Outcomes of Care and Predictors of Disability After Treatment for Peripheral Nerve Disorders

PURPOSE AND BACKGROUND: This study identified outcomes of care and predictors of disability and quality of life (QOL) in 396 patients with upper-extremity peripheral nerve disorders (UE–PND). We explored differences between groups based on diagnosis, intervention group, work status, and injury onset. UE–PND often result in pain, weakness, and paresthesias that limit people’s ability to perform daily activities and impact psychological function (Jaquet et al., 2002). UE–PND are a common cause of long-term disability, poor return-to-work outcomes, and increasing health care costs (Thorsen et al., 2012). Significantly decreased disability has been found in small samples of patients after surgery for ulnar nerve compression (Song et al., 2013) and brachial plexus injury (Liu et al., 2013). However, research has emphasized baseline status rather than outcomes of care, which is mandated given the increased focus on value-based payment systems.

METHOD: We extracted baseline and discharge data routinely documented in the medical records of 396 consenting patients with UE–PND treated by a nerve surgeon. After computing baseline and discharge scores on standardized measures, we used descriptive and inferential statistics to compare scores between baseline and discharge, diagnostic groups, and patients treated surgically and conservatively. Results were analyzed of assessments routinely administered in the surgeon’s practice, including the Disabilities of the Arm, Shoulder and Hand; Eight-Item Short-Form Health Survey; physical examination; and a questionnaire exploring pain, depressive symptoms, and stress. Multivariate linear regression models were used to predict discharge disability, work disability, and physical and mental QOL.

RESULTS: Of 100 maximum, disability was 43 at baseline and 34 at discharge and work disability 55 at baseline and 44 at discharge. Patients who were not working had higher pain, depression, stress, and disability and poorer physical and mental QOL. Significant improvements in disability, work disability, pain, depression, and stress occurred after treatment; QOL did not change. Disability decreased the most in working patients and those with a shorter duration of symptoms. Patients with proximal nerve injuries, brachial plexus injuries, and thoracic outlet syndrome demonstrated the highest disability at discharge.

Outcomes were not significantly different by gender or diagnosis or between patients receiving surgery (70%) versus conservative care (30%). Multivariate models predicted 28%–39% of the variance in the four outcome measures. Work status predicted disability, physical QOL, and mental QOL. Pain predicted work disability, disability, and physical QOL. High stress and inability to perform household chores predicted work disability and physical QOL.

CONCLUSION: Employment and work status were the most poignant factors in this research. Despite decreased disability after surgical or conservative care, many patients continue to experience pain, functional impairment, and work disruptions after discharge, especially those with proximal peripheral nerve disorders. On the basis of the results of this research, screening for emotional status is recommended as part of routine care, as well as discussion of problems performing everyday activities and fulfilling home, community, and work roles. Treatment must expand beyond structural impairments and sensorimotor functions to adaptation of environments and tasks, teaching of compensatory strategies, and prevention of long-term disability and work disability. Helping patients learn to self-manage, maintain engagement, and prevent future injury and chronic conditions is essential for this population. Collaborative models of care that can better address the wide range of factors affected in patients with UE–PND should be explored and tested in clinical trials.

References

Jaquet, J. B., Kalmijn, S., Kuypers, P. D., Hofman, A., Passchier, J., & Hovius, S. E. (2002). Early psychological stress after forearm nerve injuries: A predictor for long-term functional outcome and return to productivity. Annals of Plastic Surgery, 49, 82–90.

Liu, Y., Lao, J., Gao, K., Gu, Y., & Zhao, X. (2013). Functional outcome of nerve transfers for traumatic global brachial plexus avulsion. Injury, 44, 655–660. https://doi.org/10.1016/j.injury.2012.02.006

Song, J. W., Waljee, J. F., Burns, P. B., Chung, K. C., Gaston, R. G., Haase, S. C., . . . Yang, L. J.; Surgery for the Ulnar Nerve (SUN) Study Group. (2013). An outcome study for ulnar neuropathy at the elbow: A multicenter study by the SUN Study Group. Neurosurgery, 72, 971–982. https://doi.org/10.1227/NEU.0b013e31828ca327

Thorsen, F., Rosberg, H.-E., Carlsson, K. S., & Dahlin, L. B. (2012). Digital nerve injuries: Epidemiology, results, costs, and impact on daily life. Journal of Plastic Surgery and Hand Surgery, 46, 184–190. https://doi.org/10.3109/2000656X.2012.676554