The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries

Abstract

Background: Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction.

Methods: Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction.

Results: Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary scale increased from 30.80 ± 5.31 to 37.37 ± 8.41 (p-value = 0.028), the mental component summary scale improved from 43.19 ± 8.32 to 54.76 ± 6.78 (p-value = 0.018). VAS scores indicative of deafferentation pain improved from 7.8 to 5.6 after prosthetic hand replacement (p-value = 0.018). Negative body evaluation improved from 60.71 ± 12.12 to 53.29 ± 11.03 (p-value = 0.075). Vital body dynamics increased from 38.57 ± 13.44 to 44.43 ± 16.15 (p-value = 0.109).

Conclusions: Bionic reconstruction provides hope for patients with complete brachial plexopathies who have lived without hand function for years or even decades. Critical patient selection is crucial and the psychosocial assessment procedure including a semi-structured interview helps identify unresolved psychological issues, which could preclude or delay bionic reconstruction. Bionic reconstruction improves overall quality of life, restores an intact self-image and reduces deafferentation pain.

Fig 1. Bionic reconstruction in a patient with complete BPI.

A, A 54-year old patient with a flail, atrophic left arm following a BP avulsion injury with a denervation time of 7,5 years. Picking up a small light-weight ball during functional testing is impossible with the functionless hand. B, Prosthetic arm replacement after elective amputation of the left arm at glenohumeral level. C, The prosthetic arm is driven by two electromyographic signals, which are intuitively controlled by the patient (Cutaneous EMG-sensor position on infraspinatus muscle and pectoralis major muscle). D, Prosthetic usage in daily life activities. BP, brachial plexus. BPI, brachial plexus injury.

Fig 2. Scheme illustrating the „Vienna psychosocial assessment procedure“.

The assessment procedure is an integral component of the treatment algorithm for bionic reconstruction in patients with complete brachial plexus injury. The pre-surgical psychosocial assessment prior to elective amputation includes qualitative findings obtained from a semi-structured interview and quantitative metrics obtained from three questionnaires. The intended purpose of this assessment was to evaluate the overall psychosocial status of a patient, to uncover psychological disorders which would preclude successful prosthetic reconstruction and to offer psychological support where appropriate. EMG, electromyographic. a The complete treatment algorithm for bionic reconstruction ranging from identification of eligible patients to final prosthetic fitting can be found here: [19].

Fig 3. VAS scores for all patients.

Pain was assessed at initial evaluation and after bionic reconstruction with a mean follow-up period of 10 ± 6 months.