Advertisement

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

  • Chelsea A. Harris
    Affiliations
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
    Search for articles by this author
  • John-Michael Muller
    Affiliations
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
    Search for articles by this author
  • Melissa J. Shauver
    Affiliations
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
    Search for articles by this author
  • Kevin C. Chung
    Correspondence
    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.
    Affiliations
    University of Michigan, Section of Plastic Surgery, Division of Hand Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, MI
    Search for articles by this author
Published:August 03, 2017DOI:https://doi.org/10.1016/j.apmr.2017.06.028

      Abstract

      Objectives

      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.

      Design

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

      Setting

      Community.

      Participants

      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%).

      Interventions

      Not applicable.

      Main Outcome Measures

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

      Results

      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).

      Conclusions

      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.

      Keywords

      List of abbreviations:

      PM&R (physical medicine and rehabilitation), SCI (spinal cord injury), UER (upper extremity reconstruction)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. National Spinal Cord Injury Statistical Center Spinal. cord injury (SCI) facts and figures at a glance. 2016. Available at: https://www.nscisc.uab.edu/Public/Facts%202016.pdf. Accessed January 23, 2017.

        • Manns P.J.
        • Chad K.E.
        Components of quality of life for persons with a quadriplegic and paraplegic spinal cord injury.
        Qual Health Res. 2001; 11: 795-811
        • Putzke J.D.
        • Richards J.S.
        • Hicken B.L.
        • DeVivo M.J.
        Predictors of life satisfaction: a spinal cord injury cohort study.
        Arch Phys Med Rehabil. 2002; 83: 555-561
        • Becker D.
        • Sadowsky C.L.
        • McDonald J.W.
        Restoring function after spinal cord injury.
        Neurologist. 2003; 9: 1-15
        • Anderson K.D.
        Targeting recovery: priorities of the spinal cord-injured population.
        J Neurotrauma. 2004; 21: 1371-1383
        • Hanson R.W.
        • Franklin M.R.
        Sexual loss in relation to other functional losses for spinal cord injured males.
        Arch Phys Med Rehabil. 1976; 57: 291-293
        • Snoek G.J.
        • IJzerman M.J.
        • Hermens H.J.
        • Maxwell D.
        • Biering-Sorensen F.
        Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics.
        Spinal Cord. 2004; 42: 526-532
        • Dunkerley A.L.
        • Ashburn A.
        • Stack E.L.
        Deltoid triceps transfer and functional independence of people with tetraplegia.
        Spinal Cord. 2000; 38: 435-441
        • Elhassan B.T.
        • Wagner E.R.
        • Spinner R.J.
        • Bishop A.T.
        • Shin A.Y.
        Contralateral trapezius transfer to restore shoulder external rotation following adult brachial plexus injury.
        J Hand Surg Am. 2016; 41: e45-e51
        • Freehafer A.A.
        Tendon transfers to improve grasp in patients with cervical spinal cord injury.
        Paraplegia. 1975; 13: 15-24
        • Lipscomb P.R.
        • Elkins E.C.
        • Henderson E.D.
        Tendon transfers to restore function of hands in tetraplegia, especially after fracture-dislocation of the sixth cervical vertebra on the seventh.
        J Bone Joint Surg Am. 1958; 40: 1071-1080
        • Curtin C.M.
        • Gater D.R.
        • Chung K.C.
        Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study.
        J Hand Surg Am. 2005; 30: 94-99
        • Moberg E.
        Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience.
        J Bone Joint Surg Am. 1975; 57: 196-206
        • Bednar M.S.
        Tendon transfers for tetraplegia.
        Hand Clin. 2016; 32: 389-396
        • Bryden A.M.
        • Wuolle K.S.
        • Murray P.K.
        • Peckham P.H.
        Perceived outcomes and utilization of upper extremity surgical reconstruction in individuals with tetraplegia at Model Spinal Cord Injury Systems.
        Spinal Cord. 2004; 42: 169-176
        • Gregersen H.
        • Lybæk M.
        • Lauge Johannesen I.
        • Leicht P.
        • Nissen U.V.
        • Biering-Sørensen F.
        Satisfaction with upper extremity surgery in individuals with tetraplegia.
        J Spinal Cord Med. 2015; 38: 161-169
        • Hentz V.R.
        • Brown M.
        • Keoshian L.A.
        Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications.
        J Hand Surg Am. 1983; 8: 119-131
        • Jaspers Focks-Feenstra J.H.
        • Snoek G.J.
        • Bongers-Janssen H.M.
        • Nene A.V.
        Long-term patient satisfaction after reconstructive upper extremity surgery to improve arm-hand function in tetraplegia.
        Spinal Cord. 2011; 49: 903-908
