Tara Packham

Bilateral hand transplantation: Functional benefits assessment in five patients with a mean follow-up of 7.6 years (range 4-13 years).

Between January 2000 and July 2009, five adults who had suffered bilateral traumatic below-elbow amputations, received bilateral hand-forearm allografts performed by the Lyon team. We report the functional benefits achieved over a mean follow-up period of 7.6 years (range 4-13 years), up to December 31st, 2013. Clinical measurement is hampered by the lack of specific validated assessment tools, obliging us to use non-specific standardized evaluation means. Our assessment shows that the restoration of motion, strength, and sensibility are fair. Functional results (Carroll upper extremity function test, 400-point test, Activities of daily living) are good, as well as quality of life evaluation (RAND-36). Subjective and overall results explored with questionnaires - Disabilities of the Arm Shoulder and Hand (DASH), Hand Transplantation Score System (HTSS), are very good. Improvement was seen to continue during the first three years, and then tend to become stable. Continued efforts should be directed at designing comprehensive, condition-specific, reliable outcome measurement tools. Continuous monitoring and evaluation of patients is required to assess the long-term risk-benefit balance.

A systematic review of psychometric evaluations of outcome assessments for complex regional pain syndrome.

Purpose: To conduct a systematic review of the quality and extent of psychometric examinations of disease-specific outcome measures for complex regional pain syndrome (CRPS). Methods: Health database searches yielded 23 papers covering 19 assessment instruments. Each article was scored for quality using a 12-item structured tool; data were also extracted for comparison of tool content. Results: Article quality ratings ranged from 25 to 88%. Six of the tools were specific to the upper extremity; 5 for the lower extremities while the remaining 8 were general. Many ‘general’ tools focused on a single construct, such as pain, skin temperature or allodynia. Most psychometric data was based on small studies (mean n = 33); only one study addressed all relevant issues of reliability, validity and responsiveness. Conclusions: Despite the variety of outcome measurement tools reported for CRPS rehabilitation, large gaps in both comprehensiveness and supporting psychometric evidence remain. Comprehensive, relevant and psychometrically sound tools for monitoring treatment outcomes are needed to address the pain and functional limitations experienced by this population. Implications for Rehabilitation Complex regional pain syndrome (CRPS) is a neurological disorder with signs and symptoms that vary with activity, environment and stress. Although there is no diagnostic test for this syndrome, a need exists for tools to monitor treatment outcomes that address the pain and functional limitations experienced by this population. This review suggests that at present, there is no single comprehensive outcome measure for clinical practice and/or research which has strong supporting psychometric evidence for the evaluation of persons with CRPSAPPENDIX, a scoring sheet and scoring guidelines for critical appraisals for the evaluation of persons with CRPS.

The Ten Test for Sensation

The Ten Test (TT) is a quantitative sensory test requiring no test equipment (Strauch 2003). The subject reports his/ her light touch perception of the skin area being tested compared to the reference normal area when the examiner gives a simultaneous stimulus by stroking a normal area and the area under examination. When examining subjects with bilateral hand involvement it has been suggested that a normally innervated facial comparator could be used. The response from the patient rating the sensibility of the test area is recorded as a fraction out of 10 between 1/10 and 10/10 (10 = normal sensory perception). The test may be repeated to produce an average score. Detailed test procedure available at http://www.youtube.com/watch?v=ktvjsqbIfUM. Reliability and validity: The TT has been found to be reliable and repeatable. Inter-observer reliability was excellent (ICC = 0.91) and very strong agreement (Ð =1.00, p < 0.003) was found between examiners (Strauch 1997; Sun 2010). Good to excellent intra-observer reliability (ICC = 0.62 to 0.90, p < 0.05) was found (Strauch 1997) when equal delivery of the stimulus pressure to the test and normal areas was evaluated. Multiple studies demonstrated the TT may be used for outcome measurement (Novak 2003, 2005; Humphreys 2007). The TT is recommended for: clinical use in patients age > 5 years (Sun 2010); different conditions of upper extremities (Patel 1999; Faught 2002; Novak 2005), and lower extremities (Humphreys 2007); and pre/post operative sensory evaluation (Strauch 1997, MacDermid 2004, Novak 2003).

