Johanna Wangdell

Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia

Reconstruction of grip in tetraplegia aims to improve upper extremity performance and control in daily life. We evaluated the effects of surgery and rehabilitation on performance and satisfaction of patient identified activity goals in 20 patients (22 arms) who had grip reconstructions for both finger and thumb flexion. Patients assessed an improvement in both performance and satisfaction after surgery in all groups of activities assessed using the Canadian Occupational Performance Measure (COPM). The mean improvement at 6 and 12 months was 3.5 points better than the 2.5 points before surgery. Before surgery 36% of the goals identified were impossible to perform. After surgery, 78% of these goals were possible. The largest improvement was observed in the basic activity of ‘eating’ but significant improvement was also noted in activities generally regarded as complex and not measured in standard ADL such as ‘doing housework’ and taking part in ‘leisure’.

Enhanced independence: experiences after regaining grip function in people with tetraplegia

Abstract Purpose: To explore how surgical reconstruction of grip affects everyday life for patients with tetraplegia, with special emphasis on patients perspective of their perceived changes. Design: Qualitative method. Subjects: Eleven people (aged 22–73) with tetraplegia who had undergone surgical reconstruction to restore grip function. Methods: Qualitative interviews were conducted 7–17 months after surgery and analysed using Grounded theory. Results: The core concept describing the participants experienced gains after grip reconstructive surgery was “enhanced independence”. It was associated with changes in both practical and psychological aspects of independence. Practical aspects identified were: “perform more activities”, “smoother everyday life”, “renewed ability to participate in social activities”, “less dependence on assistance” and “less restricted by physical environment”. Psychological aspects of independence included “regained privacy”, “increased manageability”, “regained identity”, “recapture a part of the body” and “share positive experiences with relatives and friends”. Encompassing all categories was the concept “self-efficacy in hand control”. It was seen as a result included in the enhanced independency core but also as an important factor for the development of all the other categories. Conclusion: Participants in this study experienced enhanced independence after grip reconstructive surgery and rehabilitation. The enhanced independence included both practical and physical aspects and it influenced all domains using the International Classification of Function, Disability and Health model; body function and structure, activities, participation, personal factors and environmental factors. Implications for Rehabilitation Patients with tetraplegia experience grip reconstruction as a useful intervention, an enhanced independence, related to their improved hand control. The increased hand control impacted not only physical aspects but also practical and psychological aspects. It also influenced social and community participation and the interference the environment had on the person. Self-efficacy was both a result of the intervention and a catalyst allowing the subcategories to develop. Therefore, self-efficacy in hand control seems to be an important factor to focus on during the rehabilitation process.

From regained function to daily use: experiences of surgical reconstruction of grip in people with tetraplegia

Abstract Purpose: To capture patients’ relearning processes from regained function to improvements in daily life after grip reconstructive surgery in tetraplegia. Subjects: Eleven people with tetraplegia who underwent grip reconstructive surgery during February 2009 to March 2011. Methods: Qualitative interviews were conducted 7 to 17 months after surgery and analysed using grounded theory. Results: Determination to reach a higher level of independence was the core concept to integrate regained function into daily life. There were 3 phases identified; “Initiate activity training,” “Establish hand control in daily activities,” and “Challenge dependence.” Between the phases psychological stages occurred, first; “a belief in improved ability”, and later in the process; “confidence in ability”. The process to fully integrate regain function in daily life was described as long and time-consuming. However, the participants claimed it useful to do the skills training in their home environment, without long-term in clinic rehabilitation. Conclusion: Relearning activities in daily life after a grip reconstruction is a time-consuming and demanding process. It includes skills training, mental strategies and psychological stages together with environmental and social factors. Accordingly, rehabilitation after grip reconstruction in tetraplegia should focus on both grip skills and psychological stages, to encourage that patient’s keep their determination and achieve greater independence. Implications for Rehabilitation There is a stepwise process to transform improved function into daily use. The most important factor to transform improved function into daily use was motivation to reach a higher independence. Other important factors were; skills training, use of individual learning strategies, belief and confidence in personal ability, social and environmental factors. There was a long and demanding process to fully transform the improved function into daily use. The participants preferred to do activity training in the specific environment, usually at home.

