Philadelpia 2014, Birgitta Rosén, OT PhD 1 Department of Hand Surgery, Malmö, Lund University, SWEDEN [email protected], www.med.lu.se/klinvetmalmo/hand_surgery “Rosen-score - Model Instrument for outcome after Nerve Repair ” – Objectivs: Understanding of basic components in assessment of hand function after PNI and practical guidance through the use of the Model Instrument for outcome after Nerve Repair ”Rosen score”. The approach to evaluation and treatment is a combination of bottom-up (foundational factors ) and top-down (role competency and meaningfulness) approach, in an evidence based perspective. In order to achieve an understanding of the patient’s limitations, disabilities and strengths, and hand function is a prerequisites for successful occupational performance. Regeneration of the repaired nerve and recovery of function can take years. Regular follow-ups using objective clinical measures as well as patient-reported outcomes are needed to establish if regeneration is occuring as expected, obtain baseline data to plan treatment, measure change and for feedback to patient, therapist and surgeon. Assessment every 1 to 2 months is recommended for the first year. Documenting the overall final outcome of nerve repair is also critical to clinical research and to evaluate the effectiveness of interventions. Clinical measures should be used which have documented evidence of validity, responsiveness and reliability. Objective clinical measures of body structure and body function should be complemented by assessments of activity and participation. In order to obtain an overall picture of outcome composite scoring methods have been proposed. For a diagnosis-specific composite impairment score we recommend the Rosen score (also known as the Model instrument for outcome of the outcome after nerve repair) which uses a battery of tests to generate a score for sensory domain, motor domain and pain/discomfort domain as well as a total score. The Rosen score is standardised and validated and is suitable for clinical as well as research purposes. A reference interval has been calculated for adults with median and ulnar nerve repair at wrist level and is useful as feedback to patients during their sensory-motor relearning programme. For overall assessment of the impact of the nerve injury on activity and participation an upper-limb specific patient-rated questionaire is recommended such as the Disabilities of the Arm, Shoulder and Hand (DASH) or Michigan Hand Questionnaire (MHQ). Big problems from cold sensitivity may call for use of a specific instrument to reflect that in detail with e.g. CISS (cold sensitivity severity scale) Overview and Conceptual basis for Rosen-score (Model Instrument for Outcome after Nerve Repair) A composite rating scale should be patient centered, and reflect activity limitations as well as impairment of body structures. The composite rating reflecting activity limitations is of importance to gain an overview of the outcome. However, to optimize planning of interventions it should also include detailed information of specific functional limitations. Clinical measures are needed for several purposes following nerve repair; to establish that regeneration occurs as expected, to obtain baseline data for planning interventions, for feedback to patient, therapist and surgeon, for final evaluation of outcome, and for clinical research. The ability of a measure to detect changes over time is critical. Optimally, evaluation over time includes outcome measures to set goals and then determine whether detectable clinically important changes have occurred. Philadelpia 2014, Birgitta Rosén, OT PhD 2 Department of Hand Surgery, Malmö, Lund University, SWEDEN [email protected], www.med.lu.se/klinvetmalmo/hand_surgery It is essential that the outcome measures are both reliable and valid, and therapists should perform outcome evaluation using evidence based standardized test instruments. For a diagnose-specific measure of outcome after nerve repair a test battery should include measures of sensory and motor function and pain/discomfort problems to address the specific condition, and be applicable to both median and ulnar nerve injuries. A hierarchy for testing hand function after a perpheral nerve injury modified from Fess (1994) and Jerosch-Herold (2005) Functional use in daily activities Identification of shape/texture/ objects Manipulation of objects Increasing level of cognitive activity Localisation, Discrimination of touch Grip strength Touch thesholds (innervation) Musclefunction/muscle strength The integrity of peripheral nervous components and their cortical projections