• Open access
  • Published: 18 September 2020

Medical Research Council-sumscore: a tool for evaluating muscle weakness in patients with post-intensive care syndrome

  • Zeynep Turan   ORCID: orcid.org/0000-0001-8142-3467 1 ,
  • Mahir Topaloglu 1 &
  • Ozden Ozyemisci Taskiran 1  

Critical Care volume  24 , Article number:  562 ( 2020 ) Cite this article

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COVID-19 may lead to severe acute respiratory distress syndrome requiring intensive care unit (ICU) support. Patients surviving respiratory distress could develop post-intensive care syndrome (PICS) that includes ICU-acquired weakness (ICUAW). Nearly 66% of COVID-19 patients have clinically important muscle weakness following discharge [ 1 ]. Therefore, communication between the critical care and rehabilitation physician is important to evaluate the physical function of COVID-19 survivors to start rehabilitation timely.

The comprehensive examination of muscle strength in COVID-19 is not easy. Muscle strength can be evaluated by manual muscle testing and dynamometer. Electrophysiological study is important in diagnosing critical illness neuromyopathy; however, its correlation with muscle weakness is not clear. Ultrasonography can detect atrophy and structural changes but does not correlate with muscle function [ 2 ].

Medical Research Council (MRC)-sumscore evaluates global muscle strength. Manual strength of six muscle groups (shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion) is evaluated on both sides using MRC scale. Summation of scores gives MRC-sumscore, ranging from 0 to 60. This score was developed for detecting early strength alterations in patients with Guillain-Barré syndrome, especially who were bedridden and receiving artificial ventilation. The sensitivity and interobserver agreement of MRC-sumscore was demonstrated [ 3 ]. Despite its ceiling effect, this score reliably identifies significant weakness (< 48) and even better in severe weakness (< 36) [ 4 ] which is the main medical interest for treatment in ICUAW.

Handgrip strength is a rapid, simple, and objective tool that is measured by handheld dynamometer represents global muscle strength. The cutoff value for handgrip strength in critically ill patients is defined as < 11 kg force for males and < 7 kg force for females which is below that of the age- and sex-matched patients [ 5 ]. It was proposed as an alternative to MRC in ICUAW [ 5 ]. However, examination of other muscles by MRC-sumscore might give additional information since the neurological consequences of COVID-19 are not clear yet. ICUAW is more pronounced in proximal muscles; therefore, direct evaluation of proximal muscles is also valuable. MRC is associated with mortality, hospital, and ICU-free days in ICUAW more strongly than handgrip strength [ 5 ].

In conclusion, MRC-sumscore is a valid, reliable, objective, and easy method to evaluate the global muscle strength including PICS related to COVID-19. It provides beneficial information about the clinical course. Its bedside applicability without necessitating any device makes MRC-sumscore a valuable tool in the follow-up of patients with PICS.

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Abbreviations

Intensive care unit

Intensive care unit acquired weakness

Medical Research Council

Post-intensive care syndrome

Wang Z, Wang Z, Sun R, Wang X, Gu S, Zhang X, et al. Timely rehabilitation for critical patients with COVID-19: another issue should not be ignored. Version 2. Crit Care. 2020;24(1):273. https://doi.org/10.1186/s13054-020-02967-7 .

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Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19(1):274. https://doi.org/10.1186/s13054-015-0993-7 .

Kleyweg RP, van der Meché FG, Schmitz PI. Interobserver agreement in the assessment of muscle strength and functional abilities in Guillain-Barré syndrome. Muscle Nerve. 1991;14(11):1103–9. https://doi.org/10.1002/mus.880141111 .

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Hermans G, Clerckx B, Vanhullebusch T, Segers J, Vanpee G, Robbeets C, et al. Interobserver agreement of Medical Research Council sum-score and handgrip strength in the intensive care unit. Muscle Nerve. 2012;45(1):18–25. https://doi.org/10.1002/mus.22219 .

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Ali NA, O’Brien JM Jr, Hoffmann SP, Phillips G, Garland A, Finley JC, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261–8. https://doi.org/10.1164/rccm.200712-1829OC .

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Department of Physical Medicine and Rehabilitation, Koc University School of Medicine, Maltepe Mah, Davutpasa Cad, No:4, Topkapı, Zeytinburnu, 34010, Istanbul, Turkey

Zeynep Turan, Mahir Topaloglu & Ozden Ozyemisci Taskiran

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ZT contributed substantially to the conception and design of the study, drafted and provided critical revision of the article, and took responsibility in necessary literature review for the study. MT contributed substantially to the conception of the study and took responsibility in necessary literature review for the study. OOT contributed substantially to the conception and design of the study and drafted and provided critical revision of the article. All authors read and approved the final manuscript.

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Turan, Z., Topaloglu, M. & Ozyemisci Taskiran, O. Medical Research Council-sumscore: a tool for evaluating muscle weakness in patients with post-intensive care syndrome. Crit Care 24 , 562 (2020). https://doi.org/10.1186/s13054-020-03282-x

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DOI : https://doi.org/10.1186/s13054-020-03282-x

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Critical Care

ISSN: 1364-8535

medical research council scale

MedicalCRITERIA.com

MedicalCRITERIA.com

Unifying concepts, medical research council (mrc) scale for muscle strength.

The muscle scale grades muscle power on a scale of 0 to 5 in relation to the maximum expected for that muscle.

  • Grade 5: Muscle contracts normally against full resistance.
  • Grade 4: Muscle strength is reduced but muscle contraction can still move joint against resistance.
  • Grade 3: Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner’s resistance completely removed. As an example, the elbow can be moved from full extension to full flexion starting with the arm hanging down at the side.
  • Grade 2: Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane.
  • Grade 1: Only a trace or flicker of movement is seen or felt in the muscle or fasciculations are observed in the muscle.
  • Grade 0: No movement is observed.
  • Grade 0: normal.
  • Grade 1: no disability; minor sensory signs or areflexia.
  • Grade 2: mild disability; ambulatory for >200 m; mild weakness in one or more limbs and sensory impairment.
  • Grade 3: moderate disability; ambulatory for >50 m without stick; moderate weakness MRC Grade 4 and sensory impairment.
  • Grade 4: severe disability; able to walk >10 m with support of stick; motor weakness MRC Grade 4 and sensory impairment.
  • Grade 5: requires support to walk 5 m; marked motor and sensory signs.
  • Grade 6: cannot walk 5 m, able to stand unsupported and able to transfer to wheelchair, able to feed independently.
  • Grade 7: bedridden, severe quadriparesis; maximum strength MRC grade 3.
  • Grade 8: respirator and/or severe quadriparesis; maximum strength MRC grade 2.
  • Grade 9: respirator and quadriplegia.
  • Grade 10: dead.

Modified Medical Research Council (mMRC) Dyspnea Scale

References:

  • Medical Research Council. Aids to the examination of the peripheral nervous system, Memorandum no. 45, Her Majesty’s Stationery Office, London, 1981.
  • Hahn AF, Bolton CF, Pillay N, et al. Plasma exchange therapy in chronic inflammatory demyelinating polyneuropathy. A double-blind, sham controlled, cross-over study. Brain 1996;119:1055–66. [Medline]
  • Paternostro-Sluga T, Grim-Stieger M, Posch M, Schuhfried O, Vacariu G, Mittermaier C, Bittner C, Fialka-Moser V. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med. 2008 Aug;40(8):665-71. [Medline]

Created: Mar 23, 2009.

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Measuring Shortness of Breath (Dyspnea) in COPD

How the Perception of Disability Directs Treatment

Dyspnea is the medical term used to describe shortness of breath, a symptom considered central to all forms of chronic obstructive pulmonary disease (COPD) including emphysema and chronic bronchitis.

As COPD is both a progressive and non-reversible, the severity of dyspnea plays a key role in determining both the stage of the disease and the appropriate medical treatment.

Challenges in Diagnosis

From a clinical standpoint, the challenge of diagnosing dyspnea is that it is very subjective. While spirometry tests (which measures lung capacity) and pulse oximetry (which measures oxygen levels in the blood) may show that two people have the same level of breathing impairment, one may feel completely winded after activity while the other may be just fine.

Ultimately, a person's perception of dyspnea is important as it helps ensure the person is neither undertreated nor overtreated and that the prescribed therapy, when needed, will improve the person's quality of life rather than take from it.  

To this end, pulmonologists will use a tool called the modified Medical Research Council (mMRC) dyspnea scale to establish how much an individual's shortness of breath causes real-world disability.

How the Assessment Is Performed

The process of measuring dyspnea is similar to tests used to measure pain perception in persons with chronic pain. Rather than defining dyspnea in terms of lung capacity, the mMRC scale will rate the sensation of dyspnea as the person perceives it.

The severity of dyspnea is rated on a scale of 0 to 4, the value of which will direct both the diagnosis and treatment plan.

Role of the MMRC Dyspnea Scale

The mMRC dyspnea scale has proven valuable in the field of pulmonology as it affords doctors and researchers the mean to:

  • Assess the effectiveness of treatment on an individual basis
  • Compare the effectiveness of a treatment within a population
  • Predict survival times and rates

From a clinical viewpoint, the mMRC scale correlates fairly well to such objective measures as pulmonary function tests and walk tests . Moreover, the values tend to be stable over time, meaning that they are far less prone to subjective variability that one might assume.  

Using the BODE Index to Predict Survival

The mMRC dyspnea scale is used to calculate the BODE index , a tool which helps estimate the survival times of people living with COPD.

The BODE Index is comprised of a person's body mass index ("B"), airway obstruction ("O"), dyspnea ("D"), and exercise tolerance ("E"). Each of these components is graded on a scale of either 0 to 1 or 0 to 3, the numbers of which are then tabulated for a final value.

The final value—ranging from as low as 0 to as high as 10—provides doctors a percentage of how likely a person is to survive for four years. The final BODE tabulation is described as follows:

  • 0 to 2 points: 80 percent likelihood of survival
  • 3 to 4 points: 67 percent likelihood of survival
  • 5 of 6 points: 57 percent likelihood of survival
  • 7 to 10 points: 18 percent likelihood of survival

The BODE values, whether large or small, are not set in stone. Changes to lifestyle and improved treatment adherence can improve long-term outcomes, sometimes dramatically. These include things like quitting smoking , improving your diet  and engaging in appropriate exercise to improve your respiratory capacity.

In the end, the numbers are simply a snapshot of current health, not a prediction of your mortality. Ultimately, the lifestyle choices you make can play a significant role in determining whether the odds are against you or in your favor.

Janssens T, De peuter S, Stans L, et al. Dyspnea perception in COPD: association between anxiety, dyspnea-related fear, and dyspnea in a pulmonary rehabilitation program . Chest. 2011;140(3):618-625. doi:10.1378/chest.10-3257

Manali ED, Lyberopoulos P, Triantafillidou C, et al. MRC chronic Dyspnea Scale: Relationships with cardiopulmonary exercise testing and 6-minute walk test in idiopathic pulmonary fibrosis patients: a prospective study . BMC Pulm Med . 2010;10:32. doi:10.1186/1471-2466-10-32

Esteban C, Quintana JM, Moraza J, et al. BODE-Index vs HADO-score in chronic obstructive pulmonary disease: Which one to use in general practice? . BMC Med . 2010;8:28. doi:10.1186/1741-7015-8-28

Chhabra, S., Gupta, A., and Khuma, M. " Evaluation of Three Scales of Dyspnea in Chronic Obstructive Pulmonary Disease. " Annals of Thoracic Medicine. 2009; 4(3):128-32. DOI: 10.4103/1817-1737.53351 .

Perez, T.; Burgel, P.; Paillasseur, J.; et al. " Modified Medical Research Council scale vs Baseline Dyspnea Index to Evaluate Dyspnea in Chronic Obstructive Pulmonary Disease. " International Journal of Chronic Obstructive Pulmonary Disease . 2015; 10:1663-72. DOI: 10.2147/COPD.S82408 .

By Deborah Leader, RN  Deborah Leader RN, PHN, is a registered nurse and medical writer who focuses on COPD.

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MRC Scale | Muscle Strength Grading | Strength Testing

MRC Scale

  • Assessment E-Book

MRC stands for Medical Research Council which is the institution that sets up the standard for muscle strength testing.

The strength can be categorized on a level from zero to five. In our example, we will use the extension of the knee joint. So, the muscle which we are going to test is the Quadriceps.

The levels are as follows:

  • Grade 0: The patient cannot activate the muscle, so no movement is observed. For grade 0, ask the patient to contract his quadriceps. He can do this by pushing the back of his knee into the bench. For grade 0, I will not see or feel a flicker or trace of contraction or movement.
  • Grade 1: the patient can activate the muscle, without moving the limb. So only a trace or flicker of movement is seen or felt during palpation of the muscle. For grade 1, ask the patient to do the exact same thing, and this time, you will see or feel a muscle flicker or trace of movement.
  • Grade 2: movement over the full range of motion can only occur if gravity is eliminated. In order to distinguish between grades 1 and 2, we have to bring our patient in side-lying position to eliminate gravity. Then, I will support the leg of my patient, bring it into full flexion and ask my patient to move into extension. If my patient is able to move through the full range of motion, this is a grade 2. If no movement is possible at all, we are talking about grade 1.
  • Grade 3: the patient can overcome gravity and move through the full range of motion without resistance coming from the examiner. For grade 3, I’ll ask my patient to extend his knee against gravity.
  • Grade 4: weakness with resistance. So your patient can move through the full range of motion with moderate resistance coming from the examiner. For grade 4, I will give moderate resistance against the extension of my patient’s knee.
  • Grade 5: full strength. So your patient can move through the whole range of motion against full resistance coming from the examiner.And for grade 5, give full resistance against the extension of the patient’s knee. In order to distinguish between a grade 4 and 5, make sure to compare both legs.

Now that you’ve seen the basics of how to test according to the MRC scale, make sure to practice this with different joints and muscles and figure out a way of how to position your patient.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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medical research council scale

MRC Dyspnoea Scale - MRC

The MRC Dyspnoea Scale, also called the MRC Breathlessness Scale, has been in use for many years for grading the effect of breathlessness on daily activities. This scale measures perceived respiratory disability, using the World Health Organization (WHO) definition of disability being “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being”.

The MRC Dyspnoea Scale is simple to administer as it allows the patients to indicate the extent to which their breathlessness affects their mobility.

The 1-5 stage scale is used alongside the questionnaire to establish clinical grades of breathlessness.

MRC Breathlessness Scales: 1952 and 1959

Questionnaire on Respiratory Symptoms

The questionnaire was first published in 1960 under the approval of the MRC Committee on the Aetiology of Chronic Bronchitis. This was revised and a new version published in 1966. When the committee disbanded, the responsibility for it was passed to the newly formed MRC Committee for Research into Chronic Bronchitis who again revised it in 1976. When this committee disbanded, the responsibility for the questionnaire passed to the Committee on Environmental and Occupational Health (CEOH) who reviewed it and issued what remains to be the most recent version in 1986.

The Questionnaire on Respiratory Symptoms was designed to be used in large scale epidemiological studies only (100-1,000 people). It cannot be used on an individual basis.

