The level and influencing factors of quality of life in patients with brachial plexus injury

Accepted Manuscript The level and influencing factors of quality of life in patients with brachial plexus injury Jie Shen , Zhi-Wen Wang PII:

S2352-0132(14)00047-7

DOI:

10.1016/j.ijnss.2014.05.012

Reference:

IJNSS 36

To appear in:

International Journal of Nursing Sciences

Received Date: 26 February 2014 Revised Date:

17 April 2014

Accepted Date: 23 April 2014

Please cite this article as: J. Shen, Z.-W. Wang, The level and influencing factors of quality of life in patients with brachial plexus injury, International Journal of Nursing Sciences (2014), doi: 10.1016/ j.ijnss.2014.05.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Original Article The level and influencing factors of quality of life in patients with brachial plexus injury Jie Shena, Zhi-Wen Wangb,*

Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China

b

School of Nursing, Peking University, Beijing, China

*Corresponding author. Z.-W. Wang

SC

E-mail address: [email protected]

Received 26 February 2014 Revised 17 April 2014

TE D

Accepted 23 April 2014

M AN U

Article history

ABSTRACT

RI PT

a

EP

Purpose: To investigate the overall quality of life level and identify influencing factors in patients with traumatic brachial plexus injury. Methods: One hundred three patients with brachial plexus injury were assessed using the

AC C

World Health Organization Quality of Life-BREF (WHOQOL-BREF) and Family Adaptability and Cohesion Evaluation Scale (FACESII-CV) questionnaires. Results: The overall quality of life score from patients with brachial plexus injury was 65.78 ± 15.2. The scores for the physical, psychological and environmental factors were significantly lower than the norm (Ps < 0.05). Regression analysis showed that age, injury located ipsilateral to the dominant hand, upper limb function score, score of family intimacy and family income were all factors influencing the of quality of life. Conclusions: A brachial plexus injury significantly compromises an individual’s quality of life. Multiple factors influence this quality, which should be targeted to augment the physical 1

ACCEPTED MANUSCRIPT and psychological care provided.

Key words:

RI PT

brachial plexus injury family intimacy influencing factors

M AN U

SC

quality of life

1. Introduction

Injury to the brachial plexus, composed of five to eight cervical nerves and the first thoracic nerve anterior branch [1], is difficult to treat. Brachial plexus injuries can often lead to severe

TE D

upper limb dysfunction and permanent disability of patients, with serious social and economic impacts [2]. Treatment and rehabilitation for these injuries take longer than for other peripheral nerve injuries, and it is these interventions that can influence the patients’

EP

quality of life [3]. The aim of the present study was to assess the quality of life in patients with brachial plexus injuries. Furthermore, possible contributing factors were assessed in an effort to identify key components that can be targeted in the future for treating individuals

2.

2.1.

AC C

with these injuries and improve their quality of life.

Design and methods

Subjects

Patients hospitalized in the Beijing Jishuitan Hospital with brachial plexus injury between June 2012 and February 2013 were recruited for this study. Criteria for inclusion were: over 18 years of age, diagnosis for traumatic brachial plexus injury, at least one prior operation, 2

ACCEPTED MANUSCRIPT admission was at least one month from last operation, voluntary participation. Patients were excluded from the study if they had other chronic diseases, mental illness or severe mental disorder, or a non-traumatic brachial plexus injury.

Surveys

RI PT

2.2.

Upon admittance to the hospital for surgery, informed consent was obtained from the patients who were then asked to complete a four-part questionnaire that included general information

SC

and questions from the Disabilities of the Arm, Shoulder and Hand (DASH) survey, the World Health Organization Quality of Life BREF (WHOQOL-BREF) [5] assessment and the

M AN U

Family Adaptability and Cohesion Evaluation Scale (FACESII-CV) [6]. For patients unable to fill out the survey, questions and possible answers were read to them, and their oral answers were recorded. A total of 103 questionnaires were distributed, and 103 valid questionnaires were returned, yielding a 100% effective rate.

General information

TE D

2.2.1.

The first part of the questionnaire concerned demographics and medical history information, including: gender, age, occupation, education level, marital status, family income, medical

EP

expenses, payment methods, causes of injury, time from the initial injury, the number of operations, time from the most recent operation, participation in functional exercise training,

2.2.2.

AC C

whether the injury occurred ipsilateral to the dominant hand, etc.

DASH survey

The DASH survey is a 30-item, self-report questionnaire designed to measure physical function and symptoms in individuals with musculoskeletal disorders of the upper limbs. It provides clinicians and researchers the advantage of a single, reliable method to assess any or all joints in the upper extremities. Scoring involves rating the difficulty of each item on a level from one to five: no difficulty (1 point), somewhat difficult (2 points), medium difficulty but it can be done (3 points), very difficult (4 points), cannot do (5 points). The DASH value is then calculated as: (sum of all scores - 30) / 1.20, where a score of 0 3

ACCEPTED MANUSCRIPT represents normal upper limb function, and a score of 100 indicates extremely limited upper limb function.

