Peripheral Nerve Regeneration A Follow-Up Study of 3,656 World War II Injuries (1957) / Chapter Skim
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Functional Recovery and Occupational Adjustment
Functional Recovery and Occupational Adjustment
Pages 349-388
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From page 349... ...
In addition to providing the scales used in evaluating functional recovery, Dr. Lewey advocated collection of systematic information on occupation before and after injury, evaluation of the role of the peripheral nerve injury in any occupational change, and formulation of a clinical opinion as to the extent of any present occupational handicap attributable to the peripheral nerve injury.
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From page 350... ...
Consideration is then given to the occupational changes which have occurred, and to the opinions of examiners as to the role played by peripheral nerve injuries in bringing them about. In a final section appear the exarrir.crs' opinions as to the extent of any present occupational hr.ndiceps suffered by the examinees in their work, whether they had changed jobs or net.
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From page 351... ...
Lewey developed for the study group a scale of "overall functional evaluation" having 11 positions. The sensory contribution to practical function is quite variable, as is the anatomic regeneration of individual muscles.
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From page 352... ...
Combined Nerve Lesions From what has been said, a reasonable grading of combined lesions can be arrived at on the basis of the functions which are possible. Practical function of the arm is 0 percent, regardless of the muscles functioning, until the fingers can be used to grip lightly (10 percent)
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From page 353... ...
Toe movements, active inversion and eversion of the foot, and sensory disturbances are important only in the extent to which they limit walking or standing. Center variation was also explored for overall functional evaluation, and in the fashion already described for specific functional capacity.
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From page 354... ...
. Change in occupation, and the examiner's estimate of the role played by the peripheral nerve injury, were classified as follows: 0.
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From page 355... ...
Within the set of lesions affecting a single nerve, variation was greatest for the median, and the most severe limitations were imposed by injuries to this nerve. Table 201 provides a summary of data on specific functional capacity of upper extremities, by nerve and by type of definitive surgery, for pure lesions only.
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From page 356... ...
The relation between the two scales, one of specific functional capacity and the other of overall functional evaluation, may be of value in interpreting the foregoing data on the upper extremity. Tables on this relationship were run as a preliminary and exploratory measure before the present chapter was planned, and were not confined to pure nerve lesions.
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From page 357... ...
In the lower extremity there were too few pure lesions treated by lysis to justify presentation, and, accordingly, in table 206 the summary of data on specific functional capacity is limited to complete sutures. The table does not extend to the limitations which examiners found, but pain and weakness were most commonly reported.
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From page 359... ...
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From page 361... ...
Table 206. -- Specific Functional Capacity of Lower Extremities With Lesions Treated by Suture Pure Functional capacity Peroneal Tibial Sciatic ' 1. Will not bear weight Percent 0 Percent 0 Percent 1.6 2.
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From page 362... ...
The overall functional evaluation was made on somewhat more limbs than the determination of specific functional capacity, and it is of passing interest to note that the percentage ratings on limbs which examiners classified as unknown as to specific functional capacity are about the same as the ratings on limbs which were specifically classified in this way. Table 207 provides a summary of the overall ratings, which were least favorable for the complete sciatic lesions and most favorable for the pure tibial lesions.
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From page 363... ...
From the present material the median and ulnar were chosen for an exploration along these lines. Pure median and pure ulnar nerve lesions treated by complete suture were isolated and the limbs compared, both as to specific functional capacity and overall functional evaluation, with limbs in which both 363
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From page 366... ...
A high-low distinction is maintained there because combined median and ulnar nerve lesions are much more common in the arm than in the forearm, and because of the general influence of site of lesion upon the recovery of specific modalities. Although the distinction as to gross site impairs considerably the stability of any estimates one might make of the effect of the second lesion, it does not obscure the fact that the effect is real for both the median Table 209. -- Effect of Associated Nerve Lesions Upon Specific Functional Capacity, Upper Extremity by Gross Site, Complete Sutures Only Pure median Pure ulnar Median and ulnar Specific functional capacity Percent Percent Percent High lesions Useless limb 4.
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From page 367... ...
For example, among high lesions the percentages with no more than good opposition are 23.5 for pure median lesions and 6.2 for pure ulnar, but 66.7 for combined. For low lesions the figures are somewhat similar: 33.1 percent for pure median, 8.4 for pure ulnar, and 52.0 367
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From page 368... ...
Tabulations were confined to complete sutures on "pure" nerve lesions, which effectively excluded the sciatic cases, as well as men with injuries to both upper or both lower extremities. Motor recovery The relation between motor recovery and the overall functional evaluation is shown in table 211, by nerve.
