The impact of hand dominance and ulnar and median nerve impairment on strength and basic daily activities

Backward logistic regression analysis of the determinants of the hand function among patients with leprosy: A cross-sectional study

Introduction

The hands are the most common site of disability in leprosy. Hand dysfunction could result in difficulty performing activities of daily living. Therefore, hand function should be regularly assessed to ensure that any decrease in hand function could be diagnosed earlier.

Methods

This study included 110 patients with leprosy from Likupang and Lembata, Indonesia. Hand function was assessed using the modified Jebsen test to measure hand function respective of the dominance. The grip and pinch strength were used as objective measures of clinical arm function. The World Health Organization (WHO) hand disability grade were used to determine the degree of impairment. Other factors such as age, sex and the type of leprosy were also considered. All factors were analysed using backward logistic regression.

Results

Among the 110 participants, a decrease in the dominant (48.2%) and non-dominant (50.9%) hand functions were found. Pinch strength (OR: 3.39; 95% CI: 1.13-10.19) and age (OR: 4.91; 95% CI: 1.72-14.03) were significantly associated with hand function irrespective of the dominance. Conversely, the WHO hand disability grade (OR: 2.97; 95% CI: 1.10-8.04) and type of leprosy (OR: 0.34; 95% CI: 0.12-0.97) were significantly associated with only function of the dominant hand.

Conclusion

There is a significant association of age and pinch strength with hand function regardless of the hand dominance. In contrast, the WHO hand disability grade and type of leprosy are significantly associated with the function of the dominant hand only.

Functional activity limitation of leprosy cases in an endemic area in Indonesia and recommendations for integrated participation program in society

Background

Leprosy continues to be a health problem in Indonesia, with incidence reaching over 10,000 new cases by 2021. Leprosy-related disabilities cause limitation of patients’ activity and participation in social activities. To date, no studies have been conducted in Indonesia which investigates disability in terms of bodily function, structure impairment, limitations in performing daily activities, and restrictions in participation in social activities in leprosy patients. This study is aimed to determine the demographic and clinical characteristics that might affect functional activity limitations of leprosy patients in endemic areas in Indonesia.

Methods and findings

A cross-sectional study was conducted on 267 retrospectively-diagnosed cases of leprosy. The Screening of Activity Limitation and Safety Awareness (SALSA) scale was used to measure functional activity limitation, which comprises five domains: vision, mobility, self-care, work with hands, and dexterity. Differences among variables were evaluated using Kruskal-Wallis and Mann-Whitney test. The mean age of participants was 51.89±13.66 years, the majority of which were men (62.5%), uneducated (48.3%), and classified as type 2 in the World Health Organization (WHO) disability grading for hands and feet (66.3% and 68.2%, respectively). Assessment using the SALSA Scale showed 28.5% of subjects were without limitation, 43.8% with mild limitation, 13.5% with moderate limitation, 9.4% with severe limitation, and 4.9% with extreme limitation. Significant differences in the total SALSA Scale were found between age groups (p = 0.014), educational level (p = 0.005), occupation (p<0.001), and WHO disability grades (p<0.001). Multivariate analysis showed that the most significant factor influencing the total score of SALSA was disability grading for feet (score = 0.31, p <0.001) followed by occupational status, disability grading for eyes, and age. Limitation of functional activity was significantly correlated to becoming unemployed with the odds 2.59.

Conclusion

People affected by leprosy are prone to have functional activity limitation, especially the elderly, uneducated, unemployed and those with multiple disabilities. If they can overcome their barriers in functional activities, they will have better occupational opportunities.

Treatment of distal radius fractures using a cemented K-wire frame

BACKGROUND

This retrospective study included an alternative treatment for types A2, A3, and B1 distal radius fractures using percutaneous fixation with a cemented K-wire frame.

