P A R T I I
NERVE INJURIES AND
COMPRESSION
In Memoriam
JUDITH BELL-KROTOSKI, MA, OTR, FAOTA, CHT
MARCH 30, 1945 – OCTOBER 20, 2013
Through her research, teaching, and clinical applica-
tion of sensibility testing concepts, Judith Bell-Krotoski
made an indelible and lasting contribution to current
understanding and subsequent documentation of pe-
ripheral nerve function. Her interest in sensibility test-
ing escalated when, working at the Hand Center* in
Philadelphia, PA, she recognized the potential of the
Semmes-Weinstein monofilaments to delineate clinical
changes in sensory nerves.
A few years later, when she returned to Carville,
LA, in 1978, to work with Paul Brand, MB, BS, FRCS,
at the National Hansen’s Disease Center (GWLHDC),
Judy took the concept of the monofilaments with her;
a step that would forever influence the trajectory of
her career. Working with Dr. Brand’s team of elite
bioengineers, Judy delved into the instrumentation
properties of hand-held sensibility testing devices in-
cluding 2-point discrimination (2-PD), tuning forks,
and the Semmes-Weinstein monofilaments. Spanning
a thirty-six year period that culminated in multiple
seminal research papers, Judy, her bioengineer re-
search team, and her research colleagues described
the following pivotal concepts regarding peripheral
nerve testing:
(1) “Spectral analysis of the force frequency signal produced
by hand held sensibility measurement instruments shows
they all produce both high and low frequency signals
*Established by James Hunter, MD, Lawrence Schneider, MD, and Evelyn Mackin, PT
†
Some Semmes-Weinstein mini kits include a total of six filaments with the addition of the “10-gram” filament.
37
s­ufficient in strength to stimulate both slowly adapting
and quickly adapting end organs, and are not capable of
stimulating one particular group.”1,2
(2) “If their lengths and diameters are correct, the filaments
produce application forces that are repeatable within a pre-
dictable range”.3,4
(3) “Only the Semmes-Weinstein monofilaments provide some
control of force during application and can be considered
force controlled if calibrated and applied correctly.”1,2
(4) “The 2.83 filament was a good predictor of normal … for
the hand, the arm, and the leg, as was expected. It was su-
prathreshold for the face, making use of a lighter filament
possible for facial testing, and subthreshold for the plan-
tar surface of the foot, which required a slightly heavier
filament (3.61 marking number, mean force, 279 mg) for
normal threshold detection.”4
(5) “The mini-kit is sufficient for most purposes and re-
quires greatly reduced time for the test, making patient
testing more advantageous. The mini-kit employs five†
specially selected forces of the 20 available in the full
set.”5
(6) Mapping using color coded “filaments that apply force
greater than that of the 2.83 filament may be used to quan-
tify degrees of abnormality.”6
(7) During the manufacturing process, it is crucial that ex-
truded filament material be released and stored on a flat,
level surface; as opposed to being wound onto spools.
38 PART II  NERVE INJURIES AND COMPRESSION
Winding filament onto spools damages the inherent col-
umn mechanics of extruded filament, rendering it weaker,
less durable, and defective for use in sensibility testing
instruments.7
In 2000, the nonpareil clinical efficacy of the monofil-
aments was further underscored when Judy noticed that
the sensibility status of some of her Hansen’s Disease
(HD) patients continued to deteriorate despite the so-
phisticated pharmacologic interventions they were re-
ceiving. Judy’s tenacity and persistence in alerting other
personnel to her patients’ worsening neurologic changes
impelled a referring physician to biopsy the peripheral
nerves of the involved patients. Much to everyone’s sur-
prise (except Judy’s), live mycobacterium leprae bacilli
were found in the biopsied nerves. The monofilaments
were the only hand-held instruments to identify the
moderate, but highly significant, decline in patient nerve
status. Subsequently, world-wide alerts were issued de-
scribing the problem; and additional pharmacologic man-
agement was initiated for the specific HD subpopulation
that was nonresponsive to the original drug medications.
FIGURE 1  Hand surgeon pioneer, Erik Moberg, and Judy Bell-Krotoski share
thoughts about sensibility testing during the Hand Foundation/Thomas Jefferson
University sponsored 1984 symposium, The Hand: Another Decade of Tendon
Surgery, faculty dinner at the Old Original Bookbinder’s, Philadelphia, PA.
“Dr. Moberg’s lifelong interest was to correlate clinical sensory tests with hand
function. Tests of two-point discrimination, the Von Frey test, the ninhydrin test,
and the Moberg tactile-gnosis pickup test were used to define “what the hand can
do.” Even in his later years, he was still not satisfied with the known methods for
testing nerve recovery; he thought they were not totally reliable and reproducible.
He continued to promote continued study in evaluation of functional sensibility.”8
Moberg and Bell-Krotoski corresponded frequently regarding their shared interest
in sensibility testing. During his last visit to the GWLHDC, Dr. Moberg presented
Judy with his latest invention, a handmade, cantilevered, matchstick model that
introduced quantification of 2-PD pressure stimuli! He thoroughly understood, re-
spected, and acknowledged the inherent worth of Judy’s research in sensibility
instrumentation and testing.
While Judy’s work mistakenly is associated solely
with the Semmes-Weinstein monofilaments, the sig-
nificance of her research regarding other hand-held
sensibility testing instruments and their associated in-
strumentation properties and limitations is equally im-
portant. Shortcomings must first be identified before
appropriate solutions may be generated. Throughout
her professional career, Judy never deviated from her
primary focus of improving patient care. The above
scenario is an excellent example of how a knowledge-
able and tenacious therapist, armed with a valid and
reliable assessment instrument, can positively influ-
ence patient treatment on a global scale. The magni-
tude of Judy’s research in sensibility testing is valued
universally; not only in HD, but also because her work
serves as an ­all-­important model for sensibility testing
of peripheral neuropathies caused by etiologies other
than HD.
References
1. Bell-Krotoski JA, Buford WL Jr: The force/time relationship of clini-
cally used sensory testing instruments, J Hand Ther 1(2):76–85, 1988.
2. Bell-Krotoski JA, Buford WL Jr: The force/time relationship of clini-
cally used sensory testing instruments: revision and update, J Hand
Ther 10(4):297–309, 1997.
3. Bell-Krotoski J, Tomancik E: The repeatability of testing with
Semmes-Weinstein monofilaments, J Hand Surg Am 12(1):155–161,
1987.
4. Bell-Krotoski JA, et al: Threshold detection and Semmes-Weinstein
monofilaments, J Hand Ther 8(2):155–162, 1995.
5. Bell-Krotoski J, Weinstein S, Weinstein C: Testing sensibility, includ-
ing touch-pressure, two-point discrimination, point localization,
and vibration, J Hand Ther 6(2):114–123, 1993.
6. Bell-Krotoski J: Light touchh-deep pressure testing using Semmes-
Weinstein monofilaments. In Hunter JM, et al, editors: Rehabilitation
of the hand, St. Louis, 1989, C. V. Mosby, pp 585–593.
7. Bell Krotoski JA: Personal communication: spool winding during/af-
ter filament manufacturing extrusion process damages filament physical
properties (Fess EE, editor), 2010.
8. Howard FM: In Memoriam: Erik Moberg 1905–1993, J Hand Surg Am
18A(3):548–549, 1993.
Elaine Ewing FessMS, OTR, FAOTA, CHT
Adjunct Assistant Professor,
Indiana University,
School of Health & Rehabilitation Sciences,
Department of Occupational Therapy,
1140 West Michigan Street, Room 311A,
Indianapolis, IN 46202–5119, USA