THE SENSATIONAL CONTRIBUTIONS OF ERIK MOBERG

A. LEE DELLON

From the Department of Plastic Surgery, Johns Hopkins University, Baltimore, Maryland, U.S.A.

Erik Moberg is the father of functional sensory testing. During the past three decades, his research
into quantitative testing of hand sensibility has provided the insight to bring us from classic academic
tests (permitting localisation of lesions within the central nervous system) to clinical capability of
restoring sensation to the hand. He introduced the Ntiydrin test to document objectively innervation.
He defined hand function as precision-sensory and gross-sensory grips. He correlated Weber two-
point discrimination with hand function. He introduced the pick-up test to document hand function.
He coined the term “tactile gnosis”. He hypothesised that proprioception is principally due to skin,
not joint, tierents. He classified the tetraplegic hand according to its combined sensory and motor
capacity. He set the standard foF.sensory recovery after primary nerve repair, relating recovered
two-point discrimination to age (Onne’s line) and he inspired the present generation of researchers
to quantify their own studies of sensation.
Journal of Hand Surgery (British Volume, 1990) 1.5B: 14-24

“It must be emphasized that sensibility is, in my stage for the foreseeable future in terms of evaluation of
opinion and according to my experience, the basis sensibility and rehabilitation of sensory function.
for reconstructive work , . . for reconstructive Moberg, as a young orthopedic surgeon working on
surgery, “feeling” is a totally useless term, as it the Hand Service at Sahlgren Hospital in Gijteborg, was
covers far too much and distinguishes hardly required to carry out yearly re-examinations on work-
anything . . . for examination of useful sensibility men’s compensation patients. Thus, he had an opportu-
in reconstructive hand surgery, of all the tests nity to attempt to evaluate sensibility and correlate the
evaluated by the author, the only one which was results of his testing with the patient’s ability to use their
found to be significant is the two-point discrimina- hands. It was clear to Moberg that the academic tests
tion test now performed with a paperclip. All other developed by neurologists, such as testing for the
tests of sensory function, in my opinion, should in perception of sharp or dull, or of pain with a pin or of
this work be abandoned, including cotton wool and movement with a cotton wisp, were inadequate to
paper strip, pinprick, ordinary tuning fork, the determine whether a person could use their hand or not.
difference between sharp and blunt, figure writing, He thus developed (Moberg 1958) his own functional
the wrinkling skin test and the two-point discrimi- test, the “picking-up test” (Fig. 1). The blindfolded
nation test performed with sharp pointed compass. subject would be asked to pick up common objects and
They are not only useless, they are even misleading.” put them into a container. He also could be asked to
Erik Moberg. identify these objects and could be timed while doing so.
The results of this picking-up test could then be compared
At the Seventeenth Annual Meeting of The American with the academic tests and with the Weber two-point
Society for Surgery of the Hand, held in San Francisco, discrimination test (Weber, 1835). While the results of
on May 14, 1962, Erik Moberg was honoured with the this study would not be reported for four more years
privilege of presenting the first Memorial Lecture for the (Moberg, 1962), this 1958 paper clearly described the
man who “wrote the book” in our field, Sterling Bunnell. first functional test for the hand, thereby setting the stage
Moberg recalled having had the opportunity to hear for what today represents a host of tests designed to
Bunnell teach shortly after World War II. He was evaluate hand function (Baxter and Ballard, 1984).
impressed with Bunnell’s “priority for restoration of Moberg realised that most tests of sensory function
sensory function”, a principle which Bunnell stressed in were subjective, in that the patient was asked how he
his book and in teaching his pupils. Moberg said in that perceived something : none of the tests was truly objective
lecture (Moberg, 1964) that, since hearing Bunnell speak, i.e., without the ability for the patient to influence the
“I have never been able to leave the question of sensibility result. Accordingly, he developed the first truly objective
in hand function”. Moberg had been impressed with test of sensory function (Moberg, 1958), utilising tests
Bunnell’s powers of observation and ability to coin that had been developed for finger-printing criminals. In
concise expressions, such as “no-man’s land”, abilities one technique, he would take paper on which had been
which .were keenly possessed by Moberg himself. By the sublimated iodine crystals staining the paper yellow, and
time of the delivery of this First Annual Sterling Bunnell then make a fingerprint upon the paper. In the other
Memorial Lecture, Moberg already had contributed his technique, the fingerprint was made first, placing the
own fundamental observations and his own newly-coined amino-acids from the sweat onto the paper, which was
expressions (Moberg, 1958 and 1962) that were to set the subsequently sprayed with a solution of Ninhydrin.

