A model instrument for the documentation of outcome after nerve repair

Long-term subjective and objective outcomes after digital nerve repair: a cohort study

Digital nerve injuries are common, but few studies report long-term effects for the individual. The primary aim of this matched-pairs study comparing digital nerve injuries in border digits or central fingers was to investigate hand function 3-10 years after digital nerve repair, assessed using the Mini Sollerman test in 86 patients. Secondary outcomes were sensory function, range of motion, grip strength and patient-reported measures. No significant difference was seen in hand function between the groups, except for lower grip strength in patients with central finger injury. Tactile discrimination was achieved in 87%, with best results among participants aged less than 44 years. Touch perception was measurable in 99%. No statistically significant differences in sensory function were found between the groups. Patient-reported disability was low, with median Quick Disabilities of the Arm, Shoulder and Hand score of 5, but half of the patients reported neuropathic pain. Numbness and cold sensitivity were the symptoms graded worst after digital nerve injury.Level of evidence: III.

Outcome Measures after Peripheral Nerve Injury: Past, Present and Future

Peripheral nerve injuries (PNI) present substantial challenges due to variability in injury severity and limited regenerative capabilities. Historically, PNI research has focussed on measures such as subjective surgeon outcome grading, two-point discrimination (2PD) and the Medical Research Council (MRC) grading system. While these methods have use, there are also limitations related to subjectivity and sensitivity. Electrophysiological studies, including electromyography (EMG) and nerve conduction studies (NCS), provide detailed insights but are invasive and resource intensive. Currently, the landscape of outcome measurements in PNI research is diverse, incorporating a mix of surgeon-scored, patient-reported and objective measures. Advancements in wearable devices and motion-tracking technologies offer the potential for continuous, real-time monitoring of patient recovery. These innovations can provide a more comprehensive and objective view of functional recovery, moving beyond the limitations of periodic clinical assessments. The primary limitation in current PNI research is the lack of standardisation in outcome measures and the arbitrary timing of assessments. This variability complicates data interpretation and comparative effectiveness research. Standardising the selection and timing of outcome measures is crucial for enhancing the reliability of research findings and facilitating collaborative studies. Level of Evidence: Level V (Diagnostic).

The Current State of Outcome Measurements After Peripheral Nerve Injury: A Systematic Review

Purpose

The manner in which outcomes are reported after peripheral nerve injury (PNI) varies tremendously and often centers on surgeon-manual muscle testing. The purpose of our systematic review was to quantify the use of outcome measures after PNI in the contemporary literature (published in 2008 and beyond) and to evaluate which domains of recovery are assessed most frequently.

Methods

With the assistance of a medical librarian, we performed a systematic review of the literature published in or after 2008 (to represent the last 15 years) for patients with upper-extremity PNI. We excluded articles with <5 participants, minors, brachial plexus or digital nerve injuries, compressive neuropathies, or <6 months of follow-up. Data were extracted to identify which outcome measures were used in each study, categorizing the outcome measures under the domains of motor, sensory, function, and pain.

Results

Of the 4 outcome domains (pain, motor, sensory, and function), motor was reported the most frequently, followed by function. Within the motor category, more than two-thirds of the studies used manual muscle testing for assessment. Half of the articles reported outcomes in 2 of the 4 assessed domains. Pain was the least assessed domain, reported in 11 of 68 articles.

Conclusion

While there has been incorporation of functional outcomes, the majority of the literature in the last 15 years remains focused on surgeon-reported muscle testing and does not adequately reflect the multiple domains affected by PNI. Pain is the least frequently reported domain, despite being an issue that frequently vexes PNI patients.

Clinical Relevance

There is a need for clinicians and researchers to agree upon a common set of outcome measures for PNI that (A) encompass perspectives of clinicians and patients and (B) reflect multiple domains affected by PNI. This will improve the quality of outcome reporting and facilitate future comparative effectiveness studies.

Both Type I Bovine Collagen Conduits and Porcine Small Intestine Submucosa Conduits Result in Functional Sensory Recovery Following Peripheral Nerve Microsurgery: A Systematic Review and Meta-Analysis

PURPOSE

The study purpose was to measure and compare the time to functional sensory recovery (FSR) and incidence of FSR by 6 and 12 months between type I bovine collagen conduits versus porcine small intestine submucosa (SIS) conduits with primary neurorrhaphy for peripheral nerve injury repair.

METHODS

A systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were conducted. The predictor variable was the type of conduit-either bovine collagen or porcine SIS. The primary outcome variable was the number of months between surgery and the patient achieving FSR. The secondary outcome variable was the proportion of patients who achieved FSR that did so by 6 and 12 months. A log-rank test was performed to evaluate the statistical significance of the differences observed in the overall time-to-FSR data and by 6 and 12 months.

RESULTS

We screened 67 publications of which 8 were included. The sample sizes were 137 and 96 patients for the bovine collagen and porcine SIS groups, respectively. The median time to FSR for the bovine collagen conduit group was 9 months (interquartile range: 6); the median time to FSR for the porcine SIS conduit group 6 months (interquartile range: 3 months) (P = .50). Of the patients who achieved FSR, 42% of patients with bovine collagen conduits and 64% of patients with porcine SIS conduits did so within 6 months (P < .01). Of the patients who achieved FSR, 94% of patients with bovine collagen conduits and 82% of patients with porcine SIS conduits did so within 12 months (P < .01).

CONCLUSION

Although a significant difference was found in the incidence of FSR at 6 and 12 months, no significant difference was found in overall time to FSR, supporting the use of either conduit for peripheral nerve repair.

Supercharging of the ulnar nerve: clinical and neurophysiological assessment at 2 years for nine proximal injuries

LEVEL OF EVIDENCE

II.

Outcome Prediction by Diffusion Tensor Imaging (DTI) in Patients with Traumatic Injuries of the Median Nerve

Background/Objectives: The accurate quantification of peripheral nerve axonal regeneration after injury is critically important. Current strategies are limited to detecting early reinnervation. DTI is an MRI modality permitting the assessment of fractional anisotropy, which increases with axonal regeneration. The aim of this pilot study is to evaluate DTI as a potential predictive factor of clinical outcome after median nerve section and microsurgical repair. Methods: We included 10 patients with a complete section of the median nerve, who underwent microsurgical repair up to 7 days after injury. The follow-up period was 1 year, including the current strategy with clinical visits, the Rosén-Lundborg score and electroneuromyography. Additionally, DTI MRI of the injured wrist was planned 1, 3 and 12 months post-operatively and once for the contralateral wrist. Results: The interobserver reliability of DTI measures was almost perfect (ICC 0.802). We report an early statistically significant increase in the fractional anisotropy value after median nerve repair, especially in the region located distal to the suture. Meanwhile, Rosén-Lundborg score gradually increased between the third and sixth month, and continued to increase between the sixth and twelfth month. Conclusions: DTI outcomes three months post-operation could offer greater predictability compared to current strategies. This would enable faster decision-making regarding the need for a potential re-operation in cases of inadequate early reinnervation.

Evaluating Outcomes Following Nerve Repair: Beyond the Medical Research Council

Peripheral nerve injuries are common and remain a significant health challenge. Outcome measurements are used to evaluate injury, monitor recovery after nerve repair, and compare scientific advances. Clinical judgement is required to determine which available tools are most applicable, which requires a vast understanding of the available outcome measurements. In this article we discuss the highest yield tools available for clinical application.