Questionnaire on respiratory symptoms and instructions to interviewers (1966)

Questionnaire on respiratory symptoms and instructions to interviewers (1976)

Questionnaire on respiratory symptoms and instructions to interviewers (1986)

Permission to reuse the MRC Dyspnoea Scale

In accordance with MRC’s Open Access Policy , permission is granted from the MRC to use the MRC Dyspnoea Scale for any purpose (including research and commercial purposes) and MRC hereby agrees not to assert its rights in relation to the proposed use of the MRC Dyspnoea Scale.

You must give appropriate credit (“Used with the permission of the Medical Research Council”) and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests that the MRC endorses you or your use.

We cannot give permission to use any modified versions of this scale including the MRC Scale.

Note: The MRC is not in a position to authorise translations or check back-translations

Contact information

Ask a question, or get further information about any of the MRC scales. Email: [email protected]

For information about licensing

To view the full Open Government Licence, visit National Archives: Open Government Licence Version 2 .

Further context, best practice and guidance can be found in the National Archives: UK Government Licensing Framework .

LifeArc manages MRC’s intellectual property rights and commercialises findings by licensing them to industry. They can be contacted for support via the contact information on their website .

Last updated: 24 January 2022

This is the website for UKRI: our seven research councils, Research England and Innovate UK. Let us know if you have some quick feedback or help us improve your experience by taking three minutes to tell us what you think of the UKRI website .

medical research council scale

Case report

Reliability and validity of the medical research council (mrc) scale and a modified scale for testing muscle strength in patients with radial palsy.

RELIABILITY AND VALIDITY OF THE MEDICAL RESEARCH COUNCIL (MRC) SCALE AND A MODIFIED SCALE FOR testing muscle strength in PATIENTS WITH RADIAL PALSY

Tatjana Paternostro-Sluga, MD, PhD 1 , Martina Grim-Stieger, MD 1 , Martin Posch, MD, PhD 2 , Othmar Schuhfried, MD 1 , Gerda Vacariu, MD 1 , Christian Mittermaier, MD 1 , Christian Bittner, MD 1 and Veronika Fialka-Moser, MD, PhD 1

From the 1 Department of Physical Medicine and Rehabilitation and 2 Department of Medical Statistics, Medical University of Vienna, Vienna, Austria

OBJECTIVE: To assess the inter-rater and intra-rater reliability and validity of the original and a modified Medical Research Council scale for testing muscle strength in radial palsy.

DESIGN: Prospective, randomized validation study

Patients: Thirty-one patients with peripheral paresis of radial innervated forearm muscles were included.

METHODS: Wrist extension, finger extension and grip strength were evaluated by manual muscle testing. Dynamometric measurement of grip strength was performed. Pair-wise weighted kappa coefficients were calculated to determine inter-rater and intra-rater reliability. The 2 scores were compared using the signed-rank test. Spearman’s correlation coefficients of the maximal relative force measurements with the median (over-raters) Medical Research Council and modified Medical Research Council scores were calculated to determine validity.

RESULTS: Inter-rater agreement of the Medical Research Council scale (finger extension: 0.77; wrist extension: 0.78; grip strength: 0.78) and the modified Medical Research Council scale (finger extension: 0.81; wrist extension: 0.78; grip strength: 0.81) as well as intra-rater agreement of the Medical Research Council scale (finger extension: 0.86; wrist extension: 0.82; grip strength: 0.84) and the modified Medical Research Council scale (finger extension: 0.84, wrist extension: 0.81; grip strength: 0.88) showed almost perfect agreement. Spearman’s correlation coefficients of the maximal relative force measurements with the median Medical Research Council and modified Medical Research Council score were both 0.78.

CONCLUSION: Medical Research Council and modified Medical Research Council scales are measurements with substantial inter-rater and intra-rater reliability in evaluating forearm muscles.

Key words: manual muscle strength testing, Medical Research Council scale, peripheral nerve lesion, radial palsy.

J Rehabil Med 2008; 40: 665–671

Correspondence address: Tatjana Paternostro-Sluga, Department of Physical Medicine and Rehabilitation, Medical University of Vienna/Austria, Waehringer Guertel 18-20, AT-1090 Vienna, Austria. E-mail: [email protected]

Submitted August 21, 2007; accepted April 7, 2008

INTRODUCTION

For the assessment of muscle strength, quantitative methods using dynamometers (1) and more qualitative methods of manual muscle testing (MMT) are available. Dynamometric testing is not suitable for weak muscles when movement against resistance cannot be performed, as often occurs in the case of peripheral nerve lesions. This is the critical phase of nerve regeneration, when it is not known whether sufficient regeneration will occur. Nerve surgery may be indicated and the decision for or against nerve surgery depends on the clinical course of the disease. Assessment is therefore very important and MMT is the only applicable strength measurement in peripheral nerve lesions with high-grade paresis.

MMT was developed by Lovett and described by Wright in 1912 (2). This technique has been revised, advanced and promoted so that it has resulted in a range of methods from which the investigator may select the most suitable one (3). The scale proposed by the Medical Research Council (MRC) uses the numeral grades 0–5 (4). Kendall & McCreary (5) use percentages, and Daniels & Worthingham (6) use differentiation between Normal, Good, Fair, Poor, Trace and Zero.

The MRC scale is widely accepted and frequently used. Nevertheless, little is known about its reliability and validity in peripheral nerve lesions. Therefore, a major concern of this study was to examine the inter-rater and intra-rater reliability of the MRC scale in patients with peripheral nerve lesions.

Moreover, the MRC scale neither considers the range of motion (ROM) for which a movement can be performed nor defines the strength of resistance against which a movement can be performed (7). These aspects are particularly relevant for grades 3 and 4. Grade 3 of the MRC scale indicates that active movement against gravity is possible; grade 4 denotes that active movement against resistance is possible. To resolve this problem, the guidelines (4) recommend the use of plus and minus subdivisions within grade 4. Grade 4 is subdivided into 3 categories: slight, moderate and strong resistance (8). The problem with this subdivision is that the quantification of resistance is descriptive and that the meaning of “low”, “moderate” and “strong” is unclear. The different levels of resistance are highly rater-dependent. Therefore, the modification of resistance for subdivisions of the scale is not an optimum solution. Moreover, no subdivision is provided for grade 3.

In order to obtain a more specific clinical picture of a peripheral nerve lesion and its course of motor recovery, a modified MRC (mMRC) scale including ROM was defined. ROM was chosen for the subdivision because this parameter can be quantified more easily than resistance, even in clinical routine.

The aim of the present study was to investigate the inter-rater and intra-rater agreement and validity of the original and mMRC scales for assessment of muscular weakness due to peripheral paresis of radial innervated forearm muscles.

The study was approved by the local ethics committee and was performed at the department of physical medicine and rehabilitation at the General Hospital, Medical University of Vienna, Vienna, Austria. The 5 examiners were specialists in physical medicine and rehabilitation with 4–10 years of experience in the assessment of muscle strength. The sequence of the examiners was randomized.

Inclusion criteria . Muscular weakness of more than 3 months’ duration in the radial innervated forearm muscles, caused by a peripheral lesion of the radial nerve, a radicular lesion C7 or a lesion of the brachial plexus involving the C7 fibres. In the case of brachial plexus lesions patients could have additional paresis of the median and ulnar innervated muscles of the hand and arm.

Exclusion criteria. ROM less than 40° for the tested movements caused by contracture of an involved joint or by shrinkage of soft tissue due to scars. Other exclusion criteria were progression of the lesion, and systemic disease of the peripheral nervous system or the central nervous system.

Original and modified MRC scale

The original MRC scale is shown in Table I. The mMRC scale (Table II) was designed as follows: grades 0, 1, 2 and 5 of the mMRC scale are in conformity with the original MRC scale; and grades 3 and 4 are modified by including the active ROM in the grading system.

ROM was measured visually.

The strength of wrist extension (extensor carpi ulnaris and radialis muscles), extrinsic finger extension (extensor digitorum muscle) and grip (flexor digitorum superficialis and profundus muscle, intrinsic hand muscles) were evaluated by MMT, graded by the original MRC and mMRC scale. A quantitative muscle testing of grip strength was performed using the Jamar dynamometer (Jamar TEC, Clifton, USA) (9).

Three measurements were taken from the affected and the healthy hand. The testing procedure of inter-rater reliability included 15 min rest between the assessments of the different raters to avoid muscle fatigue.

All positions and procedures for testing were standardized, strictly defined, and in accordance with the recommendations of the MRC (8).

As a first step, a pilot study comprising 5 patients was performed. The results were used to discuss the problems of clinical testing that arose during the assessment of muscle strength and to estimate the required sample size. Thereafter, the process of clinical strength testing was defined in greater detail and the examiners trained together twice. The pilot patients were not included in the study. Based on the observed standard errors of the pair-wise weighted kappa values in the pilot study, a sample size of at least 30 patients was deemed necessary to achieve weighted kappa estimates with a standard error of less than 0.025 (10).

MMT with the modified MRC scale according to Paternostro-Sluga et al.

Wrist extension, extrinsic finger extension and grip strength were tested. First the feasible passive ROM was evaluated by visual measurement. Movement against gravity was then tested. For this purpose the patient’s forearm was pronated. If the movement against gravity amounted to more than 50% of the feasible passive ROM the patient was graded as at least a force grade 3. If an active movement was possible but was less than 50% of the feasible passive ROM the force grade was 2–3.

If movement against gravity was not possible, the forearm was brought into a neutral position between supination and pronation and the wrist into a 0° position. The patient was then asked to perform the movement. The examiner palpated the muscle. If there was no contraction, muscle strength was graded 0. If a contraction was perceived it was graded 1. If a movement could be performed for more than 5° it was graded 2, which meant active movement with gravity eliminated.

If movement against gravity was possible over more than 50% of the feasible passive ROM, testing against resistance followed. The patient’s forearm was in pronation. If the movement against resistance could be performed over less than 50% of the feasible passive ROM, muscle strength was graded as grade 3–4. If it was possible to move over more than 50% of the ROM, it was graded 4.

Movement against strong resistance over the entire ROM, but weaker than the contralateral side, was classified as grade 4–5.

The same resistance as that on the contralateral side was rated grade 5.

For grades 0–2, when movement against resistance was not possible, the forearm was held in a neutral position between pronation and supination and the wrist in a 0° position, which was assisted by the examiner.

For testing the other grades the forearm was held in pronation.

Three assessments of each tested movement were made and the best performance was determined. The testing procedure included 15 minutes’ rest between the assessments of the different raters in order to avoid muscle fatigue.

Dynamometric measurement

For dynamometric assessment of grip strength a Jamar dynamometer (Jamar TEC, Clifton, USA) (9) was used. The forearm was held in a neutral position between pronation and supination. Three trials were performed and the best trial was used for the evaluation. The dynamometric assessment was perfomed once for all patients and twice within one week for 22 patients, combined with the intra-rater testing.

Inter-rater reliability

To test inter-rater reliability, 5 examiners assessed 31 patients. Patients were permitted a 15-min rest between the 5 evaluations.

Intra-rater reliability

To test intra-rater reliability, one examiner tested 22 patients twice. The median time between the ratings was 7 days.

To obtain information about the validity of the MMT for grip strength, each patient was measured by MMT as well as a Jamar dynamometer (Jamar TEC, Clifton, USA).

Statistical analysis

For inter-rater reliability the pair-wise weighted kappa coefficients for all 5 raters were computed and averaged. To account for the finer classification of the mMRC scale, we assigned scores (0, 1, 2, 3, 4, 5 for the MRC scale and 0, 1, 2, 2.5, 3, 3.5, 4, 4.5, 5 for the mMRC scale) and quantified the amount of disagreement by the difference in the scores. Consequently, a disagreement between, for example, the categories 2 and 3 is weighted equally for both scales. Based on these scores, Cicchetti-Allison kappa coefficient weights were used in the calculation of the weighted kappas (11, p. 554). Kappa values from 0.61 to 0.80 were considered as substantial agreement, kappa values above 0.8 as almost perfect agreement (12).

As an additional measure of agreement, for each proband and scale the maximal deviation of the ratings (maximum score – minimum score) was calculated. A maximal deviation of 0 indicates that the raters agreed perfectly; a maximal deviation of 1 indicates that the lowest rating differs from the highest rating by 1. The resulting (paired) maximal deviations for the MRC and the mMRC scale are compared with the signed-rank test to assess whether the agreement of raters differs between the 2 scales. Additionally, the distribution of the maximal deviations is tabulated. Moreover, pair-wise kappa values for the subsets of patients where the median ratings of the unmodified MRC scores was larger than 0 and lower than 5 were calculated.

For intra-rater reliability , pair-wise weighted kappa coefficients for the 2 measurements of one examiner were computed.

From the 3 dynamometric measurements taken at both ratings, first the relative force for each was assessed. This was defined as the ratio between the values for the affected hand and the healthy hand. For each rating the maximum of the 3 ratios was calculated. For these maxima, a variance component analysis (the SAS procedure variance component with the restricted maximum likelihood option) with the independent factors rating (1, 2) and proband was performed. Then the intraclass correlation coefficients defined as (variance between probands) / (sum of all variance components) was calculated. Additionally, the differences in relative force measurements between the first and the second rating were assessed and tested with paired t -tests for significant trends.

To obtain information about validity , Spearman’s correlation coefficient of the maximum of the 3 relative force measurements and the median MRC and the mMRC score over-raters were calculated. For all tests, a 2-sided significance level of 5% was used. Analysis was performed using the statistical software SAS Release 8.2 (SAS Institute, Cary, NC, USA).

Thirty-one patients with peripheral paresis of the radial innervated forearm muscles were included in the study (16 men and 15 women). The subjects’ mean age was 45 years (range 22–84 years), mean height 171 cm (range 155–192 cm) and mean weight 73 kg (range 51–100 kg). The left hand was affected in 13 patients and the right hand in 18. Nineteen patients had a radial nerve lesion, 11 had a lesion of the brachial plexus involving C7 fibres and 1 patient had a radicular lesion C7. The grades of muscle strength rated by the most experienced examiner according to the mMRC scale are shown in Fig. 1.

984fig1.pdf

Fig. 1. Grades of muscle strength for all subjects, rated by the most experienced examiner according to the modified Medical Research Council (mMRC) scale for: (a) wrist extension; (b) finger extension; and (c) grip strength.

Inter-rater agreement

As an example, Table III shows the agreement of raters one and 2 for wrist extension for the modified score. For more than half of the patients the ratings agree perfectly. In 1 patient the difference in ratings (quantified by the distance in scores) disagrees by more than one.

Concerning the inter-rater agreement of the original MRC scale as well as the mMRC scale, the average weighted pair-wise kappas showed substantial agreement for all tested muscles (average weighted pair-wise kappas: MRC scale: wrist extension 0.78, finger extension 0.77, grip strength 0.78; mMRC scale: wrist extension 0.78, finger extension 0.81, grip strength 0.81, see Table IV (a and b). The asymptotic standard error estimates for the pair-wise weighted kappas ranged from 0.03 to 0.18 over all scores.

