Research Article| Volume 60, ISSUE 2, P103-113, February 2007

Considerations in evaluating new treatment alternatives following peripheral nerve injuries: A prospective clinical study of methods used to investigate sensory, motor and functional recovery


      The current problem finding reliable and objective methods for evaluating results after peripheral nerve repair is a challenge when introducing new clinical techniques. The aim of this study was to obtain reference material and to evaluate the applicability of different tests used for clinical assessment after peripheral nerve injuries. Fifteen patients with a history of complete median nerve transsection and repair, and 15 healthy volunteers were included. Each subject was investigated using a battery of conventional and new tests for functional, sensory and motor recovery including questionnaires, clinical evaluations, neurophysiological and physiological findings. The results were statistically analysed and comparisons were made within the patient group and between patients and healthy volunteers using a ‘per protocol’ and an ‘intention to treat’ approach. Criteria for success were stipulated in order to be able to judge the usefulness of each method. The results showed that 19 of 34 variables, representing six of 16 methods, were not able to fulfil the criteria and were thus questionable for the evaluations of nerve repair in a clinical trial setting. However, 2pd, sensory recovery according to the non-modified British Medical Research Council, sensory neurography, manual muscle test, electromyography, questionnaires (i.e. DASH and the 4 question form) and performance tests (i.e. AMPS and Sollerman's subtests 4 and 8) did fulfil the criteria defined for being useful.


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        • Lundborg G.
        • Rosén B.
        • Dahlin L.
        • et al.
        Tubular repair of the median or ulnar nerve in the human forearm: a 5-year follow-up.
        J Hand Surg [Br]. 2004; 29: 100-107
        • Cuadros-Romero M.
        Nerve regeneration using polyglicolic acid as alternative to grafting.
        J Hand Surg. 2003; 28: 17
        • Bertleff M.
        Introducing Neurolac® trial and the preliminary results.
        J Hand Surg. 2003; 28: 17-18
        • Weber R.A.
        • Breidenbach W.C.
        • Brown R.E.
        • et al.
        A randomised and prospective study of polyglycolic acid conduits for digital nerve reconstruction in human.
        Plast Reconstr Surg. 2000; 106: 1036-1048
        • Stanec S.
        • Stanec Z.
        Reconstruction of upper-extremity peripheral nerve injuries with ePTFE conduits.
        J Reconstr Microsurg. 1998; 14: 227-232
        • Mackinnon S.E.
        • Dellon A.L.
        Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube.
        Plast Reconstr Surg. 1990; 85: 419-424
        • Hart McKay A.
        Sensory neuronal protection and improving regeneration after peripheral nerve injury.
        (Medical dissertations)91-7305-370-8 Umeå University, Umeå2003
        • Lundborg G.
        A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance.
        J Hand Surg [Am]. 2000; 25: 391-414
        • Birch R.
        • Bonney G.
        • Wynn Parry C.B.
        Surgical disorders of the peripheral nerves.
        Churchill Livingstone, Edinburgh1998
        • Seckel B.R.
        Enhancement of peripheral nerve regeneration.
        Muscle Nerve. 1990; 13: 785-800
        • Rosén B.
        • Lundborg G.
        A new model instrument for outcome after nerve repair.
        Hand Clin. 2003; 19: 463-470
        • Friedman L.
        • Furberg C.
        • DeMets D.
        Fundamentals of clinical trials.
        3rd ed. 0-387-98586-71999
        • Vanderhooft E.
        Functional outcome of nerve grafts for the upper and lower extremities.
        Hand Clin. 2000; 16: 93-104
        • Allan C.H.
        Functional results of primary nerve repair.
        Hand Clin. 2000; 16: 67-72
        • Mackinnon S.
        Surgical management of peripheral nerve gap.
        Clin Plast Surg. 1989; 16: 587-603
        • Waylett-Rendall J.
        Sensibility evaluation and rehabilitation.
        Orthop Clin North Am. 1988; 19: 43-56
        • Kelly E.J.
        • Terenghi G.
        • Hazari A.
        • et al.
        Nerve fibre and sensory end organ density in the spidermis and papillary dermis of the human hand.
        Br J Plast Surg. 2005; 58: 774-779
        • Schuind F.A.
        • Mouraux D.
        • Robert C.
        • et al.
        Functional and outcome evaluation of the hand and wrist.
        Hand Clin. 2003; 19: 361-369
        • Jerosch-Herold C.
        A study of the relative responsiveness of five sensibility tests for assessment of recovery after median nerve injury and repair.
        J Hand Surg [Br]. 2003; 28: 255-260
        • Rosén B.
        • Lundborg G.
        A model instrument for the documentation of outcome after nerve repair.
        J Hand Surg [Am]. 2000; 25: 535-543
        • Cano S.J.
        • Browne J.P.
