Date Presented 03/28/20
Upper-extremity peripheral nerve disorders increase disability and cause emotional stress. Many patients with peripheral nerve disorders undergo surgical intervention, and this research tracks trajectories of disability, pain, and health postoperation (PO). Results show worsening symptoms PO, return to baseline, and finally improvement at 12 weeks. The decline PO endorses early referral to OTs for pain management education as well as activity modifications to decrease experienced disability.
Primary Author and Speaker: Melanie Hubbuck
Contributing Authors: Rose McAndrew, Vicki Kaskutas
PURPOSE: Upper extremity peripheral nerve disorders (PND) increase disability, decrease activity participation, and cause emotional stress. (Bailey, Kaskutas, Fox, Baum, & Mackinnon, 2009; Novak, Anastakis, Beaton, Mackinnon, & Katz, 2011; Stonner, Mackinnon, & Kaskutas, 2017) Many with PND undergo surgery, with the literature demonstrating mixed-to-favorable sensorimotor outcomes. Few studies report the effect of surgery on disability and health at discharge, and no studies use these measures to examine the recovery trajectory. (Dolan, Butler, Murphy, Hynes, & Cronin, 2012; Novak et al., 2011) This research addresses this gap through investigation into trajectories of disability, pain, and health pre-surgery to 12 weeks post-op (PO) for patients diagnosed with an upper extremity peripheral nerve disorder (UE-PND) to describe overall recovery. Additionally, this research compares trajectories between patients undergoing nerve decompression (ND) versus nerve reconstruction (NR), identifying the role of occupational therapy (OT) in recovery PO.
DESIGN: This retrospective analysis included 149 patients with upper extremity PND who underwent one surgery by a single nerve surgeon.
METHOD: Pain (visual analogue scale - VAS), disability (Disabilities of the Arm, Shoulder, and Hand - DASH, and physical (PH) and mental (MH) health (Short-Form 8 Health Survey) were measured pre-surgery and at each PO visit. Surgery type was assigned via medical record, with 97 patients undergoing ND and 52 NR. Number of days PO for each visit was calculated and categorized into 1-week intervals to 12 weeks. The week with the poorest rating, return to baseline, and 12-week PO as well as rates of change (ROC) were computed for total sample and each group.
RESULTS: Baseline scores indicated mid-level disability and pain, and PH and MH within population norms. All measures demonstrated similar trends following surgery for the total sample with the poorest rating occurring a few weeks PO, a return to baseline function, and improvements by 12-weeks PO. Pain peaked the earliest at 1-week PO. Disability lasted the longest at 4 weeks. Disability and pain had the greatest ROC between baseline and poorest ratings. Return to baseline occurred simultaneously for both diagnostic groups for all outcomes besides disability—NR returned to baseline by week 4 while lower scores persisted until week 6 for ND. ND experienced the greatest ROC with increase in disability/improvement, while NR experienced the greatest ROC in pain increase/improvement. Final ratings yielded similar disability, PH, and pain for both groups; however, MH ratings were lower for NR.
CONCLUSION: The worsening of pain, disability, health before improvement endorse a multi-disciplinary approach to patient education on course of recovery, and early referral to OT. Pre-surgery patient education can help patients set realistic expectations and put supports in place prior to surgery. Immediate PO referral to occupational therapy can help patients learn to manage pain, modify/adapt occupations and activities to decrease disability and facilitate social participation, and overall promote health and well-being. Patients undergoing ND may need additional attention to maximize outcomes.
References
Bailey, R., Kaskutas, V., Fox, I., Baum, C. M., & Mackinnon, S. E. (2009). Effect of upper extremity nerve damage on activity participation, pain, depression, and quality of life. J Hand Surg Am, 34(9), 1682-1688. doi:10.1016/j.jhsa.2009.07.002
Dolan, R. T., Butler, J. S., Murphy, S. M., Hynes, D., & Cronin, K. J. (2012). Health-related quality of life and functional outcomes following nerve transfers for traumatic upper brachial plexus injuries. J Hand Surg Eur Vol, 37(7), 642-651. doi:10.1177/1753193411432706
Novak, C. B., Anastakis, D. J., Beaton, D. E., Mackinnon, S. E., & Katz, J. (2011). Biomedical and psychosocial factors associated with disability after peripheral nerve injury. J Bone Joint Surg Am, 93(10), 929-936. doi:10.2106/jbjs.j.00110
Stonner, M. M., Mackinnon, S. E., & Kaskutas, V. (2017). Predictors of Disability and Quality of Life With an Upper-Extremity Peripheral Nerve Disorder. Am J Occup Ther, 71(1), 7101190050p7101190051-7101190050p7101190058. doi:10.5014/ajot.2017.022988