Occupational Nerve Injuries due to Metallic Foreign Bodies: A Case Series of Eighteen Patients

Introduction

Peripheral nerve injuries (PNIs) remain an important health problem. PNIs mostly affect young men as this age group is mostly involved in road traffic accidents and other injuries at workplace. PNI can occur from foreign bodies like metal chips while working in industries using lathe machines. Among PNI's, injuries to the ulnar nerve, the brachial plexus and the median nerve are the most frequent lesions encountered.

Materials and methods

This presentation is on a series of 18 cases of nerve injuries among industrial workers located from finger level up to the arm excluding the brachial plexus due to metallic foreign bodies entering while operating lathe machines over a period of two years with patients being followed-up over a one year period.

Results

Mean age in this series was 31.3 years with age range 16-40 years and all were males. Two patients had more than one nerve involvement and one patient had associated vascular injury. All the patients showed functional improvement. Most common nerve injured was median nerve. Most common site for nerve injury was forearm. Combined lesions most commonly involved the ulnar and median nerves.

Conclusion

Social cost of traumatic peripheral nerve injuries is significant since it has a higher incidence in young, previously healthy, and economically active people.

Touch localization after nerve repair in the hand: insights from a new measurement tool

Errors of touch localization after hand nerve injuries are common, and their measurement is important for evaluating functional recovery. Available empirical accounts have significant methodological limitations, however, and a quantitatively rigorous and detailed description of touch localization in nerve injury is lacking. Here, we develop a new method of measuring touch localization and evaluate its value for use in nerve injury. Eighteen patients with transection injuries to the median/ulnar nerves and 33 healthy controls were examined. The hand was blocked from the participant's view and points were marked on the volar surface using an ultraviolet (UV) pen. These points served as targets for touch stimulation. Two photographs were taken, one with and one without UV lighting, rendering targets seen and unseen, respectively. The experimenter used the photograph with visible targets to register their locations, and participants reported the felt position of each stimulation on the photograph with unseen targets. The error of localization and its directional components were measured, separate from misreferrals-errors made across digits, or from a digit to the palm. Nerve injury was found to significantly increase the error of localization. These effects were specific to the territory of the repaired nerve and showed considerable variability at the individual level, with some patients showing no evidence of impairment. A few patients also made abnormally high numbers of misreferrals, and the pattern of misreferrals in patients differed from that observed in healthy controls.NEW & NOTEWORTHY We provide a more rigorous and comprehensive account of touch localization in nerve injury than previously available. Our results show that touch localization is significantly impaired following median/ulnar nerve transection injuries and that these impairments are specific to the territory of the repaired nerve(s), vary considerably between patients, and can involve frequent errors spanning between digits.

Reconstructive Timing of Nail Preserved Fingertip Injury With Reverse Digital Artery Island Flap

BACKGROUND

This study aimed to compare the outcomes of reverse digital artery island flap (RDAIF) in primary and secondary reconstruction after failed replantation or composite graft method.

METHODS

This study retrospectively analyzed 42 patients that underwent RDAIF (18 primary and 24 secondary). Preoperative details (demographics, injury details, and waiting days) and postoperative outcomes (active arc of proximal interphalangeal [PIP] and distal interphalangeal (DIP) joints, extension loss of PIP, flexion arc of metacarpophalangeal joint, total active motion, flap sensation, the presence of numbness, Tinel's sign and cold intolerance) were evaluated. Quick Disabilities of the Arm, Shoulder, and Hand score (Quick-DASH) and patient satisfaction were also statistically compared between the 2 groups.

RESULTS

There was no significant difference in patient demographics between the 2 groups in sex, age, smoking and diabetic history, affected hand and finger, injury type and level, and flap area. The only difference was in waiting days. Similar sensory recovery and patient satisfaction were found in both groups. Range of motion in the DIP and PIP joints, extension loss of PIP, total active motion, and Quick-DASH were superior in the primary coverage group. Increasing age, subzone III injury, and secondary reconstruction were found to be the factors that adversely affected the postoperative range of motion.

CONCLUSIONS

Secondary reconstruction was more likely to result in joint contracture. In the event of a damaged fingertip amputation in older patients, primary flap reconstruction should be considered as the initial treatment of choice, with regard to the ultimate range of motion.

Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations

This study aimed to investigate whether ultrasonographic inspection of the repair site of median nerve lacerations may provide useful evidence about the functional outcome in the affected hand. Forty-three patients with complete transection of the median nerve at the distal forearm were examined at a median of 40.9 months after operation by detailed ultrasonographic imaging and clinical assessment of the affected hand by the Michigan Hand Questionnaire and Rosén-Lundborg Protocol to investigate the quality of nerve healing. The continuity of individual nerve fascicles was assessed and the cross-sectional area of the enlarged nerve at the repair site was measured and compared with the contralateral median nerve at the same level. An enlargement ratio for the repair site of each nerve was calculated and compared with the numeric results obtained from the two clinical tests. A statistically significant reverse correlation was observed between nerve enlargement and the functional results of the repaired nerve.Level of evidence: IV.

Efficacy and feasibility of SENSory relearning of the UPPer limb (SENSUPP) in people with chronic stroke: A pilot randomized controlled trial

BACKGROUND

Sensorimotor impairments of the upper limb (UL) are common after stroke, but there is a lack of evidence-based interventions to improve functioning of UL.

OBJECTIVE

To evaluate (1) the efficacy of sensory relearning and task-specific training compared to task-specific training only, and (2) the feasibility of the training in chronic stroke.

DESIGN

A pilot randomized controlled trial.

SETTING

University hospital outpatient clinic.

PARTICIPANTS

Twenty-seven participants (median age; 62 years, 20 men) were randomized to an intervention group (IG; n = 15) or to a control group (CG; n = 12).

INTERVENTION

Both groups received training twice weekly in 2.5-hour sessions for 5 weeks. The training in the IG consisted of sensory relearning, task-specific training, and home training. The training in the CG consisted of task-specific training.

MAIN OUTCOME MEASURES

Primary outcome was sensory function (touch thresholds, touch discrimination, light touch, and proprioception). Secondary outcomes were dexterity, ability to use the hand in daily activities, and perceived participation. A blinded assessor conducted the assessments at baseline (T1), post intervention (T2), and at 3-month follow-up (T3). Nonparametric analyses and effect-size calculations (r) were performed. Feasibility was evaluated by a questionnaire.

RESULTS

After the training, only touch thresholds improved significantly from T1 to T2 (p = .007, r = 0.61) in the IG compared to the CG. Within the IG, significant improvements were found from T1 to T2 regarding use of the hand in daily activities (p = .001, r = 0.96) and movement quality (p = .004, r = 0.85) and from T1 to T3 regarding satisfaction with performance in meaningful activities (p = .004, r = 0.94). The CG significantly improved the performance of using the hand in meaningful activities from T1 to T2 (p = .017, r = 0.86). The training was well tolerated by the participants and performed without any adverse events.

CONCLUSIONS

Combined sensory relearning and task-specific training may be a promising and feasible intervention to improve UL sensorimotor function after stroke.

Assessment of Motor Function in Peripheral Nerve Injury and Recovery

Introduction

Peripheral nerve injuries can be difficult to diagnose, treat, and monitor given their highly variable presentation. When the status of nerves is not accurately assessed, treatment may be delayed or overlooked and can result in lasting functional deficits. As our understanding of nerve repair and generation evolves, so will tools for evaluating both the functional and morphological status of peripheral nerves.