2.2.3.

WHOQOL-BREF assessment

RI PT

This survey involves a total of 26 questions concerning physical, psychological, social, and environmental factors rated on a scale of 1 to 5. Each entry is analyzed according to both the quality of life and overall health. Scores in each of the four categories range from 4 to 20 points, and are summed and converted into a percent score. A higher score indicates better

FACESII-CV

M AN U

2.2.4.

SC

quality of life.

The FACESII-CV is a scale from the 1991 Phillips et al. amendments, mainly based on the Olson cyclic model theory, with 30 entries (scored from 1 to 5) encompassing two dimensions to evaluate family function: family cohesion (total of 12 to 88 points) and adaptability (total of 14 to 70 points) [7]. The dimension of family cohesion concerns

TE D

intimacy, or emotional connection, between family members living together in time and space, their hobbies or entertainment and other aspects of consistency, such as household decision-making methods. The dimension of adaptability refers to the responses of the family

EP

to external environmental pressures, such as a change in its power structure or role assignment as a result of marriage or family development. The scale is designed to assess levels of family pride and satisfaction, consultation and cooperation among family members,

2.3.

AC C

and problem-solving skills within the family.

Statistical analysis

Data were analyzed using Student’s t-test, analysis of variance, correlational and multiple regression analyses on SPSS17.0 software (SPSS Inc., Chicago, IL, USA). Data are presented as mean ± standard deviation, and a P value of 0.05 was used to determine significance.

3.

Results 4

ACCEPTED MANUSCRIPT

3.1.

Patient characteristics and overall quality of life scores

Questionnaire results were obtained from a total of 103 patients between 19 and 55 years of

RI PT

age (30.05 ± 10.02 y) with brachial plexus injuries. The average DASH score of upper limb function was 41.43 ± 15.86 points (range: 14.17–72.50). The average family cohesion score was 64.06 ± 10.39 points (range: 43–81), and the average family adaptability score was 43.25 ± 7.05 points (range: 28–54). The overall quality of life in patients was an average 78 ± 15.24

SC

points. Scores for each of the four WHOQOL-BREF categories are shown in Table 1. Patients with brachial plexus injuries had significantly lower physical, psychological and

3.2.

3.2.1.

M AN U

environmental qualities of life compared to the norm (p < 0.05).

Factors influencing quality of life

Univariate analysis

TE D

Univariate analyses of questionnaire results revealed that education level, occupation, ability to continue working, income, cause of injury, and whether the injury was ipsilateral to the dominant hand were all factors that significantly affected the quality of life (p < 0.05; Table

EP

2). Furthermore, a correlational analysis showed that the quality of life was significantly associated with patient age, and DASH, family cohesion, and family adaptability scores (p <

3.2.2.

AC C

0.01; Table 3).

Multiple regression analysis

To perform multiple linear regression analysis, the quality of life score was used as a dependent variable against the DASH score, age, education (primary school = 1, middle school = 2, high school = 3, college or undergraduate = 4), injury ipsilateral to dominant hand (yes = 1, no = 0), cause of injury (accident = 1, non-accident = 0), family income (< 1000 yuan = 1,1000–2999 = 2, 3000–4999 = 3, > 5000 = 4), work after injury (continue working = 1, does not work = 0), occupation (located three dummy variables: workers, peasants, service industries, other occupations as a control), family cohesion score, and the family adaptability 5

ACCEPTED MANUSCRIPT score. Results indicated that a lower quality of life was associated with older age, injury ipsilateral to the dominant hand, high DASH score (poor upper limb function), low income, and a low family cohesion score (p <0.05; Table 4).

Discussion

4.1.

RI PT

4.

Brachial plexus injury patients have a lower quality of life

SC

The quality of life assessment is a multidimensional subjective comprehensive evaluation of an individual’s goals, expectations, standards and experiences, which are influenced by their

M AN U

culture and value system [5]. The results of this study show that with brachial plexus injury lowers this assessment score, consistent with other reports [8–12]. Moreover, the psychological, physiological and environmental fields scores were lower in the patients in this study compared to the national average level of the normal population, which is in agreement with results reported by Fu et al. [9,12]. However, the scores in the psychological

TE D

field in this study were lower than reported by their studies, which only included outpatients. The inclusion of inpatients in the present study may have reduced the psychological score

4.2.

Factors influencing quality of life

4.2.1.

AC C

EP

because of the additional stress that accompanies the surgical procedure.