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From page 369... ...
Table 211. -- Relation Between Motor Recovery and Overall Functional Evaluation Following Complete Suture, by Nerve, Pure Lesions Only Level of motor recovery • Percentage distribution as to overall function, as percentage of normal 0-50 60-70 80-100 Total Number of cases Median At most proximal muscles acting against CTavitv .
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From page 370... ...
. Sensory recovery As may be seen from table 212, which is arranged in the same fashion as the motor table, the correlation between sensory recovery and the overall functional evaluation is much poorer than motor and functional.
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From page 371... ...
Table 212. -- Relation Between Sensory Recovery and Overall Functional Evaluation Following Complete Suture, by Nerve, Pure Lesions Only Level of sensory recovery ' Percentage distribution as to overall function, as percentage of normal Number of cases Median 0-50 60-70 80-100 Total Not more than superficial pain 73.8 11.9 38.3 52.0 14.3 20.0 32.0 100.0 100.0 100.0 42 60 50 Some touch, overresponse still present 41.7 16.0 Overresponse has disappeared Total 42. 1 35.5 22.4 100.0 152 Radial Not more than superficial pain 17.0 10.5 19.1 31.6 30.6 63.8 57.9 62.2 99.9 100.0 99.9 47 57 98 Some touch, overresponse still present Overresponse has disappeared 7.1 Total 10.4 28.2 61.4 100.0 202 Ulnar Not more than superficial pain 13.2 13.4 3.5 57.9 39.4 34.5 28.9 47.2 61.9 100.0 100.0 99.9 114 127 113 Some touch, overresponse still present Overresponse has disappeared Total 10.2 43.8 46.0 100.0 354 Peroneal Not more than superficial pain 28.0 19.5 22.9 54.0 41.5 34.3 18.0 39.0 42.9 100.0 100.0 100.1 50 41 35 Some touch, overresponse still present Over response has disappeared Total 23.8 44.4 31.7 99.9 126 Tibial Not more than superficial pain 8.8 9.7 10.0 44.1 32.3 10.0 47.1 58.1 80.0 100.0 100.1 100.0 34 31 10 Overresponse has disappeared Total 9.3 34.7 56.0 100.0 75 1 The three groupings correspond to rubrics (0+1 +2)
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From page 372... ...
Table 213. -- Relation Between Motor and Sensory Recovery Following Complete Suture, by Nerve, Pure Lesions Only Motor recovery l Percentage distribution by sensory recovery * Number of cases Median A B C Total A 30 29 23 50 41 32 20 29 100 99 100 20 85 47 B C 45 Total 28 39 33 100 152 Radial A 33 23 13 22 33 22 44 44 64 99 100 99 45 112 45 B C Total 23 28 49 100 202 Ulnar A 63 31 21 27 40 21 10 29 100 100 100 30 271 53 B C 58 Total 32 36 32 100 354 Peroneal A 54 42 18 25 39 38 21 19 100 100 100 56 31 B C 44 39 Total 40 33 28 101 126 Tibial A 58 21 58 35 21 9 13 100 100 100 19 33 23 B 33 52 C Total 45 41 13 99 75 1 The A, B, and C groupings are precisely those of tables 211 and 212.
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From page 373... ...
The primary importance of motor recovery dictates the form of the final tables in this set. For a given level of motor recovery, the influence of sensory recovery is shown upon the overall functional evaluation, for each nerve individually.
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From page 374... ...
Motor and sensory contribute about equally to median function, but for the other nerves the influence of sensory recovery seems slight indeed. Table 215. -- Percentage of Cases With Good Functional Assessments, by Levels of Motor and Sensory Recovery Level of sensory recovery ' Percentage with good function, by level of motor recovery ' Median A *
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From page 375... ...
Table 216. -- VA Disability Ratings and Follow-up Examiners' Overall Functional Evaluations, New York Sample Representing All Major Nerves VA disability rating, percent Overall functional evaluation 100 0 10 20 30 40 50 60 70 80 90 100 Unknown Total 90 1 1 80 1 1 1 1 1 1 2 3 2 5 4 3 1 2 2 3 2 3 9 70 1 1 1 1 7 1 9 18 14 19 9 3 60 9 2 5 1 1 50 ...
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From page 376... ...
Table 217 provides a summary of the resulting observations, which also provides no real evidence of an association between the two classifications. Table 217. -- VA Disability Ratings and Follow-up Examiners' Overall Functional Evaluations, Pure Median and Pure Peroneal Lesions Overall functional evaluation VA disability rating*
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From page 377... ...