Objective

There is currently no single article which provides a detailed, comprehensive view of the literature comparing the clinical utility of various assessment modalities. Furthermore, there is no consensus on the optimal assessment algorithm for peripheral nerve injuries.

Methods

We performed a literature review using a comprehensive combination of keywords and search algorithm. The search was focused on clinical data regarding the assessment of peripheral nerves Results: This review may help to determine the appropriate tools that are currently available for monitoring nerve function both pre and postoperatively. Additionally, the review demonstrates possible roles and areas of improvement for each tool used to assess motor function.

Conclusion

As surgeons work to improve treatments for peripheral nerve injury and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Prognostic factors, symptom evolution, and quality of life of posttraumatic trigeminal neuropathy

ABSTRACT

Neurosensory disturbances (NSDs) caused by injury to the trigeminal nerve can affect many aspects of daily life. However, factors affecting the persistence of NSDs in patients with posttraumatic trigeminal neuropathies (PTTNs) remain largely unknown. The identification of such risk factors will allow for the phenotyping of patients with PTTNs, which is crucial for improving treatment strategies. We therefore aimed to identify the prognostic factors of NSD persistence, pain intensity, and quality of life (QoL) in patients with PTTNs and to use these factors to create a prognostic prediction model. We first performed a bivariate analysis using retrospective longitudinal data from 384 patients with NSDs related to posttraumatic injury of the trigeminal nerve (mean follow-up time: 322 ± 302 weeks). Bivariate and multivariate analyses were performed. The multivariable prediction model to predict persistent NSDs was able to identify 76.9% of patients with persistent NSDs, with an excellent level of discrimination (area under the receiver operating characteristic curve: 0.84; sensitivity: 81.8%; specificity: 70.0%). Furthermore, neurosensory recovery was significantly associated with sex; injury caused by local anesthesia, extraction, third molar surgery, or endodontic treatment; and the presence of thermal hyperesthesia. Pain intensity and QoL analysis revealed several factors associated with higher pain levels and poorer QoL. Together, our findings may aid in predicting patient prognosis after dental, oral, and maxillofacial surgery and might lead to personalized treatment options and improved patient outcomes.

Sensory Neurotization of the Ulnar Nerve, Surgical Techniques and Functional Outcomes: A Review

When ulnar nerve lesions happen above the wrist level, sensation recovery after acute repair or nerve grafting is often challenging. Distal sensory nerve transfers may be an option for overcoming these sequelae. However, little data has been published on this topic. This study aims to review the surgical procedures currently proposed, along with their functional results. Six donor nerves have been described at the wrist level: the palmar branch of the median nerve, the cutaneous branch of the median nerve to the palm with or without fascicles of the ulnar digital nerve of the index finger, the posterior interosseous nerve, the third palmar digital nerve, the radial branch of the superficial radial nerve, the median nerve, and the fascicule for the third web space. Three donor nerves have been reported at the hand level: the ulnar digital nerves of the index, and the radial or ulnar digital nerves of the long finger. Three target sites were used: the superficial branch of the ulnar nerve, the dorsal branch of the ulnar nerve, and the ulnar digital branch of the fifth digit. All the technical points have been illustrated with anatomical dissection pictures. After assessing sensory recovery using the British Medical Research Council scale, a majority of excellent recoveries scaled S3+ or S4 have been reported in the targeted territory for each technique.

Neonatal brachial plexus palsy and hand representation in children and young adults

AIM

To assess the impact of neonatal brachial plexus palsy (NBPP) on higher-order hand representation.

METHOD

Eighty-two left-handed children and adolescents with and without right-sided NBPP were recruited. Thirty-one participants with NBPP (mean age [SD] 11y 4mo [4y 4mo]; age range 6y 2mo-21y 0mo; 15 females; C5-6, n=4, C5-7, n=12, C5-T1, n=11, C5-T1 with Horner sign, n=4) were assessed along with 30 controls (mean age 11y 5mo [4y 4mo]; age range 6y 7mo-21y 7mo; 14 females). Participants' estimated hand size and shape on measure of implicit and explicit hand representation was assessed. A linear mixed model (LMM) was used to investigate the effect of condition, sensorimotor impairment, and age.

RESULTS

Individuals with NBPP showed a significant difference in implicit hand representation between affected and non-affected hands. LMM confirmed a significant influence of the severity of sensorimotor injury. Only the estimated implicit hand representation was associated with age, with a significant difference between 6- to 8-year-olds and 9- to 10-year-olds.

INTERPRETATION

The effect of sensorimotor impairment on central hand representation in individuals with NBPP is specific due to its implicit component and is characterized by finger length underestimation in the affected hand compared to the characteristic underestimation in the unaffected hand. Neither NBPP nor age impacted the explicit hand estimate. This study confirms the importance of sensorimotor contribution to the development of implicit hand representation.

Evaluation of outcome after primary median and/or ulnar nerve(s) repair at wrist: clinical, functional, electrophysiologic, and ultrasound study

Background

A major problem in surgery of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the proper methods of outcome assessment and the prognostic factors is necessary to improve functional outcome after repair of peripheral nerves. The objective of this study is to assess the outcome and identify possible prognostic factors for functional recovery of median and/or ulnar nerves repairs at wrist. Forty patients with median, ulnar or combined median-ulnar nerve injuries were included. Smoking, age, sex, repaired nerve, associated artery and/ or tendon repairs, joint stiffness and scar tissue were analyzed as prognostic factors for functional outcome after repair. Outcome parameters were medical research counsel (MRC) scoring for sensory and motor recovery, grip and pinch strength, disability of arm, shoulder and hand (DASH) questionnaire, electrophysiology and ultrasonographic evaluation.

Results

The mean age of the studied patients was 29.1 ± 8.3 and it was statistically correlated with grip strength (p = 0.045), DASH score (p = 0.046) and hyperesthesia score (p = 0.040). EMG results showed signs of regeneration in all patients in the form of small nascent MUAPs and polyphasic MUAPs. CMAP amplitudes of median and ulnar nerves positively correlated with the MRC scale for muscle strength (p = 0.001)

There were statistically significant negative correlations between DASH score and MRC score for sensory evaluation (p = 0.016), grip (p = 0.001), and pinch strength (p = 0.001). There were statistically significant positive correlations between patient's opinion of recovery and MRC score for sensory evaluation (p = 0.029), grip (p = 0.001), and pinch strength (p = 0.001). The MRC score for muscle strength has statistical significant positive correlations with the MRC score for sensory evaluation, grip (p = 0.003), and pinch strength (p = 0.040)

Conclusions

It was concluded that; MRC scale for muscle power, MRC scale for sensory evaluation, functional scores, grip and pinch strength are valuable tools for evaluation of functional outcome. Age, smoking, associated tendon repair, damaged nerve, compliance to rehabilitation protocol, return to work, clinically visible wound adhesions, residual hand joint stiffness, and scar tissue detected by ultrasound were found to be prognostic factors for outcome after nerve repair.

Relationship Between Sensibility Tests and Functional Outcomes in Patients With Traumatic Upper Limb Nerve Injuries: A Systematic Review

OBJECTIVE

To investigate which tests of hand sensibility correlate with functional outcomes in patients with upper limb traumatic nerve injuries and to assess if composite scales of sensibility correlate with functions.

