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Access to Upper Extremity Care for People with Tetraplegia: An International Perspective
Paige M. Fox, MD, PhD; Vincent Hentz, MD; Catherine Curtin, MD; Stanford University
Stanford University, Stanford, CA, USA


Upper extremity reconstruction in patients with tetraplegia is underutilized in the United States and lack of engagement by referring physicians is a major barrier to care. We hypothesized that similar barriers exist internationally.


One hundred and seventy attendees at the tetrahand meeting in Paris in 2010 were sent a thirteen-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice. Specialties included surgeons, physiatrists, therapists and neurologists.


We had a 30% response rate. Respondents ranged the globe including North America, South America, Europe, Asia, and Australia. Fifty-nine percent of respondents had been practicing more than 10 years. Greater than 30% of participants saw more than 20 spinal cord injury patients per month. Most worked in a spinal cord or rehabilitation center.

Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that less than 15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second.

Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery, and poor referral patterns to appropriate upper extremity surgeons.

Respondents suggested several strategies to improve access for upper limb surgery. Most felt improved communication and education between rehabilitation physicians and surgeons would be most effective. Many respondents felt that a method for patients and surgeons to connect electronically would represent a first step to improve access to care.


Access to care is an important topic in the United States. Other countries have minimized systems barriers by providing national health care. However, other major barriers may be universal. For patients with tetraplegia the underutilization of upper extremity reconstruction in the United States has been established. The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient’s address. Overcoming the problems identified in this study does not require a complete restructuring of a nation’s health care system. By addressing the lack of patient education and improving interdisciplinary physician communication, we can attack the major hindrances to the appropriate care of the tetraplegic patient. People with tetraplegia want to decrease their dependence on others. We can help them achieve this goal.

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