Ice-water (cold stress) immersion testing

Trauma-induced cold intolerance (cold sensitivity) is characterised by pain, stiffness, altered sensibility, or colour change associated with cold exposure (Campbell and Kay 1998), and is common after nerve injury or surgery (Irwin et al 1997). The Immersion in Cold water Evaluation (ICE) is a cold stress test administered through a standardised protocol where the hand is immersed in cold water and the examiner monitors the pain response and re-warming (Traynor and MacDermid 2008).

Clinical implementation of two quantitative Sensory Tests: Cold Stress Test and the Ten Test

Accurate assessment of pain or sensory function in clinical practice is challenging. Quantitative Sensory Testing (QST) is a standardized approach to measuring pain and sensory thresholds or tolerances as a means of assessing the functionality of neural pathways from the receptors along the afferent fibers to the brains. This paper reviews two simple QST techniques potentially useful to clinical practice: the Cold Stress Test and Ten Test. The background, evidence for clinical measurement properties and feasibility issues are considered.

Somatosensory rehabilitation for allodynia in complex regional pain syndrome of the upper limb: A retrospective cohort study

Study Design: Retrospective cohort study. Introduction: Somatosensory rehabilitation is a standardized method of evaluation and conservative treatment of painful disorders of vibrotactile sensation, including the mechanical allodynia and burning pain of complex regional pain syndrome (CRPS). Purpose of the Study: The purpose of this study was to examine the effectiveness of somatosensory rehabilitation for reducing allodynia in persons with CRPS of 1 upper limb in a retrospective consecutive cohort of patients. Methods: An independent chart review of all client records (May 2004‐August 2015) in the Somatosensory Rehabilitation Centre (Fribourg, Switzerland) identified 48 persons meeting the Budapest criteria for CRPS of 1 limb who had undergone assessment and treatment. Outcomes of interest were the French version of the McGill Pain Questionnaire (Questionnaire de la Douleur St‐Antoine [QDSA]), total area of allodynia as recorded by mapping the area of skin where a 15‐g monofilament was perceived as painful, and the allodynia threshold (minimum pressure required to elicit pain within the allodynic territory). Results: This cohort was primarily women (70%), with a mean age of 45 years (range: 18‐74). Mean duration of burning pain was 31 months (range: 1 week‐27.5 years), and baseline QDSA core was 48. The average primary area of allodynia was 66 cm2 (range: 2.6‐320), and the most common allodynia threshold was 4.0 g. The average duration of treatment was 81 days. At cessation of treatment, the average QDSA score was 20 (effect size Cohens d = 1.64). Allodynia completely resolved in 27 persons (56% of the total sample where only 58% completed treatment). Discussion: This uncontrolled retrospective study suggests that somatosensory rehabilitation may be an effective treatment with a large effect size for reducing the allodynia and painful sensations associated with CRPS of the upper limb. More work is in progress to provide estimates of reliability and validity for the measurement tools for allodynia employed by this method. Level of Evidence: 2c.

Measurement properties of painDETECT: Rasch analysis of responses from community-dwelling adults with neuropathic pain

BackgroundpainDETECT (PD-Q) is a self-reported assessment of pain qualities developed as a screening tool for pain of neuropathic origin. Rasch analysis is a strategy for examining the measurement characteristics of a scale using a form of item response theory. We conducted a Rasch analysis to consider if the scoring and measurement properties of PD-Q would support its use as an outcome measure.MethodsRasch analysis was conducted on PD-Q scores drawn from a cross-sectional study of the burden and costs of NeP. The analysis followed an iterative process based on recommendations in the literature, including examination of sequential scoring categories, unidimensionality, reliability and differential item function. Data from 624 persons with a diagnosis of painful diabetic polyneuropathy, small fibre neuropathy, and neuropathic pain associated with chronic low back pain, spinal cord injury, HIV-related pain, or chronic post-surgical pain was used for this analysis.ResultsPD-Q demonstrated fit to the Rasch model after adjustments of scoring categories for four items, and omission of the time course and radiating questions. The resulting seven-item scale of pain qualities demonstrated good reliability with a person-separation index of 0.79. No scoring bias (differential item functioning) was found for this version.ConclusionsRasch modelling suggests the seven pain-qualities items from PD-Q may be used as an outcome measure. Further research is required to confirm validity and responsiveness in a clinical setting.

