Original research| Volume 99, ISSUE 3, P459-467.e1, March 2018

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

  • Chelsea A. Harris
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
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  • John-Michael Muller
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
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  • Melissa J. Shauver
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
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  • Kevin C. Chung
    Corresponding author Kevin C. Chung, MD, MS, Section of Plastic Surgery, The University of Michigan Health System, 1500 E Medical Center Dr, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340.
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
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Published:August 03, 2017DOI:



      To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.


      A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews.




      A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%).


      Not applicable.

      Main Outcome Measures

      Participants' self-report of their medical experiences from the time of injury through the early recovery period.


      We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care).


      In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.


      List of abbreviations:

      PM&R (physical medicine and rehabilitation), SCI (spinal cord injury), UER (upper extremity reconstruction)
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