Measurement of Outcomes of Upper Limb Reconstructive Surgery for Tetraplegia

Reconstructive arm/hand surgery for tetraplegia is performed to improve arm/hand function and therefore personal well-being for individuals who accept such elective surgeries. However, changes at an impairment level do not always translate into functional or quality of life changes. Therefore, multiple outcome tools should be used that incorporate sufficient responsiveness to detect changes in arm/hand function, activity and participation, and quality of life of the individuals involved. This narrative review aims to assist clinicians to choose the most appropriate tools to assess the need for reconstructive surgery and to evaluate its outcomes. Our specific objectives are (1) to describe aspects to consider when choosing a measure and (2) to describe the measures advised by an international therapist consensus group established in 2007. All advised measures are appraised in terms of the underlying construct, administration, and clinical relevance to arm/hand reconstructions. Essentially there are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery. However, with judicious use of available measures it is possible to ensure the questions asked or tasks completed are relevant to the surgical reconstruction(s) undertaken. Further work in this field is required. This would be best met by immediate collaboration between 2 outcomes tool developers and by analysis of pre- and postoperative data already held in various international sites, which would allow further evaluation of the measures already in use, or components thereof.

Upper extremity reconstruction in non-traumatic spinal cord injuries: An under-recognized opportunity.

OBJECTIVE This study reviews the usefulness of surgical improvement of arm and hand function in patients with non-traumatic spinal cord injury who differ significantly from individuals with post-traumatic tetraplegia with respect to age, injury pattern, gender and socio-economic factors. DESIGN Case series. Tests were conducted preoperatively and 12 months postoperatively. PATIENTS The results of 14 upper extremity reconstructions in 11 patients (7 women, 4 men) with spinal cord injury, mean age at injury 49 years (standard deviation (SD) 12), were reviewed. METHODS Key pinch strength, grip strength and first web space opening were recorded pre- and post-operatively in all patients, 5 patients (7 hands) were evaluated prospectively regarding manual dexterity. RESULTS All parameters were significantly improved. Strength of key pinch increased from 0.3 kg in 1 case and zero in 10 cases to a mean of 1.6 kg (SD 0.9). Mean grip strength increased from 0 to 3.2 kg (SD 4.5). Maximal distance between thumb and index increased from 2.1 cm (SD 4.1) to 6.4 cm (SD 4.4). Manual dexterity increased. CONCLUSION Individuals with stable non-traumatic tetraplegia benefit from surgical rehabilitation of their upper extremities. The number of non-traumatic spinal cord injuries is likely to increase as lifespan increases worldwide, and further research into the functional rehabilitation of this population will therefore become increasingly relevant.

Satisfaction with upper limb reconstructive surgery in individuals with tetraplegia: the development and reliability of a Swedish self-reported satisfaction questionnaire

Study design:A questionnaire-based survey.Objectives:To assess satisfaction after upper limb reconstructive surgery in individuals with tetraplegia and to determine the reliability of a Swedish satisfaction questionnaire.Setting:A center for advanced reconstruction of extremities, Gothenburg, Sweden.Methods:Seventy-eight individuals with tetraplegia were invited to participate in the survey assessing satisfaction with the result of surgery across various domains. Measures of reliability included stability and internal consistency of domains consisting questions regarding global satisfaction, activities and occupation/schooling.Results:Fifty-eight individuals (76%) participated, among whom 47 (82%) completed the questionnaire twice for repeatability assessment. The responses in the domains relating to global satisfaction, activities and occupation/schooling were positive in 83%, 72% and 31% of participants, respectively. Ninety-five percent felt they had benefited from the surgery, and 86% felt that the surgery had made a positive impact on their life. The psychometric testing indicated that the questionnaire yields scores that are reliable by both test–retest and internal consistency, with the exception of the domain occupation/schooling that had a high prevalence of missing and neutral responses and seemingly represents separate and distinct entities.Conclusion:Surgical rehabilitation of the upper limb in tetraplegia is highly beneficial and rewarding from a patient perspective, leading to satisfactory gains in activities of daily living as well as enhanced quality of life. The questionnaire is a reliable instrument for measuring satisfaction after surgery. However, occupationally and educationally related aspects of the surgical outcome should constitute separate domains, and further modifications of the questionnaire are thus recommended.

Adaptive motor cortex plasticity following grip reconstruction in individuals with tetraplegia

Background: Tendon transfer is a surgical technique for restoring upper limb motor control in patients with cervical spinal cord injuries (SCI), and offers a rare window into cortical neuroplasticity following regained arm and hand function. Objective: Here, we aimed to examine neuroplasticity mechanisms related to re-established voluntary motor control of thumb flexion following tendon transfer. Methods: We used functional Magnetic Resonance Imaging (fMRI) to test the hypothesis that restored limb control following tendon transfer is mediated by activation of that limb’s area of the primary motor cortex. We examined six individuals with tetraplegia who underwent right-sided surgical grip reconstruction at Sahlgrenska University Hospital, Sweden. All were right-handed males, with a SCI at the C6 or C7 level, and a mean age of 40 years (range = 31–48). The average number of years elapsed since the SCI was 13 (range = 6–26). Six right-handed gender- and age-matched control subjects were included (mean age 39 years, range = 29–46). Restoration of active thumb flexion in patients was achieved by surgical transfer of one of the functioning elbow flexors (brachioradialis), to the paralyzed thumb flexor (flexor pollicis longus). We studied fMRI responses to isometric right-sided elbow flexion and key pinch, and examined the cortical representations within the left hemisphere somatomotor cortex a minimum of one year after surgery. Results: Cortical activations elicited by elbow flexion did not differ in topography between patients and control participants. However, in contrast to control participants, patients’ cortical thumb flexion activations were not topographically distinct from their elbow flexion activations. Conclusion: This result speaks against a topographic reorganization in which the thumb region regains thumb control following surgical tendon transfer. Instead, our findings suggest a neuroplastic mechanism in which motor cortex resources previously dedicated to elbow flexion adapt to control the thumb.

