Functional and outcome evaluation of the hand and wrist

The first evaluation of the upper extremity and hand, performed by the surgeon at the outpatient clinic, is fundamental to understanding the patient's problem, determining the best treatment options, and, in the case of a surgical indication, assessing the preoperative status. In addition to recording the patient's symptoms and complaints, the surgeon evaluates anatomic integrity, stability, mobility, trophicity, strength, and sensibility. In many patients, especially patients with severe handicaps or those who anticipate long delays in rehabilitation, in litigation problems, or as part of prospective clinical research, this classic evaluation is not sufficient. The authors recommend that to accommodate these patients, a laboratory of functional evaluation of the hand should be established. The evaluation, performed by independent reviewers, ideally includes techniques allowing objective measurements of kinematics, strength, sensibility, and global hand function and dexterity. Pain assessment using the VAS is indispensable. The results may be presented as scores based on to the patient's problem. The researchers should analyze precisely how the scores were constructed. Questionnaires are part of the evaluation armamentarium. As with other tools, questionnaires allow us to understand better what our patients experience. They do not replace physical examination. Questionnaires also could be used for routine screening in a general upper limb practice, even before the patient sees the hand surgeon. The choice of the questionnaire is important; the reviewer should make sure that the patient understands all questions, that the questions are not redundant, and that they do apply to the patient. Generic health status instruments such as the SF-36 allow comparison across a variety of health problems, including mental and physical conditions, but are not sensitive to upper extremity disability. The DASH questionnaire seems a better choice, allowing a standardized outcome evaluation. Dedicated questionnaires have been developed for specific conditions (eg, carpal tunnel syndrome). As discussed by Amadio, questionnaires are easier to perform than physical testing, can be self-administered, and require no special equipment, saving the cost of an examiner, avoiding the complexities of scheduling a follow-up examination, and eliminating the possibility of observer bias. The patient is less likely to offer polite but incorrect responses. Questionnaires are especially useful when patient's perceptions are important to assess. Questionnaires also could be used in longitudinal studies to assess improvement or aggravation. The use of questionnaires is therefore especially indicated in studies involving a large number of patients, when observer bias and costs are concerns, and when the main outcome measurements are satisfaction, symptoms, or functional status. Amadio has pointed out that questionnaires are not the best tool to measure anatomic or physiologic impairments.