14 THE JOURNAL OF HAND SURGERY

 THE SENSATIONAL CONTRIBUTIONS OF ERIK MOBERG

Fig. i The picking-up test as described by Moberg in 1958. This test employed constant touch and required a precision sensory grip

Punctate dots appeared at each sweat duct opening. The Neurologists had previously used two-point discrimina-
Ninhydrin method left a print that could be preserved. tion as a measure of a parietal lobe function termed
The starch iodine technique developed quickly but was “stereognosis”. Moberg attributes the term “tactile
not easily preserved. Moberg went on to make the critical gnosis” to Broman in 1945, suggesting that it be used for
observation that the tests of sudomotor function clearly “knowing touch” or seeing with the fingertip (Fig. 2).
demonstrated whether nerve function was present or not. Tactile gnosis, therefore, refers specifically to the sensi-
However, the fact that nerve function was present in no bility present in the fingertip being sufficient to permit
way correlated with the final functional ability of the the perception of neural impulses as a meaningful
hand. Thus, the Ninhydrin and starch iodine tests were conscious perception, i.e., functional sensation. In his
an objective method for evaluating malingerers or 1962 paper, in which correlations were made, Moberg
children, comatose or uncooperative patients, but the concluded that only the classic Weber two-point discrim-
result was not a predictor of hand function. ination test, which he had performed utilising a compass
In this first critical paper in 1958, Moberg introduced with blunted tips (so it did not produce pain), correlated
the term “tactile gnosis” to the surgical community. with the results of the picking-up test. Therefore, only
the Weber two-point test was a functional test and of use
to the hand surgeon whereas the other tests were more of
a value as academic tests, as developed by the neurologists
to localise lesions in the central nervous system.
“When eyesight is to be tested, it is considered
necessary to find out what the eye can see. When
we wish to determine improvement or impairment
of function of the ear, we try to find out what the
ear can hear (Fig. 3). Why not test the sensory
function of the hand? Why should the mere
perception of touch (with cotton wisps) or pain
(with a pin) by the hand be accepted as a sign of
normal sensation, when perception of light never
was identified with a normal capacity to see?”
Moberg 1964
Moberg set the stage for the later developments of
sensory rehabilitation. In discussing the results or nerve
repair, he stated that “As a matter of fact, it is astonishing
that improvement can be obtained at all. Nature must
provide a helping hand” (Moberg, 1964). He observed
that sensation continued to improve in its level of
Fig. 2 Moberg coined the term “tactile gnosis”. recovery for five years after a median nerve repair at the

