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PURPOSE: There is a high incidence of posttraumatic stress disorder (PTSD), depression, suicide risk, and psychological distress after orthopedic trauma and hand and upper-extremity injury. Although patients with traumatic adult brachial plexus injury are particularly vulnerable to psychologic distress, minimal clinical data exist about this cohort of patients. In this study, we sought to discover the prevalence of depression, PTSD, suicidal ideation, and substance abuse. METHODS: Between February, 2013 and July, 2014, during scheduled preoperative and/or postoperative appointments, the social worker at a metropolitan brachial plexus center conducted psychosocial assessments and questionnaire assessments of 21 patients evaluating for PTSD, depression, and substance use using 3 validated scales: PTSD Checklist-Specific, Patient Health Questionnaire-8, and National Institute on Drug Abuse Quick Screen. RESULTS: Brachial plexus injury strongly affected self-reported psychological well-being; 7 of 21 (33.3%) divulged suicidal ideation. Diagnosticand Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis was supported by PTSD Checklist-Specific and Patient Health Questionnaire-8 results: 4 of 21 (19.0%) met criteria for PTSD and 4 of 21 (19.0%) exhibited clinical depression. Patients reported no changes in social alcohol and tobacco use or substance abuse. CONCLUSIONS: Brachial plexus injury significantly influences psychological well-being and daily functioning. As a result, patients experience a high prevalence of PTSD, depression, and suicidal ideation. Patients with brachial plexus injury have a high prevalence of psychological concerns and challenges that require continued attention throughout treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

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BACKGROUND: The physical and psychological impact of brachial plexus injury (BPI) has not been comprehensively measured with BPI-specific scales. Our objective was to develop and test a patient-derived questionnaire to measure the impact and outcomes of BPI. METHODS: We developed a questionnaire in 3 phases with preoperative and postoperative patients. Phase 1 included interviews of patients using open-ended questions addressing the impact of BPI and improvement expected (preoperative patients) or received (postoperative patients). Phase 2 involved assembling a draft questionnaire and administering the questionnaire twice to establish test-retest reliability. Phase 3 involved selecting final items, developing a scoring system, and assessing validity. Patient scores using the questionnaire were assessed in comparison with scores of the Disabilities of the Arm, Shoulder and Hand (DASH) and RAND-36 measures. RESULTS: Patients with partial or complete plexopathy participated. In Phase 1 (23 patients), discrete categories were discerned from open-ended responses and became items for the preoperative and postoperative versions of the questionnaire. In Phase 2 (50 patients [14 from Phase 1]), test-retest reliability was established, with weighted kappa values of ≥0.50 for all items. In Phase 3, 43 items were retained and grouped into 4 subscales: symptoms, limitations, emotion, and improvement expected (preoperative) or improvement received (postoperative). A score for each subscale, ranging from 0 to 100, can be calculated, with higher scores indicating more symptoms, limitations, and emotional distress, and greater improvement expected (or received). Preoperative scores were worse than postoperative scores for the symptoms, limitations, and emotion subscales (composite score of 48 compared with 38; p = 0.05), and more improvement was expected than was received (69 compared with 53; p = 0.01). Correlations with the DASH (0.44 to 0.74) and RAND-36 (0.23 to 0.80) for related scales were consistent and moderate, indicating that the new questionnaire is valid and distinct. CONCLUSIONS: We developed a patient-derived questionnaire that measures the physical and psychological impact of BPI on preoperative and postoperative patients and the amount of improvement expected or received from surgery. This BPI-specific questionnaire enhances the comprehensive assessment of this population.

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Background: The goals of this study were to assess how preoperative and postoperative patients use their uninjured arm to compensate for adult brachial plexus injury (BPI) and to determine whether the Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire measures this compensation. Methods: Ten preoperative and 13 postoperative patients were enrolled in this qualitative-quantitative study. During the qualitative phase, patients were asked how they compensated because of BPI; responses were analyzed with grounded theory. During the quantitative phase, patients completed a standard-DASH reflecting the ability to do activities in any way using both arms as necessary, and a qualified-DASH reflecting their estimated ability to do activities using the uninjured arm the way they otherwise usually would. Two DASH scores were calculated (range, 0-100, higher = worse) and were compared with paired t tests. Results: There were 3 categories of compensation: using the uninjured arm more, exclusively, or to position the injured arm so that the hand (if functional) could be used. The mean standard-DASH and qualified-DASH scores, respectively, were 52 and 74 for preoperative patients (difference 22, P < .0001), and 41 and 64 for postoperative patients (difference 23, P = .0008). Conclusions: Patients with BPI report different types of compensation by the uninjured arm which can be discerned by the DASH.

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PURPOSE: This study described physical and psychosocial limitations associated with adult brachial plexus injuries (BPI) and patients' expectations of BPI surgery. METHODS: During in-person interviews, preoperative patients were asked about expectations of surgery and preoperative and postoperative patients were asked about limitations due to BPI. Postoperative patients also rated improvement in condition after surgery. Data were analyzed with qualitative and quantitative techniques. RESULTS: Ten preoperative and 13 postoperative patients were interviewed; mean age was 37 years, 19 were men, all were employed/students, and most injuries were due to trauma. Preoperative patients cited several main expectations, including pain-related issues, and improvement in arm movement, self-care, family interactions, and global life function. Work-related expectations were tailored to employment type. Preoperative and postoperative patients reported that pain, altered sensation, difficulty managing self-care, becoming physically and financially dependent, and disability in work/school were major issues. All patients reported making major compensations, particularly using the uninjured arm. Most reported multiple mental health effects, were distressed with long recovery times, were self-conscious about appearance, and avoided public situations. Additional stresses were finding and paying for BPI surgery. Some reported BPI impacted overall physical health, life priorities, and decision-making processes. Four postoperative patients reported hardly any improvement, four reported some/a good deal, and five reported a great deal of improvement. CONCLUSIONS: BPI is a life-altering event affecting physical function, mental well-being, financial situation, relationships, self-image, and plans for the future. This study contributes to clinical practice by highlighting topics to address to provide comprehensive BPI patient-centered care.