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RRP 06-151 – HSR&D Study

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RRP 06-151
Gap Analysis for Managing Upper Limb Pain and Function in SCI
Audrey L. Nelson RN PhD FAAN
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: October 2006 - September 2007

BACKGROUND/RATIONALE:
SCI QUERI's mission is to identify and address knowledge gaps and promote research to improve the medical care, health-related quality of life and community integration for persons with SCI, and one of its priorities is to address pain and function in SCI. Upper limb pain is highly prevalent in persons with spinal cord injury (SCI) and the functional consequences can be devastating. Most persons with SCI have increased biomechanical challenges and use their upper limbs to compensate for loss of lower limb function. Their upper limbs are used to propel a wheelchair, lift and transfer their body, and perform other weight-bearing tasks. Since life expectancy has increased for persons with SCI, upper limb weight-bearing is often performed for many decades; thus preserving upper limb function is critical to sustain independence into later life.

OBJECTIVE(S):
The Consortium for Spinal Cord Medicine published guidelines entitled, "Preservation of Upper Limb Function Following SCI: A Clinical Practice Guideline for Health Care Professionals" (2005)1. The purpose of this rapid response study was to identify performance gaps, and barriers and facilitators to implementing these guideline recommendations in VA SCI Centers. Using a qualitative research design, this 6 month project addressed two questions, from three perspectives: health care providers, veterans, and key informants: (1) Assessed key stakeholder perceptions regarding gaps in performance associated with routine assessment, prevention, and treatment of upper limb pain and loss of function for persons with SCI. (2) Assessed key stakeholder perceptions regarding barriers and facilitators to routine assessment, prevention, and treatment of upper limb pain and function for persons with SCI.

METHODS:
One facilitator and one co-facilitator conducted seven focus groups, on site and via teleconference, and five individual interviews at three VA SCI centers. The purposeful sample included 13 SCI providers (physical therapists, occupational therapists, and kinesiotherapists) and 16 veterans with SCI. Individual interviews were conducted with three key informants, a kinesiotherapist who specialized in wheelchair fitting and prescription, an experienced clinical nursing specialist in SCI, and a prosthetist with expertise in issuing wheelchairs. Two investigators analyzed hand-written focus group notes and audio tape transcriptions using thematic coding schemes. Points of agreement and disagreement were discussed and decisions jointly made to identify four final thematic categories of respondent perceptions of the clinical practice guidelines: (1) Agreement; (2) Disagreement; (3) Barriers to Implementation, (4) Facilitators to Implementation, many of which were solutions to closing gaps in practice. Excerpts from focus group transcripts and direct quotes that expressed themes were selected to exemplify themes.

FINDINGS/RESULTS:
Content analysis of focus group data revealed that veterans with SCI and health care providers found several of the Practice Guidelines difficult or ambiguous to interpret or understand. Furthermore, providers expressed a lack of 100% clinical consensus with certain guidelines and patients and providers expressed strong agreement with certain others. Otherwise content analysis revealed several facilitator and barrier themes to guidelines implementation that were consistent across patient, provider and organizational/systemic categories. These were (1) patient variation in age, height, weight, strength, position and duration of injury, economic, educational and living status (with or without caregiver), and others, factors that render implementation of certain of the recommendations unfeasible for all patients all of the time; (2) aspects of the VA health care system that serve to obstruct achievement of recommendation goals (limitations of staff, staff time, office space, reimbursement and service eligibility issues, lengthy or cumbersome processes and paperwork, logistical issues of patients living at a distance from the hospital, lack of staff education, equipment and other resources; (3) interdisciplinary, consistent approach to patient care was stressed, as was coordination and communication across services to improve guideline implementation; (4) weak evidence base, need for greater allowance for the role of clinical judgment and/or patient "buy-in" to recommendations; and (5) discussions of the benefit of numerous special and innovative clinical techniques, programs, approaches, product development and/or devices to support recommendation compliance. Finally providers and patients discussed at length the "Pros and Cons" or clinical tradeoffs, in guidelines recommendations, e.g., the benefits and detriments of prescribing a power WC to manual WC users.

IMPACT:
We are working with the VA SCI QUERI for implementation of selected recommendations and further research. Specifically:
-Findings suggest three areas for immediate implementation efforts focusing on recommendations with strong provider agreement: flexibility exercises, early intervention for pain, planning ahead for post-surgery recovery time.
-Findings could be used to develop a research agenda to develop a convincing evidence base for recommendations in the areas of health promotion, wellness and exercise.
-Capitalize on the importance of teamwork in SCI, as perceived by study participants, to implement key recommendations and overcome identified barriers.
-Because patients identified kineseotherapists and physical therapists as providers with valuable skills and knowledge for many of the recommendations, these groups could be called on to provider leadership for implementation.

PUBLICATIONS:
None at this time.


DRA: Acute and Combat-Related Injury
DRE: Treatment - Observational
Keywords: Spinal cord injury
MeSH Terms: none

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