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Hand function in patients with Dupuytren’s disease: Assessment, results & patients’ perspectives
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Hand and Plastic Surgery.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Dupuytren’s Disease (DD) is a soft tissue disorder that leads to finger joint contractures affecting hand function. DD can be treated with surgery or injection and hand therapy to improve finger joint extension and thereby improve hand function. However, this does not cure the disease and recurrence is common. Previous research on DD has shown improvement in finger joint extension and in self-reported disability of the upper extremity after surgery and hand therapy for DD. However, this provides only a limited perspective on hand function, and multiple dimensions of changes in hand function (i.e. physical, psychosocial aspects and including the patients’ views of results) have not been reported as a whole.

Aim: The overall aim of the thesis was to explore hand function before and after surgery and hand therapy in patients with DD, including assessment, results and patients’ perspectives.

Methods: The thesis comprises three studies: Study A was a methodological study of interrater reliability in goniometry of the finger joints. Study B was a prospective cohort study with a repeated measures design. Study C was a qualitative interview study, using the model of Patient Evaluation Process and content analysis.

Results: Interrater reliability was high or very high for goniometer measurement of finger joint range of motion (ROM) in patients with DD when experienced raters follow our standardized guidelines developed for the study. Changes in hand function consisted of improvement of finger joint extension while active finger flexion was significantly impaired during the first year after surgery and hand therapy. No patient reached a normal ROM, but the majority reached a functional ROM. Sensibility remained unaffected. Patients with surgery on multiple fingers had worse scar pliability than patients with surgery on a single finger. Most patients had their expectations met and were pleased or delighted with their hand function at 12 months after surgery and hand therapy. Safety issues of hand function were of greater concern than social issues. Patients reported less disability and improved health-related quality of life after surgery and hand therapy. The three variables “need to take special precautions”, “avoid using the hand in social context”, and health-related quality of life had significant importance for patients’ rating of functional recovery. Together, these variables explained 62% of the variance in functional recovery. Patients’ perspectives of undergoing a surgical intervention process were described through five categories. Previous experiences of care influenced participants’ expectations of results and the care they were about to receive. Previous experiences and expectations were used as references for appraisal of results, which concerned perceived changes in hand function, the care process, competency, and organization. Appraisal of results could also vary in relation to  patient character. Appraisal of results of the intervention process influenced participants’ expectations of future hand function, health and care.

Conclusions: Surgery and hand therapy for DD improve hand function and patients regain a functional ROM needed for performance of common daily activities. Despite the negative effect on finger flexion present during the first year after surgery, patients’ regards their hand function as recovered six to eight months after surgery and hand therapy. Measuring digital ROM in the finger joints with a goniometer is a reliable assessment method. However, from the patient’s perspective, it is not enough to evaluate results only in terms of digital extension or ROM. From their view, results of treatment concern consequences on daily use of the hand, what happens during the care process in terms of interaction between patient and health care provider, as well as their view of the competence and logistics of the organization providing the care.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. , 78 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1497
National Category
Physiotherapy Health Care Service and Management, Health Policy and Services and Health Economy Nursing Surgery Neurology
Identifiers
URN: urn:nbn:se:liu:diva-125973DOI: 10.3384/diss.diva-125973ISBN: 978-91-7685-873-8 (print)OAI: oai:DiVA.org:liu-125973DiVA: diva2:910742
Public defence
2016-04-22, Berzeliussalen, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-03-10 Created: 2016-03-10 Last updated: 2016-03-14Bibliographically approved
List of papers
1. Interrater Reliability in Finger Joint Goniometer Measurement in Dupuytrens Disease
Open this publication in new window or tab >>Interrater Reliability in Finger Joint Goniometer Measurement in Dupuytrens Disease
2012 (English)In: American Journal of Occupational Therapy, ISSN 0272-9490, E-ISSN 1943-7676, Vol. 66, no 1, 98-103 p.Article in journal (Refereed) Published
Abstract [en]

