A Numerical Grading Scale for Peripheral
Nerve Function
A. Lee Dellon, MD, FACS
Division of Plastic Surgery
and Department of
Neurological Surgery,
Johns Hopkins University School
of Medicine,
Baltimore, Maryland
Without assessment, we cannot treat, we cannot
communicate, and we cannot progress.
Elaine E. Fess, 19841
D espite the progress made by hand therapists,
neuroscientists, and surgeons in under-
standing and quantitating peripheral nerve function,
there remains little uniformity in the reporting of end
results of nerve repair, in staging chronic nerve
c?mpression, or in describing the degree of a pe-
npheral neuropathy. Despite the worldwide aware-
ness of the existence of the Highet's "British System"
of Sl-4 and Ml-5 for grading the results of nerve
repair/ and of the ability of the Semmes-Weinstein
nylon monofilaments to measure the perception of a
force applied to the skin,3.4 many therapists and sur-
ge~ns employ traditional, but poorly defined, de-
scnptors such as "poor," "fair," "good," and "ex-
cellent" to describe functional outcome. Such
descriptors f~il to permit detailed statistical analysis
of preoperatIve versus postoperative conditions, or
r~lative improvement in motor versus sensory func-
hon. Furthermore, these traditional descriptors frus-
trate any attempt to do intercenter or cooperative
end-result studies, now termed "meta-analysis." 5,6
Unfortunately, even when the British System is used,
it fails to specify the meaning of "some two-point
discrimination," as in its S3 + category. Sadly, even
when the Semmes-Weinstein mono filaments are used
their unique numerical markings are so poorly under~
stood that interpretations of their meaning and sta-
tistical analysis are frequently erroneous. 7 ,s
It should be possible to develop a numerical
Presented at the American Society for Peripheral Nerve meeting,
Houston, Texas, April 28, 1993.
Dr. Dellon has a financial interest in the Disk-Criminator and is
a co-patent holder of the Pressure-Specifying Sensory Device.
Correspondence and reprint requests to A. Lee Dellon, MD, Suite
104, 3901 Greenspring Avenue, Baltimore, MD 21211.
152 JOURNAL OF HAND THERAPY
ABSTRACT: A numerical grading scale for median and ulnar func-
~ion is outlined: This system, based upon the known pathophys-
Iology of chronic nerve compression, creates a hierarchical scale
of mutually exclusive categories for motor and sensory function.
The scale is responsive to incorporating new technologies for
sensorimotor evaluation if these should offer advantages in com-
puter-assisted evaluation, validity, or reliability. The scale is as-
sumed to be nonuniform, and nonparametric statistical analYSis,
such as use of the Wilcoxon rank-sum test, is appropriate. Where
motor function may predominate the peripheral nerve function,
such as the ulnar nerve, in contrast to the median nerve, the scale
may be uniquely defined to reflect this attribute. Pilot study ex-
amples of application of the numerical scoring system are given,
and specific areas to better define the scale through research are
suggested.
grading scale for peripheral nerve function. The in-
creasing availability of therapists trained in hand
ev~lu~~ion techniques, the increasing emphasis upon
rehablhty and validity of testing instruments and pro-
~edures, ar:d the recent proliferation of computer-
lmked deVIces to quantitate peripheral nerve func-
tion9~11 suggest. that the time for such a grading sys-
tem IS now. It IS the purpose of this article to con-
ceptualize a grading scale, making it available for
discussion, investigation, and refinement.
CRITERIA FOR A NUMERICAL
GRADING SCALE
. A peripheral nerve grading scale must distin-
gmsh between differing degrees of sensory and mo-
t?r function. A technique must be available to quan-
htat~ each degree of impairment in sensory function
and m motor function. It is recognized that the future
m~y see t~e development of new technologies that
WIll permIt more accurate, more reliable, or more
valid me~sures .of each of these degrees of impair-
ment. It IS deSIrable for the grading system to be
expressed in a numerical scale so that statistical anal-
ysis will be facilitated. While a uniform scale, that is,
one with the same "spacing" between points on the
scale, would be ideal, it is recognized that this may