VOL. 15-B No. 1 FEBRUARY 1990 15

 A. LEE DELLON

would be unlikely that any one surgeon in the future

would collect a large enough series of nerve repairs to be
able to control for the location of the injury and the age
of the patient and the type of repair, reports of the results
of nerve repairs should be presented as a graph of the
two-point discrimination result plotted against the pa-
tient’s age. A line, Onne’s line, would go across the graph
at a 45” angle representing the expected result from a
Fig. 3 Moberg emphasized that tests to determine hand function must
primary nerve repair. If the type of repair or the type of
emphasise what the hand can do. rehabilitation that was done had improved the results
over that which would be expected, then the location of
the plotted dot would fall below the diagonal line (Fig.
wrist, and believed this was due to continued regeneration 4). This remains an excellent reporting technique and
of the larger nerve fibres. Today, our concept is that has been used to show that sensory re-education can give
neural regeneration would be completed by six months a result by two years after nerve repair which is superior
to one year and that the progressive improvement in two- to that seen five years after primary repair without re-
point discrimination that Moberg noted occurring up to education (Dellon, 1981).
five years after surgery was due to sensory rehabilitation Another challenging concept which Moberg addressed
(Dellon, 19813. It is now appreciated that the process by was that of proprioception. In May, 1971, his successor
which this progressive improvement occurs, be it a in the Hand Surgery Department in Gbteborg, Svante
formal programme of sensory re-education or that Edshage, invited him to give a farewell address and
occurring as the patient uses his hand in daily activities, Erik’s wife, Marta, suggested the title “Fingers Were
occurs through a cortical reorganisation or cerebral Made Before Forks”. Part of this lecture was printed in
plasticity (Mackinnon and Dellon, 1988). The Hand in 1972. Here Moberg began what was to be
Moberg attempted to reconstruct sensation by bringing anextensive exposition (Moberg, 1983). He demonstrated
innervated tissue into an area of a sensory deficit. When that position sense was related not to afferents coming
Moberg reported the first neurovascular island flap for from joints but rather to afferents coming from the skin
thumb reconstruction in 1955, he credited Bunnell’s which surrounds the joints. For example, if a tendon is
concept of utilising fragments of finger which had to be pulled upon, the patient will not know whether the finger
sacrificed. Furthermore, Moberg depicted, in Figure 7 of moved in one direction or the other until the tendon has
that paper, the first volar advancement flap. This was been pulled sufficiently far that the skin over the muscle
carried out to “provide tactile gnosis by advancement of belly in the forearm is moved. Thus he showed that there
a neurovascular flap. The denervated skin (of the thumb) is no “muscle sense” in man. Furthermore, Moberg
was excised”. Here again, Moberg set the stage for future discussed his observations in patients with joint replace-
developments in restoration of sensation by flap recon-
struction (Dellon, 1982).
Moberg viewed hand function as the ability of the
hand to carry out grips (Moberg, 1958). Thus, a precision
sensory grip would permit someone to sew with a needle,
whereas a gross sensory grip would permit someone to
hold a bottle or a hammer. He found that the precision
sensory grip correlated with a Weber two-point discrim-
ination of less than 6 mm, whereas the gross sensory grip
would be possible with a grip of 7 to 15 mm. Beyond
15 mm, useful function in the hand in terms of grip was
not possible (Moberg, 1964). These values have been
adopted by the Clinical Assessment Committee of the
American Society for Surgery of the Hand.
Lars Onne, one of Moberg’s graduate students, m-7 I I 1
reviewed all Moberg’s primary digital, median and ulnar 6 I2 I8 24 30 36 42 48 54 60

nerve repairs. This work (&ne, 1962) remains a classic. AGE (years)

It demonstrates that the degree of sensation recovered in Fig. 4 Moberg suggested that the best way to report the results of
millimetres of two-point discrimination is equal to the nerve reconstruction would be to relate the patients’ age with
his two-point discrimination, The “ideal” result was that
patient’s age in years at the time of the nerve repair. The determined by ijnne (1962) in evaluating Moberg’s five-year
patients had been evaluated five years after the repair. results following a clean division and primary repair of the
Moberg was to suggest subsequently (1975) that, since it nerve (Gnne’s line).