The maximal inter-rater deviations of the MRC and mMRC ratings for each patient are shown in Table V. None of the differences in the inter-rater deviations between the MRC and the mMRC score were significant (2-sided signed-rank test, all p > 0.05).

If patients with grade 0 and grade 5 are omitted, the average kappa values decrease substantially (MRC scale: wrist extension 0.62, finger extension 0.50, grip strength 0.26; modified MRC scale: wrist extension 0.61, finger extension 0.61, grip strength 0.42)

Intra-rater agreement

Concerning the intra-rater agreement the results were also notable: the weighted kappa coefficients of the original MRC as well as the mMRC scale were all above 0.8 and thus indicated nearly perfect agreement (MRC scale: wrist extension 0.82, finger extension 0.86, grip strength 0.84; mMRC scale: wrist extension 0.81, finger extension 0.84, grip strength 0.88). The asymptotic standard errors of the kappa values did not exceed 0.12 for the MRC and 0.08 for the mMRC.

The frequency of intra-rater agreements for grades 4, 4–5 and 5 are shown in Table VI.

The maximum of the 3 relative force measurements with the dynamometer measured at the 2 time-points resulted in a very high intraclass correlation coefficient of 0.98.

None of the differences in the maximum of the second and the maximum of the first rating were significantly different from zero.

Dynamometer measurements

Grip strength was rated grade 5 in 20 patients. For these patients, the maximum muscle strength in the affected hand (over the 3 short-term repetitions) was 28.58 (standard deviation (SD) 19.96) kg and ranged from 7.26 to 77.11 kg. In the healthy hand the maximum muscle strength was 46.27 ( SD 14.51) kg and ranged from 18.14 to 74.84 kg. For these patients the median ratio between the affected hand and the healthy hand was 0.65, which indicates that the affected hand had 65% of the muscle strength of the healthy hand. Seventy-five percent of these patients had a force ratio between 33% and 95%.

The median value of 6 patients who were assigned grade 4 was 0.12, which indicates that the affected hand had 12% of the muscle strength of the healthy hand. 75% of these patients had a force ratio between 5% and 21%.

Four patients with grade 0 and the patient with grade 3 had a force measurement of 0 (see Fig. 2).

984fig2.pdf

Fig. 2. Dynamometric measurements (Jamar TEC, Clifton, USA) of grip strength are shown as the maximum relative force, defined as the ratio of values for the affected hand and the healthy hand. MRC: Medical Research Council.

Concerning validity, Spearman’s correlation coefficient of median grip strength measured by the original MRC scale with the maximal relative force measurements was 0.78.

The correlation of the mMRC scale with the maximal relative force measurements was also 0.78.

In the present study, the reliability of the original MRC scale for radial palsy was tested and was shown to be substantially good for wrist and finger extension. This is important as the MRC scale is frequently used in clinical routine as well as scientific studies (13–21).

A weakness of the original MRC scale is that it does not consider clinically relevant changes in the strength range of grade 3 and 4 in the recovery process after lesions of the peripheral nervous system. The original MRC scale does not include the ROM for which a movement can be performed. From the clinical point of view, this is an important parameter to follow the regeneration process. If a patient after, for example, traumatic nerve lesion can move against gravity by 5° and 6 weeks later he can move by 60°, then the examiners know that a further improvement has occurred. If, after 6 weeks, movement against gravity is still only 15°, than there might be an obstacle to the regeneration process. Without the modification to the scale the patient would have been scored grade 3 both times. Moreover, it is assumed that the functional relevance of whether a movement can be executed over 15° or 60° is significant. Therefore, a new mMRC scale was designed as an instrument with more grades, in order to represent better the clinical changes that occur in the motor recovery process after peripheral nerve lesions. It was decided to use sub-divisions based on ROM rather than resistance, because ROM is easier to measure and quantify than resistance.

After defining the mMRC scale according to Paternostro-Sluga et al., its reliability was tested and was shown to be as good as the reliability of the original scale. Moreover, it could be shown that the margin of deviation of the mMRC scale was no worse than the margin of deviation of the original MRC scale.

The reliability and validity of various MMT techniques have been tested in patients with poliomyelitis (22–24) and muscular dystrophy (3, 25–27). Florence et al. (3) tested the intra-rater reliability of a modified MRC scale that differentiated between movement against maximal (grade 4+), moderate (grade 4), minimal (grade 4–) and transient (grade 3) resistance. These grades were less reliable than those given in positions in which the factors of gravity and resistance had been eliminated. Moreover, in that study the intra-rater reliability for distal muscles were not as consistent (e.g. weighted kappa for wrist extensors 0.69) as that for the proximal muscles (e.g. weighted kappa for hip flexors 0.9) (3).

Barr et al. (26) assessed the reliability of an mMRC scale that uses plus and minus sub-divisions (4). Perfect agreement was seen 35.9% of the time, consistency within one consecutive strength grade was found 66.5% of the time, and within 2 consecutive steps 84.7% of the time. The agreement for measures of proximal muscle strength ( r = 0.80) was found to be more consistent than that for measures of distal muscle strength ( r = 0.58) (26). Other studies addressed the reliability of a composite score, weighted by a factor that assessed muscle bulk rather than assigning grades to individual muscle groups or individual grades within a particular score (22–24). Some studies that addressed inter-rater reliability used a sum score of various muscles rather than analysing reliability for individual muscle groups (27, 28). Escolar et al. (27) determined a sum score of the mMRC scale and compared the reliability of MMT and quantitative muscle testing. MMT was not as reliable and required repeated training of evaluators to bring all groups to a correlation coefficient > 0.75 (27). Kleyweg et al. (28) registered nearly perfect inter-observer agreement of a sum score of various muscles tested with the MRC scale in patients with Guillain-Barré syndrome. The MMT method described by Daniels & Worthingham (6) was shown to be reliable (29, 30). A more recently published study that addressed inter-rater reliability of MMT only differentiated between “normal” or “reduced” power (31), which is too approximate for assessment of motor recovery after peripheral nerve lesion.

Brandsama et al. (32) tested the reliability of the 6-point MRC scale of intrinsic muscles of the hand. They suggested testing specific movements rather than selective muscles because it is difficult to isolate, and hence grade, most of the intrinsic muscles of the hand (32). They also introduced a mMRC scale (33), which includes the description of ROM as well as resistance into the 6-point original MRC scale. In their mMRC scale, grade 3 has to have normal ROM. In our modified scale, grade 3 has to have more than 50% of the feasible ROM and additional 3 grades (grade 2–3, 3–4 and 4–5) were included, which was assumed to represent better the clinical course of nerve regeneration.

The testing procedure of inter-rater reliability included 15 min rest between the assessments of the different raters to avoid muscle fatigue.

All examiners were specialists in physical medicine and rehabilitation, with different levels of experience. Open points concerning the MMT procedure were discussed during the pilot phase and the examiners were trained to carry out the procedure. One of the issues was to improve the clinical differentiation between intrinsic and extrinsic finger extension in the presence of extrinsic finger extension paresis.

The median time between the ratings for testing the intra-rater reliability was one week. This time span was selected because the rater would probably not remember the result of the first rating and the subject’s clinical condition would remain largely unchanged. Only patients with chronic paresis were included. Thus, a constant muscle force during the entire examination procedure (one week) can be assumed. A further indicator for constant muscle force, at least for grip strength, was that the maximum of the 3 relative force measurements with the dynamometer measured at the 2 time points resulted in a very high intraclass correlation coefficient of 0.98.

Three assessments of each tested movement were made. The best result was determined in order to allow a learning effect and exclude false low muscle grading due to rapid fatigue in weak muscles.

Patients with paresis of the radial innervated forearm muscles were chosen for examination because wrist extension and extrinsic finger extension are hardly influenced by co-activation of muscles innervated by other nerves. In this context it has to be considered that the effect of gravity on the wrist and fingers is much less than on the leg or proximal upper limb and this might limit the generalization of the results.

Excluding patients with grade 0 and grade 5 decreases the reliability level. This shows that the assessment of the different grades of paresis is much more difficult than the assessment of a muscle that has no contraction at all or is evaluated as normal. This emphasizes the importance of training within the team.

Grip strength was also measured in order to obtain information about validity. The limitation of the validity testing is the fact that strength of the radial innervated forearm muscles was not directly assessed. Grip strength may be weak in the presence of radial palsy alone, as wrist dorsal extension cannot be performed, which is an important prerequisite for a strong grip. Some patients also had additional paresis of median or ulnar innervated forearm muscles, resulting in reduced grip strength. A high percentage of patients had a strong grip, which may have improved the correlation coefficient.

Hand-held dynamometers are described for wrist extension (34, 35) and for wrist and metacarpophalangeal joint extension (36). These instruments were not available in the present test setting and therefore grip strength was selected as the parameter for validation.

Measurement with the Jamar dynamometer showed a distinct difference between the left and the right sides and a wide variance of measurements for patients assigned MRC grade 5. Clinicians have to be aware that there is a wide range of strength levels summarized under grade 5. It is necessary to differentiate grade 5 dynamometry. Beasley (37) reported in post-polio children that MMT classified as “normal” were those whose knee extension force was only 50% of normal. The overestimation of the extent to which a patient is “normal” by MMT was also described by Bohannon (38). Moreover, it was shown (39) that, by comparing MMT with hand-held dynamometry, strength differences and deficits in strength were missed at least 25% of the time by MMT in acute rehabilitation patients (39).

For MMT with the mMRC scale, the ROM was measured visually. In former studies it was shown that visual and goniometric measurements of the ROM of the knee joint were equally reliable (40). Moreover, visual measurement can be applied easily and rapidly in the clinical setting. The idea was to create a scale that can be used unmodified in everyday clinical practice. However, measurement with a goniometer might have improved reliability.

In conclusion, the MRC as well as the mMRC scale are manual measurements of muscle strength in peripheral nerve palsy of forearm muscles with substantial inter-rater and intra-rater reliability and strong validity and can be recommended for clinical use. To ensure equal test conditions it is advisable to train the evaluators in advance.

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  • Published: 17 February 2024

Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study

  • Zhen Pang 1   na1 ,
  • Shuai Zhu 1   na1 ,
  • Yun-Dong Shen 1 , 2 , 3 ,
  • Yan-Qun Qiu 2 ,
  • Yu-Qi Liu 4 ,
  • Wen-Dong Xu 1 , 2 , 3 , 4 , 5 , 6 , 7 &
  • Hua-Wei Yin 1 , 2 , 3 , 4 , 5  

BMC Surgery volume  24 , Article number:  64 ( 2024 ) Cite this article

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Metrics details

This study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury.

This retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing’an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n  = 34 patients), nerve repair (group B; n  = 5 patients) and tendon transfer (group C; n  = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function.

Surgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration ( P  < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661–1.000, P  = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575–0.995, P  = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582–0.953, P  = 0.025) and 0.853 (95% CI = 0.693–1.000, P  = 0.001), respectively.

Conclusions

Our study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.

Peer Review reports

Lower extremity nerve injuries represent 20% of all peripheral nerve injuries, among which the common peroneal nerve (CPN) is the most frequently damaged in the lower limb due to its superficial location [ 1 , 2 ]. CPN injury often results in a “drop foot” symptom, with patients often exhibiting a characteristic steppage gait and suffering from ankle motor weakness in dorsiflexion [ 3 ]. The loss of great toe extension and dorsal foot sensory is also common [ 4 ]. The primary goal of surgical intervention is to enhance motor function, particularly in foot dorsiflexion, while also alleviating sensory disturbances and associated symptoms.

The choice of treatment for CPN injuries is heavily influenced by their underlying causes, which encompass various factors such as trauma, idiopathic entrapment, and iatrogenic injuries [ 5 ]. Traumatic etiologies include injuries such as lacerations, knee dislocations and fractures [ 6 ]. Idiopathic entrapment syndrome is the main cause of common peroneal palsies [ 7 ]. For instance, nerve lacerations necessitate immediate nerve repair, while neurolysis is suitable for addressing nerve entrapment. CPNs are frequently compressed by tendons, tumors or ganglion cysts, necessitating their resection during neurolysis procedures [ 8 , 9 ]. Conventional treatment options include conservative management, physical therapy, neurolysis, nerve repair (comprising direct sutures and nerve grafting), and tendon transfer [ 10 ].

Considering that some common peroneal palsies may exhibit spontaneous recovery, non-operative management is usually preferred in cases lacking well-defined injuries [ 4 ]. Successful non-operative approaches include activity restriction and the utilization of ankle-foot orthoses. However, when functional improvement remains slow or absent despite 3–6 months of conservative therapy, surgical interventions become imperative [ 11 ]. Physical therapy techniques, such as electrical stimulation, have been found effective in promoting nerve repair and improving patient function [ 12 ].

Two primary surgical strategies are employed in the treatment of CPN injuries: (1) restoration of CPN function and (2) tendon transfer to reestablish foot muscle function and balance [ 13 , 14 ]. Nerve exploration and neurolysis typically suffice for most entrapment or compression injuries, with 75% of patients demonstrating a positive nerve action potential during surgical exploration, achieving complete recovery [ 15 ]. In cases of sharp lacerations, direct nerve suturing within a few days is often the preferred choice. However, when the peroneal nerve exhibits defects or there is high anastomotic tension, autogenous nerve grafts are preferred, with the sural nerve serving as the most common donor. The success of nerve grafts is closely linked to graft length [ 16 ], as grafts shorter than 6 cm yield favorable outcomes in 64% of patients, while those exceeding 12 cm are associated with favorable outcomes in only 11% of patients [ 2 ]. In recent years, nerve transfer has emerged as a novel approach for CPN injury treatment. Transferring the soleus muscular branch of the tibial nerve to the deep fibular nerve has shown promise in CPN injury repair and the restoration of ankle dorsiflexion [ 17 , 18 ]. Additionally, the double transfer of tibial nerve branches to the flexor digitorum longus and lateral head of the gastrocnemius to the deep peroneal nerve has proven beneficial in restoring motor function for certain patients [ 19 ]. These innovative approaches have opened new avenues in nerve repair therapy.

Neurolysis, being less invasive, facilitates rapid post-surgical recovery and effectively enhances the function of patients with intact CPN continuity. Nonetheless, its precise indications remain somewhat ambiguous. Neurolysis is less efficacious for patients with an unbroken CPN but experiencing complete motor function loss [ 20 ]. Nerve repair is appropriate for individuals with a complete CPN rupture, as it can restore both sensory and motor functions. However, when the graft length becomes excessive, nerve repair outcomes tend to be suboptimal.

Tendon transfer, particularly posterior tibial tendon transfer, is an effective method for reinstating foot dorsiflexion. The primary objective across all treatments remains the correction of foot drop, which can be achieved through tendon transfer [ 21 ]. Initially, tendon transfer was considered a corrective surgery for patients whose nerve function failed to improve after repair. However, a novel surgical approach has recently emerged, wherein tendon transfer is combined with nerve repair in a one-stage protocol, aimed at rebalancing muscle forces for enhanced reinnervation [ 22 ]. Ferraresi et al. have demonstrated that one-stage nerve repair and tendon transfer can yield superior functional recovery compared to nerve repair alone [ 23 ]. Similarly, Ho et al. reported that simultaneous tendon transfer and nerve repair may offer improved function compared to tendon transfer as a sole intervention [ 4 ].