METHODS

From January 2017 to January 2020, 78 patients with distal radius fractures were treated with percutaneous internal fixation using a cemented K-wire frame. There were 47 male patients and 31 female patients. The fractures were classified into types A2 (n = 10), A3 (n = 46), and B1 (n = 22). X-rays were taken immediately after surgery and after the bone had healed. Wrist function was assessed using the Mayo Wrist Score (90-100, excellent; 80-90, good; 60-80, satisfactory; < 60, poor). Patient satisfaction was assessed using the 10-cm visual analog scale.

RESULTS

Neither fixation failure nor K-wire migration was found (P > 0.05). Osteomyelitis was not observed in this series. All patients achieved bone healing after a mean of 4.5 weeks (range, 4 to 8 weeks). Follow-up lasted a mean of 27 months (range, 24 to 33 months). The mean score of wrist function was 97 (range, 91 to 100). Among them, 66 results were excellent and 12 results were good. The mean patient satisfaction was 10 cm (range, 8 to 10 cm).

CONCLUSIONS

Percutaneous fixation with cemented K-wire frame is a safe and preferred choice for the treatment of types A2, A3, and B1 distal radius fractures. The frame provides support to prevent wire migration. The fixation technique is a minimally invasive procedure that is easy to perform.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

Failure to Compensate: Patients With Nerve Injury Use Their Injured Dominant Hand, Even When Their Nondominant Is More Dexterous

OBJECTIVE

To identify how individuals respond to unilateral upper extremity peripheral nerve injury via compensation (increased use of the nondominant hand). We hypothesized that injury to the dominant hand would have a greater effect on hand use (left vs right choices). We also hypothesized that compensation would not depend on current (postinjury) nondominant hand performance because many patients undergo rehabilitation that is not designed to alter hand use.

DESIGN

Observational survey, single-arm.

SETTINGS

Academic research institution and referral center.

PARTICIPANTS

A total of 48 adults (N=48) with unilateral upper extremity peripheral nerve injury. Another 14 declined participation. Referred sample, including all eligible patients from 16 months at 1 nerve injury clinic and 1 hand therapy clinic.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Hand use (% of actions with each hand) via Block Building Task. Dexterity via Jebsen-Taylor Hand Function.

RESULTS

Participants preferred their dominant hand regardless of whether it was injured: hand usage (dominant/nondominant) did not differ from typical adults, regardless of injured side (P>.07), even though most participants (77%) were more dexterous with their uninjured nondominant hand (mean asymmetry index, -0.16±0.25). The Block Building Task was sensitive to hand dominance (P=2 × 10-4) and moderately correlated with Motor Activity Log amount scores (r2=0.33, P<.0001). Compensation was associated only with dominant hand dexterity (P=3.9 × 10-3), not on nondominant hand dexterity, rehabilitation, or other patient and/or injury factors (P>.1).

CONCLUSIONS

Patients with peripheral nerve injury with dominant hand injury do not compensate with their unaffected nondominant hand, even if it is more dexterous. For the subset of patients unlikely to recover function with the injured hand, they could benefit from rehabilitation that encourages compensation with the nondominant hand.

Subterminal key pinch dynamometry: a new method to quantify strength deficit in ulnar nerve paralysis

Precise pre- and postoperative assessments are fundamental to recording the quality of recovery after ulnar nerve repair. Because of its imprecision, manual muscle testing is being replaced by dynamometry to measure grasping and key-pinch strengths. However, both grasping and key pinch are dependent not only on the ulnar nerve but also the median and radial nerves. We propose to measure strength using a new sort of pinch, called the 'subterminal key pinch'. Strength was measured using a commercially available pinch meter. Patients applied pressure on the dynamometer with the interphalangeal joint of the thumb, maintaining the joint in extension to avoid enhancement of strength by the flexor pollicis longus. We examined 17 patients before ulnar nerve repair. Preoperatively, grasping strength was 46% of normal, while key pinch was 58%, pinch-to-zoom strength was 26% and subterminal key pinch only 7%. Subterminal key pinch was the most affected pinch with a strength deficit of over 90%.Level of evidence: IV.