16 THE JOURNAL OF HAND SURGERY

 THE SENSATIONAL CONTRIBUTIONS OF ERIK MOBERG

ments in the hands and cited references to the orthopaedic A

literature of patients who, following hip replacement
(where clearly there is total absence of joint afferents) I-_
could tell to within a few degrees the position of their
extremity. Finally, he demonstrated, by carrying out
various blocks to the skin, that good “joint sense” was
dependent upon enough sensation being present to give
good two-point discrimination. He concluded that pro-
prioception was a function of sensibility of the skin and
that it could be measured by two-point discrimination.
Following his retirement, Moberg devoted himself
increasingly to the treatment of the tetraplegic hand
(Moberg, 1976 and 1978). His contribution here with
regard to sensibility (he made many other contributions
related to transfers for pinch and grip strength and
dynamic elbow extension), is related to his observation
that the ability of the tetraplegic patient to work with his
Fig. 5 von Frey measured the cutaneous pressure threshold by
hand depended primarily upon whether there was attaching various hairs to the tip of a candle. The force was
sensation present. Without sensation, the tetraplegic defined as that point at which the hair bent during the
must be able to see his hand to control its function. Thus, application of the stimulus.
if a patient has no functional sensation in either hand,
then Moberg’s concept was that only one hand should be the point at which the nylon monofilament would bend
reconstructed since the patient cannot watch both at after contact with the skin. The force at which the nylon
once. Therefore, his classification of tetraplegia involved monofilament bent could be calculated. Significant errors
an “0” for “ocular”, a “Cu” for “cutaneous”, and then a with this technique have been described (L.evin et al.,
number, e.g. OCu3 vs. 03, indicating whether or not 1978) : for example, these markings on the monofilament
there was ocular function required. rods were frequently mistaken to be the force in grams,
whereas, in fact, they are the logarithm to the base ten of
the force in grams. For example, however, a filament
Cutaneous pressure threshold testing
marked 1.65 is & the force of a filament marked 3.61
Although Moberg did not employ cutaneous pressure and & the force of one marked 4.56 and &m the force
threshold testing, a hand therapist working at Walter of one marked 6.65. Furthermore, the force is distributed
Reed Army Hospital, Kilulu von Prince, was greatly over the cross-sectional area of the nylon monofilament.
influenced by Moberg’s work (von Prince and Butler, Nylon monofilaments may be manufactured with various
1967). The history of the relationship of this type of cross-sectional areas. The force per unit area may be
sensory testing to hand function has been reviewed reported as either stress or “pressure”. The range for
recently (Bell, 1984b). Von Prince used the nylon normals has been reported differently, but has subse-
monofilaments developed by Semmes and Weinstein quently been standardised (Bell, 1984a).
(1960) to evaluate injured war veterans. It was clear to George Omer and his therapist, Werner, continued the
her that the ability to utilise the hand could be related to work of von Prince at Walter Reed (Werner and Omer,
the threshold for cutaneous pressure perception in a way 1971). They standardised the reporting scales and clearly
that could not be determined by the academic tests, an separated the Weber 2 P.D. from the Semmes-Weinstein
observation similar to that which Moberg had made with nylon monofilaments in testing. They continued the
regard to the Weber test. Over a period of time, von measurement of multiple areas on each hand, including
Prince attempted to relate the Weber test to the cutaneous each phalanx and different areas of the palm. This type
pressure threshold tests but ultimately determined that of intensive measurement with the Semmes-Weinstein
this could not be done. The Semmes-Weinstein nylon monofilaments reached its height (Fess, 1984) with
monofilaments had been developed in an attempt to patterns indicating up to 67 separate areas requiring
create a sensory testing instrument more reliable than recording of a threshold reading (Fig. 6). Furthermore,
the sensory hairs (Fig. 5) originally used by von Frey the sensory testing as carried out at Walter Reed included
(1896) who obtained a graded series of hairs from his measurements of the Weber 2 P.D. in each of these areas
children, horses and other animals which were glued to as well. These tests were done each time the patient had
the ends of candies. He was able to identify different a sensory evaluation. The use of cutaneous pressure
thresholds for perception of pressure. Semmes and threshold measurements has continued in the Hand
Weinstein realized that by standardizing the thickness of Center in Philadelphia established by James M. Hunter
the nylon monofilaments, a force could be generated at with his therapist, Evelyn Mackin. From this school of