Tendon transfer can effectively restore foot dorsiflexion but cannot fully restore muscle strength or range of motion and may result in flatfoot or hindfoot valgus [ 2 , 20 ]. In addition, tendon transfer was less effective in restoring toe extension and dorsal foot sensory function.

While previous research has established the safety and efficacy of the three surgical treatments, there is a lack of studies investigating the postoperative recovery characteristics of each surgical approach, leading to a lack of evidence-based guidance for the decision-making process of physicians in selecting the most suitable surgery based on individual patient conditions and needs. Consequently, some patients may require a second surgery due to unsatisfactory results, particularly those who have previously undergone neurolysis. Thus, it is important to determine whether neurolysis can indeed yield the desired functional recovery.

Considering the limited number of systematic studies analyzing the factors that influence the prognosis of neurolysis, we designed this study to address these gaps by conducting a comprehensive retrospective analysis of patients post-treatment and investigating the factors that impact surgical outcomes. Our objective is to assess the therapeutic effects of different surgical interventions for CPN injuries and identify the key factors that influence the outcome of neurolysis to provide valuable guidance for clinical decision-making.

Study design and patient population

This descriptive, retrospective study included 45 patients with CPN injuries treated between 2009 and 2019 in Jing’an District Central Hospital. Patients were considered eligible if they met the following criteria: (1) confirmed CPN injury through examination, classified as partial or complete based on EMG grades, and attributable to diverse causes such as trauma, nerve entrapment, or idiopathic origins; (2) demonstrated weak foot dorsiflexion, graded as M0 to M4 on the Medical Research Council (MRC) scale for muscle strength, and/or sensory deficits on the dorsum of the foot; (3) underwent surgical treatments at Jing’an District Central Hospital, with comprehensive preoperative evaluation data available, and; (4) adhered to the follow-up recommendations. The study exclusion criteria were presence of severe organ dysfunction or severe ankle contracture/deformity on the affected side, inability to communicate normally due to severe neuropsychiatric disorders, and unwillingness of patients or their family members to participate in follow-up. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki (as revised in 2013) and was approved by the Ethics Committee of Jing’an District Central Hospital (No. 202303), which waived the requirement for individual consent due to the retrospective nature of the present study.

Treatment selection

The patients were classified into the following groups based on the treatments they underwent rather than the type of injuries; namely, Group A underwent neurolysis, Group B underwent nerve repair, and Group C underwent tendon transfer. The type of treatment was based on the surgeons’ discretions. Potential criteria for considering neurolysis were a closed injury or spontaneous compression in which preoperative electromyography (EMG) shows that stimulation proximal to the injury can elicit compound muscle action potentials at the target muscle, or although no signal is elicited on preoperative EMG, signals are re-recorded after intraoperative exploration of the nerve to release adhesions and open compression, and the texture of the injured nerve is good and continuity is still present; for nerve repair they were a direct cut injury in which the nerve is known to be ruptured preoperatively, or although the patient suffered a non-cut injury, intraoperative exploration reveals a neuroma-like structure at the site of the nerve injury and no evidence of nerve fiber regeneration on EMG; and for tendon transfer they were a patient who has been injured for more than a year and already has muscle atrophy such as a tibialis anterior, or who has had previous neurolysis or nerve repair surgery that has not been effective.

Surgical technique

Patients received either lumbar anesthesia or general anesthesia while in the prone position, and the surgery followed standard sterile procedures with the application of a lower extremity tourniquet. The tourniquet was set at a pressure of 55 kPa and was in use for less than 60 min.

For neurolysis, a surgical oblique incision, typically 6–8 cm in length, was made extending from the fibular head to the popliteal space. The nerve, often entering the peroneal muscle layer near the head of the fibula, was tracked to locate the compression site. Frequently, the nerve is entrapped by the peroneus longus and brevis tendons or scar tissue. The tissue causing the nerve entrapment was excised, and in certain cases, partial dissection of the CPN’s epineurium was necessary (Fig.  1 ).

figure 1

The release of the nerve distally. The white arrow indicates the common peroneal nerve after release. This is a lateral incision at the fibular head on the right leg, with the popliteal fossa on the right and the calf on the left

In the nerve graft procedure, an S-shaped incision of approximately 12 cm in length was made beneath the fibular head. The CPN was explored and released from the fibular head to the sites where the superficial and deep peroneal nerves bifurcate. Both nerves were separately exposed to confirm their continuity, and any ruptured or necrotic sections of the nerve were revealed. These damaged portions of the nerve were dissected, and the stumps on either side were trimmed to expose the healthy nerve papilla. The length of the nerve defect was then measured. When the defect gap was less than 1 cm, a direct suture was performed as the preferred approach. In cases with larger gaps, nerve grafting was required. The sural nerve, typically obtained through a surgical incision in the lateral calf, was used as the donor for nerve grafts, with the cut length of the sural nerve determined by the length of the CPN defect. Three- or four-strand sural nerves were employed in parallel to bridge the peroneal nerve (Fig.  2 ).

figure 2

Suturing of the sural nerves between the common peroneal nerve stumps. The white arrow indicates the distal end of the common peroneal nerve, the gray arrow indicates the proximal end of the common peroneal nerve, and the white asterisk indicates the transplanted nerve

In tendon transfer, two longitudinal incisions were made, one on the medial foot and the other on the medial calf. The posterior tibialis tendon was exposed and cut at its tendon insertion sites (Fig.  3 ). In some cases, the peroneal brevis tendon and flexor digitorum longus were also utilized for transfer. Subsequently, two longitudinal incisions were created, one over the dorsal surface of the foot and the other on the dorsal calf. An electric drill was used to perforate the diaphysis of the third cuneiform bone, extending through to the sole of the foot. The posterior tibialis tendon was guided through the tibiofibular interosseous membrane to reach the anterolateral foot incision. A puncture needle was used to facilitate the passage of the tendon through the cuneiform hole to the plantar surface, with the foot held at 80° of dorsiflexion. The site of tendon fixation was then sutured and reinforced (Fig.  4 ).

figure 3

The posterior tibialis tendon was delivered from the wound on the medial calf. The gray arrow indicates the posterior tibialis tendon. The incision outlined by the white dotted line is used to find and resect the insertion of the posterior tibialis tendon. See Fig.  4 for the specific surgical operation

figure 4

Fixing the tendon by sutures. The posterior tibialis tendon indicated by the white arrow is sutured to the third cuneiform bone. This is a front-and-rear view with the toe in front and the heel behind

Assessments

The following data were retrieved and assessed: demographic information, medical history, preoperative evaluations and postoperative outcomes. In both preoperative and follow-up physical examinations, motor strength and sensory function were assessed using the British Medical Research Council Scale. For motor rating comparison, we utilized the following convention: the standard S3 + sensory rating was designated as S4, and the standard S4 sensory rating was denoted as S5. Motor strength assessments were based on the anterior tibia-based foot dorsiflexion, soleus muscle-based foot plantarflexion, as well as toe dorsiflexion and plantarflexion. Sensory function scoring focused on the dorsal foot and lateral lower leg. Preoperative physical examinations also included Tinel’s sign evaluation at the fibular head. All patients underwent preoperative EMG to confirm the CPN injuries.

In the outcome evaluation, pain was assessed using the numeric rating scale (NRS) from 0 (no pain) to 10 (worst pain imaginable). The functional recovery level was assessed by questioning the patients on their activity level and participation in sports. The activity level included ambulatory walking, independent walking, and running. All of the patients were asked to rate their “overall satisfaction with the outcome of the operation” on a scale of extremely satisfied, satisfied, satisfied with reservation, and dissatisfied.

We considered a patient to have achieved good function if their motor grade was M3 or higher, while an M2 motor grade indicated fair function. Poor function was assigned for scores falling within the M0–1 range. Simultaneously, sensory functions are classified according to the same criteria as the above classification of motor functions [ 22 ].

Follow-up was conducted through telephone, online communication software, or outpatient visits, with a minimum 1-year post-surgery duration and included assessing surgical efficacy (i.e., postoperative sensorimotor function, daily activities), detecting postoperative adverse events (i.e., pain, numbness), and evaluating satisfaction to the surgical treatments.

Statistical analysis

Statistical analysis was performed using the SPSS V22 statistics tool (IBM Corporation, Armonk, New York, USA). Due to the nature of our data, non-parametric methods were predominantly used. Spearman correlation test assessed relationships between ordinal variables, such as the time interval from injury to surgery and postoperative functional outcomes. Graphs were generated using GraphPad Prism 7 software (Dotmatics, Boston, Massachusetts, USA). Data are presented as mean ± standard deviations. Quantitative variables were analyzed using Student’s t -test and qualitative variables using the Mann-Whitney U test.

Receiver operating characteristic (ROC) curve analysis was performed to determine the threshold time interval from injury to surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function. To validate the predictive ability of the time elapsed from injury to surgery, the area under the curve (AUC) was computed, and the optimal cut-off points were identified based on the highest Youden Index.

Quantitative data were analyzed using the Student’s t-test for normally distributed variables and the Mann-Whitney U test for non-normally distributed variables. Subgroup analyses within Group A were performed using one-way analysis of variance (ANOVA) to identify factors associated with the outcome of neurolysis. Post-hoc tests incorporating Tukey correction were conducted to determine the significant differences among various subgroup means.

All comparisons were two-tailed, and statistical significance was determined based on P  < 0.05.

General clinical data of the patient

The study cohort included 35 males and 10 females, aged between 2 and 67 years old, with a mean age of 31.16 years old. Of them, 34 underwent neurolysis, five received nerve graft, and 6 underwent tendon transfer. On average, patients underwent neurolysis 6.1 ± 5.4 months (ranging from 0.5 to 24 months) after the onset of the disease, nerve graft 2.2 ± 0.4 months after disease onset (with four cases at 2 months and one case at 3 months), and tendon transfer 38.2 ± 23.3 months after disease onset (ranging from 10 to 72 months, with three cases under 36 months and three cases over 36 months). The patient groups were designated as groups A, B and C, corresponding to those who underwent neurolysis, nerve graft, and tendon transfer, respectively.

Regarding the nature of the injuries, ten patients experienced peroneal nerve injuries due to cut trauma (five of whom underwent neurolysis, as confirmed by electromyography and intraoperative exploration that revealed intact CPN continuity). Eight injuries resulted from traffic accidents, six from falls, six from knee dislocations, two from crush injuries, one from an unspecified trauma, eight from idiopathic nerve compression (including local compression and strenuous exercise), two from iatrogenic causes, one from poisoning, and one had an unknown cause (Table  1 ).

Recovery of motor function

Before surgery, most patients had poor or fair foot dorsiflexion. However, nine patients in group A presented with good foot dorsiflexion function before the operation and their surgical indications primarily aimed to alleviate pain, further enhance functionality, improve toe dorsiflexion, and alleviate severe numbness.

The mean follow-up duration for the patients was 5.28 years. Compared to their preoperative levels, patients who underwent neurolysis ( P  < 0.001), nerve repair ( P  = 0.032) and tendon transfer ( P  = 0.015) all demonstrated improvements in foot dorsiflexion muscle strength after surgery. Specifically, in group A, 31 patients (91%) who received neurolysis achieved good foot dorsiflexion function, with 22 (71%) initially presenting with poor or fair dorsiflexion function preoperatively (Table  2 ). In group B, three patients (60%) who underwent nerve repair attained active dorsiflexion with a strength of M3. In group C, five patients (83%) who underwent tendon transfer achieved active dorsiflexion, demonstrating strengths ranging from M3 to M5 (Table  2 ). Notably, one patient in group B with fair recovery underwent secondary nerve repair. Furthermore, one patient in group C with poor recovery exhibited irreversible muscle atrophy. Toe dorsiflexion function, which is governed by the deep peroneal nerve branch of the CPN [ 24 ], was also monitored. In group A, 26 patients (76%) who underwent neurolysis achieved good toe dorsiflexion; in group B, three patients (60%) achieved good or fair toe dorsiflexion, with one patient in this group demonstrating an upgrade from fair to good function postoperatively; and in group C, one patient (17%) achieved good toe dorsiflexion (Table  3 ). Therefore, compared to nerve repair, tendon transfer proved more effective in restoring foot dorsiflexion function but displayed lower efficacy in restoring toe dorsiflexion.

In group A, patient satisfaction levels were as follows: 15 patients (44%) were extremely satisfied, nine patients (26%) were satisfied, eight patients (24%) were satisfied with reservation, and two patients (6%) were dissatisfied. In group B, one patient (20%) was extremely satisfied, two patients (40%) were satisfied, and two patients (40%) were dissatisfied. In group C, one patient (17%) was extremely satisfied, three patients (50%) were satisfied, and two patients (33%) were dissatisfied (Table  2 ). Patients in groups B and C who had fair or poor dorsiflexion outcomes expressed dissatisfaction. Additionally, one patient in group C, a 4-year-old, expressed dissatisfaction as the patient had hoped for more substantial improvements in foot dorsiflexion and toe dorsiflexion.

Recovery of sensory function

Neurolysis effectively restored sensory function in the dorsal foot and lateral lower leg for patients with CPN injuries ( P  < 0.001). However, patients who underwent nerve repair ( P  = 0.310) or tendon transfer ( P  = 0.699) did not show significant improvements in sensory function after surgery compared to their preoperative status. In group A, 30 patients (88%) experienced substantial sensory function recovery in the dorsal foot and lateral calf (Table  4 ). In group B, two patients had improved their sensory function from poor to fair, and one patient from fair to good, while the remaining patients exhibited no changes in sensory function. In Group C, one patient’s sensory function in the dorsal foot and lateral calf improved from fair to good. Comparatively, nerve repair appeared more effective than tendon transfer in restoring sensory function.

Among the patients, numbness in the dorsal foot and lateral calf was reported by 17 patients (50%) in group A. In contrast, four patients (80%) in group B and only one patient (17%) in group C reported numbness. In terms of the highest level of achieved activity, 23 patients (68%) in group A were able to run, and 11 patients (32%) could walk unaided. In group B, two patients (40%) could run, while three patients (60%) were limited to walking. In group C, three patients could run, and two patients could walk barefoot after tendon transfer. Pain was infrequently reported among these patients, with only three patients (9%) in group A describing slight pain. Among the five patients in group B, one reported severe pain with an NRS rating of 7. In group C, two patients (33%) experienced pain, with ratings of 3 or 5. All patients underwent Tinel’s sign testing at the lateral aspect of the fibular head and neck. Most of the 34 patients in the neurolysis group, two of the five patients in the nerve repair group, and four of the six patients in the tendon transfer group exhibited positive results. However, no significant relationship was observed between the presence of Tinel’s sign and surgical outcomes.

