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Hand

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The loss of upper limb function especially the use of the hand is one of the most significant and devastating losses an individual can experience. Tetraplegia is responsible for many problems in daily living, especially related to the preservation of independence for the individual with tetraplegia (Welraeds et al., 2003). A study by Hanson and Franklin (1976) showed recovery of hand function was preferred to that of the bladder, bowel or even sexual function among persons with tetraplegia. In a survey of tetraplegia patients, 75% responded that hand function was very important for their independence in ADL and to increase their quality of life (Snoek et al., 2004). In another study conducted in the United States with a sample of individuals with tetraplegia, 42% of the individuals viewed upper limb as the function they wanted restored first and 44% of the surveyed individuals reported an interest in receiving upper extremity reconstructive surgery (Wagner et al., 2007).

Despite the many reported studies of hand reconstructive surgery, it is not common practice in many spinal units. Internationally, many barriers for SCI injured individuals exist which results in an underutilization of reconstructure survey (Fox et al., 2015). The efficacy of surgery to improve hand function still remains controversial (Forner-Cordero et al., 2003). Guttmann (1976), McSweeney (1969) and Bedbrook (1969) believed that only a small percentage of persons with tetraplegia (5%) benefit from hand surgery because they re-adjust the function of their arm and hands if properly rehabilitated, while other authors have estimated that 75% of persons with tetraplegia can benefit from hand surgery (Moberg 1975). A review of epidemiologic data from 1988 to 2000 in the USA found that only seven percent of appropriate surgical candidates actually received surgery (Curtin et al. 2005). In a study completed by Wuolle et al. (2003), individuals with tetraplegia who received upper extremity surgery were surveyed and 70% of the individuals were satisfied with their results and 68% reported improvement in ADLs. These statistics are consistent with physician estimates of 75% of client’s being satisfied, suggesting that both the client and medical professional often view reconstructive surgery as being beneficial and satisfying (Wagner et al., 2007). Reason for underutilization of reconstructive surgery for those with tetraplegia have been identified as; lack of clarity in the literature about the value of reconstructive procedures, lack of access to centres that perform reconstructive surgeries, lack of qualified and experienced hand surgeons and physiatrists who have an interest in this area of surgery and negative physician bias toward reconstructive surgery (Curtin et al., 2005; Squitieri and Chung 2008).

Reconstructive surgery and tendon transfers are generally performed following an identifiable pattern based on the level of injury and results depend on the patient’s residual motor and sensory function as identified in each group (Freehafer et al., 1984). In 1978, the International Classification for Surgery of the Hand in Tetraplegia was developed and has since been modified. The classification takes into account the residual motor strength below the elbow, considering that only the muscles graded four or five according to the Medical Research Council Scale are adequate for muscle transfer, as well as the sensibility in thumb and index. The sensibility was evaluated by the two-point discrimination test in the thumb and the index. If it is lower than 10mm the classification belongs to the group Cutaneous (Cu-) and if it is higher than 10mm and the patient needs visual help it is classified in the group Ocular (O-).

Table 12: Modified International Classification for Surgery of the Hand in Tetraplegia

Candidates for reconstructive surgery are carefully selected and are followed by a rehabilitation team that includes an orthopedic surgeon, rehabilitation physiatrist, and therapist over a significant period of time. The identified criteria for selection are as follows: at least one year post-injury, completed a comprehensive rehabilitation program, neurologically stable, and psychologically adjusted to their injury.

The measure of outcomes following reconstructive surgery continues to be debated in the literature. Many of the reported studies on surgical outcomes are older, are case series evaluations and lack the rigor of randomized controlled trials, and have subjective outcomes based on reported client satisfaction. In addition, there is little consensus in the literature on the assessment instruments and tools to be used in this population as their reliability, validity and responsiveness have not been adequately proven. The methodology appears to be a major failing of the various scales and the absence of clear conceptual models forming the basis of their scales. Also, the scales or instruments have been deemed to be too insensitive to document the small but meaningful functional gains made by those with tetraplegia after functional surgery (Fattal 2004). Many authors state that comparing the post-surgical condition is the best way to evaluate results (Freehafer et al. 1984). There have been several articles published that discuss the use of the ICF conceptual framework as a way to interpret hand function outcomes following tendon transfer surgery for tetraplegia (Bryden et al. 2005; Sinnott et al. 2004).

The reconstructions of upper limb to obtain functions of pinch and grasp often require multiple procedure and are also individualized to each person. The reconstructions performed are also dependent on what motor muscles/tendons are present and strong enough for transfer (Kozin 2002). Dunn et al. (2012) completed a study that addressed client’s decision making process for reconstructive UL surgery and it was found that that a client’s decision to have surgery were underpinned by 6 core influences. These influences were the overall outcome of surgery, the client’s current goals and priorities in their life, the hope that their overall quality of life (QOL) would be improved, a stable home environment, available social supports and assistance for assisting with increased care needs post-surgery and access to information on surgery. It was also found that these factors were individualized to each person and is dependent on any number of issues at one time and can change in its priority over time.