VOL. 15-B No. I FEBRUARY 1990 17

 A. LEE DELLON

RIGHT
Medical Society and subsequently published in the Johns
Hopkins Medical Journal (Dellon, Curtis and Edgerton,
1972). The functional sensibility of the hand is mediated
through the large myelinated (group A beta) fibres. Tests
for hot and cold, sudomotor function and pain are
mediated through the thinly myelinated (group A delta)
and non-myelinated (group C) fibres. Therefore, tests for
hot, cold, pain and sudomotor function cannot predict
the outcome for tactile gnosis. Among the group A beta
fibres, some are quickly-adapting and some slowly-
adapting. Precision grip, gross grip and the pick-up test
require the patient to know that an object is held in
constant touch between the fingers and to know how
hard to press to prevent the object from falling out of the
hand. The Weber two-point discrimination test measures
the innervation density of these slowly-adapting group A
beta fibres and therefore would be the test to predict the
Fig. 6 Up to 67 discrete areas have been suggested as the appropriate findings Moberg observed.
way in which to measure both cutaneous pressure threshold Moberg did not attempt to measure the cutaneous
and two-point discrimination for detailed sensibility evaluation pressure thresholds by means of Semmes-Weinstein
of the hand.
monofilaments, as these were not produced until 1962. It
may be speculated that Moberg would have found a
teaching have come Judy Bell and Ann Callahan, under relationship between the speed with which the patient
whose continuing direction cutaneous pressure threshold could carry out the pick-up test and a correlation with
measurements have reached their acme (Bell-Krotoski precision and gross sensory grip with the von Frey type
and Tomancik, 1987). testing apparatus, had it been available to him (Dellon
and Kallman, 1983). Recognising that the group A beta
fibres also contain a quickly-adapting sub-set, the
Neurophysiological basis for Moberg’s clinical observa- possibility of testing moving touch in addition to constant
tions touch and the possibility of using tuning forks of varying
Erik Moberg’s influence was extended to Baltimore frequencies to evaluate the sub-set of the quickly-
through his association with Raymond M. Curtis who adapting fibres was realised. These realisations culmi-
was a direct disciple of Sterling Bunnell and began the nated in the identification of the sequence of recovery of
Hand Surgery School in Baltimore. As a medical student touch sub-modalities following nerve regeneration : the
at Johns Hopkins, I encountered Dr Curtis in the Hand first to recover (after pain and sudomotor function and
Surgery Conference on the Plastic Surgery Service at the perception of cold and heat) is perception of the 30 cycle
end of my second year of medical school. In the summer per second stimulus, then moving touch, then constant
of 1968, between my second and third year of medical touch and finally 256 cycle per second vibratory stimulus
school, I received permission to watch Dr Curtis (Dellon, Curtis and Edgerton, 1972). The tuning forks
operating. He inspired me that summer to spend the used are shown in Figure 7.
major effort of my research on peripheral nerves and Erik Moberg visited Raymond Curtis in Baltimore
upper extremity reconstruction. Having been exposed to during the academic year 1969-70 which provided me
the neurophysiological investigations of Vernon B. with my first opportunity to meet Professor Moberg.
Mountcastle during my physiology course at Johns Moberg listened patiently while the theories of the above
Hopkins, it was natural to attempt to provide a paragraph and their applications to sensory rehabilitation
neurophysiologic basis for the clinical evaluation of the were described. At this time, sensory re-education based
hand that I had seen being carried out by Dr Curtis, who on the institution of specific sensory exercises at the
turned me to the 1958 and 1962 writings of Erik Moberg. specific time in the recovery process, as determined by
The possibility of attempting to provide the neurophy- the evaluation of sensibility, was being developed.
siological basis for Moberg’s observation that Weber Moberg was extremely encouraging of this early work
two-point discrimination could predict the outcome of and his enthusiasm further strengthened Curtis’ support
whether a patient would have precision or gross sensory for this early work. Subsequently, the first efforts in
grip, the outcome of the pick-up test and the explanation sensory re-education were presented to the American
of why the classic academic tests could not predict such Society for Surgery of the Hand at their 1971 Meeting
function proved to be a challenge. The hypothesis was (Dellon, Curtis and Edgerton, 1974). The discusser of
presented on February 3, 1969 to the Johns Hopkins that paper was Svante Edshage, Moberg’s pupil and