DATA SOURCES

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched in May 2020, with a supplementary search in July 2020. Reference lists of the included publications were hand searched.

STUDY SELECTION

Database search found 2437 records. Eligible studies reported on inferential association between sensibility tests and functions pertaining to adults after upper limb nerve repair. Two reviewers independently assessed eligibility. Fifteen publications were included.

DATA EXTRACTION

Extracted data contain patient characteristics, surgical procedure, follow-up duration, sensibility tests, and functional assessments. Two reviewers independently assessed data quality.

DATA SYNTHESIS

Fifteen publications involving 849 patients were reviewed. All publications reported on median and/or ulnar nerve injuries. Monofilament tests correlated with Short-Form Health Survey (r=0.548, P<.05), pick-up test (r=0.45, P<.05), and function domain of Patient-Rated Wrist and Hand Evaluation Questionnaire (PRWHE) (r=0.58, P<.05). The 8 studies of static and moving 2-point discrimination provided conflicting correlations with activities of daily living (ADL) and/or the pick-up test. Data for area localization and object/shape identification were equivocal as well. No data were found for Ten test and vibration tests. Rosén score sensory domain correlated with ADL (r=0.59; 95% confidence interval [CI], 0.41-0.72) and PRWHE function domain (r=-0.56, P<.05). Medical Research Council sensory scale was related to pick-up test; return to work status; and Disabilities of the Arm, Shoulder, and Hand questionnaire.

CONCLUSIONS

Monofilament tests allow practitioners to gather sensibility data meaningful to patients' overall recovery of functions after upper limb nerve trauma. For 2-point discrimination and other sensibility tests, practitioners should be aware that improvement in test performance does not necessarily translate to improved hand function. Findings from the composite scales indicate that hand sensibility, in general, is related to functions. Future research on other common sensibility tests is recommended to explore how the test relates to patients' functions.

Tactile stimulation programs in patients with hand dysesthesia after a peripheral nerve injury: A systematic review

STUDY DESIGN

This is a systematic review performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.

INTRODUCTION

Diverse approaches based on tactile stimulation are used in hand rehabilitation settings to treat touch-evoked dysesthesias. However, there is a lack of literature synthesis on the description and the effectiveness of the various approaches based on tactile stimulation that can be used for treating hand dysesthesia after nerve injury.

PURPOSE OF THE STUDY

The purpose of the study was to summarize the current evidence on tactile stimulation programs for managing touch-evoked hand dysesthesia due to nerve injury.

METHODS

The search was carried out on Medline, Embase, CINAHL, and the Cochrane Library databases. The selected studies had to present patients with touch-evoked dysesthesia after nerve injury who were treated with tactile stimulation approaches to reduce pain. The methodological quality of the included studies was assessed using the methodological index for nonrandomized studies scale, as well as the risk of bias.

RESULTS

Eleven studies met the inclusion criteria. These studies present tactile stimulation interventions that are heterogeneous relative to the target populations and the intervention itself (desensitization versus somatosensory rehabilitation method). Painful symptoms appear to diminish in patients with touch-evoked hand dysesthesia, regardless of the tactile stimulation program used. However, the included studies present significant risks of bias that limit the confidence in these results.

DISCUSSION

The evidence does not unequivocally support the beneficial effects of tactile stimulation to treat touch-evoked hand dysesthesia.

CONCLUSION

Future studies with more rigorous methodological designs, such as randomized controlled trials, are required to verify the potential benefits of these approaches.

Neuroplasticity following Nerve Transfer of the Anterior Interosseous Nerve for Proximal Ulnar Nerve Injuries

Background:

Injuries to the ulnar nerve at or above proximal forearm level result in poor recovery despite early microsurgical repair, especially concerning the intrinsic motor function of the hand. To augment the numbers of regenerating axons into the targeted muscles, a nerve transfer of the distal branch of the median nerve, the anterior interosseous nerve, to the ulnar motor branch has been described.

Methods:

Two patients with severe atrophy of the intrinsic hand muscles following an initial proximal ulnar nerve repair had surgery with an end-to-side transfer of the anterior interosseous nerve to the ulnar motor branch at the wrist level. Outcome and neuroplasticity were prospectively studied using questionnaires, clinical examinations, electroneurography, electromyography, somatosensory evoked potentials at pre nerve transfer and 3-, 12-, and 24-months post nerve transfer as well as navigated transcranial magnetic stimulation at pre nerve transfer and 3- and 12-months post nerve transfer.

Results:

Successively improved motor function was observed. Complete reinnervation of intrinsic hand muscles was demonstrated at 12- to 24-months follow-up by electroneurography and electromyography. At the cortical level, navigated transcranial magnetic stimulation detected a movement of the hot-spot for the abductor digiti mini muscle, originally innervated by the ulnar nerve and the size of the area from where responses could be elicited in this muscle changed over time, indicating central plastic processes. An almost complete reinnervation of the pronator quadratus muscle was also observed.

Conclusion:

Both central and peripheral plastic mechanisms are involved in muscle reinnervation after anterior interosseous nerve transfer for treatment of proximal ulnar nerve injuries.

Management of Traumatic Trigeminal and Facial Nerve Injuries

In the area of craniomaxillofacial trauma, neurosensory disturbances are encountered commonly, especially with regard to the trigeminal and facial nerve systems. This article reviews the specific microanatomy of both cranial nerves V and VII, and evaluates contemporary neurosensory testing, current imaging modalities, and available nerve injury classification systems. In addition, the article proposes treatment paradigms for management of trigeminal and facial nerve injuries, specifically with regard to the craniomaxillofacial trauma setting.

Influence of surface peripheral electrical stimulation on nerve regeneration after digital nerve neurorrhaphy: study protocol for a randomized clinical trial

We will study the influence of low intensity and frequency surface peripheral electrical stimulation (PES) on nerve regeneration of digital nerve injuries of the hand after its surgical repair in humans. Participants will be patients with acute traumatic peripheral nerve injury referred to the Hand Surgery Service of the General Hospital of the State of Bahia, a reference service in the state. These patients will undergo surgery followed by PES in the immediate postoperative period. After hospital discharge, they will be followed up on an outpatient basis by researchers, who will remotely supervise a physiotherapy program. Our hypothesis is that PES will positively influence the recovery of sensory function in patients undergoing neurorrhaphy of digital nerves of the hand. ReBEC registration:  U1111-1259-1998 (12/18/2020).

Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments

There are many outcome measures to choose from when caring for or studying fingertip and nail bed trauma and treatments. This article outlines general outcome measures principles as well as guidelines on choosing, implementing, and interpreting specific tools for these injuries. It also presents recent results from the literature for many of these measures, which can help learners, educators, and researchers by providing a clinical knowledge base and aiding study design.