Effects of serious games in strength and functionality of patients with ulnar nerve lesion: two single-case reports

The objective of this study was to investigate the effect of serious games on hand muscle strength and functionality in a series of cases with ulnar nerve damage. Two patients were included in this 16-week intervention study using biofeedback. Electromyography electrodes and dynamometers were used in treatment. Functionality was assessed by Rosen and Lundborg score, Disabilities of the arm, shoulder and hand (DASH) questionnaire and International Classification of Functioning, Disability and Health (ICF). Grip and pinch strength were assessed by dynamometers. Results revealed an increase in sensory domain of Rosen and Lundborg score of the two patients. Patients increased values from the DASH questionnaire; however, they got better results with ICF. Grip strength of the two patients increased; pinch strength varied between patients; key pinch had the best results. Serious games can be effective to enhance hand strength and improve functionality in patients with ulnar nerve damage.

Prior to Repair Functional Deficits in Above- and Below-Elbow Ulnar Nerve Injury

PURPOSE

Clinical deficits might vary, depending on whether an ulnar nerve lesion is above or below the elbow. Lack of strength and clawing are common manifestations of ulnar nerve paralysis. However, the magnitude of strength deficit relating to different pinch patterns and the rate and range of proximal interphalangeal extension deficits are poorly described.

METHODS

I prospectively evaluated 14 patients with above-elbow and 16 with below-elbow unrepaired ulnar nerve injuries. The completeness of flexion of the ring and little fingers was tested at the metacarpophalangeal and distal interphalangeal joints. Proximal interphalangeal joint extension lag of the ring and little fingers was assessed by goniometry, and adduction and abduction of the little finger. With dynamometers, I bilaterally evaluated grasp, key pinch, and pinch-to-zoom strength. Hand sensibility was evaluated with monofilaments.

RESULTS

Metacarpophalangeal flexion in the ulnar fingers was absent in all patients, whereas distal interphalangeal joint flexion was preserved in 29 of 30 patients. In above-elbow ulnar nerve injuries, there was no paralysis of the flexor digitorum profundus. One-third of patients exhibited no clawing. There were minimal differences between the rate of clawing and proximal interphalangeal extension lag in above- and below-elbow ulnar nerve lesions, or its occurrence in the ring or little finger. In relation to the normal hand, grasping, key pinch, and pinch-to-zoom decreased by 62%, 51%, and 75% compared with 59%, 61%, and 76% in below- and above-elbow injuries groups, respectively. In both groups, sensory deficits were predominantly over the little finger and ulnar side of the hand.

CONCLUSIONS

Minimal differences were observed in clinical deficits after above- and below-elbow ulnar nerve injuries. Hand weakness was the most frequent problem, whereas pinch-to-zoom strength was highly affected.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Quantification of hand function by power grip and pinch strength force measurements in ulnar nerve lesion simulated by ulnar nerve block

INTRODUCTION

In the assessment of hand and upper limb function, grip strength is of the major importance. The measurement by dynamometers has been established.

PURPOSE OF THE STUDY

In this study, the effect of a simulated ulnar nerve lesion on different grip force measurements was evaluated.

METHODS

In 25 healthy volunteers, grip force measurement was done by the JAMAR dynamometer (Fabrication Enterprises Inc, Irvington, NY) for power grip and by a pinch strength dynamometer for tip pinch strength, tripod grip, and key pinch strength.

STUDY DESIGN

A within-subject research design was used in this prospective study. Each subject served as the control by preinjection measurements of grip and pinch strength. Subsequent measurements after ulnar nerve block were used to examine within-subject change.

RESULTS

In power grip, there was a significant reduction of maximum grip force of 26.9% with ulnar nerve block compared with grip force without block (P < .0001). Larger reductions in pinch strength were observed with block: 57.5% in tip pinch strength (P < .0001), 61.0% in tripod grip (P < .0001), and 58.3% in key pinch strength (P < .0001).