Factors affecting the prognosis of neurolysis

Three neurolysis patients later received tendon transfer to improve motor function. For individuals with suboptimal neurolysis outcomes, alternative surgeries were considered to enhance functional recovery. Factors influencing neurolysis outcomes were then explored, and the results indicated that foot dorsiflexion recovery showed no significant age correlation (ρ = 0.052, P  = 0.77). However, it exhibited a weak correlation with preoperative EMG results (ρ = 0.353, P  = 0.04) and a significant negative correlation with the time from onset to surgery (ρ=−0.481, P  = 0.004). Patients with preoperative EMG findings suggesting partial CPN injury tended to achieve better neurolysis outcomes than those with complete CPN injury. Moreover, shorter intervals between onset and surgery were associated with improved neurolysis results.

When assessing motor function recovery, we focused on the tibialis anterior muscle responsible for foot dorsiflexion, a crucial aspect impacting patients’ daily lives. A correlation was observed between higher postoperative foot dorsiflexion muscle strength and shorter time intervals (Fig.  5 A). However, due to variations in preoperative muscle strengths among patients, the reliability of this finding is limited. Subsequently, we narrowed our analysis to 21 patients with poor preoperative dorsiflexion muscle strength (Table  2 ) to investigate changes in muscle strength after neurolysis. Consistent with previous results, shorter time intervals were associated with greater functional improvements (Fig.  5 B-C). However, statistical significance in Fig.  5 B is limited due to the small number of patients with muscle strength changes from 0 to 2 ( n  = 3). Combining patients with 0–2 grade changes and those with 3 grade changes into one group, we found that a short time from symptom onset to surgery can lead to substantial foot dorsiflexion functional recovery (muscle strength increased by 4–5). However, a longer interval did not necessarily imply a lack of functional recovery, as muscle strength can still improve by 0–3.

figure 5

The tibialis anterior muscle force among the three groups. A . Relationship between the time from symptom onset to neurolysis and post-surgery muscle strength (M3 vs. M5). Patients with M5 muscle strength after surgery (3.37 ± 2.43) had a significantly shorter period from symptom onset to surgical treatment compared to those with M3 muscle strength (7.25 ± 3.07). P =0.011. Data from one patient, whose muscle strength had recovered to M5, was excluded from the analysis due to an unusually long time interval (24 months) between symptom onset and neurolysis. When including this patient’s data, the time interval for patients with M5 was 4.66 ± 5.52, and the P value was 0.0549. B-C . Duration from symptom onset to neurolysis in relation to changes in tibialis anterior muscle force. B. Patients with 4 (4.16 ± 2.79) or 5 (3.5 ± 1.89) grade muscle strength improvements exhibited shorter time intervals than those with 0–2 improvements (13.33 ± 7.72). P =0.03 (compared to 4 grade improvements), P =0.02 (compared to 5 grade improvements). C . Patients with 4-5 grade muscle strength improvements (3.83 ± 2.41) had shorter time intervals than those with 0–3 improvements (8.78 ± 5.98). P =0.03. *, P <0.05; error bars represent the standard deviation (SD). n =33 for panel A , n =21 for panels B-C . TA, tibialis anterior

Investigation of toe dorsiflexion function recovery showed a significant association between better recovery and shorter time intervals (Fig.  6 A). Analysis of patients who lacked toe dorsiflexion before surgery ( n  = 22 patients; Table  3 ) showed that a shorter time interval between symptom onset and surgery correlated with improved toe dorsiflexion (Fig.  6 B). It was found that once a specific time threshold was exceeded, patients lost the opportunity to restore toe dorsiflexion function.

figure 6

The toe dorsiflexion muscle strength among the three groups. A . Relationship between the time from symptom onset to neurolysis and post-surgery toe dorsiflexion muscle strength (M0-M2 vs. M3-M5). Patients with M3 to M5 muscle strength (5.14 ± 3.06) had significantly shorter time intervals between symptom onset and surgical treatment compared to patients with M0 to M2 muscle strength (9.38 ± 5.74). P =0.04. B . Graph illustrating that patients with 3 to 5 grade muscle strength improvements had shorter time intervals (5.4 ± 5.5) than those without improvements (11 ± 6). P =0.0074. *, P <0.05; **, P <0.01; error bars represent the standard deviation (SD). n =34 for panel A , n =21 for panel B

Next, we investigated the recovery of sensory function in the dorsal foot and lateral lower leg following neurolysis. Similar to motor function recovery, we observed that better sensory function recovery was associated with shorter time intervals (Fig.  7 A). Assessment of 28 patients with poor or fair sensory function prior to treatment (Table  4 ) revealed a trend toward sensory function improvement among those with shorter durations between disease onset and neurolysis (Fig.  7 B). However, due to limited sample sizes in each group, statistical significance was not established. When combining patients with no improvement and those with only one level of improvement, we found that individuals with shorter time intervals achieved significant sensory function recovery, whereas those with longer intervals experienced limited improvements (Fig.  7 C).

figure 7

The sensory grade analysis among the three groups. A . Relationship between the time from symptom onset to neurolysis and sensory grade (Grade 3 vs. Grade 5). Patients with Grade 5 sensory function (3.38 ± 2.37) had a significantly shorter period from symptom onset to surgical treatment compared to those with Grade 3 (8.92 ± 2.43). P =0.002. B-C . Time from symptom onset to treatment for patients with different changes in sensory grade. C. Patients with 3 to 4 grade sensory function improvements exhibited shorter intervals (4.41 ± 5.26) than those with 0–1 improvement (11.43 ± 5.34). P =0.02. *, P <0.05; **, P <0.01; error bars represent the standard deviation (SD). n =34 for panel A , n =28 for panels B-C

To assess the predictive value of time intervals for neurolysis outcomes, ROC analysis was conducted. Using M3 foot dorsiflexion recovery as the reference standard, the optimal time interval cut-off was 9.5 months, with an AUC area of 0.871 (95% CI = 0.661–1.000, P  = 0.04; Fig.  8 A), indicating that patients undergoing neurolysis within 9.5 months of injury had a good chance of achieving foot dorsiflexion at or above M3. When considering M4 foot dorsiflexion recovery as the reference standard, the optimal cut-off interval was 5.5 months, with an AUC area of 0.785 (95% CI = 0.575–0.995, P  = 0.02; Fig.  8 D). Therefore, for patients aiming for foot dorsiflexion at or above M4, early neurolysis within 5.5 months after injury is advisable. Similarly, when using M3 toe dorsiflexion recovery or S4 sensory function recovery as the reference standards, the optimal cut-off remained at 5.5 months, with AUC areas of 0.768 (95% CI = 0.582–0.953, P  = 0.025; Fig.  8 B) and 0.853 (95% CI = 0.693–1.000, P  = 0.001; Fig.  8 C), respectively. In summary, the best chances of recovering foot dorsiflexion, toe dorsiflexion, and sensory function are associated with neurolysis within 5.5 months after injury. Neurolysis performed between 5.5 and 9.5 months post-injury still allows partial foot dorsiflexion recovery.

figure 8

ROC curves for time to surgery. A . ROC analysis using M3 foot dorsiflexion recovery as the gold standard, with a best cut-off value of 9.5 months (AUC=0.871, 95% CI=0.661-1.000, P =0.04). B . ROC analysis using M3 toe dorsiflexion recovery as the gold standard, with a best cut-off value of 5.5 months (AUC=0.768, 95% CI=0.582-0.953, P =0.025). C . ROC analysis using S4 sensory function recovery as the gold standard, with a best cut-off value of 5.5 months (AUC=0.853, 95% CI=0.693-1.000, P =0.001). D . ROC analysis using M4 foot dorsiflexion recovery as the gold standard, with a best cut-off value of 5.5 months (AUC=0.785, 95% CI=0.575-0.995, P =0.02). n =25 for panels A and D ; n =33 for panel B ; n =30 for panel C . ROC, Receiver Operating Characteristic; AUC, Area Under the ROC Curve

The high incidence of CPN injuries presents a significant challenge in selecting the most appropriate treatment. In our study, we explored various treatment options, including conservative treatment, physical therapy, neurolysis, direct suture or nerve graft, and tendon transfer. Each treatment method was selected based on the etiology and severity of the patient’s injury, acknowledging that the right treatment approach can vary significantly depending on these factors. Patients with CPN transection or traction injuries can be considered for tendon transfer, while those with CPN rupture may benefit from nerve graft or tendon transfer and those with CPN compression are often considered for neurolysis [ 25 ]. However, in cases of cut traumas, intraoperative exploration has sometimes revealed CPN continuity. When these patients undergo timely surgery, simple neurolysis can lead to significant functional recovery. In a previous study, we did not observe a clear relationship between the causes of injury and postoperative outcomes, which might be attributed to the high incidence of trauma as the primary cause of injury and the varying degrees of injury severity among patients.

The CPN innervates muscles responsible for both foot and toe dorsiflexion. In this study, we aimed to provide a comprehensive assessment of CPN function by including both foot and toe dorsiflexion. While foot dorsiflexion is crucial for gait, toe dorsiflexion, governed by the deep peroneal nerve branch of the CPN, also plays a role in balanced and functional gait, particularly during the swing phase. Our findings revealed that a significant proportion of patients achieved good toe dorsiflexion recovery postoperatively. Specifically, 76% of patients undergoing neurolysis and 60% in the nerve repair group achieved good or fair toe dorsiflexion. This indicates the potential for functional recovery of toe dorsiflexion, which we believe is an important aspect of overall CPN function. The recovery of toe dorsiflexion function showed a significant association with shorter time intervals between symptom onset and surgery, indicating that patients who underwent surgery within shorter time intervals were more likely to achieve improved toe dorsiflexion, highlighting the time-sensitive nature of this aspect of recovery.

Conservative treatment can be effective for some CPN injuries, as spontaneous recovery is possible in certain cases. However, Maalla et al. found that if symptoms do not start to improve within the first month, early surgery within the first few months is advisable, which could otherwise delay or lead to incomplete spontaneous recovery [ 7 ]. Some patients with subtle symptoms and no significant findings in EMG may also benefit from surgery [ 26 ]. While physical therapy, including electrical stimulation, is a safe clinical approach [ 27 ] that can accelerate axon regeneration beyond the site of injury after surgery [ 28 ], it should be viewed as a complementary method that requires coordination with surgical intervention. Neurolysis of the CPN generally leads to faster recovery compared to rehabilitation therapy alone [ 7 ]. However, not all patients are willing to undergo surgery, and some may not be suitable candidates for neurolysis. Furthermore, there are no well-defined criteria to recommend or avoid neurolysis. Nerve repair has become increasingly effective with advancements in microsurgery techniques, although it tends to yield suboptimal results in patients not treated within 12 months of injury or those requiring grafts longer than 12 cm [ 2 ]. Tendon transfer is a common alternative for patients with limited nerve function. However, some patients may be hesitant to undergo tendon transfer, especially when ankle-foot orthoses like shoe dorsiflexion splint inserts can adequately support their daily activities [ 29 ].

One significant finding from our study is the independent predictive value of the time elapsed between symptom onset and neurolysis on patient outcomes, which can aid surgeons in making informed decisions regarding surgical interventions. Patients who underwent neurolysis within 5.5 months of their injury achieved substantial recovery in foot/toe dorsiflexion function and sensation. However, those who had surgery between 5.5 and 9.5 months post-injury only experienced partial foot dorsiflexion improvement, and neurolysis was less likely to restore effective function in individuals injured for over 9.5 months. In such cases, alternative options like tendon transfer or nerve repair may be more appropriate. Prior studies have also noted a correlation between the timing of surgery and postoperative recovery [ 30 , 31 , 32 ]. Nonetheless, our study offers a more comprehensive and systematic exploration of how CPN neurolysis influences postoperative sensorimotor function recovery, with potential clinical implications. Given the potential for spontaneous recovery in some patients, we cannot definitively attribute the functional improvements observed within shorter time intervals solely to neurolysis. Nevertheless, we can conclude that patients with more favorable motor and sensory functional recoveries tend to have shorter time intervals. For patients with longer intervals, additional treatment modalities may be necessary to facilitate substantial functional recovery. Taken together, our findings provide important insights for clinical decision-making and emphasize the importance of timely surgical intervention.

Neurolysis can achieve favorable outcomes in 80% of patients [ 2 ], with reduced functional recovery observed as surgery is delayed [ 33 ]. Timely medical attention is crucial, but treatment delays can occur due to patient referral issues [ 33 ]. The CPN has a poorer blood supply than the tibial nerve [ 34 , 35 ], which can lead to irreversible CPN damage with long-term compression, rendering traditional neurolysis less effective.

Some patients may choose observation over neurolysis, as advocated by Rose et al., for a 6-month observation period in peroneal nerve palsy [ 36 ]. In our series, all patients (except one) were treated after at least 1 month of observation. However, we found that observation alone did not yield satisfactory results. Despite potential drawbacks, the benefits of surgery outweigh the disadvantages. Currently, a 6–8 cm incision is made at the fibular head, but Ducic et al. recommended a minimally invasive 3 cm approach to reduce surgical trauma [ 37 ].

Our results indicated that tendon transfer generally led to better foot dorsiflexion recovery compared to nerve grafting, while nerve grafting was more effective in toe dorsiflexion and sensory function recovery. Giuffre et al. reported a 30% functional recovery rate ( n  = 10) in patients undergoing nerve repair, which is suboptimal [ 38 ]. Due to the limited number of nerve repair cases in our study, we refrain from making a definitive conclusion about the efficacy of nerve grafting. Yeap et al. reported that 83% of patients ( n  = 12) who underwent posterior tibial tendon transfer achieved excellent or good outcomes [ 39 ], consistent with our findings. Overall, these highlight the need for a tailored approach in treating CPN injuries, considering the specific functional deficits and patient needs.

Nerve repair, also known as nerve graft in our studies, yielded favorable motor recovery in 60% of patients and sensory recovery in 40%. Among our series, four patients had grafts shorter than 6 cm, with three of them achieving good motor function recovery, as reported by Kim et al. [ 33 ]. Notably, graft length, rather than the number of cables, significantly influenced the outcomes [ 31 , 40 ]. Fragility of the nutrient arteries of the CPN is a critical consideration; Lundborg et al. observed complete nerve ischemia with a 15% elongation of nerves [ 41 ]. To enhance nerve graft success, it is advisable to minimize graft length, reduce intraoperative nerve stretching, and ensure tension-free anastomosis. However, nerve grafting is inevitably associated with complications, including numbness.

The decision to use the Peroneus brevis tendon in transfers was influenced by its potential to enhance motor function, particularly in cases where nerve repair alone might not suffice. Our findings revealed that 83% of patients who underwent tendon transfer achieved favorable foot dorsiflexion recovery. While toe dorsiflexion function was not fully restored by tendon transfer, one patient exhibited improved toe dorsiflexion postoperatively. This improvement may be attributed to the balancing effect of tendon transfer on foot extension and plantar flexion forces, thereby promoting CPN regeneration. The mean time interval to surgery was 3 years, consistent with the understanding that nerve function may take up to 2 years to recover after nerve repair [ 42 ]. However, patients with prolonged foot dorsiflexion dysfunction may develop rigid equinus contracture, potentially leading to permanent deficits in plantarflexion [ 4 ]. Early tendon transfer is already widely accepted for ulnar and radial nerve injuries [ 43 , 44 ], suggesting that it may be a suitable option for patients who do not benefit from neurolysis.