Sensory retraining improves light touch threshold of the paretic hand in chronic stroke survivors: a single-subject A-B design

Background: Light touch, one of the primary and basic sensations, is often neglected in sensory retraining programmes for stroke survivors.Objective: This study aimed to investigate the effects of sensory retraining on the light touch threshold of the hand, dexterity and upper limb motor function of chronic stroke survivors.Methods: Five chronic stroke survivors with sensory impairment participated in this single-subject A-B design study. In baseline (A) phase, they only received standard rehabilitation. In the treatment (B) phase, they received a 6-week sensory retraining intervention in addition to standard rehabilitation. In both phases, they were evaluated every 3 days. Light touch threshold, manual dexterity and upper limb motor function were assessed using Semmes-Weinstein Monofilaments, Box-Block Test and Fugl-Meyer Assessment, respectively. Visual analysis, nonparametric Mann-Whitney U test and, c-statistic were used for assessing the changes between phases.Results: All participants indicated changes in trend or slope of the total score of light touch or both between the two phases. The results of the c-statistic also showed the statistical difference in the total score of light touch between baseline and treatment in all participants (p < 0.001). Also, the results of the c-statistic and Mann-Whitney U test supported the difference of manual dexterity and motor function of the upper limb between baseline and treatment in all participants (p < 0.001).Conclusion: Current findings showed that sensory retraining may be an effective adjunctive intervention for improving the light touch threshold of the hand, dexterity and upper limb motor function in chronic stroke survivors.

Shape-texture-identification-STI-A test for tactile gnosis: Concurrent validity of STI2

STUDY DESIGN

Cross-sectional study.

INTRODUCTION

The shape-texture-identification (STI) test (Össur Nordic AB, Sweden) is used to evaluate one aspect of tactile gnosis in nerve disorders, and it has proven good methodological properties.

PURPOSE OF THE STUDY

A new version of the STI test was recently introduced-STI² (www.sensory-test.com). The purpose of this study was to test the concurrent validity in STI².

METHODS

Using a cross-sectional design, this methodological study compared STI² to the original version based on 2 cohorts; 1 including 20 persons (1 affected finger and corresponding finger on in opposite hand) with affected sensibility after hand injuries and 1 healthy group including 20 persons (digits II and V in both hands). The agreement between the 2 versions of the instrument was calculated statistically by a percentage comparison of the test results and weighted kappa.

RESULTS

The 112 tested fingers showed a complete agreement, or 1-point accepted deviation, between the 2 tests in 92% with weighted kappa of 0.74 and 95% confidence interval of 0.63-0.89. The result showed that there is no significant deviation between the 2 versions of the test.

DISCUSSION

The use of standardizes and evidence based assessment tools in clinical practice is paramount for a patient centered healthcare. Previous research has shown good psychometric proprties in the STI-test. This study contributes to the scientific evidence of the instrument.

CONCLUSION

As the new STI² proved good agreement within the accepted deviation, we conclude that there is evidence to use the new STI² test in assessment of tactile gnosis.

More severe cold intolerance is associated with worse sensory function after peripheral nerve repair or decompression

The aim of the study is to investigate the correlation between cold intolerance and sensory function after repair of nerve transection or decompression of peripheral neuropathy in the upper extremity. We included patients with abnormal cold sensitivity who had a score of 30 or more in the Cold Intolerance Symptom Severity Questionnaire. There were 30 individuals after surgery to repair nerve transection and 30 with compression neuropathy, aged between 18-65 years. We used the Cold Intolerance Symptom Severity Questionnaire to evaluate cold intolerance and the Rosen Score to evaluate sensory function. There was a significant negative correlation between cold intolerance and sensory function in both peripheral nerve transections and compression neuropathies. We conclude that greater cold intolerance is associated with worse sensory function in peripheral nerve injuries. Interventions for sensory function in cold intolerance treatment may reduce the severity of cold intolerance. Level of evidence: III.

Evaluation of functional outcomes after brachial plexus injury

Major nerve injuries such as those of the brachial plexus present a significant challenge for both rehabilitation and evaluation of outcome. With these often complex and multi-faceted injuries, correct selection of outcome measures is important. Healthy nerve function in humans heightens our interactions with the world, creating quality and enjoyment through our experiences of movement and touch. Therefore, assessments should be holistic and representative of all of these features. This article considers the assessment and evaluation of all of the features of nerve injury: sensorimotor, sensation (including that of pain), function and the psychosocial aspects. Current practice is described and combined with clinical experience and research findings to provide suggestions and recommendations for the selection of the most appropriate tools for use with this patient group.

The effect of sensory-motor training on hand and upper extremity sensory and motor function in patients with idiopathic Parkinson disease

STUDY DESIGN

Blinded randomized controlled trial.

INTRODUCTION

Patients with Parkinson disease (PD) have sensory problems, but there is still no accurate understanding of the effects of sensory-motor interventions on PD.

PURPOSE OF THE STUDY

To investigate the effects of sensory-motor training (SMT) on hand and upper extremity sensory and motor function in patients with PD.

METHODS

Forty patients with PD were allocated to the SMT group or the control group (CG) (mean ages ± standard deviation: SMT, 61.05 ± 13.9 years; CG, 59.15 ± 11.26 years). The CG received the common rehabilitation therapies, whereas the SMT group received SMT. The SMT included discrimination of temperatures, weights, textures, shapes, and objects and was performed 5 times each week for 2 weeks.

RESULTS

Significantly reducing the error rates in the haptic object recognition test (dominant hand [DH]: F = 15.36, P = .001, and effect size [ES] = 0.29; nondominant hand [NDH]: F = 9.33, P = .004, and ES = 0.21) and the error means in the wrist proprioception sensation test (DH: F = 9.11, P = .005, and ES = 0.19; NDH: F = 13.04, P = .001, and ES = 0.26) and increasing matched objects in the hand active sensation test (DH: F = 12.15, P = .001, and ES = 0.24; NDH: F = 5.03, P = .03, and ES = 0.12) founded in the SMT. Also, the DH (F = 6.65, P = .01, and ES = 0.15), both hands (F = 7.61, P = .009, and ES = 0.17), and assembly (F = 7.02, P = .01, and ES = 0.15) subtests of fine motor performance, as well as DH (F = 10.1, P = .003, and ES = 0.21) and NDH (F = 8.37, P = .006, and ES = 0.18) in upper extremity functional performance, were improved in the SMT.

DISCUSSION

SMT improved hand and upper extremity sensory-motor function in patients with PD.

CONCLUSION

The SMT group showed improved sensory and motor function. But these results were limited to levels 1 to 3 of the Hoehn and Yahr Scale.

Measuring intrinsic hand strength in healthy adults: The accuracy intrarater and inter-rater reliability of the Rotterdam Intrinsic Hand Myometer

STUDY DESIGN

Clinical measurement study.

INTRODUCTION

Measuring the isometric strength generated during isolated hand joint motions is a challenging feat. The Rotterdam Intrinsic Hand Myometer (RIHM; med.engineers, Rotterdam, Netherlands) permits measurement of isolated movements of the hand. To date, there is limited evidence on the inter-rater reliability and limited adult normative data of RIHM. Given that multiple raters, often with varying degrees of experience, are needed to collect normative data, inter-rater reliability testing and a comparison of novice and experienced raters are needed.

PURPOSES OF THE STUDY

The purposes of this study were to test the accuracy, intrarater reliability, and inter-rater reliability of the RIHM in healthy-handed adults.

METHODS

RIHM accuracy was tested through use of precision class F weights. Adults 18 years or older without upper limb dysfunction were recruited. Each participant was tested by 4 raters, 3 occupational therapy graduate students, and an experienced certified hand therapist, through use of a calibrated RIHM. Five strength measures were tested bilaterally (ie, thumb carpometacarpal palmar abduction, index finger metacarpophalangeal [MP] abduction, index finger MP flexion, thumb MP flexion, and small finger MP abduction) 3 times per a standardized protocol. Statistical methods were used to test accuracy, inter-rater reliability, and intrarater/response stability.