not be possible either to achieve or to demonstrate.
Therefore, in my opinion, statistical analysis that does
not ~ssume ~n interval distribution, i.e., nonpara-
metnc analYSIS, must be applied instead of the usual
"t-test." The clinical tests used to localize sensori-
motor function to a point along the scale should be
sufficiently (1) valid, (2) reliable, (3) cost-effective,
and (4) available. Ideally, all numerical grades of the
scale should be mutually exclusive.
Historically, the British System2 is a prototype
of t~is scale, but the sensory and motor grades were
not mtegrated, requiring, therefore, a dual designa-
tion to describe each nerve, e.g., S3M4. Furthermore,
the numerical integers used for the scale proved to
be insufficient, requiring the addition of "+" cate-
gories into the sensory side, e.g., 52 + and 53 +.
Finally, the grades were poorly defined and usually
not able to be quantified. Other grading schemes
have been reported for specific peripheral nerve stud-
ies, such as McGowan's classification for ulnar nerve
entrapment at the elbow, described in 1950, which
lacked a sensory component. 12 The electrophysio-
logic definition of an ulnar grading scale by Eisen
and Danen 13 in 1974 is not suited to widespread clin-
ical use by the hand surgeon or therapist, and re-
quires the assumption that the electro physiologic
measurement correlates with either patient symp-
toms or hand function, which, in my experience, it
does not. 14 The classification of Dellon in 1983 of
degrees of chronic nerve compression was applied
to the carpal tunnel syndrome and cubital tunnel
syndrome. 1s The grades of compression, which were
termed "early," "moderate," and "severe," are clin-
ically relevant, and correlated with measurements,
such as vibratory perception with the tuning fork,
vibratory threshold with a vibrometer, and two-point
discrimination, that could be obtained readily. This
grading scheme, however, did not permit indepen-
dent reporting of the sensory versus the motor com-
ponent of the peripheral nerve function, and also did
not lend itself easily to statistical analysis.
PATHOPHYSIOLOGIC BASIS FOR A
PERIPHERAL NERVE GRADING SCALE
Investigation of the pathophysiology of chronic
nerve compression has demonstrated that the earliest
changes are related to disruption of the blood-nerve
barrier, causing endoneurial and subperineurial
edema. This isJollowed by progressive demyelina-
tion, and finally by degeneration of nerve fi-
bers. 16 - 18 Electrophysiologic changes, such as delay
in conduction, do not occur until there is thinning
of the myelin, with decrease in amplitude not oc-
curring until there is axonal loss.19
Threshold change for a "motor" nerve, recog-
nizing that every so-called motor nerve contains af-
ferents from the muscle spindles and Golgi tendon
organs,20 would be equivalent to weakness of the
muscle, and innervation density change would be
equivalent to loss ofaxons with subsequent atrophy
of the muscle. Threshold change for a sensory nerve
would be an increased stimulus required for the slowly
adapting fiber/receptor system or for the quickly
adapting fiber/receptor system, i.e., constant touch-
pressure and moving touch-vibration. 21 Innervation
density change for the same sensory nerve subpopu-
lations is hypothesized to be an abnormal static or
moving two-point discrimination. 22
While the terms that I have used previously,
"early, moderate, and severe," for degrees of nerve
compression lS represent the gradient of the above
pathophysiologic changes of chronic nerve compres-
sion, it may be better to structure the proposed grad-
ing scale according to the classical clinical observa-
tions that the patient's symptoms precede the
TABLE 1. Pathophysiologic Basis for Peripheral Nerve
Grading
Degree of
Severity Pathophysiologic Clinical
Mild Blood - nerve barrier Symptoms, no signs
breakdown
Moderate Demyelination Symptoms plus thresh-
old signs
Severe Axonal loss Symptoms plus inner-
vation density signs
appearance of clinical signs: symptoms without clin-
ical signs, progressing to symptoms associated with
clinical signs of threshold change, and, finally, symp-
toms associated with clinical signs of innervation
density change (Table 1).
CLINICAL ASSESSMENT TECHNIQUES
THAT CAN SUPPORT A GRADING SCALE