Tendon transfer primarily enhances motor function, while nerve repair offers both motor recovery and sensory improvement. Consequently, combining these complementary procedures can facilitate patient recovery. Milesi’s theory suggests that reinnervation may be impeded by the force imbalance between active plantar flexor muscles and passively stretched denervated foot extensors [ 45 ]. Tendon transfer can rectify this imbalance, and simultaneous tendon transfer and nerve graft may enhance rehabilitation according to this theory [ 40 ]. Considering the limitations of each surgical method, our study supports the idea of combining tendon transfer and nerve repair to achieve better rehabilitation outcomes. This combined approach, in line with Milesi’s theory, suggests that rebalancing muscle group strength through tendon transfer, alongside nerve repair, can promote more comprehensive patient recovery.

Our research has several limitations that should be considered. First, this was a retrospective study in a single medical center, and the number of patients was limited. Second, data regarding postoperative rehabilitation were not reported in most patient’s reports and could not be analyzed. Third, several patients had incomplete physical examination results, and we did not perform simultaneous tendon transfer and neurolysis or nerve graft and could not evaluate combination procedures. Lastly, we acknowledge that focusing solely on toe dorsiflexion may not fully capture the functional gait outcomes. In future studies, larger sample sizes, more comprehensive data sets and more detailed analysis (i.e., ankle dorsiflexion and its direct impact on gait ability, alongside toe dorsiflexion) would be needed to provide a more holistic understanding of CPN injury recovery and validate these obtained results.

Our retrospective study on CPN injury therapy demonstrates the effectiveness of surgical treatment in improving clinical outcomes. While some patients may experience spontaneous recovery, our findings suggest that early surgical intervention leads to better outcomes, especially in cases where conservative treatment does not yield significant improvements. Thus, the choice of treatment should be guided not only by the nature of the CPN injury but also by the timing of surgical intervention, which is a crucial factor for motor and sensory function recovery after neurolysis, evidenced by the optimal results achieved when neurolysis was performed within 5.5 months of injury. Neurolysis alone can partially restore foot dorsiflexion function between 5.5 and 9.5 months after injury, but combining it with other procedures yielded the best therapeutic results. For patients who have been injured for more than 9.5 months, neurolysis alone may not be advisable, and in such cases, nerve repair and tendon transfer could be more appropriate options, as nerve repair was found to enhance the recovery of toe dorsiflexion and sensation in the dorsal foot and lateral lower leg. However, patients undergoing nerve repair often experience numbness and occasional pain. Tendon transfer was suitable for patients aiming at improving foot dorsiflexion function to some extent. Taken together, these results could help assist clinicians in selecting appropriate treatment plans tailored to the characteristics and needs of CPN injury patients.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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This work was supported by the National Natural Science Foundation of China (Nos. 81801941, 82021002, 81830063); the National Science and Technology Innovation 2030 Major Program (No. 2021ZD0204200); the Shanghai Technology Innovation Plan (No. 21Y11902900); the Fujian Province Science and Technology Innovation Joint Fund Programme (No. 2021Y9129); the Shanghai Municipal Clinical Medical Center Project (No. 2022ZZ01007); and the Program of Shanghai Municipal Commission of Health and Family Planning (No. 20164Y0018).

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Zhen Pang and Shuai Zhu contributed equally to the article as Co-first author.

Authors and Affiliations

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China

Zhen Pang, Shuai Zhu, Yun-Dong Shen, Wen-Dong Xu & Hua-Wei Yin

Department of Hand and Upper Extremity Surgery, Jing’an District Central Hospital, Shanghai, China

Yun-Dong Shen, Yan-Qun Qiu, Wen-Dong Xu & Hua-Wei Yin

Department of Orthopedics and Hand Surgery, the First Affiliated Hospital of Fujian Medical University, Fujian, China

Yun-Dong Shen, Wen-Dong Xu & Hua-Wei Yin

Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China

Yu-Qi Liu, Wen-Dong Xu & Hua-Wei Yin

State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, China

Wen-Dong Xu & Hua-Wei Yin

Priority Among Priorities of Shanghai Municipal Clinical Medicine Center, Shanghai, China

Wen-Dong Xu

The National Clinical Research Center for Aging and Medicine, Fudan University, Shanghai, China

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(I) Conception and design: HW Yin, WD Xu, Z Pang; (II) Administrative support: YD Shen, YQ Qiu; (III) Provision of study materials or patients: YD Shen, YQ Qiu; (IV) Collection and assembly of data: Z Pang, S Zhu, YQ Liu; (V) Data analysis and interpretation: Z Pang, S Zhu; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

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Pang, Z., Zhu, S., Shen, YD. et al. Functional outcomes of different surgical treatments for common peroneal nerve injuries: a retrospective comparative study. BMC Surg 24 , 64 (2024). https://doi.org/10.1186/s12893-024-02354-x

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  • Common peroneal nerve injury (CPN injury)
  • Nerve repair
  • Tendon transfer

BMC Surgery

ISSN: 1471-2482

medical research council scale

Stop COVID Cohort: An Observational Study of 3480 Patients Admitted to the Sechenov University Hospital Network in Moscow City for Suspected Coronavirus Disease 2019 (COVID-19) Infection

Collaborators.

  • Sechenov StopCOVID Research Team : Anna Berbenyuk ,  Polina Bobkova ,  Semyon Bordyugov ,  Aleksandra Borisenko ,  Ekaterina Bugaiskaya ,  Olesya Druzhkova ,  Dmitry Eliseev ,  Yasmin El-Taravi ,  Natalia Gorbova ,  Elizaveta Gribaleva ,  Rina Grigoryan ,  Shabnam Ibragimova ,  Khadizhat Kabieva ,  Alena Khrapkova ,  Natalia Kogut ,  Karina Kovygina ,  Margaret Kvaratskheliya ,  Maria Lobova ,  Anna Lunicheva ,  Anastasia Maystrenko ,  Daria Nikolaeva ,  Anna Pavlenko ,  Olga Perekosova ,  Olga Romanova ,  Olga Sokova ,  Veronika Solovieva ,  Olga Spasskaya ,  Ekaterina Spiridonova ,  Olga Sukhodolskaya ,  Shakir Suleimanov ,  Nailya Urmantaeva ,  Olga Usalka ,  Margarita Zaikina ,  Anastasia Zorina ,  Nadezhda Khitrina

Affiliations

  • 1 Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 2 Inflammation, Repair, and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.
  • 3 Soloviev Research and Clinical Center for Neuropsychiatry, Moscow, Russia.
  • 4 School of Physics, Astronomy, and Mathematics, University of Hertfordshire, Hatfield, United Kingdom.
  • 5 Biobank, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 6 Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 7 Chemistry Department, Lomonosov Moscow State University, Moscow, Russia.
  • 8 Department of Polymers and Composites, N. N. Semenov Institute of Chemical Physics, Moscow, Russia.
  • 9 Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy.
  • 10 Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany.
  • 11 Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 12 Department of Intensive Care, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 13 Clinic of Pulmonology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 14 Department of Internal Medicine No. 1, Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 15 Department of Forensic Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • 16 Department of Statistics, University of Oxford, Oxford, United Kingdom.
  • 17 Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
  • 18 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
  • 19 Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
  • 20 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
  • PMID: 33035307
  • PMCID: PMC7665333
  • DOI: 10.1093/cid/ciaa1535

Background: The epidemiology, clinical course, and outcomes of patients with coronavirus disease 2019 (COVID-19) in the Russian population are unknown. Information on the differences between laboratory-confirmed and clinically diagnosed COVID-19 in real-life settings is lacking.

Methods: We extracted data from the medical records of adult patients who were consecutively admitted for suspected COVID-19 infection in Moscow between 8 April and 28 May 2020.

Results: Of the 4261 patients hospitalized for suspected COVID-19, outcomes were available for 3480 patients (median age, 56 years; interquartile range, 45-66). The most common comorbidities were hypertension, obesity, chronic cardiovascular disease, and diabetes. Half of the patients (n = 1728) had a positive reverse transcriptase-polymerase chain reaction (RT-PCR), while 1748 had a negative RT-PCR but had clinical symptoms and characteristic computed tomography signs suggestive of COVID-19. No significant differences in frequency of symptoms, laboratory test results, and risk factors for in-hospital mortality were found between those exclusively clinically diagnosed or with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR. In a multivariable logistic regression model the following were associated with in-hospital mortality: older age (per 1-year increase; odds ratio, 1.05; 95% confidence interval, 1.03-1.06), male sex (1.71; 1.24-2.37), chronic kidney disease (2.99; 1.89-4.64), diabetes (2.1; 1.46-2.99), chronic cardiovascular disease (1.78; 1.24-2.57), and dementia (2.73; 1.34-5.47).

Conclusions: Age, male sex, and chronic comorbidities were risk factors for in-hospital mortality. The combination of clinical features was sufficient to diagnose COVID-19 infection, indicating that laboratory testing is not critical in real-life clinical practice.

Keywords: COVID-19; Russia; SARS-CoV-2; cohort; mortality risk factors.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected].

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Hospitalization
  • Middle Aged

Grants and funding

  • 20-04-60063/Russian Foundation for Basic Research

National Academies Press: OpenBook

Terrorism: Reducing Vulnerabilities and Improving Responses: U.S.-Russian Workshop Proceedings (2004)

Chapter: the role of the russian ministry of emergency situations and executive branch agencies of the city of moscow in dealing with emergency situations arising from acts of terrorism, the role of the russian ministry of emergency situations and executive branch agencies of the city of moscow in dealing with emergency situations arising from acts of terrorism.

Aleksandr M. Yeliseev *

Moscow Main Administration for Civil Defense and Emergency Situations

The problems of ensuring the security of people and territory are a top priority for executive- and legislative-branch agencies of the Russian Federation. The major radiation accident at the Chernobyl Atomic Power Station in 1986 and the destructive Spitak earthquake in 1988 demonstrated the need for creating a Russian system for preventing and eliminating the consequences of emergency situations. The Ministry for Civil Defense, Emergency Situations, and Elimination of the Consequences of Natural Disasters (MChS) became the central component in this system. Territorial subunits of the MChS are among the executivebranch agencies of the various republics and oblasts that make up the Russian Federation, and they act at the local level to implement state policy with regard to protecting people and territory from emergency situations.

Moscow has historically represented the spiritual center of the Russian land. It is Russia’s largest industrial center, making a substantial contribution to the country’s overall economic indicators. Our city is the country’s most important transport hub, on which the operation of the entire Russian transportation system is dependent. It represents the most important concentration of financial and information flows, which has a significant impact on the development of the state as a whole. Moscow is the center of scientific and cultural life, the focal point of a significant part of our national heritage, and a unique world-class historical and architectural center. All of these factors determine the level of the threat to the vital interests of citizens, social groups, and the city as a whole.

The following types of threats are most typical: criminal, terrorist, social, political, infrastructural, natural, industrial, environmental, informational, and psychological. These threats are of a complex and interrelated nature, with the majority being transnational in scale. These circumstances are characteristic of almost all the world’s major megacities; therefore, they call for a great deal of attention to be devoted by the city leadership to problems of ensuring the security of urban facilities and residents of the capital.

Here, we proceed from the belief that ensuring the security of the population against emergency situations resulting from terrorism, natural and industrial disasters, and other causes is a difficult and complex task, and carrying it out successfully can be done only with the active involvement of all city departments, agencies, and organizations. Therefore, the Moscow City System for Preventing and Eliminating the Consequences of Emergency Situations was created in 1996, functionally linking the city’s various district and departmental services units. City policy for ensuring the security of the population and the urban infrastructure is implemented through the Commissions on Emergency Situations, which have been established in each agency and department of the city administration and which are headed by leaders at the corresponding level. This operating principle facilitates management of the actions of city units in preventing emergencies as well as responding to threats and responding to emergencies once they have occurred. It is also helpful in coordinating the actions of the various services and organizing and efficiently carrying out emergency rescue operations.

In connection with the implementation of a special law passed by the city of Moscow, work is under way citywide to implement a comprehensive targeted program for improving the Moscow city system for preventing and eliminating the consequences of emergency situations. The program was developed on the initiative of the Moscow City Government and the MChS and was supported by the deputies of the Moscow City Duma. The basic goals of the program include

implementing a set of measures aimed at preventing emergency situations, including the establishment of an effective system for monitoring and predicting accidents, catastrophes, and natural disasters

modernizing the management and communications system through the widespread use of the latest information technologies

improving the speed and efficiency of emergency response by creating a highly mobile and technically well equipped rescue service and by developing aviation technologies for use in emergency rescue operations

improving the citywide system for educating the population on the appropriate actions to be taken during emergency situations

However, in recent years terrorism has been one of the main threats to public security. It presents a special danger to major cities and political, economic, and cultural centers. Terrorist acts are taking on ever-increasing scale and

becoming more and more diverse both in form and in the goals for which they are carried out.

Since 1998, Moscow has been subjected to terrorist attacks on more than one occasion. We remember the bombings of apartment buildings on Guryanov Street and Kashirskoe Shosse, the shopping mall at Manezh Square, the underground passageway at the Pushkinskaya metro station, and the seizure of hostages during the performance of the musical Nord-Ost , in which more than 3,000 people were victims, of whom about 600 were killed.

These events have shown that terrorist acts are ever more frequently moving from the realm of potential threats to that of real emergency situations. In our view it is the world community’s failure to respond appropriately to the terrorist acts committed in Moscow in the fall of 1999 that led to the tragic events of September 11, 2001, in the United States. Those events demonstrated once again that terrorism has no nationality but rather is international in nature, and not a single state is secure against it.

Expert assessments highlight the broad scope of this phenomenon, and many believe that at present in the various countries of the world there are about 100 major terrorist organizations, which maintain contacts among themselves. Therefore, the problem goes beyond the bounds of individual states. Furthermore, in recent years terrorism has acquired the capability of using the achievements of science and technology to further its criminal aims.

We have great understanding for the position of the New York City authorities, as we ourselves were on the scene only minutes after the bombings of the Moscow apartment buildings in 1999. Under the leadership of Moscow Mayor Yury M. Luzhkov and Russian Emergency Situations Minister Sergei K. Shoigu, we organized efforts to deal with the consequences of these explosions. We provided detailed reports on these incidents to the European community at an international conference in Vienna in 2000.

Antiterrorism activities in Moscow are conducted at all levels of the city government. This work is coordinated by an antiterrorism commission operating under the leadership of the city’s mayor, and includes the following activities:

improving laws related to the struggle against terrorism

increasing the effectiveness of preventive measures

ensuring the secure operations of industrial facilities and sites where large numbers of people gather

I would like to say that we have done a certain amount of work to ensure the security of residents and of the capital in general, primarily with regard to the creation of laws and regulations addressing these matters.