DISCUSSION

The effect of the distal ulnar nerve block on grip and pinch force could be confirmed. However, the assessment of other dimensions of hand strength as tip pinch, tripod pinch and key pinch had more relevance in demonstrating hand strength changes resulting from an distal ulnar nerve lesion.

CONCLUSIONS

The measurement of tip pinch, tripod grip and key pinch can improve the follow-up in hand rehabilitation.

LEVEL OF EVIDENCE

II.

Quantification of weakness caused by distal median nerve lesion by dynamometry

INTRODUCTION

In the assessment of hand and upper limb function, grip strength is of major importance. Use of the JAMAR dynamometer has been an accepted test of grip strength and routinely part of the physical examination.

PURPOSE OF THE STUDY

The aim of this study was to determine by means of a median nerve block simulating a patient group if the measurement of different types of grip force can improve the quantification of impairment of the hand beyond the sole power grip measurements.

METHODS

In 29 healthy volunteers, grip force measurement was done by the JAMAR dynamometer for power grip and by a pinch grip dynamometer for pincer grip, precision grip, pinch grip, and palmar abduction. At the power grip, the force of digit 2-5 was measured separately by a sensor glove. For each measurement, 3 trials were recorded subsequently.

STUDY DESIGN

A within-subject research design was used in this prospective study. Each subject served as the control by preinjection measurements of grip and pinch strength. Subsequent measurements after median nerve block were used to examine within-subject change.

RESULTS

In power grip, there was no significant reduction of maximum grip force with median nerve block compared with grip force without block. By measuring the finger forces by a sensor glove, a reduction of force at the individual fingers was found compared with the setting with no block, although significant only at the middle finger (P < .017). With median nerve block, average grip force decreased significantly 20% in pincer grip (P < .021), 29.5% in pinch grip (P < .002), 39.5% in precision grip (P < .001), and 70.7% in palmar abduction (P < .013).

CONCLUSIONS

These experiments suggest a minor role of the measurement of the power grip force in the diagnostics of distal median nerve block with the dynamometer, which could not be substantially improved by the digit forces and the force distribution of the individual fingers. The assessment of other grip forms, such as pincer grasp, precision grip, pinch grip, and especially palmar abduction, leads to a relevant improvement in the diagnostics of distal median nerve lesion.

LEVEL OF EVIDENCE

II.

The impact of finger position on pinch strength

Introduction

Pinch strength is a widely used measurement of hand function, but digit position on the pinch gauge has not been described in the literature. The aim of this study was to assess for differences in tip, lateral, and three-jaw-chuck pinch force when the digits are placed on the groove or bridge of a Bernadette and Linda pinch gauge.

Methods

Thirty-six healthy volunteers each pinched six times in random order: one for each type of pinch force with the digits placed in each position.

Results

There were no significant differences in pinch strength measurements based on digit position, except for three-jaw-chuck pinch which was slightly higher on the groove. Equivalence was found within one pound for tip and lateral pinch but not for three-jaw-chuck.

Conclusion

Variations in finger position may result in similar pinch strength measurements for tip and lateral pinch. Clinicians may reliably assess lateral and tip pinch using either position; however, standardized positioning is still recommended.

Transfer of the Motor Branch of the Abductor Digiti Quinti for Thenar Muscle Reinnervation in High Median Nerve Injuries

PURPOSE

In high median nerve repairs, thenar muscle reinnervation is impossible because of the long distances over which axons must regenerate. To overcome this obstacle, we propose transferring the abductor digiti quinti motor branch (ADQMB) to the thenar branch of the median nerve (TBMN).

METHODS

We used 10 embalmed hands for anatomical and histological studies. Thereafter, 5 patients with a high median nerve injury underwent surgical reconstruction within 8 months of their accident and were followed for at least 10 months after surgery (mean, 13.2 months). We transferred the ADQMB to the TBMN. The median nerve was grafted in 4 patients and the motor branch of the extensor carpi radialis brevis was transferred to the anterior interosseous nerve in 3. Patients had pre- and postoperative evaluations of thumb range of motion and strength.