Upper limb function

Results from this study demonstrate that quality of life is impacted by injury to the brachial plexus ipsilateral to the individual’s dominant hand, which is consistent with previous reports [9,12,13]. As many of the participants were men that were injured before they had families to support, impaired function of the dominant limb would affect their ability to engage in skilled work, thus influencing their subsequent experiences and quality of life. As a result, medical staff can guide patients to enhance the function of the contralateral limb through preoperative and postoperative functional exercise, as well as to enable the completion of daily activities and maximize upper limb function. 6

ACCEPTED MANUSCRIPT

4.2.2.

Age

Patient age correlated with quality of life assessment, such that older individuals reported lower quality of life scores after brachial plexus injury, consistent with previous reports

RI PT

[9,12]. While the majority of patients included in this study were young adults at the peak of physical condition, the injury to the older patients may have had a greater impact because of declining physiological function and health status.

Income

SC

4.2.3.

The high cost of treatment for brachial plexus injury and the consequent reduction of fixed

M AN U

income brings heavy economic and psychological burdens to patients and their families. Accordingly, the quality of life scores decreased with income in the patient population included in this study. The impact of medical expenses on quality of life is universal, affecting patients worldwide, including Western countries [13]. Additionally, national policies, laws and regulations are closely linked with the governmental health insurance

TE D

system [14]. The results of the present study suggest that the added pressure to those without sufficient income has a significant impact, and that income may help to offset the effects of

4.2.4.

EP

the injury and help to improve quality of life.

Family cohesion

Family cohesiveness, or a strong emotional connection between family members [15], was

AC C

found to correlate with patient quality of life. A brachial plexus injury is a strong source of stress for patients and their families, and a tremendous psychological pressure and economic burden. Brachial plexus injury treatment and rehabilitation is a long process, and patients need repeated treatment and long periodic review. Furthermore, surgical complications will cause patients and their families a great deal of pain, and the debilitation sometime requires patients to arrange for full-time care, which is difficult on both the patient and their family. However, supportive comfort and encouragement can relieve some of this burden. In addition, the need to gather together to discuss how to face a series of problems caused by the injury, can enhance this emotional connection, increase family cohesion and thus increase the 7

ACCEPTED MANUSCRIPT patient's quality of life.

Conflicts of Interest Statement

RI PT

The authors declare no conflicts of interest.

SC

REFERENCES

M AN U

[1] Xu ST. Practical Orthopedics 3rd edition, Beijing: People's Medical Publishing House 2005; 950-4.

[2] Terzis JK, Kostopoulos VK. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2007; 119(4): 73e-92e.

[3] Bengtson KA, Spinner RJ, Bishop AT, et al. Measuring outcomes in adult brachial plexus

TE D

reconstruction. Hand Clin 2008; 24(4): 401-15. [4] Chen ZB, Hong GX, Wang F. Upper limb functional rating scale. Chinese Reconstructive Surgery 2004; 18 (6): 520-1.

EP

[5] Hao YT, Fang JQ. The introduction and usage of Chinese version of Quality of Life Scale of World Health Organization. Modern Rehabilitation 2000; 8: 1127-9.

AC C

[6] Wang XD. The Manual of Mental Health Assessment Scale. Chinese Mental Health Journal 1993; 102.

[7] Fei LP, Shen Q, Zheng YP. The preliminary evaluation of family cohesion and adaptability scales and the Family Environment Scale. Chinese Mental Health Journal 1991; 5(5): 198-202. [8] Guoyong B, Wang E, Ling H. The application of the scales of quality of life of stroke. Chinese Journal of Rehabilitation Theory and Practice 2009; 15(7): 632-4. [9] Fu K, Gu LQ, Qin BG, et al. The survey and analysis of quality of life in patients with brachial plexus injury. Chinese Journal of Microsurgery 2010; 33(2): 125-6. 8

ACCEPTED MANUSCRIPT [6] Kitajima I, Doi K, Hattori Y, et al. Evaluation of quality of life in brachial plexus injury patients after reconstructive surgery. Hand Surg 2006; 11(3): 103-7. [10] Fang JQ. Quality of life measurement methods and applications. Beijing: Beijing Medical University Press 2001.

RI PT

[11] Bailey R, Kaskutas V, Fox I, et al. Effect of upper extremity nerve damage on activity participation, pain, depression, and quality of life. J Hand Surg Am 2009; 34(9): 1682-8. [12] Fu K. Investigation and analysis of quality and erectile function and mechanism of male erectile dysfunction caused by brachial plexus injury patients survive exploration and

SC

research. Guangdong: Zhongshan University 2010; 6.

[13] Kretschmer T, Ihle S, Antoniadis G, et al. Patient satisfaction and disability after brachial

M AN U

plexus surgery. Neurosurgery 2009; 65(4 Suppl): A189-A196.