We investigated interrater reliability of range of motion (ROM) measurement in the finger joints of people with Dupuytrens disease. Eight raters measured flexion and extension of the three finger joints in one affected finger of each of 13 people with different levels of severity of Dupuytrens disease, giving 104 measures of joints and motions. Reliability measures, represented by intraclass correlation coefficient (ICC), standard error of the mean (SEM), and differences between raters with the highest and lowest mean scores, were calculated. ICCs ranged from .832 to .973 depending on joint and motion. The SEM was andlt;= 3 degrees for all joints and motions. Differences in mean between highest and lowest raters were larger for flexion than for extension; the largest difference was in the distal interphalangeal joint. The results indicate that following these standardized guidelines, the interrater reliability of goniometer measurements is high for digital ROM in people with Dupuytrens disease.

Place, publisher, year, edition, pages
American Occupational Therapy Association, 2012
Keyword
arthrometry, articular, Dupuytren contracture, finger joint, range of motion, articular, reproducibility of results
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75284 (URN)10.5014/ajot.2012.001925 (DOI)000299362000012 ()
Available from: 2012-02-27 Created: 2012-02-24 Last updated: 2017-12-07
2. Hand function and quality of life before and after fasciectomy for Dupuytren contracture
Open this publication in new window or tab >>Hand function and quality of life before and after fasciectomy for Dupuytren contracture
2014 (English)In: Journal of Hand Surgery-American Volume, ISSN 0363-5023, E-ISSN 1531-6564, Vol. 39, no 7, 1333-1343 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE:

To describe changes in joint motion, sensibility, and scar pliability and to investigate the patients' expectations, self-reported recovery, and satisfaction with hand function, disability, and quality of life after surgery and hand therapy for Dupuytren disease.

METHODS:

This prospective cohort study collected measurements before surgery and 3, 6, and 12 months after surgery and hand therapy. Ninety patients with total active extension deficits of 60° or more from Dupuytren contracture were included. Outcomes measures were range of motion; sensibility; scar pliability; self-reported outcomes on expectations, recovery, and satisfaction with hand function; Disabilities of the Arm, Shoulder, and Hand scores; safety and social issues of hand function; physical activity habits; and quality of life with the Euroqol.

RESULTS:

The extension deficit decreased, and there was a transient decrease in active finger flexion during the first year after surgery. Sensibility remained unaffected. Generally, patients with surgery on multiple fingers had worse scar pliability. The majority of the patients had their expectations met, and at 6 months, 32% considered hand function as fully recovered, and 73% were satisfied with their hand function. Fear of hurting the hand and worry about not trusting the hand function were of greatest concern among safety and social issues. The Disability of the Arm, Shoulder, and Hand score and the Euroqol improved over time.

CONCLUSIONS:

After surgery and hand therapy, disability decreased independent of single or multiple operated fingers. The total active finger extension improved enough for the patients to reach a functional range of motion despite an impairment of active finger flexion still present 12 months after treatment.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
Dupuytren contracture; surgical treatment; range of motion; satisfaction; occupational therapy
National Category
Clinical Medicine Physiotherapy
Identifiers
urn:nbn:se:liu:diva-109387 (URN)10.1016/j.jhsa.2014.04.029 (DOI)000338905000014 ()24969497 (PubMedID)
Available from: 2014-08-15 Created: 2014-08-15 Last updated: 2017-12-05Bibliographically approved
3. Factors affecting functional recovery after surgery and hand therapy in patients with Dupuytren's disease
Open this publication in new window or tab >>Factors affecting functional recovery after surgery and hand therapy in patients with Dupuytren's disease
2015 (English)In: Journal of Hand Therapy, ISSN 0894-1130, E-ISSN 1545-004X, Vol. 28, no 3, 255-260 p.Article in journal (Refereed) Published
Abstract [en]