For the sample as a whole, change in occupation was the rule for men with previously established occupations, and the great majority of the changes appeared to examiners to have resulted, at least partly, from the nerve injuries. A control group would be necessary to delineate the precise role of the nerve injury, but the clinical opinion is quite clear: The peripheral nerve injury contributed to a change in occupation in 49 percent of the cases, and to an apparent inability to work in another 7 percent.
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From page 378... ...
The identity of the injured nerve seems not to affect the gross picture of occupational change. When attention is confined to pure nerve lesions treated by complete suture, as in table 220, changes attributed to nerve injuries are somewhat more common for men whose lower extremities were involved, but otherwise the particular nerve involved seems unimportant.
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From page 379... ...
. 2,576 2,169 2,450 2,088 Since only the distinction between upper and lower extremity seems to be associated with the chance of occupational change, in table 221, giving the precise change in Socioeconomic category, the individual nerves are grouped in accordance with this distinction.
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From page 380... ...
, by Occupation Prior to Service, and by Nerve Injured, Pure Lesions Treated by Complete Suturt Nerve and change in status Previous occupation Clerical and sales Craftsmen and foremen Operatives Nonfarm laborers Median Number of men Total i 25 28.0 16.0 30 60.0 53.3 49 55.1 38.8 15 66.7 60.0 137 50.4 40.1 Percent A Percent B Radial Number of men 30 26.7 23.3 33 54.5 54.5 54 63.0 42.6 17 52.9 35.3 155 48.4 37.4 Percent A Percent B Ulnar Number of men 56 26.8 16.1 61 62.3 52.5 118 46.6 33.1 24 54.2 50.0 297 Percent A 44.4 34.0 Percent B Peroneal 13 53.8 15.4 14 57.1 50.0 41 53.7 41.5 14 57.1 42.9 99 54.5 41.4 Percent A Percent B Tibial 15 26.7 13.3 16 21 61.9 47.6 7 85.7 85.7 63 55.6 46.0 Percent A 56.3 50.0 Percent B Sciatic ' Number of men 33 48.5 24.2 38 47.4 47.4 74 59.5 43.2 26 69.2 69.2 205 57.6 46.8 Percent A Percent B 1 Includes all other occupations not shown separately. 1 Complete sciatic lesions, i.
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From page 381... ...
Table 222 provides the data for these comparisons, and is confined to pure lesions and complete sciatic lesions.
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From page 382... ...
Men with median or complete sciatic lesions were considered by examiners to be the most handicapped, and men with ulnar or tibial the least. When the examiners' assessments as to occupational handicap were studied in relation to overall functional evaluation, some correlation, by no means close, was found.
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From page 383... ...
The occupational category has no such influence upon the handicap of men whose injuries involved the lower extremities. Table 223. -- Percentage Distribution of Cases by Occupational Handicap at Follow-up, by Nerve, Pure Lesions Treated by Complete Suture Nerve Occupational handicap Present Number of men None apparent Not severe Severe Unemployable1 Total Median 26.7 31.2 32.6 34.5 44.9 24.2 56.2 59.7 61.5 54.0 47.8 58.4 8.9 4.8 3.4 5.3 5.8 6.1 8.2 100.0 100.0 100.0 100.0 99.9 100.0 146 186 322 113 69 231 Radial 4.3 2.5 6.2 1.4 11.3 Ulnar Peroneal Tibial Sciatic *
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From page 384... ...
and men were compelled by personal motives having to do with furthering and continuing their careers in the Armed Forces. The peripheral nerve injuries included 2 of the sciatic nerve, 3 of the common peroneal nerve, 3 of the radial nerve, (1 combined with a median nerve division)
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From page 385... ...
Letters from these patients or their superior officers describe excellent or at least adequate functional rehabilitation. The first patient was injured by shell fragments on 14 January 1944, with evidence of complete sciatic nerve division in the upper third of the thigh.
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From page 386... ...
From the neurological examination, anatomical regeneration was grossly inadequate. The following comment was appended to the examination report: "From a functional standpoint, this man has had a good recovery from a serious injury in that he can walk with minimal objective evidence of disability and minimal subjective discomfort from pain." Two of the 3 patients with radial nerve division did well and the third patient had a double nerve injury.
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From page 387... ...
is able to perform all his duties properly, including fine movements required in maintenance of material." In summary the reports upon the physical status of these men are admittedly inadequate. They serve to demonstrate the fact that resolute individuals, with proper motivation, can resume useful military duties in spite of any type of common peripheral nerve injury.
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