Fess has stressed the desirability during clinical
assessment of employing standardized tests, i.e., tests
that ideally have been proven to be both valid and
reliable, are well-described in terms of equipment
specifications and methods of use, and have nor-
mative data available. l From a practical point of view,
Fess notes that "unfortunately only a small number
of tests meet all requirements of standardization. The
remaining hand assessment instruments fall at vary-
ing levels along the validity and reliability con tin-
uums ... instrument selection should be predicated
on satisfying as many of the standardization requi-
sites as possible, thus ensuring an identifiable level
of quality control." 1
Clinical assessment that is available today for the
motor system threshold includes manual muscle
testing23 and, for specific muscles, such as those that
are median- and/or ulnar-innervated, quantitative
measurements such as pinch and grip strength. 24-26
For the motor system innervation density assess-
ment, there is just the description of the degree of
muscle atrophy. Clinical assessment that is available
today for the sensory system threshold includes qual-
itative descriptors of constant- and moving-touch and
vibratory perception,27.28 quantitative measurement
of the slowly adapting fiber/receptor system, the cu-
taneous pressure threshold with either the 5emmes-
Weinstein nylon monofilaments3A·29.30 or the Pres-
sure-Specifying Sensory Device,lO* or quantitative
measurement of the quickly adapting fiber/receptor
system, the cutaneous vibratory threshold with a vi-
brometer. IS.31* For the sensory system innervation
density assessment, there is the measurement of static
and moving two-point discrimination with the Disk-
Criminator32 - 34 or with the Pressure-Specifying Sen-
sory DevicelO (Table 2).
Clinical assessment techniques for the measure-
ment of pain or sudomotor function or the perception
*NK Biotechnical Engineering Co., P.O. Box 26335, Minneapolis.
MN 55426.
April-June 1993 153
 TABLE 2. Clinically Available Assessment Technique worst. The worst degree of function of the motor
system would be severe atrophy and the worst de-
Neuro-
physiologic gree of function for the sensory system would be
Correlate Motor Sensory anesthesia. Because it is theoretically not possible to
Threshold Manual muscle Constant-touch
have a muscle recover from severe wasting of more
testing Moving-touch than two years duration, whereas theoretically and
Tuning fork in reality it is still possible to recover some degree of
sensibility even if the finger is anesthetic, the grade
Pinch and grip Semmes-Weinstein mono- of 10 must go logically to "severe wasting" and the
strength filaments grade of 9 to "anesthesia."
Pressure-Specifying Sen-
sory Device
Because the first symptoms of peripheral nerve
Vibrometer compression are those of intermittent numbness and
tingling, or paresthesias, most likely due to the early
Innervation Atrophy Two-point discrimination' decrease in blood flow as the blood - nerve barrier
Density Static function changes, and as these symptoms usually
Moving "come and go," the grade of 1 is assigned to "inter-
'Obtained with either the Disk-Criminator or the Pressure- mittent paresthesia." Complaints of weakness, in my
Specifying Sensory Device. experience, almost always occur after the sensory
symptoms, and are almost always accompanied by
TABLE '3. Outline for a Numerical Grading Scale for a objective changes in the muscle strength. Therefore,
Peripheral Nerve a motor category of symptoms without signs is not
necessary.
Numerical The numerical scale for symptoms with signs of
Clinical Observation Grade
threshold changes can be given the grades of 2, 3,
Normal o and 4, assigning them with more sensory or more
Symptoms, no signs 1 motor components depending upon the function of
Symptoms plus signs of abnormal threshold 2,3,4
Persistent symptoms 5 the individual peripheral nerve. For example, the
Symptoms plus signs of abnormal innervation median nerve at the wrist level might have 2 and 4
density assigned to sensory, whereas the ulnar nerve at the
Mild 6,7 elbow might have 2 and 4 assigned to motor.
Severe 8,9, 10 A symptom category that was suggested by the
clinical observations of Curtis and Eversmann36 is