        • Lamb D.W.
        • Chan K.
        Surgical reconstruction of the upper limb in traumatic tetraplegia. A review of 41 patients.
        J Bone Joint Surg Br. 1983; 65: 291-298
        • Meiners T.
        • Abel R.
        • Lindel K.
        • Mesecke U.
        Improvements in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: self-assessment by patients.
        Spinal Cord. 2002; 40: 574-580
        • Wangdell J.
        • Friden J.
        Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia.
        J Hand Surg Eur Vol. 2010; 35: 563-568
        • Punj V.
        • Curtin C.
        Understanding and overcoming barriers to upper limb surgical reconstruction after tetraplegia: the need for interdisciplinary collaboration.
        Arch Phys Med Rehabil. 2016; 97: S81-S87
        • Dunn J.A.
        • Hay-Smith E.J.
        • Whitehead L.C.
        • Keeling S.
        Issues influencing the decision to have upper limb surgery for people with tetraplegia.
        Spinal Cord. 2012; 50: 844-847
        • Dunn J.A.
        • Hay-Smith E.J.
        • Whitehead L.C.
        • Keeling S.
        Liminality and decision making for upper limb surgery in tetraplegia: a grounded theory.
        Disabil Rehabil. 2013; 35: 1293-1301
        • Brabers A.
        • de Jong J.
        • Groenewegen P.
        • van Dijk L.
        Do people intend to have an active role in medical decision-making? The role of social resources.
        Eur J Public Health. 2015; 25 (ckv174.026-ckv174.026)
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making—the pinnacle of patient-centered care.
        N Engl J Med. 2012; 366: 780-781
        • Charles C.
        • Gafni A.
        • Whelan T.
        Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango).
        Soc Sci Med. 1997; 44: 681-692
        • Freehafer A.A.
        • Peckham P.H.
        • Keith M.W.
        New concepts on treatment of the upper limb in the tetraplegic. Surgical restoration and functional neuromuscular stimulation.
        Hand Clin. 1988; 4: 563-574
        • Waters R.L.
        • Sie I.H.
        • Gellman H.
        • Tognella M.
        Functional hand surgery following tetraplegia.
        Arch Phys Med Rehabil. 1996; 77: 86-94
        • Dunn J.A.
        • Sinnott K.A.
        • Rothwell A.G.
        • Mohammed K.D.
        • Simcock J.W.
        Tendon transfer surgery for people with tetraplegia: an overview.
        Arch Phys Med Rehabil. 2016; 97: S75-S80
        • Adriaansen J.J.
        • Post M.W.
        • de Groot S.
        • et al.
        Secondary health conditions in persons with spinal cord injury: a longitudinal study from one to five years post-discharge.
        J Rehabil Med. 2013; 45: 1016-1022
        • Jensen M.P.
        • Truitt A.R.
        • Schomer K.G.
        • Yorkston K.M.
        • Baylor C.
        • Molton I.R.
        Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review.
        Spinal Cord. 2013; 51: 882-892
        • Wannapakhe J.
        • Arrayawichanon P.
        • Saengsuwan J.
        • Amatachaya S.
        Medical complications and falls in patients with spinal cord injury during the immediate phase after completing a rehabilitation program.
        J Spinal Cord Med. 2015; 38: 84-90
        • Devers K.J.
        • Frankel R.M.
        Study design in qualitative research-2: sampling and data collection strategies.
        Educ Health (Abingdon). 2000; 13: 263-271
        • Harris C.A.
        • Muller J.-M.
        • Shauver M.J.
        • Chung K.C.
        Checkpoints to progression: qualitative analysis of the personal and contextual factors that influence selection of upper extremity reconstruction among patients with tetraplegia.
        J Hand Surg Am. 2017; 42: 495-505.e11
        • Boeije H.
        A purposeful approach to the constant comparative method in the analysis of qualitative interviews.
        Qual Quant. 2002; 36: 391-409
        • Corbin J.M.
        • Strauss A.
        Grounded theory research: procedures, canons, and evaluative criteria.
        Qual Sociol. 1990; 13: 3-21
        • Shauver M.S.
        • Chung K.C.
        A guide to qualitative research in plastic surgery.
        Plast Reconstr Surg. 2010; 126: 1089-1097
        • Aboumatar H.
        • Forbes L.
        • Branyon E.
        • et al.
        Understanding treatment with respect and dignity in the intensive care unit.
        Narrat Inq Bioeth. 2015; 5: 55A-67A
        • McCarthy M.
        US doctors are judged more on bedside manner than effectiveness of care, survey finds.
        BMJ. 2014; 349: g4864
        • Hashim M.J.
        Patient-centered communication: basic skills.
        Am Fam Physician. 2017; 95: 29-34
        • Ajzen I.
        From intentions to actions: a theory of planned behavior.
        in: Kuhl J. Beckmann J. Action control: from cognition to behavior. Springer Berlin Heidelberg, Berlin, Heidelberg1985: 11-39
        • Curtin C.M.
        • Hayward R.A.
        • Kim H.M.
        • Gater D.R.
        • Chung K.C.
        Physician perceptions of upper extremity reconstruction for the person with tetraplegia.
        J Hand Surg Am. 2005; 30: 87-93