18 THE JOURNAL OF HAND SURGERY

 THE SENSATIONAL CONTRIBUTIONS OF E,RIK MOBERG

the finger (Fig. 8) which gave quantitation to the quickly-

adapting fibre receptor population. In essence, the Weber
static or classic 2 P.D. test underestimated the functional
capacity of the hand: since it tested only a sub-set of the
group A beta fibres. The attempts to provide better
instrumentation for this paradox had led Poppen et al.
(1979) to build upon Renfrew’s (1969) concept of depth-
sense. A ridge device was moved along the surface of the
hand and the patient asked to tell when he could
discriminate between two different ridges of a different
depth. This test correlated with other tests of sensory
function but not with those that were related to the
slowly-adapting fibre receptor population, and has been
suggested to be a form of moving 2 P.D. testing (Dellon,
1980a). The Clinical Assessment Committee of the
American Society for Surgery of the Hand has subse-
quently endorsed the measuremernt of both moving and
static two-point discrimination in the end assessment
following nerve repair.
The exact correlations between the neurophysiological
parameters and the sensory receptors (Dellon, 1979 and
198 1) have been studied in biopsies from human fingertips
in patients recovering from nerve repair (Dellon and
Munger, 1983) and the statistical correlations for predic-
tion of hand function between cutaneous pressure
threshold (Semmes-Weinstein), cutaneous vibratory
Fig. 7 Some instruments used in sensory testing. Left: tuning fork threshold (Vibrometer) and moving and static 2 P.D.
with 256 cycles per second. Centre: tuning fork with 30 cycles measured against the number of objects recognised (not
per second. Right: Boley gauge (note the sharp tips) and paper- the pick-up test) have been analysed by linear regression
clip bent into shape for testing.
analysis (Dellon and Kallman, 1983) which indicates
that a firm neurophysiological basis now exists for the
clinical evaluation of sensibility in the hand. Moberg
wrote in 1981:
successor in Giiteborg. That first data on the results of
sensory re-education in patients following nerve repair “Once the world knew only two centres of culture,
was initially presented in tabular form and compared one in Europe and the other in China. Only
with previously published results of nerve repair but at distorted rumours connected the two, arriving over
the subsequent suggestion of Moberg (1975), the results endless camel trains. Neither centre influenced the
were rearranged to be compared with Onne’s line (Fig.
4). These showed clearly that, after two years of sensory
re-education, the patient had recovered better than could
be expected after a primary repair left without re-
education for five years.
The moving two-point discrimination test was devel-
oped, paradoxically, as a further attempt to provide a
neurophysiological explanation and defence of Moberg’s
clinical observations. After two decades of working to
get hand surgeons throughout the world to use the Weber
2 P.D. test, with a paper-clip, writings appeared that
demonstrated that patients who had no Weber 2 P.D.
nevertheless completed the pick-up test and could identify
coins (Dellon, 1978). The explanation of this paradox
was that the Weber test did not identify the large
percentage of group A beta fibres which were quickly- Fig. 8 The moving two-point discrimination test as first practiced
adapting. Thus the strategy was conceived (Dellon, 1978) using a paper-clip moving from proximal to distal, with the
that the paperclip should be moved along the surface of points transverse to the long axis of the finger.