TABLE 4. Numerical Grading Scale for a Peripheral Nerve "persistent sensory discomfort." They observed that
patients with chronic nerve compression progressed
Grade Description through a stage in which they perceived numbness
o Normal or paresthesias constantly in their digits, and that
1 Paresthesias, intermittent this occurred before two-point discrimination became
2 Abnormal sensory threshold, mild abnormal. This observation has proven true in my
3 Abnormal motor threshold clinical experience. It may be the pathophysiologic
4 Abnormal sensory threshold, moderate correlate of intraneural fibrosis, which has been ob-
5 Paresthesias, persistent
6 Abnormal two-point discrimination, mild served in the experimental and human models of
7 Atrophy, mild chronic nerve compression. 37 Therefore, for this pro-
8 Abnormal two-point discrimination, severe posed grading system, persistent paresthesias would
9 Anesthesia be assigned a value of 5.
10 Atrophy, severe The numerical scale for the category of symp-
toms with clinical signs of innervation density would
include the grades of 6-10, with 9 and 10 having
of temperature have not been included in this anal- already been assigned, as described above. The num-
ysis. While assessment of these unmyelinated and bers 6, 7, and 8 would be for either motor or sensory
small-diameter myelinated fibers may be of interest descriptions involving abnormal two-point discrimi-
in the diagnosis of certain spinal cord lesions and nation or mild wasting depending upon the given
peripheral neuropathies, and while some of these
individual peripheral nerve's function.
nerve fibers may be assessed by automated sys-
A proposed numerical grading scale for the me-
tems/· l l they have not been found clinically useful
in quantitating hand function or predicting recovery dian nerve at the wrist is given in Table 5, and one
of hand function after nerve repair or decompres- for the ulnar nerve at the elbow is given in Table 6.
sion. 21 •35
PILOT STUDIES WITH THE NUMERICAL
THE PROPOSED GRADING SCALE GRADING SYSTEM
The general format of a numerical grading sys- Results of Treatment for Recurrent Carpal
tem is given in Table 3, and expanded in Table 4, on Tunnel Syndrome
the basis of the following considerations:
The grading scale proposed would begin with a
value of 0 being given for normal nerve function, The numerical grading in Table 5 was evaluated
both sensory and motor, and 10 being given for the in a series of 30 patients who had recurrent carpal
154 JOURNAL OF HAND THERAPY
TABLE 5. Numerical Grading S~ale for the Median Nerve at
the Wrist
Numerical Score
Sensory Motor Description of Impairment
o o None
Paresthesia, intermittent
2 Abnormal threshold: pressure, W fila-
ment 3.22-3.61 fLg; vibration, biothe-
siometer 3-10 fLg
3 Weakness, thenar muscles
Abnormal threshold: pressure, Semmes-
4
Weinstein filament marking
3.84-4.31, Pressure-Specifying Sensory
Device> 1.0 g/mm2; vibration,
biothesiometer 11- 20 fLg
5 Paresthesia, persistent
6 Abnormal 2PD* - index finger: s2PD 7-
lO mm; m2PD 4-6 mm
7 Muscle wasting (1-2/4)
8 Abnormal 2PD-index finger: s2PD
11 mm; m2PD 2: 7 mm
tunnel syndrome, whose symptoms would be suf-
ficiently severe and whose outcomes would be suf-
ficiently variable to permit application of the full range
of the scale. The patients' sensorimotor evaluations
before and after surgery were graded according to
the numerical scale in Table 5. 38 The surgery con-
sisted of a new approach to the carpal tunnel and an
internal neurolysis of the median nerve as indicated
by the intraoperative findings. The mean length of
follow-up was 23.5 months. Utilizing each patient's
worst preoperative score, i.e, the highest value for
either motor or sensory, and comparing it with the
patient's worst postoperative score, i.e., the highest
value for either motor or sensory, the grading scale
demonstrated that there was a statistically significant
improvement resulting from the surgery (6.7 preop
versus 1.8 postop, p < 0.001). The numerical grading
scale permitted subgrouping of the entire population
into those with different degrees of severity so that
statistical analysis could be applied to determine
TABLE 7. Application of Numerical Grading Scale: Results of
Surgical Management of Recurrent Carpal Tunnel Syndrome3s
2: Preoperative Postoperative
Patient Group Grade Grade p Value