RESULTS

The accuracy of RIHM device error was 5% or less. Reliability testing included the participation of 19 women and 10 men (n = 29). All raters were in excellent agreement across all muscles (intraclass correlation coefficient, ≥0.81). Low standard error of measurement values of ≤8.3 N (1.9 lb) across raters were found. The response stability and/or intrarater reliability of the novice and certified hand therapist raters were not statistically different.

DISCUSSION

The RIHM has an acceptable instrument error; the RIHM and its standardized procedure have excellent inter-rater reliability and response stability when testing those without hand limitations; and the response stability and/or intrarater reliability of expert and novice raters were consistent.

CONCLUSIONS

The use of the RIHM is justified when multiple raters of varying expertise collect normative data or conduct cohort studies on persons with healthy hands. Future research is warranted.

LEVEL OF EVIDENCE

Not applicable.

Quantifying regeneration in patients following peripheral nerve injury

Healthy nerve function provides humans with the control of movement; sensation (such as pain, touch and temperature) and the quality of skin, hair and nails. Injury to this complex system creates a deficit in function, which is slow to recover, and rarely, if ever, returns to what patients consider to be normal. Despite promising results in pre-clinical animal experimentation effective translation is challenged by a current inability to quantify nerve regeneration in human subjects and relate this to measurable and responsible clinical outcomes. In animal models, muscle and nerve tissue samples can be harvested following experimental intervention. This allows direct quantification of muscle mass and quality and quantity of regeneration of axons; such an approach is not applicable in human medicine as it would ensure a significant functional deficit. Nevertheless a greater understanding of this process would allow the relationship that exists between neural and neuromuscular regeneration and functional outcome to be more clearly understood. This article presents a combined commentary of current practice from a specialist clinical unit and research team with regard to laboratory and clinical quantification of nerve regeneration. We highlight how electrophysiological diagnostic methods (which are used with significant recognised limitations in the assessment of clinical medicine) can potentially be used with more validity to interpret and assess the processes of neural regeneration in the clinical context, thus throwing light on the factors at play in translating lab advances into the clinic.

Artificial tactile and proprioceptive feedback improves performance and confidence on object identification tasks

Somatosensory feedback of the hand is essential for object identification. Without somatosensory feedback, individuals cannot reliably determine the size or compliance of an object. Electrical nerve stimulation can restore localized tactile and proprioceptive feedback with intensity discrimination capability similar to natural sensation. We hypothesized that adding artificial somatosensation improves object recognition accuracy when using a prosthesis. To test this hypothesis, we provided different forms of sensory feedback–tactile, proprioceptive, or both–to two subjects with upper limb loss. The subjects were asked to identify the size or mechanical compliance of different foam blocks placed in the prosthetic hand while visually and audibly blinded. During trials, we did not inform the subjects of their performance, but did ask them about their confidence in correctly identifying objects. Finally, we recorded applied pressures during object interaction. Subjects were free to use any strategy they chose to examine the objects. Object identification was most accurate with both tactile and proprioceptive feedback. The relative importance of each type of feedback, however, depended on object characteristics and task. Sensory feedback increased subject confidence and was directly correlated with accuracy. Subjects applied less pressure to the objects when they had tactile pressure feedback. Artificial somatosensory feedback improves object recognition and the relative importance of tactile versus proprioceptive feedback depends on the test set. We believe this test battery provides an effective means to assess the impact of sensory restoration and the relative contribution of different forms of feedback (tactile vs. kinesthetic) within the neurorehabilitation field.

Functional, motor, and sensory assessment instruments upon nerve repair in adult hands: systematic review of psychometric properties

BACKGROUND

Outcome after nerve repair of the hand needs standardized psychometrically robust measures. We aimed to systematically review the psychometric properties of available functional, motor, and sensory assessment instruments after nerve repair.

METHODS

This systematic review of health measurement instruments searched databases from 1966 to 2017. Pairs of raters conducted data extraction and quality assessment using a structured tool for clinical measurement studies. Kappa correlation was used to define the agreement prior to consensus for individual items, and intraclass correlation coefficient (ICC) was used to assess reliability between raters. A narrative synthesis described quality and content of the evidence.

RESULTS

Sixteen studies were included for final critical appraisal scores. Kappa ranged from 0.31 to 0.82 and ICC was 0.81. Motor domain had manual muscle testing with Kappa from 0.72 to 0.93 and a dynamometer ICC reliability between 0.92 and 0.98. Sensory domain had touch threshold Semmes-Weinstein monofilaments (SWM) as the most responsive measure while two-point discrimination (2PD) was the least responsive (effect size 1.2 and 0.1). A stereognosis test, Shape and Texture Identification (STI), had Kappa test-retest reliability of 0.79 and inter-rater reliability of 0.61, with excellent sensibility and specificity. Manual tactile test had moderate to mild correlation with 2PD and SWM. Function domain presented Rosén-Lundborg score with Spearman correlations of 0.83 for total score. Patient-reported outcomes measurements had ICC of 0.85 and internal consistency from 0.88 to 0.96 with Patient-Rated Wrist and Hand Evaluation with higher score for reliability and Spearman correlation between 0.38 and 0.89 for validity.

CONCLUSIONS

Few studies included nerve repair in their sample for the psychometric analysis of outcome measures, so moderate evidence could be confirmed. Manual muscle test and Rotterdam Intrinsic Hand Myometer dynamometer had excellent reliability but insufficient data on validity or responsiveness. Touch threshold testing was more responsive than 2PD test. The locognosia test and STI had limited but positive supporting data related to validity. Rosén-Lundborg score had emerging evidence of reliability and validity as a comprehensive outcome following nerve repair. Few questionnaires were considered reliable and valid to assess cold intolerance. There is no patient-reported outcome measurement following nerve repair that provides comprehensive assessment of symptoms and function by patient perspective.

Development and validation of a new patient-reported outcome measure for peripheral nerve disorders of the hand, the I-HaND© Scale

Following guidelines from the Patient-Centred Outcomes Research Institute and using a mixed methods study, a new patient-reported outcome measure (PROM) for both nerve trauma and compression affecting the hand, the Impact of a Hand Nerve Disorders (I-HaND) Scale, was developed. Face-to-face interviews with 14 patients and subsequent pilot-testing with 61 patients resulted in the development of the 32-item PROM. A longitudinal validation study with 82 patients assessed the psychometric properties of the I-HaND. Content and construct validity was confirmed by cognitive interviews with patients and through principal component analysis. The I-HaND has high internal consistency (α = 0.98) and excellent test-retest reliability (intraclass correlation coefficient = 0.97). Responsiveness statistics showed that the I-HaND can detect change over 3 months and discriminate between improvers and non-improvers. We conclude that the I-HaND can be used as a PROM for people with a range of hand nerve disorders.

Atypical sensory processing pattern following median or ulnar nerve injury - a case-control study

BACKGROUND

Due to brain plasticity a transection of a median or ulnar nerve results in profound changes in the somatosensory areas in the brain. The permanent sensory deprivation after a peripheral nerve injury might influence the interaction between all senses. The aim of the study was to investigate if a median and/or ulnar nerve injury gives rise to a changed sensory processing pattern. In addition we examined if age at injury, injured nerve or time since injury influence the sensory processing pattern.