Birgitta Rosén, Lund University 2010 Over the years we have been presented with a variety of outcome instruments to use after nerve repair. Protocol and manual for use of Rosen-score can be found on: www.med.lu.se/klinvetmalmo/hand_surgery/projects/clinical_projects/assessment_of_hand_s ensibility (see example in attached pdf) The Model Instrument for Outcome after Nerve Repair referred to as the ”Rosen-score” was introduced 2000. It is based on the conceptual basis described in the introduction above. It assesses and illustrates specific functional limitations regarding sensory and motor function and pain/discomfort. It gives a summarized outcome over time, and predicts development of the outcome. The Rosen-score has data confirming validity and reliability and includes a protocol with a numerical scoring system. “Rosen-score” is a model for routine clinical documentation and quantification of the functional outcome after nerve repair at wrist or distal forearm level. The three domains addressed include sensory, motor, and pain/discomfort. The scale provides a way of scoring impairment in motor or sensory function of the median and ulnar nerves, as well as cold sensitivity and hyperesthesia/allodynia. A” total score” is calculated based on the results from the three domains. All subtests are scored as a percent of normal and a total score is computed by adding the summative scores across each of the three domains. Equipment, Forms and Description of test procedure Equipment and Forms Philadelpia 2014, Birgitta Rosén, OT PhD 3 Department of Hand Surgery, Malmö, Lund University, SWEDEN [email protected], www.med.lu.se/klinvetmalmo/hand_surgery - Raw-data sheet (can vary in lay-out, one example can be found on: http://www.med.lu.se/klinvetmalmo/hand_surgery/clinical_projects/assessment_of_hand_sensibility - Protocol for ”Rosen-score” http://www.med.lu.se/klinvetmalmo/hand_surgery/clinical_projects/assessment_of_hand_sensibility - Semmes-Weinstein monofilament or equivalent e.g. WEST - DiskCriminator - Shape-Texture Identification test (STI-test ) http://www.ossur.se/ - Three selected test items of Sollerman griptest - #4, #8 and #10 http://www.procare.dk/ - Jamar dynamometer (in second position) TM TM Subtests Sensory domain - Sensory innervation (touch/pressure thresholds) is measured using Semmes Weinstein Monofilaments (SWM). For the median nerve, the tip of Digit 1 and 2 and base of Digit 2 are tested; for the ulnar nerve, the tip and base of Digit5 and the proximal hypothenar eminence in line with Digit 5 are tested. - Tactile gnosis is tested using both classic static 2PD ). and the shape texture identification test (STI). - Dexterity is tested using three tasks selected from Sollerman griptest task # 4 Pick up coins, # 8 Put nuts on bolts , # 10 Do up buttons). Motor domain - Motor innervation is tested using manual muscle testing (MMT) ). - Grip strength is tested in second position with Jamar dynamometer. Pain/Discomfort domain Cold sensitivity and hyperesthesia/allodynia are quantified by the patient using a four-point self-report scale answering the following two questions: “Which of the following expressions does best describe your perceived problems at touch of the hand?” “Which of the following expressions does best describe your perceived problems when you are exposed to cold?” -none/minor (3), -moderate (2), -disturbing (1), -hinders function (0) Scoring - The obtained test-result for each test instrument (in all 8 tests) is divided by normal value. The ratio is written in the area for Score in the protocol. Maximum score for each subtest is1.00 (two decimals) - Since the three domains (sensory/motor/pain-discomfort) not contain identical number of subtests, the mean score (ratio) i calculated for each domain (Figure 1). Maximum score for each domain is 1.00 (two decimals). - The mean score for the three domains are summarized to a ”Total score”, that can be maximum 3.0 (one decimal). The Total score is inserted in the graph (see Figure 1) showing the estimated predicted values for “total score in the shaded area (95% individual prediction interval). The normal result for each subtest is given in the ”Instrument and quantification” column (seee attachment). For grip strength result from uninjured hand is regarded as ”normal”. Philadelpia 2014, Birgitta Rosén, OT PhD 4 Department of Hand Surgery, Malmö, Lund University, SWEDEN [email protected], www.med.lu.se/klinvetmalmo/hand_surgery Construct being measured Rosen-score (Model Instrument for Outcome after Nerve Repair) The scale provides a way of scoring impairment on ”body function level” according to the