VOL. 15-B No. ! FEBRUARY 1990 19

 A. LEE DELLON

other . . . In important parts of basic neuroscience The concept that in nerve compression there is a
and clinical nerve work the situation has been gradation in which first there are threshold changes and
similar . . . The young author of this book is the then innervation density changes has been documented
first one to connect these two antipodes, each so experimentally in subhuman primates (Dellon, 1983) as
important to the other . . . Dr Dellon’s enormous well as in hands of experimental subjects (Szabo et al.,
enterprise, to travel through and scrutinise modern 1984) and in the legs of surgical house officers (Phillips et
physiology and other basic sciences and to summar- al., 1987). The first changes in acute or chronic nerve
ise and combine these with modern hand surgery compression are threshold changes which are clinically
reminds one of the ancient explorer Marco Polo. . . manifested by numbness and tingling and can be most
this book is unique in the flood of hand surgery easily tested by alterations in perception of a 256 cycle
literature of today. No doubt it will give rise to per second tuning fork compared with an opposite
conflicting opinions and controversy, which is the extremity, but may be documented by any of the
basis of all progress.” techniques for measuring threshold changes. Then there
are electrical changes which can be measured. It is not
until nerve fibres are lost, i.e., the electrical testing
becomes unresponsive, that two-point discrimination is
Threshold versus innervation density
altered.
The apparent conflict in the world of sensibility evalua- Following nerve repair and nerve regeneration, the
tion lies between those who champion the use of threshold first physiological parameters to recover are threshold, as
measurements (such as Semmes-Weinstein nylon mono- there are very few nerve fibres at the extremity so two-
filaments) to measure cutaneous pressure threshold and point discrimination cannot be tested. Thus, it is most
those who champion measurements of innervation appropriate early in the course of nerve regeneration to
density (i.e. two-point discrimination). Understanding test for threshold changes, not innervation density.
the physiological response to nerve injury permits the Considering the sequence of recovery following nerve
rational choice of the clinical test of sensibility and injury (Dellon, Curtis and Edgerton, 1972), first a 30
resolves this conflict. The distinction is generally appre- cycle per second tuning fork may be utilised and then a
ciated for the motor system : the early clinical manifesta- 256 cycle per second tuning fork. Alternatively, nylon
tion is muscle weakness but once motor nerve fibres monofilament determinations may be made. Once the
degenerate, there is also muscle wasting or atrophy. The perception of the 256 cycle per second vibration has
analogy in the sensory system is that the first changes to reached the fingertips, enough nerve fibres will have
occur are threshold changes, such as differences in the recovered to allow one to begin measuring two-point
cutaneous pressure threshold or changes for the slowly- discrimination. At this time, continued orderly progres-
adapting fibre receptor system or changes in the cutaneous sion towards a plateau at some level of threshold may be
vibratory threshold for the quickly-adapting fibre recep- expected and threshold determinations need not be
tor system. Thus, in compression of the median nerve at measured theafter. Two-point discrimination, both static
the wrist, the patient will have an altered perception of a and moving, may be tested with the expectation that
vibratory stimulus applied to the index finger when these will continue to improve for a period of years at a
compared with the little finger of the same hand (Dellon, speed which will be determined by the amount of sensory
1980b). Semmes-Weinstein testing would show two re-education given in the post-operative period.
different thresholds of the index versus that in the little
finger. Vibratory thresholds could be quantitated with a
Current evaluation of sensibility
Vibrometer (Dellon, 1983). As there exists a whole
battery of nylon monofilaments, one can envision testing Erik Moberg’s influence continues to inspire new
the whole spectrum of frequencies and determining their attempts to quantify sensibility and thus improve the
stimulus intensity (i.e., threshold) at each frequency to capacity of the reconstructive surgeon to restore sensation
determine an audiogram for the finger. This was first by enabling him to compare different methods accurately.
proposed by McQuillan in 1970 and G&an Lundborg, a Microvascular surgery gave us the ability to replant digits
student with Moberg in Goteborg, has developed such and transplant toes. After the initial excitement over the
an instrument (Lundborg et al., 1986). vascular triumph of these techniques, the emphasis was
In the sensory system, once nerve fibres have degener- placed on rehabilitation. The results of sensibility testing
ated, there is a decrease in innervation density and this and sensory re-education in this population ,of patients
is measured by alterations in two-point discrimination. utilising the sensory testing techniques described above
When the static 2 P.D. becomes abnormal, slowly- has been reported (Dellon, 1986). Various sites for
adapting fibre receptors have been lost. When the moving innervated free-tissue transfers exist and their true
2 P.D. becomes abnormal, the quickly-adapting fibres potential for sensory function is unknown. Discrimina-
have been lost. tive capacity, even in these normal tissues, was improved