[14] Shen J. Advances in mass traumatic brachial plexus injury patients living. Journal of Modern Nursing 2012; 18(6): 723-4.

[15] Tong XL. The study of the relationship between mental health and family functioning

AC C

EP

TE D

children. Shanghai: East China Normal University 2009; 9.

9

ACCEPTED MANUSCRIPT Table 1 - Quality of life score of brachial plexus injury patients compared with the national norm [5] (mean ± standard deviation) Patients

Norm

t

p

Physical

11.77 ± 3.01

15.80

-13.573

0.000

Psychological

9.83 ± 3.04

14.30

-14.920

0.000

Social

13.14 ± 3.70

13.70

-1.539

0.127

Environmental

12.52 ± 2.84

13.20

-2.415

0.017

AC C

EP

TE D

M AN U

SC

RI PT

Domain

10

ACCEPTED MANUSCRIPT Table 2 - Quality of life score according to sociologic and injury characteristics (n = 103) Quality of n

%

t/F

p

0.011

0.918

life Male

99

96.1

65.81 ± 15.25

4

3.9

65.00 ± 17.32

17

16.5

55.29 ± 7.17

Middle school

51

49.5

65.49 ± 15.88

High school

22

21.4

71.36 ± 15.75

College

13

12.6

Married

52

50.5

Primary

Education

Marital status

Unmarried or 51

68.04 ± 11.96

38.8

66.50 ± 15.11

35.0

59.13 ± 12.67

22.3

70.97 ± 15.34

4

3.9

50.00 ± 0.00

25

24.3

58.80 ± 13.33

78

75.7

68.01 ± 15.21

32

31.0

64.06 ± 12.85

Worker

40

Farmer

23

Service

36

Other

TE D

Occupation

Still working Work after

EP

Sickness or disease

0.008

1.507

0.135

4.793

0.004

2.711

0.008

7.284

0.000

2.516

0.086

1.467

0.236

63.56 ± 17.72

49.5

divorced

3.689

67.86 ± 16.55

M AN U

school

SC

Female

RI PT

Gender

Bingtui

AC C

< 1000 Family income

1000–

53

51.5

64.43 ± 13.72

(yuan/mo)

3000–

12

11.7

63.33 ± 19.69

> 5000

6

5.8

91.67 ± 6.83

1–12

33

32.0

68.33 ± 17.57

13–24

33

32.0

66.67 ± 15.09

> 24

37

36.0

61.08 ± 9.36

Time from last

1–12

74

71.8

66.69 ± 15.88

operation (mo)

13–24

21

20.4

61.90 ± 9.81

Time from injury (mo)

11

ACCEPTED MANUSCRIPT Quality of n

%

t/F

p

0.891

0.473

8

7.8

60.00 ± 7.56

1

52

50.5

67.02 ± 16.19

2

35

34.0

64.86 ± 13.48

≥3

16

15.5

60.26 ± 5.77

Payment of

Own expense

43

41.7

65.93 ± 14.73

medical

Bursaries / 60

58.3

65.67 ± 15.72

45

43.7

SC

life > 24

operations

expenses

Medicare Road accident

Cause of injury 58

Yes

42

No

61

Injury

Yes

46

ipsilateral to dominant hand

No

40.8

TE D

training

56.3

57

0.932

2.645

0.010

0.131

0.718

23.219

0.000

62.24 ± 12.36

65.12 ± 15.24

59.2

66.23 ± 15.35

44.7

58.48 ± 10.43

55.3

0.086

70.33 ± 17.40

M AN U

Functional

Non-accident

RI PT

Number of

71.67 ± 16.02

AC C

(F).

EP

Note: t/F indicates value is obtained either by Student’s t-test (t) or by analysis of variance

12

ACCEPTED MANUSCRIPT Table 3 - Correlational analysis of quality of life with age, upper limb function score and family functioning score (n = 103) p

Age

-0.319

0.001

DASH score

-0.306

Family cohesion score

0.347

Family adaptability score

0.332

RI PT

r2

0.002

0.000

AC C

EP

TE D 13

0.000

SC

M AN U

Item

ACCEPTED MANUSCRIPT Table 4 - Multiple linear regression analysis of factors affecting the quality of life (n = 103) r2

β

t

p

-0.655

-0.431

-6.105

0.000

Dominant hand injured

-10.720

-0.351

-4.658

0.000

Family cohesion score

0.417

0.284

3.687

0.000

Family monthly income

3.853

0.205

2.896

-0.179

-0.186

-2.516

0.005

0.014

AC C

EP

TE D

M AN U

DASH score

14

0.539

SC

Age

F

RI PT

B

Factors

18.710

p

0.000