brachial plexus - nerve transfer - activities of daily living
plexo braquial - transferência de nervo - atividades cotidianas
The brachial plexus provides motor and sensory innervation to muscles in the shoulders,
arms, wrist and fingers. Traumatic injury of the brachial plexus due to upper trunk
injury is common among victims of motorcycle accidents. Damage to the C5-C6 nerves
cause dysfunction of shoulder joint movement, forearm flexion, forearm external rotation
and wrist flexion (to a certain degree). In addition, C5-C7 nerve injuries cause a
reduction in the forearm extension[1],[2].
Restoring active forearm flexion is the primary goal of surgical treatment of upper
trunk brachial plexus injuries[3],[4]. This injury affects motor function and can impair the ability of patients to do
physical work as well as engage in their activities of daily living. Although recent
studies of nerve transfers after traumatic brachial plexus in adults have shown excellent
functional outcomes, evaluations of daily living activities have not routinely been
performed following this surgery[5],[6].
The Disabilities of the Arm, Shoulder and Hand (DASH), a 30-item self-report questionnaire[7], was translated to Brazilian Portuguese and referred to as the DASH Brazil questionnaire[8]. It has been used to describe moderate or severe disabilities of the upper limbs
in multiple disorders. Although the DASH has been the most widely-used patient-reported
questionnaire for brachial plexus injury[9]. This tool is rarely used to describe the outcomes in adults undergoing nerve transposition
surgery after traumatic brachial plexus injury[10]. In the DASH questionnaire, each item is ranked on a five-point scale. Its total
score calculation ranges from 0 to 100[11]. A higher DASH score reflects a higher level of disability[7],[11] and a score of 10 or less is within normal limits, according to data from the USA
general population norm study[6].
The purpose of this paper was to correlate motor function recovery of the upper limbs
as measured by the Louisiana State University Health Sciences Center (LSUHSC) scale
and the ability of the patients to perform their daily living activities using the
DASH Brazil questionnaire. To the best of our knowledge, there was no study in the
literature that correlated the LSUHSC score and the results of the DASH Brazil questionnaire
in patients with C5-C6 or C5-C7 injury, who have undergone nerve transfer.
METHODS
Patient population
This study was conducted following a protocol approved by the Ethics Research Commissions
on Human Research at the University of São Paulo Medical School (approval number 266.433).
The recruitment began in October 2013 and finished in December 2014. The study was
conducted at the Peripheral Nerve Surgery Unit at the Functional Neurosurgery Division
of the Psychiatry Institute/University of São Paulo Medical School.
The primary goal of this study was to correlate the daily living activities and recovery
of motor function, and the secondary goals were to correlate these outcomes with those
routinely recorded after surgery, such as age, sex, dominant and non-dominant side
and the ability to return to work.
We report on the results of 30 patients who met the inclusion criteria and had a postoperative
follow-up for a minimum of one year. The inclusion criteria were adult patients with
C5, C6 or additional C7 lesions after traumatic brachial plexus injury who underwent
nerve transfer surgery and did not present with associate fractures or lesions.
A total of 23 male, and seven female patients between the ages of 22 and 68 years
(37.5 ± 55 years [mean ± SD]) were evaluated. The dominant extremity was affected
in 12 of the 30 patients. The extent of injury at diagnosis was established by clinical
evaluation, and the preoperative diagnosis was confirmed by electrophysiological evaluation
and surgical exploration. The time between the traumatic brachial plexus injury and
the nerve transfer surgery ranged from three to 17 months (7.6 ± 3.49 months [mean
± SD]).
Outcome assessment
Motor evaluation
Evaluation of upper limb motor function was performed using the LSUHSC scale, which
can be used following surgery to repair the upper injury to the brachial plexus ([Table]).
Table
The Louisiana State University Health Sciences Center (LSUHSC) grading of neural function12.
|
Grade
|
Description
|
|
0
|
No muscle contraction
|
|
1 (poor)
|
Proximal muscles contract but not against gravity
|
|
2 (fair)
|
Proximal muscles contract against gravity and distal muscles do not contract; sensory
grade, if applicable, is usually ≤ 2
|
|
3 (moderate)
|
Proximal muscles contract against gravity and some resistance; some distal muscles
contract against gravity; sensory grade, if applicable, is usually 3
|
|
4 (good)
|
All muscles contract against gravity and some resistance; sensory grade, if applicable,
is 3 or 4
|
|
5 (excellent)
|
All muscles contract against moderate resistance; sensory grade, if applicable, is
4
|
Daily living activities
The daily living activities were assessed independently by an occupational therapist
using self-reporting and administration of the DASH Brazil questionnaire one year
after surgery.
Statistical analysis
The demographic, clinical characteristics and assessments were expressed as the mean,
standard deviation, median, minimum and maximum as appropriate. The Spearman’s rank
correlation coefficient was used to correlate the DASH Brazil questionnaire and the
LSUHSC scores at a significance level of 5% or lower.
Fisher’s exact test, Student’s t-test and Mann-Whitney test with significance set
at 5% (r > 0 and p < 0.05) or lower were used to compare the performance of patients
who returned to work. The Mann-Whitney test was used to determine the differences
between the dominant side, or non-dominant side, and the ability to return to work
using the DASH Brazil questionnaire responses and LSUHSC scores. The ability to return
to work was estimated using simple logistic regressions for each variable and reported
as the odds ratio with 95% confidence intervals. Age, sex, and the average time between
the accident and the surgery were examined using statistical tests and correlated
with the DASH Brazil and LSUHSC scores.
RESULTS
Correlation between the DASH Brazil questionnaire responses and Louisiana State University
Health Sciences Center (LSUHSC) scores
According to Spearman’s rank-order correlation coefficient, both methods showed a
linear statistical association between the variables (r = 0.479, p = 0.007).