RESULTS

In cadaveric hands, the ADQMB was the first branch of the ulnar nerve to arise near the pisiform bone. The TBMN arose from the anterior surface of the median nerve, underneath the flexor retinaculum. Retrograde dissection of the TBMN allowed tension-free coaptation with the ADQMB. Both branches contained approximately 650 myelinated fibers. After surgery, all our patients improved thumb pronation, thenar eminence bulk, and abductor pollicis brevis British Medical Research Council score. They recovered approximately 75% of their normal-side grasp and pinch strength. No patient lost little finger abduction.

CONCLUSIONS

Transfer of the ADQMB to the TBMN reinnervated the thenar muscles, which improved thumb range of motion and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

A comparison of minimally invasive approach vs conventional approach for volar plating of distal radial fractures

Background

The aim of this study was to introduce and to evaluate the functional results of volar plating of distal radial fractures through a longitudinal minimally invasive approach.

Methods

From January 2010 to January 2013, 157 patients with distal radial fractures were randomly allocated to group A (n = 83; 49 men, 34 women; mean age: 42 (18–67)) and B (n = 74; 46 men, 28 women; mean age: 41 (22–65)), including type A2, A3, B3, C1, and C2 fractures, based on AO Foundation and Orthopaedic Trauma Association Classification. Patients in group A were treated through a 1.5- to 2-cm longitudinal incision, and patients in group B were treated through the conventional flexor carpi radialis approach. All fractures were treated with a locking volar plate. The functional results were compared with range of motion, grip and pronation strengths for each fracture type.

Results

After a follow-up of 2 years, similar measurements were noted on range of motion and grip strength in both groups. Regarding pronation strength, group A was superior to group B (p < 0.05).

Conclusions

Minimally invasive volar plating of distal radial fractures is a safe and reliable technique, resulting in better pronation function and appearance.

Level of Evidence

Level I, Therapeutic study

Management of dominant upper extremity injuries: a survey of practice patterns

STUDY DESIGN

Internet survey.

PURPOSE

To describe current practice patterns in hand therapy to 1) gain insights into beliefs of certified hand therapists (CHTs) related to initiating a hand dominance transfer, 2) describe CHTs' clinical decision-making strategies, and 3) describe research priorities related to hand dominance transfer in hand therapy.

PARTICIPANTS

Five hundred sixty-three members of the American Society of Hand Therapists.

METHODS

The online Internet survey contained 30 questions related to four categories: 1) demographics of clinicians, 2) beliefs about hand dominance transfer, 3) clinical strategies and decision making, and 4) a research agenda related to hand dominance transfer. Data were sorted, compiled, and analyzed descriptively.

RESULTS

Respondents were primarily occupational therapists working as full-time staff therapists treating between nine and 15 patients per day with orthopedic injuries to the dominant upper extremity caused by trauma. The overwhelming majority of respondents (92.7%) believed that motivation is a factor in the success of the hand dominance transfer. Most respondents (83%) do not directly initiate a hand dominance transfer. The number one reason (64%) for not initiating a dominance transfer is that CHTs believe that their patients will regain full recovery of injured hand over time. If a transfer is initiated, the number one task addressed is handwriting (62%); the most commonly recommended piece of adaptive equipment was the handsfree can opener (63.8%); 72% educate on the risk of overuse injury to the noninjured (intact) limb. Most respondents agreed or strongly agreed that more research needs to be done related to hand dominance transfer, specifically related to return to work rates, interventions using virtual reality, and assessments using neuroimaging technologies.

LEVEL OF EVIDENCE

3b.

The development of a short questionnaire for screening of activity limitation and safety awareness (SALSA) in clients affected by leprosy or diabetes

PURPOSE

The purpose of this study was to develop and validate a method of measuring activity limitation in leprosy and diabetes. The resulting questionnaire should be quick and simple to use in basic clinical settings, not require any testing skills or equipment, be validated across a number of cultures in order to be widely applicable, be relevant for anyone with long-standing peripheral neuropathy and be sensitive to changes in clients' capabilities. Because of impaired sensibility in hands or feet, persons affected by leprosy or diabetes are expected to be aware that many activities carry a risk of injury, particularly repetitive stress, excess pressure, friction or burns. They are expected to avoid these risky activities, or modify how they are carried out, in order to prevent injury. An additional aim of the study was therefore to find ways of assessing how far clients were aware of safety issues and how much they limited their activities voluntarily because of safety concerns.

