Clinical Follow-Up


Score

Description

1

No rehabilitation at all or less than once per week

2

Rehabilitation more than once weekly, but not at a specialized centre

3

Good progress with a comprehensive rehabilitation programme, but not in a specialized centre; periodically supervised by a specialized neurorehabilitation centre

4

Patient adheres perfectly to the whole rehabilitation programme at a specialized neurorehabilitation centre



Furthermore, functional outcomes repairing different nerves in comparable circumstances are not always the same. Numerous studies have been published describing better results after the repair of the radial nerve than the median or ulnar nerves; there also is a better prognosis repairing the tibial versus peroneal nerve [11, 14].

To put treatment results in proper perspective, it is important to document these aforementioned factors. This is especially important for interpreting and evaluating the results of a specific treatment and, thereby, optimizing treatment strategies.

The degree of sensory and motor recovery is the criterion most commonly used to evaluate the results of nerve repair. Sensory recovery is not a reliable sign of regeneration, however, mainly because of its late appearance and difficulties with its objective evaluation. However, it is important after the repair of particular nerves like the median, ulnar and tibial nerve, as these provide protective sensation. It is less important as an outcome following the repair of nerves like the radial, axillary, musculocutaneous, femoral and fibular nerve.

On the other hand, although motor recovery is also late, it is a reliable sign of successful regeneration. It takes between 2 and 3 years to achieve maximum motor recovery, versus 5–7 years for maximum sensory restoration.

In general terms, the follow-up of any patient submitted to a peripheral nerve reconstructive surgery should be every 2 or 3 months. Clinical evaluation – including progression of Tinel’s sign – and serial neurophysiological studies can help determine early recoveries. The regular endpoint of follow-up is around 3 years for motor results and around five for sensory recovery. At that time, it is presumed that the maximum recovery point will be reached. Of course it is not possible to generalize these time spans for every patient: depending on the time from trauma to surgery, the distance from the injury site to the target muscles/skin, the type of reconstruction and so on, the end of follow-up variates from patient to patient.

One important concept to keep in mind when analysing the results of nerve repair is that of ‘useful recovery’, which entails the functional impact of recovery. The definition of ‘useful’ is variable and depends on the nerve involved. For example, useful sensory recovery for the tibial nerve means recovery of superficial pain and some tactile sensation (≥S2). However, for the median or ulnar nerve, it is also imperative to recover some two-point discrimination.

Similarly, useful motor recovery (≥M3) after peroneal nerve repair involves plantar dorsiflexion to 90°, since this is enough for the patient to stop using a foot brace [19].

A variety of scales and questionnaires have been developed and published to objectify these results. They may be categorized according to the function they evaluate: motor, sensory, pain or global.


8.1 Sensorimotor Evaluations


The scale most commonly used to assess sensorimotor reinnervation is the British Medical Research Council (BMRC) scale [15] (Tables 8.2 and 8.3). This scale was promoted and standardized after the Second World War in order to eliminate or reduce interobserver variability. The motor and sensory components are not integrated, actually operating as two separate scales. The widely used motor scale can be used to evaluate either bulky muscles or muscle groups or small muscles like the intrinsic muscles of the hand. On the other hand, the sensory scale has been criticized [20] as being based on subjective parameters.


Table 8.2
British Medical Research Council motor scale [12]
























M0

No contractions

M1

Visible or palpable contractions

M2

Active movement, with gravity eliminated

M3

Active movement against gravity

M4

Active movement against resistance

M5

Normal power



Table 8.3
British Medical Research Council sensory scale [12]



























S0

Absence of sensation

S1

Recovery of deep cutaneous pain sensation

S2

Recovery of superficial pain and some tactile sensation

S2+

Same as S2, with overresponse

S3

Recovery of pain and tactile sensation, with disappearance of overresponse

S3+

Same as S3, with some two-point discrimination

S4

Complete recovery

Tools exist to help us to quantify these results. The goniometer is used to evaluate active range of motion, and the dynamometer to measure muscle strength. The tested limb should always be compared with the contralateral limb (if normal).

The grip strength test (using a Jamar dynamometer) is the method most often used to communicate motor strength results.

Similarly, there are tools to quantify sensory results. The Semmes-Weinstein monofilament test can be employed to assess cutaneous pressure threshold. Compared to using a classical tuning fork, this test provides quantitative data that can be used to monitor nerve regeneration.

The two-point discrimination (2PD) test is a tool for evaluating tactile gnosis. Tactile gnosis is the hand’s ability to recognize the characteristics of different objects, like their shape and texture. It is an important marker of functional recovery. One major flaw this test has is that the results can be variable, since there is no standardization of the technique, and different examiners perform the test differently. For this reason, it is important to provide a detailed description of the protocol used, especially the pressure applied. It also is not recommended that this test be used as the sole instrument to measure sensory function.

The shape/texture identification (STI) is a test developed by Rosen and Lundborg that consist of identifying three forms and three textures, with the index finger in median nerve injuries and the little finger if the ulnar nerve is affected. In patients with injury to both nerves, the index finger is assessed.

The Sollerman hand function test consists of 20 activities that replicate the main handgrips utilized in daily life, such as taking coins from a purse or undoing buttons. Each subtest has a score depending on the quality of handgrip and the difficulty the patient has performing the task. This test reflects the integration of sensory and motor functions.


8.2 Pain Evaluation


The numerical rating scale (NRS) for pain and the pain visual analogue scale (PVAS) are often used to determine pain intensity. Both are easy to apply but have flaws. First, they treat pain as a linear and continuous phenomenon, which is not so in most cases. On the other hand, not all patients respond to these scales the same way, since the experience of pain is very variable.

The McGill Pain Questionnaire [16] is a multidimensional scale that provides information not only on the intensity of pain but on other characteristics like sensation quality (e.g. sharp, pins and needles) and the patient’s emotional response to pain. However, it is too long a questionnaire to readily integrate into daily clinical practice.

The Integrated Pain Score scale [2] (Table 8.4) allows us to record, over time, the characteristics and intensity of pain. Since it is simple and quick, it allows patients to be monitored successively before and after surgery. It separately analyses pain intensity and frequency, degree of disability, the use of analgesics, number of territories involved (proximal, middle or distal) and the effects of pain on sleep.


Table 8.4
Integrated pain score [2]

















































































Parameter

Description

PTS

Sum

Intensity (VAS)
 
0–10


Incapacity
 
0–10


Frequency of pain

Never

0

 
Rarely

1
 
 
Once a day

2
 
 
More than once a day

3
 
 
Continuous

4
 

Use of pain medication

Never

0

 
Occasionally

1
 
 
Once a day

2
 
 
More than once a day

3
 
 
All the time

4
 
 
No alleviation

1


Zones affected by pain

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Sep 23, 2017 | Posted by in NEUROLOGY | Comments Off on Clinical Follow-Up
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