9 Anesthesia Entire group (2-10) 6.5 ± 2.2 1.8 ± 3.0 <0.001

Abnormal threshold
(2,3,4) 2.0 ± 0.0 0.0 ± O.O*t 0.014
lO Muscle wasting (3-414)
Abnormal innerva-
*2PD = two-point discrimination. tion density (5, 6,
7) 6.4 ± 0.9 1.6 ± 2.4*t <0.001
Abnormal innerva-
tion density (8, 9,
TABLE 6. Numerical Grading Scale for the Ulnar Nerve at 10) 8.5 ± .07 3.0 ± 4.1t:j: 0.003
the Elbow Motor (7, 10) 7.2 ± 0.8 2.3 ± 3.5 <0.001
Sensory (5, 6, 8, 9) 7.3 ± 1.6 2.0 ± 3.0§ 0.003
Numerical Score
*p = 0.034.
Sensory Motor Description of Impairment tp = 0.059.
o o None :j:p = 0.288.
§p = 0.95.
Paresthesia, intermittent

2 Weakness-pinch/grip: female, lO-l41 TABLE 8. Application of Numerical Grading Scale: Results of

26-39Ib; 13-19/31-59 lb Surgical Management of Recurrent Ulnar Nerve Entrapment at
the Elbow39
3 Abnormal threshold: pressure, Semmes-
Weinstein filament marking Preoperative Postoperative
3.22-3.61, Pressure-Specifying Sensory Patient Group Grade Grade p Value
Device> 1.0 g/mm2; vibration, bio-
Entire group (2-10) 7.1 ± 2.2 2.9 ± 3.7 <0.001
thesiometer 3-10 fLg
Motor (2, 4, 7, 10) 4.7 ± 3.3 2.0 ± 2.8* <0.001
Sensory (3, 5, 6,
4 Weakness-pinch/grip: female, 6-9/15- 8,9) 6.3 ± 1.8 2.6 ± 3.6* <0.001
25 lb; male, 6-12115-30 lb
Abnormal innerva-
5 Paresthesia, persistent tion density (5, 6,
7)
6 Abnormal 21PD*-5th finger: s2PD 7- Motor (7) 7.0 ± O.Ot 2.2 ± 2.6:j: 0.038
lO mm; m2PD 4-6 mm Sensory (5, 6) 5.7 ± 0.5§ 0.9 ± 2.1* <0.001

7 Muscle wasting (1-214) Abnormal innerva-

tion density (8, 9,
8 Abnormal 2PD-5th finger: s2PD 2: 11 lO)
mm; m2PD 2: 7 mm Motor (10) 10.0 ± O.Ot 4.4 ± 4.2:j: 0.017
Sensory (8, 9) 8.2 ± 0.4§ 5.2 ± 3.8* 0.016
9 Anesthesia
*p = 0.465.
10 Muscle wasting (3-414) tp = <0.001.
:j:p = 0.007.
*2PD = two-point discrimination. §p = 0.014.

April-June 1993 155

 A 100
Vl
I-
~w 90
0
Z >- 0 80
z
;:: '"
w w
<:> L - - - - " - L_ _ _ _ SCORE 1 0
< 0.. 70
"- '":::> III
W
.... V) L - - - - - - - , L - -_ _ _ _ _ SCORE 2.3 and 4
a: 60
0 <:> LL 50
w
z 0
50
~
<:> w
< :r
I-
Z I-
0
" - -_ _ _ _ _ SCORE 5,6 and 7 "~
W
25 w
~ z (.)
...
w a:
w
0..

2 3 4 5 6 7 8 9
20 40 60 80 100 NUMERICAL SCORE
TIME AFTER DIAGNOSIS
(MONTHS) B ~
100
z 90
FIGURE 1. Life-table analysis of the results of nonoperative w
0 80
management of the cubital tunnel syndrome. For statistical z
0
purposes, a successful outcome of the nonoperative manage- 0.. 70
III
ment was not having an operation. Frocn the graph, 89% of W 60
a: anes.
thresh;
patients with symptoms only (score 1), 67% of patients with LL
severe
0
symptoms and abnormal sensorimotor thresholds (scores 2, 3, w
and 4), and 38% of patients with symptoms and abnormal
sensorimotor innervation density (scores 5, 6, and 7) did not "~
have surgery. These differences were significant at the p < w
(.)
0.001 level. From: Dellon AL, Hament W, Gittelshon A: Non- a:
w
0..
operative management of the cubital tunnel syndrome: An
eight year prospective study. Neurology, in press, 1993. 4 5 6 7
NUMERICAL SCORE

