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Abstract
This article presents a case report regarding a 34-year-old obese male who works as a chipper and grinder at a steel manufacturing mill and uses high-frequency vibratory power tools. He presents with typical complaints of carpal tunnel syndrome, including numbness in all five digits, wrist pain, nocturnal awakening/numbness, and others. Two-point discrimination (2PD) using a caliper was tested in the digits of the upper extremities and was 5 mm throughout. 2PD first appeared in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, and the Sixth Edition states, “sensory deficits can be challenging to grade, since the clinical examination is based on subjective reports by the patient. Grading is based on the results of sensibility testing and two-point discrimination, to improve inter-rater reliability.” The discussion of “sensibility” involves a concept of sensory perception that is more appropriate in surgery literature than neurological literature, and the discussion of the case report in this article reflects the recent literature regarding 2PD as a measure of sensibility. The authors report that sensibility is not a simple recovery of sensory function following nerve injury but rather is a complex interaction between nerve recovery and modulation of central nervous system function in spinal cord, subcortical, and cortical structures. The authors ask if the value of 2PD in the clinical assessment of impairment has been overrated within the AMA Guides, as was range of motion in the assessment of spine impairment.
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Melhorn JA, Martin DP, Brooks CN, Seaman SM. Upper Limb. In: Melhorn JM, Talmage JB, Ackerman WE, Hyman MH, Guides to the Evaluation of Disease and Injury Causation. Chicago; American Medical Association, 2013: 243–356
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Gardner EP, Johnson KO. Touch. In: Kandel ER, Schwartz JH, Jessell TM, et al., eds. Principles of Neural Science. 5th ed. New York;McGraw-Hill; 2013.
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Aronson A, Barron JA, Brown JR et al.. The sensory examination. In: Clinical Examinations in Neurology. 3rd ed. Mayo Clinic. Philadelphia: WB Saunders; 1971:189–190.
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Novak CB. Evaluation of hand sensibility. J Hand Ther. 2001;14:266–272.
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Pynsent PB, Fairbank JCT, Carr JC. Outcome Measures in Orthopaedics and Orthopaedic Trauma. London: Arnold; 2004.
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Tamura Y, Hoshiyama M, Inui K et al.. Central mechanisms for two-point discrimination in humans. Neurosci Lett. 2003;342:187–190.
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Cope EB, Anthony JH. Normal values for the two point discrimination test. Pediatr Neurol. 1992;8:251–254.
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Lungborg G, Rosen G. Two point discrimination test: time for a re-appraisal? J Hand Surg Br 2004, 29:418–422.
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Jerosch-Herold C. Study of the relative responsiveness of five sensibility tests for assessment of recovery after median nerve injury and repair. J Hand Surg Br 2003, 28:255–260.
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Jerosch-Herold C. Assessment of sensibility after nerve injury and repair: systematic review of evidence for validity, reliability, and responsiveness of tests. J Hand Surg Br 2005;30:252–264.
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D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000;283:3110–3117.
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Stedman's Medical Dictionary. Boston: Houghton Mifflin Company; 2002.
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Taylor MT. Peripheral nervous system impairment. In: Demeter SL, Andersson GBJ, eds. Disability Evaluation. 2nd ed. Chicago: American Medical Association; 2003.
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Kandel ER. From nerve cells to cognition: internal representations of space and action. In: Kandel ER, Schwartz JH, Jessell TM, et al., eds. Principles of Neural Science. 5th ed. New York; 2013.
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