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Table of Contents    
COMMENTARY
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1031-1032

Restoration of hand function: A critical parameter during neurorehabilitation, and the confounding factors influencing its evaluation


1 Department of Neurosurgery, Institute of Neurosciences and Spinal Disorders, Gleneagles Global Health City, Chennai, Tamil Nadu, India
2 Department of Neuro Rehabilitation, Institute of Neurosciences and Spinal Disorders, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Date of Web Publication6-Sep-2017

Correspondence Address:
K Sridhar
Department of Neurosurgery, Institute of Neurosciences and Spinal Disorders, Gleneagles Global Health City, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_729_17

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How to cite this article:
Sridhar K, Krishnamoorthy E S. Restoration of hand function: A critical parameter during neurorehabilitation, and the confounding factors influencing its evaluation. Neurol India 2017;65:1031-2

How to cite this URL:
Sridhar K, Krishnamoorthy E S. Restoration of hand function: A critical parameter during neurorehabilitation, and the confounding factors influencing its evaluation. Neurol India [serial online] 2017 [cited 2019 Dec 15];65:1031-2. Available from: http://www.neurologyindia.com/text.asp?2017/65/5/1031/214071


One of the most critical functions affecting neurorehabilitation is the restoration of hand function. The paper by Sanil John et al., from Christian Medical College, Vellore, India, evaluates the utility of the Nine-Hole Peg Test (NHPT) as a measure of hand function. It provides normative data on hand function, showing, for example, that there is a significant difference in the median time between the right and left hand function, the right being faster; as also differences exist in how women and men perform on the test.[1]

Deploying the test in a series of individuals with cervical spondylotic myelopathy undergoing central corpectomy, the authors manage to demonstrate the utility of NHPT as a measure of hand function, and emphasize that it compares well with two other measures, the modified Japanese Orthopaedic Association (MJOA) and the Nurick scales.

It is noteworthy that:

  • None of those with a good pre-operative hand function suffered any decrements in their functional status post-operatively, validating the surgical procedure and the skills of the surgeons[1],[2]
  • Many patients could not be assessed in the one-week postoperative period; and, those who could, did not show any significant differences in the hand function within this time frame
  • A substantial proportion of patients improved in their neurological status within the 6-month post-operative evaluation.


One of the key points highlighted by the authors is that the left and right hand function have not been separately evaluated in most of the previous studies and that their study is quite unique in this respect. Having made that important contention, it is surprising that the authors chose to measure the median time taken to perform the NHPT, as an average of the time taken by the right hand and left hand of the individual participants to perform the test. In our view, the authors would have done well to estimate the left and right hand median times separately, as we do well know that many patients with cervical spondylotic myelopathy may have relative or even absolute sparing of function in one hand when compared to the other. Equally, it is curious that the evaluation of handedness does not figure in the list of tests carried out by the authors, even among the subjects with normal hand function. While admittedly, the larger proportion of individuals in any community are right-handed, in a study of this nature, where normative data for the times taken by the left and right hand to perform the test is being assessed, such an information is of crucial importance.

The authors have not explained adequately why the NHPT result had a negative correlation with both the other measures (the mJOA and Nurick scales) employed, that is, if the nature of scoring predicates such negative correlation, or indeed whether or not this result was in itself aberrant. The authors suggest that the NHPT is perhaps a more sensitive and specific measure of long-term hand function recovery, unlike the mJOA and Nurick scales that are affected by other potential confounders, or indeed the rapid hand flick test, which is sensitive early (when compared to NHPT) but not later. They would have done well to conclude that the one-week post-operative testing they employed was futile with a test like the NHPT and was inappropriate for the vast majority of participants. Indeed, the one-month, three-month and six-month evaluation would perhaps have been more appropriate testing timelines for those undergoing this test.

Other confounding factors that may have influenced the results of this testing and, therefore, need a candid acknowledgement, include:

  • The premorbid hand-eye coordination and dexterity
  • The pre-morbid gross and fine motor function and the pre-existence of any neurodevelopmental disability
  • Base of skull or cerebellar involvement, for example, the presence of associated craniovertebral junction anomalies
  • The occupation of the said individual, as some occupations demand better hand-eye coordination skills, and therefore, people engaged in these occupations develop better coordination
  • The role of practice needs to be considered; repeated testing may enhance performance
  • Perhaps the most important influencing factor is whether or not rehabilitation delivered to and received by all the included participants was ubiquitous, as the six month response in particular could be strongly influenced by such an intervention.


In sum, this is a useful and interesting study that provides data both in normal subjects and those with disease. The NHPT could well be a useful measure, easily employed in several settings, and should be a subject of further research.

 
  References Top

1.
John S, Moorthy RK, Sebastian T, Rajshekhar V. Evaluation of hand function in healthy individuals and patients undergoing uninstrumented central corpectomy for cervical spondylotic myelopathy using nine-hole peg test. Neurol India 2017;65:1025-30.  Back to cited text no. 1
  [Full text]  
2.
Gupta A, Rajshekhar V. Functional and radiological outcome in patients undergoing three level corpectomy for multi-level cervical spondylotic myelopathy and ossified posterior longitudinal ligament. Neurol India 2016;64:90-6.  Back to cited text no. 2
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