and pinch strength did
not improve after surgery and that the DASH and the
CTSI-FS were not as sensitive as the CTSI-SS eventhough surgery was done correctly. The DASH
and CTSI-SS are affected more by functional changes,
whereas the CTSI-SS is affected by paresthesia or
pain (or both), which can improve soon after
surgery.
Although statistically not compared, SRM or ES of
the CTSI in our patients was less than that found by
previous investigators.6,10–13 Only Greenslade et al. reported data almost comparable to ours.11 There are a
few factors that should be considered before making
direct comparisons.
Some reports did not provide any information regarding the duration of the symptoms, the severity ofthe disease, or the presence of coexisting disease; furthermore, our study population had more severe stagesof the disease (as determined by nerve conduction
studies), longer duration of the symptoms, or older age
than was reported in the other studies.10,11,14,15 Simply
comparing the SRM or ES among the studies should
be done with caution, with other outcome measures
being included to ensure adequate comparison of theprocedures.13

S. Uchiyama et al.: Comparison of responsiveness of the Japanese Society

Conclusions
The CTSI-JSSH version was proven to be more sensitive to clinical changes after carpal tunnel release thanthe other outcome measures. Thus, it should be used toevaluated patients with carpal tunnel syndrome who
speak Japanese as their native language.

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