Outcome reporting in traumatic brachial plexus injury: a systematic review to inform a core outcome set: the COMBINE study

Purpose

This study aimed to identify outcomes and measurement tools reported in studies evaluating treatments for traumatic brachial plexus injury. Results will inform the development of a core outcome set in brachial plexus injuries to facilitate evidence synthesis.

Approach

This systematic review was conducted using methods described in the Cochrane Handbook for Systematic Reviews of Interventions and is registered with PROSPERO (Registration number: CRD42018109843).

We systematically searched Medline (OVID), EMBASE, CINAHL, and AMED, from 2013 for studies evaluating the effectiveness of any surgical or non-surgical intervention in traumatic brachial plexus injuries. There were no language restrictions. Two reviewers independently screened the titles and then the abstracts. Full text articles were read to assess for eligibility. Dual data extraction (outcomes reported, area of body, name of measurement tool, timepoints of measurement) was performed until there was no difference in data extracted. Verbatim outcomes were categorised into outcome domains through an iterative process within the research team.

Outcomes

We analysed data from 132 studies comprising 3048 patients reporting 538 outcomes. The mean number of outcomes reported per study was 4 with a range of 1-15. No single outcome was consistently reported in all studies. Seventy percent of studies assessed only clinical outcomes. Twenty four percent of studies assessed both a patient reported and clinical outcome. Motor activity (e.g. active movement, muscle force, strength) was reported in 295/538 (54.8%) of outcomes, sensory function (e.g. vibration, proprioception light touch) was assessed in 34/538 (6.03%) and clinically assessed function in 14/538 (2.6%). Complications comprised 11.5% (62/538) of outcomes assessed. The Medical Research Council muscle scale was the most frequently reported measure in 90/132(68.1%) of studies. The Disability of the Arm Shoulder and Hand was the most frequently patient reported outcome measure in 20.4% (27/132) studies.

Cost and savings

Not identified

Implications

Outcome reporting in traumatic brachial plexus injury is inconsistent and focuses on clinician led outcome assessment with motor outcomes being favoured. This is concerning as it is well documented that patients with a traumatic brachial plexus injury also suffer psychological, social and pain issues. Thus, interventions being evaluated at present may not be assessing outcomes important to patients. Clinicians and researchers may therefore miss potentially important treatment effects or continue with ineffective treatments. Finally, due to the myriad of different outcomes being reported in the literature we are unable to synthesise the results of studies to make evidence-based decisions.

There are issues with outcome assessment and reporting in traumatic brachial plexus injury. A core outcome set is the minimum set of outcomes which should be assessed and reported in an area of healthcare and this review informs the development of these for traumatic brachial plexus injuries.

Top three learning points

1. Outcomes meaningful to both patients and health professionals will be identified by including patient interviews and involving both in a consensus process.

2.This will ensure meaningful outcomes are assessed in future studies and clinical care.

Funding acknowledgements

This study is funded as part of Caroline MillerĀ“s NIHR/HEE Clinical Doctoral Research Fellowship award ICA-CDRF-2017-03-039.

Additional notes

This work was presented at Physiotherapy UK 2019