whether the results of treatment diminished with
increasing degree of preoperative severity or whether
it was relatively easier to achieve better results for
sensory or for motor impairment. Table 7 contains
these comparisons, with the mean ± standard de-
viation instead of the median value being listed. Be-
cause nonlinearity of the scale was assumed, all sta-
tistical comparisons were done with the nonparametric
Wilcoxon rank-sum test.
Results of Treatment for Recurrent Cubital
Tunnel Syndrome
The numerical grading scale in Table 6 was eval-
uated in a series of 40 patients who had recurrent
cubital tunnel syndrome, whose symptoms would be
sufficiently severe and whose outcomes would be
sufficiently variable to permit application of the full
range of the scale. The patients' sensorimotor eval-
uations before and after surgery were graded ac-
cording to the numerical scale in Table 6. 39 The sur-
gery consisted of a submuscular transposition of the
ulnar nerve by a musculofascial lengthening tech-
nique, and an internal neurolysis of the ulnar nerve,
as indicated by the intraoperative findings. The mean
length of follow-up was 38 months. Utilizing each
patient's worst preoperative score, i.e., the highest
value for either motor or sensory, and comparing it
with the patient's worst postoperative score, i.e., the
highest value for either motor or sensory, the grading
scale demonstrated that there was a statistically sig-
nificant improvement resulting from the surgery (7.1
preop versus 2.0 postop, p < 0.001). The numerical
grading scale permitted subgrouping of the entire
156 JOURNAL OF HAND THERAPY
FIGURE 2. Twenty experts ranked the elements of the grad-
ing scale for the median nerve at the wrist (see Table 5). The
distribution of their responses for each of the grades from 0 to
10 are viewed in relationship to the rank order of Table 5. (A)
If all respondents agreed exactly with the grading scale's se-
quence, there would be a series of sharply defined peaks in
the numerical sequence 0 through 10. Note the excellent agree-
ment on the ordering of the categories 0, I, 9, and 10. (8)
Focusing upon just the sensory categories, it is clear that most
respondents ranked mild threshold (thresh) abnormalities be-
fore severe, e.g., 2 before 4, and the same for abnormal two-
point discrimination (2PD), e.g., 6 before 8. However, the re-
lationship between the development of abnormal two-point
discrimination and the degree of threshold abnormality was
uncertain, e.g., 6 preceded 4 for many respondents. Further-
more, some ranked anesthesia (anes) as occurring before a
severe loss of two-point discrimination.
population into those with different degrees of se-
verity so that statistical analysis could be applied to
determine whether the results of treatment dimin-
ished with increasing degree of preoperative severity
or whether it was relatively easier to achieve better
results for sensory or for motor impairment. Table 8
contains these comparisons, with the mean ± stan-
dard deviation being expressed instead of the median
value. Because nonlinearity of the scale was as-
sumed, all statistical comparisons were done with
the nonparametric Wilcoxon rank-sum test.
The nonoperative management of cubital tunnel
syndrome. To determine whether this numerical
grading scale would permit sufficient specificity to
evaluate a patient group by the Kaplan-Meier pro-
portional hazards model, or what-is usually termed
"life-table analYSis," the scale for ulnar nerve en-
trapment at the elbow level, given in Table 6, was
applied to a cohort of cubital tunnel patients accrued
from 1983 through 1987. This group was character-
ized by having sufficiently early or minimal-enough
symptoms and signs, or who otherwise refused sur-
gical treatment such that they were treated with a
standardized nonoperative regimen to reduce pres-
sure within the cubital tunnel. 40 The group com-
prised 164 cubital tunnel syndromes, with a mean
length of follow-up of 58.6 months. Failure of the
nonoperative treatment was defined as surgical in-
tervention. The patients were subgrouped such that
the most minimally involved group would be symp-
toms without signs, or grade 1; the next most in-
volved group was symptoms with signs of abnormal
threshold, or grades 2, 3, and 4; and the most in-
volved group was symptoms with signs of abnormal
innervation density, or grades 5,6, and 7. There was
no patient in this study with scales of 8 through 10
who was treated nonoperatively. Figure 1 illustrates
fiGURE 4. The Pressure-Specifying Sensory Device now has
the results of the life-table analysis, which demon-
an adjustable bar that dampens the oscillations of the exam-
strated a statistically significant increase in the per- iner's hand. When examining a hand with suspected near-
centage of patients having surgery (failing the non- normal sensibility, maximum dampening is selected by moving
operative management) in relation to the staging cre- the adjustable knob toward th e prongs. For the patient for
ated by the numerical grading scale. whom severe sensibility change is anticipated or found, the
prongs need their maximum available excursion, and the knob
is moved away from the prongs.
Survey of the Experts on the Grading Scale's
Rank Ordering
has come from my own personal experience. Another
approach to determining the validity of this grading
Thus far, the conceptualization has all been from scale, in addition to demonstrating that it can eval-
one individual: the rank ordering of the grading scale uate certain clinical situations as in the three pilot
projects above, would be to ask a panel of "experts"
TIBIAL NERVE PERONEAL NERVE to rank the same categories, and then compare their
(BIG TOE : PLANTAR) (FOOT : DORSUM) ranking with mine. In February 1992, a questionnaire
:;: was sent to 40 "experts" to do exactly this. They
30 :;:
0 RIGHT
were given a set of 11 cards with the category names
:!
~ LEFT
described in Table 5 for the median nerve and an-
E
E \ other set for the ulnar nerve as described in Table 6,
C" 20 :;: and asked "to structure a rank/order series of events
~ :;:
N
that constitute the natural history of the injured pe-
:iE :;:
~
ripheral nerve." Twenty responses were received from
c:t
a: :;: :; a group that included both orthopedic and plastic
(!) 10 :! :;:
N
~
surgeons who have published in the field of periph-
• l~ eral nerve surgery, as well as hand therapists rec-