METHOD

Lists of activities of daily living relevant for the target populations were generated through individual interviews and focus group discussions. A questionnaire of 374 items was compiled and administered to 436 persons affected by leprosy and 132 affected by diabetes in five countries in four continents. A total of 76% of respondents had impairments. Occupational therapists not otherwise involved in this study gave an independent assessment of the degree of activity limitation of 207 respondents. The process of item selection from this database is presented step by step. Items for the SALSA scale were practised by at least 70% of respondents in all participating populations, were easy to perform for some but difficult for others, correlated well with the assessment of independent practitioners and had good item-total correlation. The present set of 20 items is well represented by a single principal component and had a high scale reliability coefficient.

RESULTS

On a 20-item scale, one would expect a score of 20 if the respondents practiced all the activities listed without difficulty. Higher scores reflect increasing activity limitation. The SALSA score varied from 10 to 75 with a mean of 32. The distribution of the scores was not different between men and women or between disease groups. There was a consistent increase of the SALSA score with age and with the level of impairment. Compared to India and Nigeria, the average SALSA scores, adjusted for age and impairment level, were higher in Israel and Brazil, but lower in China. The spearman correlation coefficient between the SALSA scores and the scores assigned by the independent experts was 0.67. Among 23 respondents without overt disease, the SALSA score had a median of 19 and half the respondents scored between 18 and 20.

CONCLUSIONS

The present research has resulted in the SALSA scale, a short questionnaire which can be administered within 10 min and which provides a standardized measure of activity limitation in clients with a peripheral neuropathy. It can be used to make comparisons between (groups of) individuals in different countries and in the same person (or group) over time. General health workers can use SALSA to screen clients and refer those with high scores to specialised services. In addition, the scale will assist service providers in designing appropriate interventions.

A possible anatomical and biomechanical explanation of the 10% rule used in the clinical assessment of prehensile hand movements and handed dominance

A current doctrine in the dynamometric approach to determine lateralization of hand function states that in 10% of cases, the non-dominant hand will be stronger than the dominant hand. In this study, a novel MRI based modelling approach was applied to the first dorsal introsseus muscle (FDI), to determine whether the 10% rule may be applied to the FDI and may be partially explained by the arrangement of the anatomical components of the FDI.

METHODS

Initially the force generated by the thumb segment during an isometric pushing task in the horizontal plane was measured from 25 strongly right-handed young males. Nine of these participants then had structural magnetic resonance imaging (sMRI) of the thumb and index osseous compartment. A modelling technique was developed to extract the muscle data and quantify the muscle line of action onto to the first metacarpal bone segment in order to quantify the muscle force at the point of momentary rotation--equilibrium.

RESULTS

Eight of 25 subjects exhibited stronger force from the left hand. Six out of nine subjects from the MRI possessed significantly greater angles of attachment of the index osseous compartment on the left (non-dominant) hand. These six subjects also generated greater maximal isometric forces from the FDI of the left side. There was a significantly greater muscle volume for the right FDI muscle as compared to the left as measured from the reconstructed MRI slice data.

CONCLUSIONS

The calculated force produced by the muscle is related to the angle of attachment of the muscle to bone in the index osseous compartment. The MRI findings indicate that the 10% rule may be anatomically and biomechanically explained.

Opponens plasty rehabilitation protocol--a case report

In this case report of opponens plasty, we will attempt to accomplish two objectives: 1) to characterize some innovative modifications to the standard rehabilitation protocol for an opponens plasty and 2) to explain the role and advantages of a new muscle re-education splint in this modified protocol.