WHO international classification for functioning (ICF)1. Motor or sensory function of the median or ulnar nerves are monitored, as well as components attributed to cold sensitivity and hyperesthesia/allodynia. IASP 2011, http://www.iasp-pain.org The ”total score” has proved to correlate with DASH (disability of the shoulder and hand) patient´s own opinion about how much the injury affects ADL i.e. ”activity” in ICF-terms[. Body functions such as detection of touch and muscle function should initially be assessed to examine the integrity of the afferent and efferent fiber populations. If detection of touch is present the next level is to examine is if the patient can discriminate the touch. This is an interpretation of the new sensory input in the brain e.g. to discriminate between one or two pressure points—tactile gnosis—which requires physiological processes in the peripheral as well as in the central nervous system. Identification of touch based on active touching such as identification of different shapes, textures or objects, is the third level – a more refined tactile gnosis - that also should be assessed. Functional sensibility –haptics - is the end-point where tactile gnosis acts “in concert with muscles and joints” for a useful grip function. 5 Skills requiring this integrated and interacting sensory and motor function are ultimately expressed in activity i.e. the capacity to carry out activities, but also in body functions such as dexterity, and grip strength . Cold intolerance (pain, aching, stiffness, weakness, numbness, swelling, skin colour change), and hyperaesthesia/allodynia (Increased sensitivity to stimulation/Pain due to a stimulus that does not normally provoke pain, are frequently seen after nerve repair hindering activities of daily living (ADL) and should be examined as well. Evaluation over time The ability to detect changes over time is important in all serial measurements, and based on the results obtained from a scientific and an empirical standpoint, the test battery design was evaluated from that perspective. A group of patients was followed during four years and the analyses showed good responsiveness in four of the instruments used—Semmes-Weinstein monofilaments, manual muscle testing, selected tasks of the Sollerman grip function test, and the Jamar dynamometer. However, the results of 2PD did not show any statistically verified changes at all over the four year period. Hence, the lack of responsiveness in 2PD test despite of clinically observed changes, in combination with the frequently described problems to achieve measurable 2PD results in adult patients suffering from a nerve repair, called for other or complementary instruments. The STI-test (shape-texture identifcation test) has shown higher sensitivity to changes over time Factor analysis has confirmed the domains are distinct entities and the instrument has been shown to change over time as the patient improve.. Groups who can be tested The Rosen-score is validated for patients with peripheral nerve injury (median or ulnar nerves) in the distal forearm or at wrist level. References Philadelpia 2014, Birgitta Rosén, OT PhD 5 Department of Hand Surgery, Malmö, Lund University, SWEDEN [email protected], www.med.lu.se/klinvetmalmo/hand_surgery - World Health Organization: International Classification of Functioning, Disability and Health. Available at: http://www3.who.int/icf/icftemplate.cfm?myurl=homepage.html&mytitle=Home%20Page. Accessed March 1, 2005. - MacDermid J (2011) Outcome measurement in upper extremity practice. In: Skirven O, Fedorczyk, Amadio (ed) Rehabilitation of the Hand and Upper Extremity. Elsevier, Mosby Philadelphia - Lundborg G (2004) Nerve injury and repair. Regeneration,reconstruction and cortical remodelling. Elsevier, Churchill Livingstone Philadelphia. Chapter 11. - Rosén B (1996) Recovery of sensory and motor function after nerve repair: A rationale for evaluation. J Hand Therapy 9:315-327 - MacDermid J (2005) Measurement of health outcomes following tendon and nerve repair. J Hand Ther Apr-Jun;18:297-312 - Szabo RM (2001) Outcome assessment in hand surgery: When are they meaningful. Journal of Hand Surgery 26A:993-1002 - Rosén B, Lundborg G (2000) A model instrument for the documentation of outcome after nerve repair. J Hand Surg 25A:535-544 - Rosén B, Lundborg G (2001) The long-term recovery curve in adults after median or ulnar nerve repair : A reference interval. J Hand Surg 26B:196-200 - Brandsma JW, Schreuders JA, Birke JA, Piefer A, Oostendorp RAB (1995) Manual muscle testing. Intra-and interobserver reliability of the intrinsic muscles of the hand. J