A Mixed Methods Approach to Better Appreciate Arm/hand Reconstructions for Tetraplegia in Aotearoa New Zealand

Abstract

Aim To explore the unique intersection between arm/hand surgical reconstructions, timing of intervention, current clinical assessments and the life impacts described by individuals with tetraplegia in Aotearoa New Zealand. Background In view of nerve transfer (NT) procedures becoming more commonplace, instead of or done in conjunction with more traditional tendon transfers (TT), an in-depth qualitative study to explore the unique intersection between arm/hand surgical reconstructions, timing of intervention(s), current clinical assessment processes and the life impacts described by individuals with tetraplegia was warranted. Methods A mixed methods convergent design was utilized for concurrent analysis of the New Zealand upper limb registry data. The International Classification of Functioning, Disability and Health (ICF) taxonomy was used as an analytical lens to guide data interpretation. In Study 1, a word-mapping content analysis of the three patient-reported outcome measures (PROMs) and one clinical test was undertaken. In Study 2, a qualitative case series explored the lived experience of tetraplegia at various time points between the onset of tetraplegia and making a decision to either accept or decline arm/hand reconstruction surgeries, including early NT procedures. In Study 3, pre and post-surgery scores from the PROMs and the single clinical test were analyzed between two functionally distinct groups based on the requirement for elbow reconstructions in the first instance. Finally, the integrative analysis drew on Donabedian’s theory of 1966, using the Stewart Model for both data display. Results In Study 1, a total of 885 goals were identified from the priority identification data across all reconstructions. By comparison, the representation of human functioning of the PROMs and clinical tool was more limited. In Study 2, five themes embodied the participants’ experience of hand clinic system, assessment processes and outcomes. Essentially, these results indicate the ‘pursuit of independence’ was greatest in the NT group who were less than two years after SCI. The quantitative findings of Study 3 provide evidence from the 43 surgery participants with complete data sets that positive changes in arm/hand function occur as a result of surgical reconstructions to the elbow, hand and fingers for individuals with mid-cervical tetraplegia. When integrating all three studies using a convergence system the results raise five fundamental points not evident in any one of the studies. Conclusion A mixed methods approach allowed for greater appreciation of both participant characteristics and surgery uptake, and the relativity of arm/hand function than can be achieved by either quantitative or qualitative enquiry.