Making the decision about upper limb surgery Dr Jennifer Dunn
PhD, MPhil(Rehab), Dip Phty
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Introduction Pioneered by Moberg in early 1970s Commenced in NZ
in 1982 and since this time over 260 people who tetraplegia have
had surgery
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Reported benefits of upper limb surgery Restoration of elbow
extension (mean strength went from MRC 0 MRC 3.3 after
reconstruction) Hamou et al (2009) Increased pinch strength (mean
post- operative strength 2kg) Hamou et al (2009) Improvement in
activities of daily living
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From Wangdell & Friden (2011)
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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.
Improved self belief and confidence improved self-efficacy. It also
influenced social and community participation and the interference
the environment had on the person. Wangdell, et al (2013)
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Uptake of upper limb surgery Variable uptake of upper limb
surgery around the world Reported uptake in the USA less than 10%
(Curtin et al, 2005) Uptake in NZ 65% of the people assessed for
surgery (Dunn et al, 2010)
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Decision making process
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No thanks Let me have it ! Possibly Decide that upper limb
surgery is not an option for them. Actively pursue the option of
upper limb surgery. View upper limb surgery favourably, but is not
a priority at this stage.
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Let me have it! Want to get on with the rest of their life
Improve independence Return to previous activities Did not
reconsider decision to have surgery once it was made
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No thanks May get more recovery Cure for SCI Im okay as I
am
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Possibly Maybe later Often decided to have surgery then
reconsidered Not willing to take time out of life for surgery/rehab
Decision influenced by a number of factors
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Issues influencing the decision Hope for further recovery/cure
for SCI Particularly in the no thanks group Temporal component to
this issue so that as hopes for continued recovery faded with time,
often hope for the cure continued Contrasting with let me have it
group Physical environment/social support The need for increased
care/support during period while in plaster casts more of an issue
for women, and those who were married/in a relationship Home
environment need to be adapted and stable
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Issues influencing the decision Life roles A big issue for
women with tetraplegia as they were less willing to temporarily
relinquish their life roles Life goals Many in the let me have it
group viewed upper limb surgery as a way of improving on
rehabilitation and attaining previous life roles/goals Those in the
possibly group felt that the time required for surgery/rehab was
considered too large a sacrifice to their immediate goals and
priorities.
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Making the decision SURGERY NO SURGERY Liminality An ambiguous
state that is neither one thing nor another, a condition that is
betwixt and between two states
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Making the decision Liminal state not a steady state Many
people appeared to be on the threshold of having upper limb surgery
and may have just required a stimulus such as re-offer for surgery
No-one approached me again to see if I wanted (surgery)..... I
think if I had been encouraged by the right person, I probably
would have had it done. CW
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Allows for changing life goals and circumstances Encourages the
person with tetraplegia to re- examine their decision Re-offers for
surgery Changes in thoughts on hope and the cure for SCI
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Clinical implications Decision making is a process in time but
the moment of making the decision is elusive therefore multiple
offers of surgery at different timeframes in an individuals life
are required. Flexibility of timing for surgery to lessen impact of
upper limb surgery on an individuals goals and priorities.
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I like to keep an open mind about everything and in the future
I might want to change my mind...so its always a possibility, yeah
I haven't, Im not sort of cold on the issue JB not saying never!
CW
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Thank you
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References Curtin, C. M., Gater, D. R., & Chung, K. C.
(2005). Upper extremity reconstruction in the tetraplegic
population, a national epidemiologic study. The Journal of Hand
Surgery, 30A, 94-99. Dunn, J. A., Hay-Smith, E. J. C., Whitehead,
L. C., Keeling, S., & Rothwell, A. G. (2010). Upper limb
reconstructive surgery uptake for persons with tetraplegia in New
Zealand: a retrospective case review 2001-5. Spinal Cord, 48,
832-837. doi: 1362.4393/10 Dunn, J., Hay-Smith, E., Whitehead, L.,
& Keeling, S. (2012). Issues influencing the decision to have
upper limb surgery for people with tetraplegia. Spinal Cord,
50(11), 844-847. Dunn, J. A., Hay-Smith, E. J. C., Whitehead, L.
C., & Keeling, S. (2012). Liminality and decision making for
upper limb surgery in tetraplegia: a grounded theory. Disability
and Rehabilitation(00), 1-9. Hamou, C., Shah, N. R., DiPonio, L.,
& Curtin, C. M. (2009). Pinch and elbow extension restoration
in people with tetraplegia: a systematic review of the literature.
The Journal of Hand Surgery, 34A, 692-699. Wangdell, J., &
Friden, J. (2010). Satisfaction and performance in patient selected
goals after grip reconstruction in tetraplegia. Journal of Hand
Surgery (European). doi: 10.1177/1753193410373184 Wangdell, J.,
Carlsson, G., & Fridn, J. (2013). Enhanced independence:
experiences after regaining grip function in people with
tetraplegia. Disability & Rehabilitation(0), 1-7.