        • Lamping D.L.
        • et al.
        The Patient Outcomes of Surgery-Hand/Arm (POS-Hand/Arm): a new patient-based outcome measure.
        J Hand Surg [Br]. 2004; 29: 477-485
        • Bindra R.R.
        • Dias J.J.
        • Heras-Palau C.
        • et al.
        Assessing outcome after hand surgery: the current state.
        J Hand Surg [Br]. 2003; 28: 289-294
        • Amadio P.C.
        Outcome assessment in hand surgery and hand therapy: an update.
        J Hand Ther. 2001; 14: 63-67
        • Hall S.
        Nerve repair: a neurobiologist's view.
        J Hand Surg [Br]. 2001; 26: 129-136
        • Rosén B.
        • Lundborg G.
        A long term recovery curve in adults after median or ulnar nerve repair: a reference interval.
        J Hand Surg [Br]. 2001; 26: 196-200
        • Rosén B.
        • Dahlin L.B.
        • Lundborg G.
        Assessment of functional outcome after nerve repair in a longitudinal cohort.
        Scand J Plast Reconstr Surg Hand Surg. 2000; 34: 71-78
        • Rosén B.
        Recovery of sensory and motor function after nerve repair. A rationale for evaluation.
        J Hand Ther. 1996; 9: 315-327
        • Moberg E.
        Two-point discrimination test: a valuable part of hand surgical rehabilitation, e.g. in tetraplegia.
        Scand J Rehabil Med. 1990; 22: 127-134
        • Bara-Jimenez W.
        • Shelton P.
        • Hallett M.
        Spatial discrimination is abnormal in focal hand dystonia.
        Neurology. 2000; 55: 1869-1873
        • Medical Research Council
        • Nerve injuries committee
        Results of nerve suture.
        in: Seddon H.J. Peripheral nerve injuries. Her Majesty's Stationary Office, London1954
        • Wiberg M.
        • Hazari A.
        • Ljungberg C.
        • et al.
        Sensory recovery after hand replantation: a clinical, morphological and neurophysiological study in humans.
        Scand J Plast Reconstr Surg Hand Surg. 2003; 37: 163-173
        • Stålberg E.
        • Falck B.
        • Gilai A.
        • et al.
        Standards for quantification of EMG and neurography. The International Federation of Clinical Neurophysiology.
        Electroencephalogr Clin Neurophysiol Suppl. 1999; 52: 213-220
        • Hilz M.J.
        • Stemper B.
        • Axelrod F.B.
        • et al.
        Quantitative thermal perception testing in adults.
        J Clin Neurophysiol. 1999; 16: 462-471
        • Yarnitsky D.
        Quantitative sensory testing.
        Muscle Nerve. 1997; 20: 198-204
        • Yarnitsky D.
        • Sprecher E.
        Thermal testing: normative data and repeatability for various test algorithms.
        J Neurol Sci. 1994; 125: 39-45
      1. Somedic Sales AB.
        • Semmes J.
        • Weinstein S.
        • Gent L.
        • et al.
        Somatosensory changes after penetrating brain wounds in man.
        Harvard University Press, Cambridge1960
        • von Frey M.
        Zur Physiologie der Juckempfindung.
        Arch Neerland Physiol (La Haye). 1922; 7: 142-145
        • Brandsma J.W.
        • Schreuders J.A.
        • Birke J.A.
        • et al.
        Manual muscle testing. Intra- and interobserver reliability of the intrinsic muscles of the hand.
        J Hand Ther. 1995; 8: 185-190
        • SooHoo N.F.
        • McDonald A.P.
        • Seiler J.G.
        • et al.
        Evaluation of the construct validity of the DASH questionnaire by correlation to the SF-36.
        J Hand Surg [Am]. 2002; 27: 537-541
        • Beaton D.E.
        • Katz J.N.
        • Fossel A.H.
        • et al.
        Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of arm, shoulder and hand outcome measure in different regions of the upper extremity.
        J Hand Ther. 2001; 14: 128-146
        • McConnell S.
        • Beaton D.E.
        • Bombardier C.
        The DASH outcome measure: a user's manual.
        Institute for Work & Health, Toronto, Ontario1999
      2. The DASH outcome score, the disabilities of arm, shoulder& hand.
        • Fisher A.G.
        Assessment of motor and process skills.
        4th ed. Development, standardization, and administrative manual. vol. 1. Three Star Press, Fort Collins, CO2001
        • Fisher A.G.
        Assessment of motor and process skills.
        4th ed. User manual. vol. 2. Three Star Press, Fort Collins, CO2001
        • Bernspång B.
        • Fisher A.G.
        Validation of the assessment of motor and process skills for use in Sweden.
        Scand J Occup Ther. 1995; 2: 3-9
      3. The AMPS (Assessment of Motor and Process Skills).
        (international website)
        • Sollerman C.