Study design: Prospective cohort study. Introduction: The evidence of the relationship between functional recovery and impairment after surgery and hand therapy are inconsistent. Purpose of the study: To explore factors that were most related to functional recovery as measured by DASH in patients with Dupuytrens disease. Methods: Eighty-one patients undergoing surgery and hand therapy were consecutively recruited. Functional recovery was measured by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Explanatory variables: range of motion of the finger joints, five questions regarding safety and social issues of hand function, and health-related quality of life (Euroqol). Results: The three variables "need to take special precautions", "avoid using the hand in social context", and health-related quality of life (EQ-5D index) explained 62.1% of the variance in DASH, where the first variable had the greatest relative effect. Discussion: Safety and social issues of hand function and quality of life had an evident association with functional recovery. Level of evidence: IV.

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Dupuytrens contracture; Emotional function; Range of motion; Recovery of function; Quality of life
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-121325 (URN)10.1016/j.jht.2014.11.006 (DOI)000359329100005 ()25998546 (PubMedID)
Note

Funding Agencies|Medical Research Council of southeast Sweden [FORSS-72231]; County Council of Ostergotland, Sweden [LIO-77311]

Available from: 2015-09-14 Created: 2015-09-14 Last updated: 2017-12-04
4. Patients'€™ perspective on surgical intervention for Dupuytren'€™s disease€: experiences, expectations and appraisal of results
Open this publication in new window or tab >>Patients'€™ perspective on surgical intervention for Dupuytren'€™s disease€: experiences, expectations and appraisal of results
2016 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 38, no 24-26, 2538-2549 p.Article in journal (Refereed) Published
Abstract [en]

Purpose To explore patients’ perspectives on surgical intervention for Dupuytren’s disease (DD), focusing on patients’ appraisal of results, involving previous experiences, expectations and patient characters.

Method The participants were 21 men, mean age 66 years, scheduled for DD surgery. Qualitative interviews were conducted 2–4 weeks before surgery and 6–8 months after surgery. The model of the Patient Evaluation Process was used as theoretical framework. Data were analyzed using problem-driven content analysis.

Results Five categories are described: previous experiences, expectations before surgery, appraisal of results, expectations of the future and patient character. Previous experiences influenced participants’ expectations, and these were used along with other aspects as references for appraisal of results. Participants’ appraisal of results concerned perceived changes in hand function, care process, competency and organization, and could vary in relation to patient character. The appraisal of results influenced participants’ expectations of future hand function, health and care.

Conclusions Patients’ appraisal of results involved multidimensional reasoning reflecting on hand function, interaction with staff and organizational matters. Thus, it is not enough to evaluate results after DD surgery only by health outcomes as this provides only a limited perspective. Rather, evaluation of results should also cover process and structure aspects of care.

Implications for Rehabilitation

  • To improve health care services, it is important to be aware of the role played by patient’s previous experiences, expectations as well as staff and organizational aspects of care.
  • Knowledge about patients’ experience and view of the results from surgery and rehabilitation should be established by assessment of care effects on health as well as structure and process aspects of care.
  • Evaluation of structure and process aspects of care can be done by using questions about if the patient felt listened to, received clear information and explanations, was included in decision-making, and their view of waiting time or continuity of care.
  • Improving health care services means not only providing the best treatment method available but also developing individualized care by ensuring good interaction with the patient, providing accurate information, and working to improve the structure of the care process.
  • Before treatment, health care providers should have a dialogue with the patient and consider previous experiences and expectations in order to ensure the patient has balanced expectations of the outcome.
Keyword
Care process; hand function; hand surgery; interviews; outcome
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Nursing Physiotherapy
Identifiers
urn:nbn:se:liu:diva-125964 (URN)10.3109/09638288.2015.1137981 (DOI)000385478900020 ()26878688 (PubMedID)
Note

Funding agencies: County Council of Ostergotland, Sweden

Available from: 2016-03-10 Created: 2016-03-10 Last updated: 2017-11-30Bibliographically approved

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