The city has recently enacted a Law on Protecting the Population and Territory of the City of Moscow from Emergency Situations of Natural and Industrial Origin. A strategy for the security of Moscow has also been adopted, outlining in

systematic form the views of the city’s leadership on ensuring the safety of its residents. In the process of developing this strategy, the programs Moscow Radiation Security and Moscow Chemical Security were also created and adopted to deal with matters related to protecting potentially dangerous facilities against terrorism. In the past few years, Moscow has passed more than 100 regulations governing matters related to the city’s security, and we are prepared to acquaint representatives of the international community with them.

Executive-branch agencies are devoting special attention to monitoring and controlling the activities of all officials involved in implementing preventive measures against emergency situations. In 2002 alone, the State Inspectorate for Protecting the Population and Territory from Emergency Situations conducted checks at more than 10,000 enterprises, organizations, and institutions. Those guilty of violating urban security regulations face administrative penalties and are prosecuted through the civilian court system.

City policy regarding new construction is pursued rather effectively. Moscow has established a system of measures that prohibits the construction or reconstruction of any industrial buildings, housing, or other public facilities that do not include design features intended to prevent possible emergency situations, including potential terrorist acts.

The city has created the Center for Monitoring and Forecasting Emergency Situations, for which the main objectives are the prevention and early detection of emergencies. The components of this system include stationary and mobile Lidar units, which use laser, infrared, and visual observation methods to detect fires and atmospheric emissions of harmful substances.

In accounting for the large amounts of special cargo (gasoline, reagents for refrigeration systems, and so forth) that pass through Moscow and other world cities, cargo that also represents a potential threat of the commission of terrorist acts, we have tightened controls on the transport of such materials by road and rail within the city limits. The city’s law enforcement agencies are paying special attention to the safety of capital residents in locations where large numbers of people gather, such as markets, fairs, and the sites of large cultural events and sports competitions.

The quality of efforts to prevent and eliminate the consequences of emergency situations depends primarily on the level of preparedness of the leadership, specialists, and city residents. This matter is being addressed by providing training to almost all categories of city residents at special educational institutions, enterprises, and places of residence. For example, in 2002, about 30,000 people received special training at educational centers and more than 2 million blue- and white-collar personnel received training at their worksites.

Training games represent the most effective form of preparation for individuals in positions of leadership. Such games allow participants to practice dealing with matters such as procedures for notification and assembly of senior officials, technologies for application in emergency rescue operations and oth-

er urgent activities, organization of assistance to city service providers in eliminating the consequences of emergency situations, comprehensive provision of aid and services to the affected population, and a number of other citywide undertakings.

Earlier this year, a special tactical training exercise was conducted at a Moscow subway station to focus on coordinating the activities of city services in eliminating the consequences of a possible terrorist act involving the use of dangerous chemical substances. During the training exercise, a number of practical measures were developed with the aim of improving the efficiency of emergency rescue efforts under such conditions, and these measures have now been submitted to the Moscow City Government for review.

Efforts to train young people occupy an important place in our work. Last year, in cooperation with the Moscow Educational Committee, we began training students from the capital’s higher educational institutions to serve as reserve rescue personnel. A class entitled “Principles of Everyday Safety” has also been introduced for students in all grades in elementary and secondary schools. The number of participants in “Safety School” competitions is constantly on the rise. Each year, more and more secondary school students participate in “Young Rescuer” summer camps.

Regarding measures to prevent emergencies, we must not forget that the city must also be prepared to eliminate their consequences. The main element of this system is the Center for Crisis Situation Management, which is designed to gather and process information about emergency situations, inform the population, and make well-founded decisions on how to handle such situations.

At present, plans call for the creation of a Unified Monitoring and Dispatch Center for the city of Moscow on the basis of the facilities of the Moscow City Crisis Situation Management Center and the Force Management Center of the State Fire Service Administration of MChS. This new center, which would be reachable by dialing 01, would facilitate the efficient collection and processing of emergency reports, analyze an enormous amount of information under extremely time-critical conditions, and coordinate the actions of all dispatch services included in the city’s unified dispatch system.

The current combined daily volume for the two centers mentioned above is approximately 6,000 calls. After the switch to the single telephone number 01, it is predicted that the number of calls alone will rise to 18,000 per day. This will require a large set of organizational and technical changes to be made, taking into account foreign experience in operating rescue services using single telephone numbers such as 112 and 911.

Creating, training, and developing forces for eliminating the consequences of emergency situations is of enormous significance in the functioning of the system. To this end, the Moscow City Search and Rescue Service has been created in the capital. Also operating in cooperation with us in the city are various MChS rescue units and a number of commercial entities. If a major emer-

gency occurs, plans call for augmenting the rescue service by calling in specialists and equipment from other city organizations.

Since the city search and rescue service was established, rescuers have carried out about 60,000 rescue operations and have saved more than 25,000 people. In 2002 alone, Moscow firefighters handled about 7,000 fires. The timely and skillful actions of personnel from the city’s medical service have saved the lives of thousands of Muscovites involved in emergency situations and accidents.

Unfortunately, Muscovites have been forced to confront inhuman acts of terrorism in practice. We profoundly share the pain and suffering of other nations affected by emergency situations of any kind. Therefore, the government of Moscow is devoting a great deal of attention to humanitarian operations, including those of international scope. We are providing humanitarian aid to the suffering population in various regions of Russia and in other countries, including Kosovo, Afghanistan, Korea, Bolivia, the Balkans, Germany, the Czech Republic, and others.

Overall, we may conclude that the government of Moscow has a great focus on international cooperation in combating terrorism and crime and eliminating the consequences of terrorist acts and natural and industrial disasters. In recent years, stable contacts have been established among counterpart police and emergency services agencies at the municipal level as part of the comprehensive cooperation between Moscow and foreign cities, including those in Europe. Close cooperation is under way with the cities of Vienna, Berlin, Madrid, Dublin, Helsinki, and others in the form of information sharing, exchanges and training of specialists, and joint training exercises.

In May 2002, on the initiative of Moscow Mayor Yury M. Luzhkov, a meeting of police officials from European countries was convened to promote better coordination in the struggle against terrorism. Moreover, an international meeting on matters of security in major cities is to be held in Moscow in June 2003.

In conclusion, I would like to say that the system that has been created in Moscow for preventing and eliminating the consequences of emergency situations stands ready to cooperate closely in the twenty-first century with any who treasure the ideals of humanism and defense of the most important human right, the right to life.

This book is devoted primarily to papers prepared by American and Russian specialists on cyber terrorism and urban terrorism. It also includes papers on biological and radiological terrorism from the American and Russian perspectives. Of particular interest are the discussions of the hostage situation at Dubrovko in Moscow, the damge inflicted in New York during the attacks on 9/11, and Russian priorities in addressing cyber terrorism.

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How to Measure Outcomes of Peripheral Nerve Surgery

Yirong wang.

1 Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing

Malay Sunitha

2 Clinical Research Coordinator, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI

Kevin C. Chung

3 Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School

Evaluation of outcomes after peripheral nerve surgeries include a number of assessment methods that reflect different aspects of recovery, including reinnervation, tactile gnosis, integrated sensory and motor function, pain and discomfort, neurophysiological and patient- reported outcomes. This review makes a list of measurements addressing these aspects as well as advantage and disadvantage of each tool. Because of complexities of neurophysiology, assessment remains a difficult process, which requires researchers focus on measurements best relevant to specific conditions and research questions.

The outcomes movement, initiated in 1988 was stimulated by the national emphasis on cost containment and efforts to limit geographic differences in the use of various medical procedures. 1 - 3 Goals of the outcomes movement included “increased understanding of the effectiveness of different interventions, the use of this information to make possible better decision making by physicians and patients, and the development of standards to guide physicians and aid third-party payers in optimizing the use of resources, by investigating and comparing patient experiences.” 1 , 4 Patient experiences can range from mortality, physiologic measures, reduction of symptoms, improvement in daily functioning, clinical events, to patient satisfaction. 4 , 5 The outcomes chosen to evaluate care need to be carefully considered based on criteria that are most pertinent to the patient’s need. Additionally vital are the criteria for selecting outcome measurement instruments, which comprise of reliability, validity, and responsiveness of measures, their clinical utility, and relationship to the care under investigation. 5

Peripheral nerve injuries can be caused by trauma, accidental injuries during extensive surgery, nerve tumors, compressive disease or congenital anomalies, with the majority (81%) located on upper extremity. 6 , 7 Among upper or lower-limb trauma, incidence of nerve injuries is reported to be 1.64%, with crush injuries having the highest rate at 1.9%. 8 These injuries may lead to irreversible disabilities in patients, such as sensory loss, deficient motor function, pain problems in terms of cold intolerance and hyperesthesia, that ultimately impair hand function, and affect quality of life at work and in society. 7 Despite marked advances in the neuroscience arena, peripheral nerve injuries continue to pose challenges for surgical reconstruction, as the clinical outcomes still appear unsatisfactory. 6 , 7 Advances in this field will require accurate measures of treatment effectiveness to assess new treatments that are certainly on the horizon.

The assessment of recovery after peripheral nerve surgery remains a challenging process to therapists and surgeons. Numerous cellular and biochemical mechanisms that occur in peripheral and central nervous systems affect the outcomes and result in difficult evaluation of recovery. 9 Measurement instruments for peripheral nerve surgery need to aid clinical diagnosis, assess and compare surgical repair techniques, track rehabilitation progress, provide feedback to both patient and therapist, as well as ascertain disability after injury. 9 The list of objectives useful in evaluation of hand function after peripheral nerve repair is provided in Table 1 . Outcomes research after nerve injury recently emphasizes more on functional results and patient-reported outcomes. 10 - 13 This review focuses on the scope of outcomes assessment tools and the current choices of measurements in outcomes research of peripheral nerve surgery. Table 2 details available methods for assessing patient outcomes after peripheral nerve surgeries.

List of Objectives to Evaluate Hand Function after Peripheral Nerve Repair *

Outcomes Assessment Tools for Measuring Outcomes after Peripheral Nerve Surgeries

Outcomes Assessment

Outcomes assessment in peripheral nerve injuries can be broadly categorized into tests of sensory function, motor function, pain and discomfort, neurophysiological and patient-reported outcomes.

Sensory function

Sensory tests indicate the sensory acuity of the hand and how well the patient is able to use it. 14 Semmes-Weinstein monofilament test is used to assess perception of cutaneous pressure threshold, which reflect reinnervation of peripheral targets. 15 Compared with using a common tuning fork, the test provides quantitative data that can be used to follow a patient serially during the course of nerve regeneration. 16 Tactile gnosis is the capability of the hand to recognize the character of objects, such as shapes, textures, and is a prime marker of functional recovery. 17

Two-point discrimination (2-PD) is an established assessment tool for tactile gnosis. 17 The static two-point discrimination test (S2-PD) measures the innervation density of the slowly-adapting receptor (fire continuously as long as pressure is applied) population. 14 One study showed an age-related decline in the ability to discriminate two points and there was no significant difference between men and women. 18 The moving two-point discrimination test (M2-PD) relies on the quickly-adapting receptor system (fire at onset and offset of stimulation), which recover sooner and in larger numbers. 19 The threshold values are lower than those of the static test. 20 2-PD outcome in nerve repair studies, however, is reported to be extremely variable, because there is a lack of standardization of the technique and the test is probably performed in different ways by different authors. 21 It is a serious problem because the test is frequently used to compare different nerve repair techniques. Therefore, when 2PD results are reported in a study, a detailed and referenced description, especially the pressure applied and the testing protocol should be mandatory. 21 Dellon has introduced a Pressure-Specifying Sensory Device (PSD) to provide a standardized pressure, however it may be difficult to use this technique in routine clinical practice. 22 2PD test is not recommended as the only instrument to monitor sensory function. Localization of touch, and identification based on active touching are also recommended to be assessed for an over-all evaluation of sensory function. 21 Other functional sensory tests include shape, texture identification, 23 , 24 vibration, and temperature perception, sharp and dull discrimination, and thickness discrimination. 25 , 26 These tests are timed and the results are converted into scores in multiple ways. 23 - 26

Medical Research Council scale , published in 1954, 27 is commonly used, by including 2-PD for grading the sensory outcome after peripheral nerve surgery. 17 , 23 , 28 This scale is categorized into S0-S4: S0 is the absence of sensibility; S1 is the recovery of deep cutaneous pain; S2 is the return of superficial cutaneous pain and some degree of tactile sensibility; S3 is the return of superficial cutaneous pain and tactile sensibility without over response; and S4 is the complete recovery. 23 This scale has also been criticized because it is based on subjective findings and vague nonstandardized data. It is recommended to be used with additional evaluation of motor recovery and pain. 23 Moberg proposed the pick-up test as an objective method to measure integrated function of the hand by scoring both the speed and accuracy of identification of the test objects. 24 , 29

Finger dexterity

The Sollerman hand function test consists of 20 activities that replicate the main hand grips in daily living, and is used to evaluate the quality of basic grip types. 30 Each subtest is scored depending on the quality of the hand grip and patient’s difficulty in performing the task. 9 This test can reflect integrated sensory and motor functions. 9

Motor function

Manual muscle testing (MMT) is used to assess motor innervation using British Medical Research Council muscle strength grading . 31 It can be conducted to assess larger muscles or muscle groups as well as intrinsic muscles of the hand. For median nerve, palmar abduction in the thumb is evaluated. For ulnar nerve, abduction in index, small finger, and adduction in small finger are tested. 23 , 31 Brandsma made some modifications to the MRC grades definitions, which were defined by range of motion and resistance, and made it more practical for intrinsic muscles of the hand. 31 Assessment of grip strength with dynamometry is a most common method of reporting motor outcome. 32 Power grip requires synergistic function of intrinsic and extrinsic muscles of the hand, so it is difficult to determine muscle dysfunction in isolation with this test. 4 It is also influenced by pain or increased sensitivity to pressure over the pillar region or scar, and should not be used where tissue healing is incomplete and testing would cause pain. 32 Pinch strength tests include key pinch, tip pinch and tripod pinch. Tip pinch and tripod pinch dynamometry more specifically target the thenar musculature and appears to be more responsive for assessing motor function after carpal tunnel release, compared with grip and key pinch strength test. 32

Pain and discomfort

Pain is associated with disability in patients after peripheral nerve injury. 33 The evaluation of pain will always be a self-report by patients. Numerical Rating Scale (NRS) for pain and Pain Visual Analog Scale (PVAS) are used to determine pain intensity and are easy to use. However, there are some deficiencies about these measurements. 34 First, it assumes that pain is a linear continuous phenomenon, which is not tenable in most cases. Second, all patients cannot respond to these scales in a uniform manner, because of the high variability in the pain they experience. 34 McGill Pain Questionnaire is a multidimensional pain scale which provides much more information on dimensions of pain beyond the simple factor of intensity, such as sensory components (tingling and hypersensitivity) as well as affective responses to pain. 33 - 36 However, it is a long questionnaire and imposes a larger burden on patients and might be less responsive than VAS. 34 The Pain Disability Index assesses the impact of pain on life domains. 33 It includes seven categories of life activity: family/ home responsibility, recreation, social activity, occupation, sexual behavior, self-care and life support activity. 37 Consistency, validity and reliability of this questionnaire were tested and proved to be useful in nerve injury studies. 33 In patients with chronic nerve injury, pain intensity is only one component of pain, and the impact of pain in the disability should also be considered. 33 A clear understanding of the goal of the research question will help determine which measurement is appropriate.