Rehabilitation After Posterior Deltoid to Triceps Transfer in Tetraplegia

OBJECTIVE To describe and evaluate the rehabilitation concept after posterior deltoid to triceps transfer in patients with tetraplegia. DESIGN Retrospective observational study. SETTING Rehabilitation units. PARTICIPANTS Patients with tetraplegia who had posterior deltoid to triceps tendon transfer and had muscle strength measurements 1 year postsurgery from 2009 to 2013 (N=44). INTERVENTIONS Posterior deltoid to triceps tendon transfer to restore elbow extension and postoperative rehabilitation. MAIN OUTCOME MEASURES Elbow extension range of motion and muscle strength and the modified Canadian Occupational Performance Measure (COPM). RESULTS Surgery was performed on 53 arms. No major complications (eg tendon rupture, lengthening) were reported. Muscle strength measured 1 year after surgery was on average grade 3 (out of 5) in the 53 operated arms. The ability to extend the elbow against gravity was achieved in 62% of the arms (muscle strength of grade ≥3). In patients with a preoperative elbow extension deficit (n=14), the deficit was reduced on average from 16° to 9°. The performance of the prioritized activities as measured with the COPM improved on average 2.6 scale steps, from 3.3 to 5.9. Satisfaction with the performance improved on average 3.2 scale steps, from 2.8 to 6.0. CONCLUSIONS The posterior deltoid to triceps tendon transfer with the applied rehabilitation protocol is a safe and effective procedure. There were no tendon ruptures, and all patients were able to complete the rehabilitation protocol. The shorter restriction time after surgery allows the patient to be independent at an earlier stage of the rehabilitation and reduces hospitalization or care burden.

Activity gains after upper limb surgery for spasticity in patients with spinal cord injury

Spasticity is a common and increasingly prevalent secondary complication of spinal cord injury. The aim of the study was to evaluate patient-experienced gains in prioritized activities after surgery to reduce the effects of spasticity in upper limbs in tetraplegia. The study includes evaluation of 30 operations for 27 patients performed on hypertonic tetraplegic hands during 2007–2015 using the Canadian Occupational Performance Measure. Activity performance increased at both 6 months and 12 months by a mean of 3.0 and 2.9 points, respectively. Satisfaction increased by 3.3 and 3.4, respectively. All types of activities improved, with wheelchair manoeuvring as one of the highest rated. The intervention increased prioritized activity performance and persisted at least 12 months after surgery. Patients with mild upper limb impairment showed greater improvement after surgery. After operation, patients were able to perform 71% of their prioritized activities, which they could not perform before. Patients’ satisfaction with the performance was high. Level of evidence: IV

Outcomes of reconstructive hand surgery in patients with tetraplegia and neuropathic pain

Study designRetrospective cohort studyObjectivesTo evaluate the impact of preoperative neuropathic pain on outcome and postoperative compliance after grip reconstructive surgery in people with tetraplegia.SettingSpecialized tetraplegia upper-limb surgery center in Sweden.MethodsAll patients who underwent grip reconstructive surgery and attended a 6 month follow up during January 2012 and May 2015 were included. Participants were divided into two groups, pain group and no pain group, based on preoperative rating of experienced pain on a visual analog scale. The main outcome measures were grip strength, grasp ability (Grasp and Release Test) and prioritized activity outcome (Canadian Occupational Performance Measure) together with compliance to the rehabilitation plan.ResultsThe study include 37 patients (86% of the cohort). Seventeen patients experienced preoperative pain (46%). There were no differences in outcome between the pain- and the no pain group regarding grip strength (5 vs. 4.6 kg), grip ability or activity performance and satisfaction (COPM improvement of 3.1 vs. 3.0 for performance and 3.6 for both groups in satisfaction). Both groups experienced improvements in all aspects and there were no differences in the ability to fulfill postoperative treatment.ConclusionsIndividuals with tetraplegia and preoperative neuropathic pain in the arm/hand improve after grip reconstructions in a similar way to those without pain. Patients with neuropathic pain therefore should be considered as surgery candidates to the same extent as those without pain.