Correlation between patient age and DASH Brazil questionnaire responses
The comparison between the patients’ age and the DASH Brazil questionnaire scores
using Spearman’s rank-order correlation coefficient (r > 0, p < 0.05) showed that
these two variables have a linear relationship (r = 0.397, p = 0.030).
The patients’ age and LSUHSC scores were assessed using Spearman’s rank-order correlation
coefficient (r > 0, p < 0.05), which showed a positive association and a weak correlation
(r = 0.186, p = 0.323) between these variables.
When assessed with the time elapsed between injury and surgery using Spearman’s rank-order
correlation coefficient, there was a strong positive correlation identified with patient
age (r = 0.038, p = 0.0842), a moderate-to-strong correlation with the DASH Brazil
questionnaire responses (r = 0.107, p = 0.574) and a weak correlation with the LSUHSC
scores (r = 0.554, p = 0.001).
Twenty-eight patients were right handed (93.3%) and two were left handed (6.7%). A
C5, C6 and C5-C7 nerve transfer was performed on the right arm of 12 (40%) patients
and on the left arm of the remaining 18 (60%) patients. Regarding dominance, 18 (60%)
underwent surgery on their non-dominant arm and 12 (40%) on their dominant arm.
According to the Mann-Whitney test (p > 0.05), injury in the dominant arm was not
statistically associated with either the DASH Brazil questionnaire outcomes (p = 0.632)
or the LSUHSC scores (p = 0.491). On the other hand, adults who underwent post traumatic
brachial plexus injury involving C5-C6 or C5-C7 roots might experience an increased likelihood of returning to work after
nerve transfer.
DISCUSSION
We have reported the results of 30 patients who underwent nerve transfer after traumatic
brachial plexus injury involving C5-C6 or C5-C7 nerve roots, which results in functional
deficits.
Previous studies have described severe and devastating conditions due to this injury[12],[13],[14]. However, the daily living activities in adult patients suffering from traumatic
brachial plexus injury who undergo nerve transfer have not been widely reported. In
2011, Hill et al.[15] reviewed 265 papers and noted the infrequent evaluation of daily living activities
after brachial plexus injury. In 2015, Dy et al.[5] systematically reviewed 88 papers, 83 (94%) of which reported postoperative motor
function. Of these, only five studies (6%) reported either function or disability
after nerve transfer.
The original DASH questionnaire was translated into Brazilian Portuguese, culturally
adapted and validated; this modified version is known as the DASH Brazil questionnaire.
The DASH Brazil questionnaire can be effectively used in research studies to screen
for symptoms as well as the physical, social and psychological status of patients
suffering from upper limb injury[8].
The symptoms covered by the DASH questionnaire are pain, weakness and tingling/numbness.
Variables that assess the physical functional status are daily activities, leisure activities, self-care, dressing, eating, sexual activities,
sleep and sport/arts (optional); social status variables include family care, occupational, socializing with friends/relatives;
and psychological status includes the self-image[8]. Novak et al.[16] used the DASH for assessing symptoms in individuals after brachial plexus nerve
injury with good results.
The characteristics of this study and the cause of injury fully corroborated earlier
literature. Most of the patients’ injuries occurred from motorcycle accidents involving
young male motorcyclists on the road[1],[17].
In this study, the preoperative time intervals were widely varied (ranging from three
to 17 months). According to previous publications, the timing of the surgery depends
on the mechanism and type of injury. However, spontaneous recovery for a period of
up to three months has been observed in the year after injury[4].
The time elapsed between injury and surgery is one of the primary influences on the
prognosis of patients who underwent brachial plexus surgery. In the present study,
the average time between injury and surgery was 8.2 ± 3.7 months (mean ± standard
deviation), with a median of 7.5 months (range, 3.9 to 17 months).
The LSUHSC score is directly correlated with the time elapsed between injury and surgery
(r = 0.554 and p = 0.001), and these results were in accordance with most studies
published on this subject[4],[18]. A similar correlation, albeit weaker, was observed between the time elapsed before
surgery and the DASH Brazil questionnaire responses.
In studies that evaluate how daily activities are affected by upper limb injury, the
DASH questionnaire has been extensively used. However, when assessing the impact of
brachial plexus injury on daily activities, the DASH questionnaire has not been widely
used in patients with partial injuries[10],[18],[19].
According to Spearman’s rank-order correlation coefficient (r > 0, p < 0.05), the
DASH Brazil score showed a statistically significant linear association with the LSUHSC
score (r = 0.479, p = 0.007), age (r = 0.397, p = 0.030) and the time between injury
and surgery. This finding is consistent with the established literature. The DASH
scores also showed influence regarding gender, age and the patients’ ability to perform
daily living activities after upper limb injury. In 2002, the American Academy of
Orthopedic Surgeons conducted a survey among individuals in the USA (n = 1800) and
described similar correlations[14].
Assessing the motor function gradation using the LSUHSC scale has been successfully
applied in postoperative patients following surgery to repair traumatic brachial plexus
injury[18]. In this study, the LSUHSC scale showed a positive correlation with the time between
injury and surgery and the DASH Brazil questionnaire responses.
In conclusion, the recovery of motor function in the upper limb after nerve transfer
correlated with the patients’ ability to perform daily living activities. In addition,
the time between injury and surgery also correlated with the recovery of upper limb
function. On the other hand, side dominance and the injured arm was not was statistically
associated with the LSUHSC scores and DASH Brazil questionnaire responses. Better
outcomes regarding the LSUHSC scores and the DASH Brazil questionnaire responses were
reported from patients who returned to work than from patients who were either retired
or pensioners.