o !TIl
1PS 2PS
r1
1PM 2PM
rb
1PS 2PS
rJ",

1PM
CUTANEOUS PRESSURE THRESHOLD
fiGURE 3; Example of relationship between changes in
threshold and two-point discrimination (2PD) determined with
the Pressure-Specifying Sensory Device. These measurements
are for a 34-year-old patient with bilateral tarsal tunnel syn-
drome. The left tarsal tunnel had been released, with a neu-
rolysis of the medial and lateral plantar nerves in their distal
tunnels seven months before these measurements. Note that
there is no difference in the thresholds between the left and
right peroneal nerves, which were without surgery. Note that
the thresholds for one-point static (7 PS) touch, one-point mov-
ing (7 PM) touch, and for two two-point static (2 PS) and two-
point moving (2PM) discriminations are decreased, i.e. , im-
proved in the left, operated on, foot for the big toe. Note that
threshold changes have improved before innervation density
changes, i.e., 2PD 74 for static and 72 for moving in both left
and right big toes. With further time after surgery, and further
neural regeneration, a decrease in 2PD may be expected.
2PM
ognized for expertise in sensory rehabilitation and
sensibility testing. 41 Figure 2 illustrates the responses
for the median nerve and demonstrates how the re-
sponses to this questionnaire help focus upon the
additional information that must be acquired to create
a numerical grading scale that has widespread ac-
ceptance. For example, it was unclear to most re-
spondents where to place "persistent paresthesias,"
which is number 5. Is this because most respondents
do not ask their patients this historical question, and
therefore have insufficient information upon which
to have made their decisions? This is the most likely
explanation, because most respondents simply ranked
this category just after 1, "intermittent paresthesia."
This illustrates a problem with the questionnaire, in
that it did not provide information as to. whether the
respondents truly had experience with each of the
categories, yet it also demonstrates an area for both
investigation as well as education. Similarly, is the
problem with the overlap of threshold and mild two-
April-June 1993 157
 316
A 110.0
105.0 ~

100.0 100

95.0
90.0 31.6
11
~

~I
85.0
w
Q
:i:
10.0 0
5
80.0
:.xl
0
Q.
75.0 r---' :z
til
::IE
ct 70.0 3.16

65.0
60.0 1.00 fiGURE 5. The Force-Defined
Vibrometer (N K Biotechnica l En-

.
55.0 1 1 36 1 1 3~ gin eering Co., Minneapo lis, MN).
50.0
1o 6 24 06214
.316 (AJ Example of th e va ri atio n in vi-
10 Hz 16 Hz 32 Hz 64 Hz 128 Hz 256 Hz 500 Hz bratory threshold with in creasing
force of application of th e vibro-
LEFT INDEX FINGER meter to the normal fin gertip , for
two different frequen cies. (B) Ex-

B 110 ·or···,.... :··ii:.:oo(i:.:i99i··· .. '·.. ...,.... ......... ....,', .. ..... ,. ."., ... ,.... ',.,.... ............ ,'
10:5 .0; ................ ... .... .... . .. .. r-
100.0: .. .... · .. · .. · ...... .. .... .. ...... ·
.... 316
ample of the vibrogram of apatient
w ith lead neuropath y. (Fro m : Del-
Ion AL, Keough J: Th e surgical
t-.: ......... ............ .. ........ .. .................. " .. .. .. :~ ... management of lead neuropathy.
J Hand Surg, submitted f o r publi-
';. .. ................. ........... ......... .... ...... ....... . :. 1"''' 100
cation, 7993). Note that th e thresh-
olds are high, and th at there is no
perception of the low frequenc ies,
i .e., 70, 76, and 32 fo r th e inde x
· .. · 31.6
finger, and 70 and 76 for the little
finger.