METHODS

Fifty patients (40 men and 10 women, median age 43) operated due to a median and/or ulnar nerve injury were included. The patients completed the Adolescent/Adult Sensory Profile questionnaire, which includes a comprehensive characterization on how sensory information is processed and how an individual responds to multiple sensory modalities. AASP categorizes the results into four possible Quadrants of behavioral profiles (Q1-low registration, Q2-sensory seeking, Q3-sensory sensitivity and Q4-sensory avoiding). The results were compared to 209 healthy age and gender matched controls. Anova Matched Design was used for evaluation of differences between the patient group and the control group. Atypical sensory processing behavior was determined in relation to the normative distribution of the control group.

RESULTS

Significant difference was seen in Q1, low registration. 40% in the patient group scored atypically in this Quadrant compared to 16% of the controls. No correlation between atypical sensory processing pattern and age or time since injury was seen.

CONCLUSION

A peripheral nerve injury entails altered sensory processing pattern with increased proportion of patients with low registration to sensory stimulus overall. Our results can guide us into more client centered rehabilitation strategies.

Sensory and functional morbidity following sural nerve harvest in paediatric patients

BACKGROUND

The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients' ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients.

METHODS

A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) - Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper.

RESULTS

Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function.

CONCLUSIONS

Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit.

The effect of early relearning on sensory recovery 4 to 9 years after nerve repair: a report of a randomized controlled study

Twenty patients randomized to early sensory relearning (nine patients) or traditional relearning (11 patients) were assessed regarding sensory recovery 4 to 9 years after median or ulnar nerve repair. Outcomes were assessed with the Rosen score, questionnaires, and self-reported single-item questions regarding function and activity. The patients with early sensory relearning had significantly better sensory recovery in the sensory domain of the Rosen score, specifically, discriminative touch or tactile gnosis and dexterity. They had significantly less self-reported problems in gripping, clumsiness, and fine motor skills. No differences were found in questionnaires between the two groups. We conclude that early sensory relearning improves long-term sensory recovery following nerve repair.

LEVEL OF EVIDENCE

I.

Association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale in hand functional evaluation of patients with leprosy diagnosis

PURPOSE

To evaluate the association of results from the Rosén and Lundborg Score and the screening activity limitation and Safety Awareness scale for the assessment of hand in patients diagnosed with leprosy.

METHOD

An association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale for hand was evaluated in a cross-section study with 25 people of a mean age of 51 years old (SD 14), undergoing drug treatment for leprosy.

RESULTS

The mean quantitative score in the Screening Activity Limitation and Safety Awareness scale was 27.9 (SD 10.5). Rosén and Lundborg Score for the median nerve were 2.43 (SD 0.38) on the right hand and 2.41 (SD 0.54) on the left hand whilst for the ulnar nerve, the scores observed were 2.33 (SD 0.42) for the right hand and 2.31 (SD 0.61) for the left hand. Significant correlations between the two instruments in assessment of the median and ulnar nerves on both hands were found.

CONCLUSIONS

Due to the association found between the scales, the Rosén and Lundborg Score may be used in assessment of the hand in patients diagnosed with leprosy, as a tool to assist the result evaluation after the drug treatment, surgical treatment, rehabilitation and follow-up in the hand dysfunction in leprosy. Implications for Rehabilitation The leprosy inflammatory neuropathy may cause limitations and disabilities related to hand functions of patients. Instruments with quantitative scores provide a reliable basis for therapeutic intervention prognosis. New evaluation methods promote a better monitoring of treatment and hand function evolution of people with leprosy.

Sensation, mechanoreceptor, and nerve fiber function after nerve regeneration

OBJECTIVE

Sensation is essential for recovery after peripheral nerve injury. However, the relationship between sensory modalities and function of regenerated fibers is uncertain. We have investigated the relationships between touch threshold, tactile gnosis, and mechanoreceptor and sensory fiber function after nerve regeneration.

METHODS

Twenty-one median or ulnar nerve lesions were repaired by a collagen nerve conduit or direct suture. Quantitative sensory hand function and sensory conduction studies by near-nerve technique, including tactile stimulation of mechanoreceptors, were followed for 2 years, and results were compared to noninjured hands.

RESULTS

At both repair methods, touch thresholds at the finger tips recovered to 81 ± 3% and tactile gnosis only to 20 ± 4% (p < 0.001) of control. The sensory nerve action potentials (SNAPs) remained dispersed and areas recovered to 23 ± 2% and the amplitudes only to 7 ± 1% (P < 0.001). The areas of SNAPs after tactile stimulation recovered to 61 ± 11% and remained slowed. Touch sensation correlated with SNAP areas (p < 0.005) and was negatively related to the prolongation of tactile latencies (p < 0.01); tactile gnosis was not related to electrophysiological parameters.

INTERPRETATION

The recovered function of regenerated peripheral nerve fibers and reinnervated mechanoreceptors may differentially influence recovery of sensory modalities. Touch was affected by the number and function of regenerated fibers and mechanoreceptors. In contrast, tactile gnosis depends on the input and plasticity of the central nervous system (CNS), which may explain the absence of a direct relation between electrophysiological parameters and poor recovery. Dispersed maturation of sensory nerve fibers with desynchronized inputs to the CNS also contributes to the poor recovery of tactile gnosis. Ann Neurol 2017. Ann Neurol 2017;82:940-950.

Cortical and functional responses to an early protocol of sensory re-education of the hand using audio–tactile interaction

Introduction

Early sensory re-education techniques are important strategies associated with cortical hand area preservation. The aim of this study was to investigate early cortical responses, sensory function outcomes and disability in patients treated with an early protocol of sensory re-education of the hand using an audio-tactile interaction device with a sensor glove model.

Methods

After surgical repair of median and/or ulnar nerves, participants received either early sensory re-education twice a week with the sensor glove during three months or no specific sensory training. Both groups underwent standard rehabilitation. Patients were assessed at one, three and six months after surgery on training-related cortical responses by functional magnetic resonance imaging, sensory thresholds, discriminative touch and disability using the Disabilities of the Arm, Shoulder and Hand patient-reported questionnaire.

Results

At six-months, there were no statistically significant differences in sensory function between groups. During functional magnetic resonance imaging, trained patients presented complex cortical responses to auditory stimulation indicating an effective connectivity between the cortical hand map and associative areas.

Conclusion

Training with the sensor glove model seems to provide some type of early cortical audio-tactile interaction in patients with sensory impairment at the hand after nerve injury. Although no differences were observed between groups related to sensory function and disability at the intermediate phase of peripheral reinnervation, this study suggests that an early sensory intervention by sensory substitution could be an option to enhance the response on cortical reorganization after nerve repair in the hand. Longer follow-up and an adequately powered trial is needed to confirm our findings.