        • Ejeskar A.
        Sollerman hand function test: a standardised method and its use in tetraplegic patients.
        Scand J Plast Reconstr Surg Hand Surg. 1995; 29: 167-176
        • Ohki Y.
        • Johansson R.S.
        Sensorimotor interactions between pairs of fingers in bimanual and unimanual manipulative tasks.
        Exp Brain Res. 1999 Jul; 127: 43-53
        • Jenmalm P.
        • Johansson R.S.
        Visual and somatosensory information about object shape control manipulative fingertip forces.
        J Neurosci. 1997; 17: 4486-4499
        • Johansson R.S.
        Sensory input and control of grip.
        Sensory guidance of movement. Novartis foundation symposium. Wiley, Chichester1998 (p. 45–59. [218])
        • Johansson R.S.
        • Cole K.J.
        Sensory-motor coordination during grasping and manipulative actions.
        Curr Opin Neurobiol. 1992; 2: 815-823
        • Johansson R.S.
        • Westling G.
        Roles of glabrous skin receptors and sensorimotor memory in automatic control of precision grip when lifting rougher or more slippery objects.
        Exp Brain Res. 1984; 56: 550-564
        • Ehrsson H.H.
        • Fagergren A.
        • Jonsson T.
        • et al.
        Cortical activity in precision- versus power-grip tasks: an fMRI study.
        J Neurophysiol. 2000; 83: 528-536
        • Lemon R.N.
        • Johansson R.S.
        • Westling G.
        Corticospinal control during reach, grasp, and precision lift in man.
        J Neurosci. 1995; 15: 6145-6156
        • Johnson K.
        • Van Bowen R.
        • Hsiao S.
        The perception of two points is not the spatial resolution threshold.
        in: Boivie J. Hansson P. Lindblom U. Touch, temperature and pain in health and disease: mechanisms and assessments, progress in pain research and management. vol. 2. IASP Press, Seattle1994: 389-404
        • Rozental T.D.
        • Beredjiklian P.K.
        • Guyette T.M.
        • et al.
        Intra- and interobserver reliability of sensibility testing in asymptomatic individuals.
        Ann Plast Surg. 2000; 44: 605-609
        • Lundborg G.
        • Rosén B.
        The two-point discrimination test – time for a re-appraisal?.
        J Hand Surg [Br]. 2004; 29: 418-422
        • Novak C.B.
        • Kelly L.
        • Mackinnon S.E.
        Sensory recovery after median nerve grafting.
        J Hand Surg [Am]. 1992; 17: 59-68
        • Chard G.
        An investigation into the use of the assessment of motor and process skills (AMPS) in clinical practice.
        Br J Occup Ther. 2000; 63: 481-488
        • Meek M.F.
        • Coert J.H.
        Clinical use of nerve conduits in peripheral nerve repair. Review of the literature.
        J Reconstr Microsurg. 2002; 18: 97-109
        • Aagaard B.D.
        • Lazar D.A.
        • Lankerovich L.
        • et al.
        High-resolution magnetic resonance imaging is a non-invasive method of observing injury and recovery in the peripheral nervous system.
        Neurosurgery. 2003; 53: 199-204
        • Aagaard B.D.L.
        • Maravilla K.R.
        • Kliot M.
        Magnetic resonance neurography. Magnetic resonance imaging of peripheral nerves.
        Neuroimaging Clin N Am. 2001; 11: 131-146
        • Barberie J.E.
        • Connell D.G.
        • Munk P.L.
        • et al.
        Ulnar nerve injuries of the hand producing intrinsic muscle denervation on magnetic resonance imaging.
        Australas Radiol. 1999; 43: 355-357
        • West G.A.
        • Haynor D.R.
        • Goodkin R.
        • et al.
        Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury.
        Neurosurgery. 1994; 35: 1077-1086
        • Esposito M.
        • Hirsch J.M.
        • Lekholm U.
        • et al.
        Biological factors contributing to failures of osseointegrated oral implants (I). Success criteria and epidemiology.
        Eur J Oral Sci. 1998; 106: 527-551
        • Roos J.
        • Sennerby L.
        • Lekholm U.
        • et al.
        A qualitative and quantitative method for evaluating implant success: a 5-year retrospective analysis of the Brånemark implant.
        Int J Oral Maxillofac Implants. 1997; 12: 504-514
        • Faulkner A.
        • Kennedy L.G.
        • Baxter K.
        • et al.
        Effectiveness of hip prostheses in primary total hip replacement: a critical review of evidence and an economic model.
        Health Technol Assess. 1998; 2: 1-133
        • Urokinase Pulmonary Embolism Trial Study Group
        Urokinase pulmonary embolism trial. Phase 1 results: a cooperative study.
        JAMA. 1970; 214: 2163-2172