Identifying Barriers to Upper Extremity Reconstruction in Tetraplegia: A Scoping Review
Celine Yeung, MSc, MD1, Sabrin Salim, BSc1, Ida Fox, MD2, Christine B Novak, PT, PhD3 and Jana Dengler, MASc, MD4, (1)University of Toronto, Toronto, ON, Canada, (2)Division of Plastic Surgery, Washington University School of Medicine, Saint Louis, MO, (3)Toronto Western Hospital Hand Program, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada, (4)University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Introduction: Loss of upper limb function in people with cervical spinal cord injuries (SCI) contribute to substantial disability, loss of independence, and decreases quality of life. Despite its recognized benefits, upper extremity (UE) reconstruction is unfortunately underutilized among people with tetraplegia. The purpose of this study was to understand the barriers to accessing upper extremity reconstructive surgery among those living with tetraplegia and to identify gaps in knowledge.
Materials and Methods: Using a standardized guided protocol, a scoping review was conducted using four databases (MEDLINE/PubMed, SciVerse Scopus, Embase, and Web of Science) and 1032 articles were procured. Two independent reviewers systematically screened the articles in two phases and identified 25 relevant articles. Study characteristics were extracted using a standardized form and the articles underwent thematic analysis using a constructivist grounded theory methodology to identify the most prevalent themes.
Results: The reviewed articles (n=25) were published between 2002 and 2019, and study designs included: cross-sectional (64%); retrospective (16%); and review articles (8%). Common barriers to UE reconstruction were categorized into person with SCI-, provider- and system-related factors, and included lack of awareness of UE reconstruction and its benefits among patients and providers, poor interdisciplinary working relationships, and a lack of specialized centers that provide these reconstructive surgeries. Person with SCI-related barriers were mapped on a timeline from time of injury to surgery. At each time point, intrinsic (coping skills, hope, health literacy) and extrinsic (support network, cost, post-operative course) factors influenced the decision-making process. For example, those who were on the extreme ends of the coping spectrum, had poor health literacy, or a weak support network were less likely to consider UE surgery.
Conclusions: There are many barriers that prevent individuals with tetraplegia from accessing surgery at different levels of the healthcare system. Establishing specialized centers with strong interdisciplinary working relationships and raising awareness about the benefits of UE reconstruction may help to improve accessibility. Future efforts exploring how individuals with SCI weigh each decision factor when considering surgery may help providers develop better aligned treatment plans.
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