Clinical and biometrical 12-month follow-up in patients after reconstruction of the sural nerve biopsy defect by the collagen-based nerve guide Neuromaix

Many new strategies for the reconstruction of peripheral nerve injuries have been explored for their effectiveness in supporting nerve regeneration. However only a few of these materials were actually clinically evaluated and approved for human use. This open, mono-center, non-randomized clinical study summarizes the 12-month follow-up of patients receiving reconstruction of the sural nerve biopsy defect by the collagen-based nerve guide Neuromaix. Neuromaix was implanted as a micro-structured, two-component scaffold bridging 20–40 mm nerve defects after sural nerve biopsy in twenty patients (eighteen evaluated, two lost in follow-up). Safety of the material was evaluated by clinical examination of wound healing. Performance was assessed by sensory testing of modalities, pain assessment, and palpation for the Hoffmann–Tinel’s sign as well as demarcating the asensitive area at each follow-up visit. Every patient demonstrated uneventful wound healing during the complete 12-month time course of the study. Two patients reported complete return of sensation, whereas eleven out of eighteen patients reported a positive Hoffmann–Tinel’s sign at the lower leg with simultaneous reduction of the asensitive area by 12 months. Our data show that Neuromaix can be implanted safely in humans to bridge sural nerve gaps. No procedure-related, adverse events, or severe adverse events were reported. These first clinical data on Neuromaix provide promising perspectives for the bridging of larger nerve gaps in combined nerves, which should be investigated more through extensive, multi-center clinical trials in the near future.

Age does not affect the outcome after digital nerve repair in children - A retrospective long term follow up

BACKGROUND

Digital nerve injuries in children are not common, but they are considered to have an excellent prognosis, compared to adults, after nerve injury and repair. In studies including both children and adults age have been found to have an effect on outcome after nerve repair.

METHODS

We investigated in a retrospective follow up study the long-time result after digital nerve injury and repair in children, 1-16 years of age (n = 38), and evaluate if age influences outcome. A group with young children, 1-10 years of age (n = 18), was compared with a group with older children, 11-16 years of age (n = 20). A clinical evaluation to evaluate sensation and grip strength was performed and questionnaires were used [Disability of the Arm, Shoulder and Hand (DASH), Cold Sensitivity Severity Scale (CISS), VAS-function and VAS-cosmetic] in median 40 months (range 12-131 months) after the injury and repair.

RESULTS

All patient regained normal sensation. No correlations between age and monofilaments were found. Twenty children (52%) reported some problems with cold intolerance (i.e. CISS), but no other abnormal disability was found (i.e. DASH, VAS); again with no differences between the two groups.

CONCLUSIONS

Children have an excellent long-term recovery after a digital nerve repair and without any influence of age.

Nerve injuries of the upper extremity and hand

A nerve injury has a profound impact on the patient’s daily life due to the impaired sensory and motor function, impaired dexterity, sensitivity to cold as well as eventual pain problems.

To perform an appropriate treatment of nerve injuries, a correct diagnosis must be made, where the injury is properly classified, leading to an optimal surgical approach and technique, where timing of surgery is also important for the outcome.

Knowledge about the nerve regeneration process, where delicate processes occur in neurons, non-neuronal cells (i.e. Schwann cells) and other cells in the peripheral as well as the central nervous systems, is crucial for the treating surgeon.

The surgical decision to perform nerve repair and/or reconstruction depends on the type of injury, the condition of the wound as well as the vascularity of the wound.

To reconnect injured nerve ends, various techniques can be used, which include both epineurial and fascicular nerve repair, and if a nerve defect is caused by the injury, a nerve reconstruction procedure has to be performed, including bridging the defect using nerve-grafts or nerve transfer techniques.

The patients must be evaluated properly and regularly after the surgical procedure and appropriate rehabilitation programmes are useful to improve the final outcome.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160071. Originally published online at www.efortopenreviews.org

Developing an instrument for the measurement of grip ability after distal radius fracture

BACKGROUND

Distal radius fracture (DRF) often causes reduced ability to perform activities of daily living (ADLs). There is a need for recurrent evaluation of the ability to perform ADL in the early stage of rehabilitation as a complement to traditional functional measures.

AIM

Develop a short and simple performance test for use in clinical practice through modification of the Sollerman Grip Function Test (GFT).

METHOD

DRF patients and controls performed the GFT. The tasks that discriminated patients from controls were calculated for sensitivity to change and correlated to the QuickDASH questionnaire at three subsequent occasions. Interrater reliability was tested.

RESULTS

Twelve GFT tasks discriminated DRF patients from healthy controls. One task was excluded due to heavy load. Remaining 11 tasks were all sensitive to change. Four tasks with correlation to the QuickDASH and representing the grip types most frequently used in ADL came to constitute the Wrist Performance Test (WPT). A test-retest showed satisfactory interrater reliability (rs = 0.87).

CONCLUSION

A short performance test was developed through modification of the GFT. It is easy to use in clinical practice to evaluate the rehabilitation process after DRF.

Effect of Pre-Procedural Chair-Side Finger Stretches on Pinch Strength amongst Dental Cohort- A Biomechanical Study

INTRODUCTION

Ergonomics is the essential principle behind the health and successful practice for a dentist and dental hygienist. During the procedure of dental Scaling and Root Planing (SRP), a high level of pinch force is exerted by the finger muscles resulting in early muscle fatigue.

AIM

This pilot study comparatively evaluated the Pinch Strength (PS) of the finger muscles, prior to and after SRP, amongst dental cohort performing chair-side hand and finger stretches to those not performing the same.

MATERIALS AND METHODS

Forty dental professionals were recruited by purposive sampling for the study and allocated into a test and control group. PS was recorded for both groups following which the test group performed finger stretches comprising of rubber band stretch, tendon glide, finger flexion and extension, thumb flexion and finger webbing. The subjects of both the groups carried out SRP for 30 minutes after which PS was again recorded. Inter-group difference was analysed for variability at baseline and 30 minutes after SRP using independent samples/unpaired t-test. Within group comparison of PS measurement was done using paired t-test.

RESULTS

The PS for the test group declined from 14.425±2.577 pounds (lbs) to 13.725±2.557 lbs, while for the control group, a decline in PS from 13.65±2.636 lbs to 10.675±2.478 lbs after SRP was noted. On comparing the difference of means of both groups, a statistically significant result was obtained.

CONCLUSION

Work-related musculoskeletal disorders can be reduced by performing a few simple chair-side stretches. These stretches can help prevent the finger muscle fatigue during SRP and thus, increase its efficacy.

Direct, indirect and intangible costs of acute hand and wrist injuries: A systematic review

BACKGROUND

Injuries sustained to the hand and wrist are common, accounting for 20% of all emergency presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be extensive and rise sharply with the increase of severity.

OBJECTIVE

This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a particular focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature.

MATERIALS AND METHODS

A search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in various databases was conducted. Data extracted for each included study were: design, population, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator RESULTS: The search yielded 764 studies, of which 21 met the inclusion criteria. Twelve studies were cost-of-illness studies, and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6951 (IQR $3357-$22,274) for cost-of-illness studies and US$8297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries.

CONCLUSIONS

Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodologies. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology, however, by any standards, these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

An Evidence-Based Approach to Choosing Outcome Measures: A Checklist for the Critical Appraisal of Validity, Reliability and Responsiveness Studies

Selecting outcome measures for clinical practice or research needs to be based on a critical evaluation of the evidence on the validity and reliability of the available measures. This paper presents both a theoretical framework based on the methodological literature of how these psychometric properties can be assessed and a checklist designed to facilitate the critical appraisal of studies on outcome measures.

Through examples drawn from the published literature, the concepts of instrument validity, reliability and responsiveness and how these can be evaluated and reported are illustrated. It is suggested that a structured checklist can facilitate a more evidence-based approach to the selection and employment of outcome measures in clinical practice and research.