The Hamilton Inventory for Complex Regional Pain Syndrome: A Cognitive Debriefing Study of the Clinician-based Component

STUDY DESIGN Descriptive. INTRODUCTION The Hamilton Inventory for Complex Regional Pain Syndrome (HI-CRPS) is a multidisciplinary assessment tool under development. PURPOSE OF THE STUDY This study examined the assessment practices, beliefs and preferences of health care professionals working with CRPS to inform the content and structure of the clinician-based portion of the HI-CRPS (CB-HI-CRPS), as well as refine the user manual. METHODS Semi-structured cognitive interviews were conducted with health care professionals from a spectrum of disciplines working with CRPS. Assessment practices and scaling preferences for 15 assessment concepts were collected, relating directly to items on the CB-HI-CRPS. Interviews were transcribed and coded with emergent themes. RESULTS Participants reported using the concepts from the CB-HI-CRPS 85.2% of the time. Physicians and nurses preferred present/absent judgements, while therapists used none/mild/moderate/severe scaling. Emerging themes highlighted assessment values, beliefs about CRPS, professional roles, and knowledge translation. CONCLUSIONS Lack of uniformity in terminology and assessment behaviours underscores the need for clear scoring frameworks and standardized assessment instructions to improve reliability across the proposed users of the HI-CRPS. LEVEL OF EVIDENCE Level 4.

Clinical Commentary in Response to: Severity of Contracture and Self-reported Disability in Patients with Dupuytren’s Contracture Referred for Surgery

Loss of motion, particularly functional extension, and the resultant activity limitations in Dupuytren’s disease (DD) are among the motivations for a patient to pursue hand surgery. The authors of this article set out to investigate if there was a relationship between the loss of active extension and the level of selfreported disability in persons planning to undergo surgical release for DD. Because the small finger is affected more often than other digits in DD, they also were interested in determining if self-reported disability was associated with the amount of extension loss (contracture) of any particular digit or a product of the total movement losses in the entire hand. Evidence from this study will add to the larger body of evidence that previously looked for a relationship using the same patient-reported instrument (the DASH—Disabilities of the Arm, Shoulder and Hand Questionnaire) and range-of-motion (ROM) measures.

Content validation of the Patient-Reported Hamilton Inventory for Complex Regional Pain Syndrome: Validité de contenu du Hamilton Inventory for Complex Regional Pain Syndrome, une mesure des résultats déclarés par le patient

Background. Complex regional pain syndrome (CRPS) is a perplexing neurological condition, and persons with CRPS experience substantial loss of daily roles and activities. A condition-specific measure is being developed to evaluate CRPS. Purpose. We describe the use of cognitive interviews to examine content validity of this patient-reported outcome measure for CRPS. Method. Interviews with 44 persons with CRPS were analyzed to identify problems with wording and support content validation. Item-total correlations were calculated for proposed subscales, and scores were plotted to consider floor/ceiling effects. Findings. Interviews identified questions where respondents considered factors unrelated to the construct of interest or were underaddressed by the questionnaire, including depression and skin temperature. The symptoms, daily function, and coping/social impact scales demonstrated satisfactory correlations (Cronbach’s alpha 0.76–0.86). Despite a sampling bias of severity, no frank floor/ceiling effects were noted. Implications. This study builds a foundation for continuing development and evaluation of the measurement properties of the Patient-Reported Hamilton Inventory for CRPS. It makes explicit the iterative decisions involved in rigorous instrument development.