Hand Ther 8:185-190 - Wynn-Parry CB (1986) Peripheral nerve injuries: sensation. J Bone Joint Surg 68B:15-19 - Lundborg G, Rosen B (2004) The two-point discrimination test--time for a re-appraisal? J Hand Surg 29:418-422 - Jerosch-Herold C (2005) Assessment of sensibility after nerve injury and repair: a systematic review of evidence for validity, reliability and responsiveness of tests. J Hand Surg 30:252-264 - Vordemvenne T, Langer M, Ochman S, Raschke M, Schult M (2007) Long-term results after primary microsurgical repair of ulnar and median nerve injuries. A comparison of common score systems. Clin Neurol Neurosurg 109:263-271 - Galanakos SP, Zoubos AB, Ignatiadis I, Papakostas I, Gerostathopoulos NE, Soucacos PN (2011) Repair of complete nerve lacerations at the forearm: an outcome study using Rosen-Lundborg protocol. Microsurgery 31:253-262 - Galanakos SP, Zoubos AB, Mourouzis I, Ignatiadis I, Bot AG, Soucacos PN (2012) Prognostic scoring system for peripheral nerve repair in the upper extremity. Microsurgery - Bell-Krotoski JA, Buford WL (1997) The force/time relationship of clinically used sensory testing instrument. J Hand Ther 10:297-309 - Rosen B, Lundborg G (1998) A new tactile gnosis instrument in sensibility testing. J hand Ther 11:251-257 - Sollerman C, Ejeskar A (1995) Sollerman hand function test. A standardised method and its use in tetraplegic patients. Scand J Plast Rec Surg Hand Surg 29:167-176 - Mathiowetz V, Weber K, Volland G, Kashman N (1984) Reliability and validity of grip and pinch strength evaluations. Journal of Hand Surgery 9A:222-226 - Mathiowetz V, Kashman, N., Volland, G., Weber, K., Dowe, M., Rogers, S. (1985) Grip and pinch strength: Normative data for adults. Arch Phys Med Rehabil 66:69-74 - IASP (1994) Classification of Chronic Pain. Descriptions of chronic pain syndromes and definitions of pain tesrm. IASP Press Seattle nd -ASHT. Clinical assessment recommendations. 2 edition 1992. -Ewing-Fess E:The need for reliability and validity in hand assessment instruments. Journal of Hand Surgery 1986;11A:621-623. -Jerosch-Herold C, Rosen B and Shepstone L:The reliability and validity of the locognosia test after injuriesto peripheral nerves in the hand. J. Bone Joint Surg. Br. 2006;88:1048-52. -Law M:Measurement in occupational therapy: Scientific criteria for evaluation. Canadian Journal of Occupational Therapy 1987;54:133-138. -Moberg E:Objective methods for determining the functional value of sensibility in the hand. J. Bone Joint Surg. Am. 1958;40B:454-476. -Moberg E:Criticism and study of methods for examining sensibility in the hand. Neurology 1962;12:819. -Moberg E:The unsolved problem - how to test the functional value of hand sensibility. J. Hand Ther. 1991;4:105-110. PROTOCOL FOR DOCUMENTATION OF HAND FUNCTION AFTER NERVE INJURY From: Rosén B, Lundborg G. A model instrument for the documentation of outcome after nerve repair. J Hand Surg 2000;25A:535-543 Patient example: Man 42 years old with median nerve repair at wrist Score (scoring key: result / normal) Instrument and quantification Innervation Tactile gnosis Dexterity Semmes-Weinstein Monofilament 0=not testable 1=filament 6.65 2=filament 4.56 3=filament 4.31 4=filament 3.61 5=filament 2.83 s2PD (digit II el V) 0= 16 mm 1=11-15 mm 2=6-10 mm 3 5 mm STI-test (digit II el V) Month 3 6 12 24 36 48 60 0.40 0.53 0.53 0.60 0.60 0.60 0.60 0 0 0 0 0 Result:0-15 Normal median:15 Normal unlar:15 Result:0-3 0 Normal:3 Result:0-6 0 0 0 0 0.17 0.17 0.33 0.50 0.67 0.62 0.67 0.75 0.75 0.83 0.92 0.27 0.29 0.30 0.38 0.38 0.44 0.51 0.40 0.60 0.80 0.80 1.0 1.0 1.0 0.26 0.88 1.0 1.0 1.0 1.0 1.0 0.33 0.74 0.90 0.90 1.0 1.0 1.0 0.67 0.33 0.33 0.33 0.33 0.33 0.33 0.33 0.50 0.67 0.50 0.33 0.33 0.33 0.33 0.50 0.50 0.67 0.67 0.67 0.67 1.1 1.5 1.6 1.7 1.9 2.1 2.2 Normal:6 Result:0-12 Sollerman test (task 4,8,10) Normal:12 Mean sensory domain: Motor Innervation Grip strength Manual muscle test 0-5 Median:palmarabd Result medians:0-5 Ulnar: abd dig II, V Result ulnar: 0-15 add dig V Normal median:5 Normal ulnar:15 Jamar dynamometer Normal: Result Mean of 3 trials in second uninjured hand position, right and left Mean motor domain: Pain/discomfort Cold intolerance Hyperestesi Patienten’s estimation of problem 0=Hinders function 1=Disturbing 2=Moderate 3=None/minor As for cold intolerance Result:0-3 Normal:3 Mean pain/discomfort domain: Total score: sensory + motor + pain/discomfort = Department of Hand Surgery, University Hospital MAS, Malmö, Sweden Domain Sensory _________________________________________________________________________________________________
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