Cold sensitivity is a complex symptom, which may present as pain, numbness, stiffness, weakness, swelling and change in skin color. The Cold Sensitivity Severity Scale (CSS) is used to evaluate sensitivity of cold intolerance during daily life. 38 Potential Work-Exposure Scale assesses exposure in the work place. 38 The CSS scale, in conjunction with Potential Work-Exposure Scale can be used to predict the likelihood of the patient’s return to pre-injury employment. 39 The reliability and validity of these two questionnaires have been demonstrated in the development phase and in other studies. 38 , 39 The Cold Intolerance Symptom Severity questionnaire is a reliable and valid measurement with the threshold value for pathological cold intolerance of 30 40 and 50 for population with Scandinavian climate. 41

Neurophysiological outcome measurements

Neurophysiological examinations include electroneurography (ENG), also known as nerve conduction studies (including sensory nerve conduction velocity and amplitude, motor nerve velocity, distal motor latency), and electromyography (EMG). They measure the electrical activity of muscles and nerves, and are the primary studies used to gain information on the location, number, and pathophysiology of lesions affecting the peripheral nerve. 42 In evaluation of carpal tunnel syndrome (CTS), distal motor latency (DML) and sensory nerve conduction velocity (SCV) are often performed. American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation published the parameters for performing CTS electrodiagostic (EDX) testing to address the best EDX studies to confirm the diagnosis and guide clinical researches. 43 Studies of ENG in CTS patients have presented contradictory results between neurophysiological findings, patient symptoms and clinical improvements. 44 - 47 However, they did not refute the necessity of conducting ENG when evaluating patients with CTS. 44 - 47 Grading scales for the neurophysiological changes of median nerve entrapment were also introduced to facilitate comparison of the severity of the disease. 47 , 48 A study showed that both ENG and patient-oriented questionnaires were highly responsive to treatment of CTS, but no correlation was observed between them. Therefore both outcome measurements are recommended to provide a multifaceted assessment. 49 ENG test can also be used to evaluate outcomes of nerve grafting, 50 nerve repair, 25 and cubital tunnel syndrome. 51 , 52 Patients showed continued improvement in sensory and motor nerve conduction velocity even beyond 2 years in cubital tunnel syndrome. 51 In brachial plexus injury, EMG is commonly used to evaluate muscle reinnervation. 53

Patient reported outcomes

There is a shift towards using patient-reported outcome with valid and reliable measurement tools in hand surgery. In a systematic review of hand surgery outcomes studies, quality of life outcomes were reported in 31% of the studies, comprising of symptoms, patient satisfaction, and time to return to work and data from quality-of-life-related questionnaires. 2 Questionnaires commonly used in peripheral nerve surgery outcome studies include Short Form 36, Disability of the Arm, Shoulder and Hand (DASH), Boston Carpal Tunnel questionnaire (BQ or CTQ), the Michigan Hand Outcomes Questionnaire (MHQ), Stothard and Kamath questionnaire.

The Short Form- 36 (SF-36) is a validated measure for patient’s functional health and quality of life, to assess the extent to which a patient’s day-to-day life is affected by their health. 54 It includes 8 domains: physical functioning, social functioning, role limitations due to physical functioning, role limitations due to emotional problems, energy and vitality, mental health, bodily pain, and general perception of health. 55 Although a general health assessment questionnaire and not sensitive enough to evaluate regional conditions, 13 SF-36 is used in combination with other region specific questionnaires to evaluate peripheral nerve injury. In Novak’s study, SF-36 bodily pain is proved to be a predictor of the DASH score, indicating that long-term disability in patients after nerve injury can be predicted by more pain. 10 Other studies used SF-36 to evaluate functional outcome by assessing quality of life. 11 , 54

DASH questionnaire is designed to measure disability for any region of the upper extremity and can be used for single or multiple disorders. 56 It consists of 30 core questions and an optional additional 8 questions assessing work, sports and performing arts activities, with a higher score indicating more disability. 56 The DASH score is a subjective instrument to estimate the patient’s view of disability. 57 It is used for evaluation of brachial plexus surgery, 11 , 58 , 59 nerve transfer, peripheral neuromas surgery, 60 nerve repair, 11 carpal tunnel release, 61 and ulnar nerve transposition. 62 The QuickDASH was developed in 2005 to minimize time and responder burden. 63 It demonstrated reliability, validity and responsiveness when used for patients with either a proximal or distal disorder of the upper extremity. Compared to DASH, it is a more efficient version and retains its measurement properties. 63

Boston carpal tunnel questionnaire (Levine and Katz questionnaire) is a self-administered questionnaire for the assessment of severity of symptoms and functional status in patients who have carpal tunnel syndrome. 64 It consists of symptom severity and functional status subscales. The first scale includes 11 questions of pain, altered sensibility and weakness. The second assesses the patient’s self-reported ability to perform 8 tasks. 56 It is proved to be useful in quantifying severity of symptoms and functional state of patients before and after surgery. But it was not possible to predict the outcome results in CTS from the preoperative scores because there was no statistically significant relationship between them. 65 A study indicates that BQ score at 2 weeks is a reliable, responsive and practical instrument for outcome measure in carpal tunnel surgery, and it is equivalent to 6 months postoperative score. 66 The questionnaire has also been used to identify potential prognostic factors influencing outcome, 47 and predictor of scar pain after carpal tunnel release. 67 In relation with objective measurements, both scales had a positive, but modest or weak correlations with 2-PD and Semmes-Weinstein monofilament testing, 64 and no relation with nerve conduction studies pre and postoperatively. 65 , 68 , 69 Some authors recommend that BQ and nerve conduction data should be used together to monitor CTS patients. 65

The Michigan Hand Outcomes Questionnaire (MHQ) is a 37-item self-assessment instrument that measures disability along 6 domains: function, activities of daily living, pain, hand appearance, patient satisfaction, and work disability. 70 It is used to assess different hand disorders, including carpal tunnel syndrome (CTS). In assessing CTS, the MHQ is more specific than the DASH, because it has questions only relating to the hand, and can measure symptom and function separately. It is more versatile than BQ but also less specific, because questions relating to pain are not phrased explicitly for CTS, such as tingling and numbness. MHQ may be more useful when independent score from multiple domains are required or when comparison with an unaffected control hand is needed. A study also revealed that the MHQ might be more sensitive to functional changes; the DASH seems more correlated with disability days. 71

Because of the complexities of neurophysiology, assessment of recovery after peripheral nerve surgery remains a complex process to therapists and surgeons. A combination of tests, which correlate with neurophysiological parameters and integrated hand function, are required to provide a valid, reproducible and comprehensive assessment of outcomes. Measurement instruments for peripheral nerve surgery generally include sensory tests, motor function tests, integrated hand function tests, pain and discomfort assessments, neurophysiological outcome measurements, and patient reported outcomes. With a plethora of tests to choose from, researchers need to focus on measurements best relevant to specific conditions and research questions. These data will help researchers have a better understanding of the recovery process and provide the best possible outcomes for the patients.

  • Outcomes assessment tools and the current choices of measurements in outcomes research of peripheral nerve surgery
  • Several aspects relating to function, pain, and patient perception of outcomes are evaluated after peripheral nerve repair
  • Choice of specific measures depend on the researchers’ interest and the disease or treatment under investigation

Acknowledgments

Supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to Dr Kevin C. Chung).

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

IMAGES

  1. Original and simplified Medical Research Council (MRC)

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  2. Escala Council

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  3. Table I from Reliability and validity of the Medical Research Council

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  4. Medical Research Council Scale and needle electromyograms of the

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  5. Use of the Medical Research Council muscle strength grading system in

    medical research council scale

  6. Intra-rater agreement for the Medical Research Council scale

    medical research council scale

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COMMENTS

  1. Muscle Strength Grading

    The most commonly accepted method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale. This method involves testing key muscles from the upper and lower extremities against the examiner's resistance and grading the patient's strength on a 0 to 5 scale accordingly: 0 No muscle activation

  2. Medical Research Council-sumscore: a tool for evaluating muscle

    Summation of scores gives MRC-sumscore, ranging from 0 to 60. This score was developed for detecting early strength alterations in patients with Guillain-Barré syndrome, especially who were bedridden and receiving artificial ventilation. The sensitivity and interobserver agreement of MRC-sumscore was demonstrated [ 3 ].

  3. Medical Research Council (MRC) Scale for Muscle Strength

    [Medline] Paternostro-Sluga T, Grim-Stieger M, Posch M, Schuhfried O, Vacariu G, Mittermaier C, Bittner C, Fialka-Moser V. Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy. J Rehabil Med. 2008 Aug;40 (8):665-71. [Medline] Created: Mar 23, 2009.

  4. MRC Muscle Scale

    In a recent comparison to an analogue scale the MRC scale is more reliable and accurate for clinical assessment in weak muscles (grades 0-3) while an analogue scale is more reliable and accurate for the assessment of stronger muscles (grades 4 and 5). Permission to reuse the MRC Muscle Scale

  5. Muscle Power Assessment (MRC Scale)

    As a result, it is important to familiarise yourself with the Medical Research Council's scale (MRC scale) of muscle power. The MRC scale of muscle strength uses a score of 0 to 5 to grade the power of a particular muscle group in relation to the movement of a single joint.

  6. Measuring Shortness of Breath (Dyspnea) in COPD

    5 of 6 points: 57 percent likelihood of survival 7 to 10 points: 18 percent likelihood of survival The BODE values, whether large or small, are not set in stone. Changes to lifestyle and improved treatment adherence can improve long-term outcomes, sometimes dramatically.

  7. Modifying the Medical Research Council grading system through Rasch

    The Medical Research Council grading system has served through decades for the evaluation of muscle strength and has been recognized as a cardinal feature of daily neurological, rehabilitation and general medicine examination of patients, despite being respectfully criticized due to the unequal width of its response options.

  8. Reliability and validity of the Medical Research Council (MRC) scale

    10.2340/16501977-0235 To assess the inter-rater and intra-rater reliability and validity of the original and a modified Medical Research Council scale for testing muscle strength in radial palsy. Prospective, randomized validation study. Thirty-one patients with peripheral paresis of radial innervated forearm muscles were included.

  9. Does the Score on the MRC Strength Scale Reflect Instrumented Measures

    Abstract It remains unknown whether variation of scores on the Medical Research Council (MRC) scale for muscle strength is associated with operator-independent techniques: dynamometry and surface electromyography (sEMG).

  10. The Association of the Medical Research Council Scale and Qu ...

    The Medical Research Council (MRC) muscle scale is a commonly used bedside measure of voluntary muscle strength in the ICU, which involves subjective grading of strength during movements against gravity or manual resistance . 11-13 The MRC scale has the advantage of being generally easy to modify and administer with critically ill patients ...

  11. MRC Scale

    Grade 1: the patient can activate the muscle, without moving the limb. So only a trace or flicker of movement is seen or felt during palpation of the muscle. For grade 1, ask the patient to do the exact same thing, and this time, you will see or feel a muscle flicker or trace of movement.

  12. Medical Research Council (MRC) Dyspnoea Scale

    1. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease 2. Measurement of breathlessness in advanced disease: A systematic review. 3. The Medical Research council Dyspnoea Scale . Reliability and Validity

  13. MRC Dyspnoea Scale

    MRC Dyspnoea Scale - UKRI Home Medical Research Council (MRC) Facilities and resources Find an MRC facility or resource MRC Dyspnoea Scale MRC Dyspnoea Scale The MRC Dyspnoea Scale, also called the MRC Breathlessness Scale, has been in use for many years for grading the effect of breathlessness on daily activities.

  14. Reliability and validity of the Medical Research Council (MRC) scale

    CONCLUSION: Medical Research Council and modified Medical Research Council scales are measurements with substantial inter-rater and intra-rater reliability in evaluating forearm muscles. Key words: manual muscle strength testing, Medical Research Council scale, peripheral nerve lesion, radial palsy. J Rehabil Med 2008; 40: 665-671

  15. Modified Medical Research Council Scale

    The mMRC scale is a self-assessment tool used to measure the level of impairment caused by breathlessness during daily activities, rated on a scale from 0 to 4. [2]

  16. Oxford Scale

    The scale was originally developed by a UK government research group called the Medical Research Council (MRC), and first described in a paper titled Aids to the Investigation of Peripheral Nerve Injuries (War Memorandum No. 7), released in 1943 and reprinted as an updated version in 1976. Measurement is scored on a 0 to 5 scale, with 5 ...

  17. A guided approach to diagnose severe muscle weakness in the intensive

    Original and simplified Medical Research Council (MRC) scales. Both scales are bilaterally applied to six muscle groups of the upper and lower limbs in order to obtain a summed score ranging from 0 to 60 for the classic MRC scale and from 0 to 36 for the simplified version: (1) abduction of the arm; (2) flexion of the forearm; (3) extension of ...

  18. Medical Research Council Scale Predicts Spontaneous Breathing Trial

    PMID: 33653914 DOI: 10.4187/respcare.07739 Abstract Background: Handgrip strength is an alternative measure to assess peripheral muscle strength and is correlated with the Medical Research Council (MRC) scale, with promising values for diagnosing ICU-acquired weakness (ICUAW).

  19. Functional outcomes of different surgical treatments for common

    In both preoperative and follow-up physical examinations, motor strength and sensory function were assessed using the British Medical Research Council Scale. For motor rating comparison, we utilized the following convention: the standard S3 + sensory rating was designated as S4, and the standard S4 sensory rating was denoted as S5.

  20. Stop COVID Cohort: An Observational Study of 3480 Patients ...

    17 Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, ... Methods: We extracted data from the medical records of adult patients who were consecutively admitted for suspected COVID-19 infection in Moscow between 8 April and 28 May 2020.

  21. The Role of the Russian Ministry of Emergency Situations and Executive

    National Research Council. 2004. ... and cultural centers. Terrorist acts are taking on ever-increasing scale and. Page 71 Share Cite. Suggested Citation: ... The timely and skillful actions of personnel from the city's medical service have saved the lives of thousands of Muscovites involved in emergency situations and accidents.

  22. How to Measure Outcomes of Peripheral Nerve Surgery

    Peripheral nerve injuries can be caused by trauma, accidental injuries during extensive surgery, nerve tumors, compressive disease or congenital anomalies, with the majority (81%) located on upper extremity. 6, 7 Among upper or lower-limb trauma, incidence of nerve injuries is reported to be 1.64%, with crush injuries having the highest rate at ...

  23. Undergraduate Programs

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    Students can undergo a mandatory annual medical examination at the polyclinic. Diagnostic Medical Center №1, located at ul. Miklouho-Maclay 29 bldg. 2, provides round-the-clock emergency medical care for students living in University dormitory. Emergency phone number: + 7-495-330-80-65 (around the clock).