3.16
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:{ ::<:
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,~

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THUfUJ I HOEK "I DOLE RING

point discrimination abnormalities due to a true dif- The surgical oncologist's approach to head and neck
ference of opinion, or does it reflect that most re- tumors based upon their size, location, involvement,
spondents do not measure both threshold and in- or regional nodes or distant metastases (the TMN
nervation density changes when they examine their classification) is another example .45 Grading the de-
patients? gree of involvement of joints enables more effective
management of osteoarthritis of the hip. 46 Develop-
ment of an appropriate grading scale for chronic pain
DISCUSSION is approaching a realityY I believe that creating a
universally acceptable numerical grading scale is es-
The history of clinical medicine is replete with sential to elevating the clinical care of the peripheral
examples of improved patient care based upon a bet- nerve to the scientific level it deserves. The under-
ter understanding of the histopathology and the standing of the pathophysiology of the peripheral
pathophysiology of the disease. The analysis and nerve and the clinical assessment techniques are now
communication of the information that forms the ba- available to achieve this goal.
sis of this progress usually rely upon a graded clas- The numerical grading scale conceptualized in
sification. The increased survival obtained in the cur- this article remains to be validated. By selecting two
rent approach to Hodgkin's disease is an excellent well-understood peripheral nerves, the median nerve
example of the necessity of such a graded scale. 42 - 44 at the wrist level and the ulnar nerve at the elbow
158 JOURNAL OF HAND THERAPY
level, it was possible to design three pilot studies to
test the applicability of this grading scale. The ease
with which the commonly utilized clinical assessment
techniques can be converted into a numerical grade,
the ease with which the numerical grade can be an-
alyzed statistically, and the variety of statistical anal-
yses possible suggest that this grading scale already
may be appropriately rank ordered and may, there-
fore, be valid. While some of the individual clinical
assessment tests, such as two-point discrimination,
have been validated with respect to predicting hand
function 48 - 51 and have been ranked, in general, in
relation to threshold testing,15,52,53 the relationships
between motor and sensory components have not
been previously documented,
The experts' responses to the rank-order ques-
tionnaire highlight areas of agreement, such as the
sequence for both the median and ulnar nerves of 0,
1, 2 and 8, 9, 10. The experts' responses highlight
areas of potential ambiguity, such as the relationship
of persistent paresthesias to threshold and innerva-
tion density measurements; the order in degrees of
weakness gives way to atrophy; and abnormal sen-
sory threshold gives way to abnormal two-point dis-
crimination (Fig. 2)-each of these areas may be clar-
ified by an appropriately designed research study. In
particular, the new Pressure-Specifying Sensory De-
vice,lO the measurements of which correlate poorly
with the traditional Semmes-Weinstein nylon mon-
ofilament measurements on the same set of fingers, 54
offers the research opportunities to investigate the
time relationships between threshold changes and
two-point discrimination changes (Fig. 3). The new
Pressure-Specifying Sensory Device has an oscillation
reduction modification (Fig. 4) that minimizes the
hand-held oscillations observed by Bell-Krotoski and
Buford. 55
While the grading scale is designed to be hier-
archical, it remains to be proven that it is. Recently
statistical tests have been developed to measure the
degree to which a scale meets certain criteria. 56,57 It
would be appropriate to subject this scale to such
analysis. With further refinement of the scale, it may
approach a series of uniform intervals, in which case
the non parametric tests applied above could be
changed to the more familiar t-test. 58-60
The grading scale described here has the unique
feature that it is "modular" in the sense that if the
future witnesses the development of a clinical as-
sessment technique that is clearly more reliable and
more valid than an extant technique, that new de-
vice's measurement may replace the one that cur-
rently exists in the grading scale. For example, the
currently available vibrometers do not control for the
force of application. A new instrument, a force-de-
fined vibrometer, will be available in the near future.
This device demonstrates that the vibration threshold
is dependent upon the force of application (Fig. 5).
The new device, being both amplitude- and fre-
quency-variable, can test seven different frequencies.
It can demonstrate, for example, that in lead neu-
ropathy there is an inability to perceive low-fre-
quency vibratory stimuli before the thresholds for
high frequencies are affected 61 (Fig. 5). If this device
were to become used commonly, it might be most
appropriate to use it for grading certain peripheral
neuropathies instead of the cutaneous pressure
threshold, while it may be that both types of thresh-
old measurements will prove valuable.
The numerical grading scale is presented here
only for the median nerve at the wrist and the ulnar
nerve at the elbow. Clearly, if this concept is ac-
cepted, it would be necessary also to apply this scal-
ing technique to each peripheral nerve for which we
wish to express a diagnosis, a prognosis, and a treat-
ment result. This will take the cooperation of an in-
ternational panel of peripheral nerve experts. The
American Society for Peripheral Nerve has formed a
committee whose goal is to address the validity of
such a scale and seek international collaborators for
their expertise with individual nerves.
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