20 THE JOURNAL OF HAND SURGERY

 THE SENSATIONAL CONTRIBUTIONS OF ERLK MOBERG

by a short course of sensory re-education (Brown et al.,

1989). The fundamental neurophysiological principles as
applied to the clinical evaluation of sensibility are
currently being extended to the evaluation of breast
reconstruction (Terzis et al., 1987) and to the diabetic
(Dellon, 1988 ; Nakada and Dellon, 1989).
Judy Bell and her biomedical engineer colleague,
William Buford, have demonstrated that, during the
application of a sensory testing instrument, there are
continual movements applied to the sensory testing
instrument both by the patient and by the minute
movements of the examiner’s hand (Bell-Krotoski and
Buford, 1988). The effect these have on sensory testing
equipment has highlighted the need to be able to define
the force at which a sensory testing instrument is applied Fig. 10 Use of the Disk-CriminatorTM permits the examiner to see the
tips of the prongs against the finger without the transverse
(Bell, 1984a). Previously, only the Semmes-Weinstein
edge of the instrument touching the skin. The set consists of
nylon monofilaments were able to specify the force at two disks, with prongs spaced between 2 and 15 mms. Note
which they were applied by the bend that occurs in the the roughened centre, smooth surface and elevated letters
nylon monofilament. Elaine Fess (1984) continues to which make the instrument useful for a home sensory re-
emphasise the need to establish the reliability and validity education device.

of our testing instruments. Accordingly, an instrument

that was more precise than the paperclip was required.
Susan Mackinnon modified several existing instruments
reliable and valid instrument (Fig. II) for evaluating
(Fig. 9) to develop a prototype for a better instrument
two-point discrimination (Dellon, Mackinnon and
(Fig. lo), the Disk-criminatorTM (Mackinnon and Dellon,
1985).* The Disk-criminatorTM has been shown to be a Crosby, 1987; Crosby and Dellon, 1989). It has two
separate disks with prongs at set spaces of intervals from
2 mm up to 15 mm. The ends of the prongs are rounded.
The prongs are long enough that, as the instrument is
moved along the surface of the finger, the transverse edge
of the instrument itself does not touch the fingertip and
the examiner is given a clear view of the interface
between the prongs and the fingertip. The instrument, by
virtue of its raised letters and roughened surface on its
sides, can also be used for early-phase sensory re-
education and may be given to the patient as a home
sensory re-education device in the late phase (Mackinnon
and Dellon, 2988).
The up-to-date sensory testing instrument for two-
point discrimination should include the ability to specify

Fig. 9 Early prototypes of the Disk-CriminatorT”. The DeMayo

device (manufactured by Padgett Instrument Company) is at
the top left. The first prototype with longer prongs and a ridged
surface to permit better handling is illustrated at the top right.
Bottom right: the first plastic version of the instrument with
long prongs.
Fig. 11 The Disk-Criminator (round tips) compared w:th the three-
*Available from Post Office Box 16392, Baltimore, Maryland 21210, USA pronged Aesthesiometer (pointed tips).

VOL. 15-B No. 1 FEBRUARY 1990 21

 A. LEE DELLON

another prototype has been developed (Fig. 13) through

the NK Biotechnical Engineering Company?. This force-
defined two-point discriminator is directly linked to
computer software. There is a strain gauge at the base of
each of the two prongs. The distance between the prongs
may be altered by a micromanipulator in the handle of
the instrument. As the two prongs are placed on the
surface of the skin, the force is continuously read out and
averaged over a two-second period to give the average
force at which the two points are discriminated. One of
the two prongs can be disengaged so that the instrument
may act to give the cutaneous pressure threshold (instead
of using a Semmes-Weinstein nylon monofilament). The
data is read out directly as force and does not need to be
Fig. 12 The Kanatani sensory testing device which can alter the force
at which the two prongs deliver their stimulus. A series of converted by logarithmic factors. The force-defined two-
these instruments would be required, one for each different point discriminator, therefore, will allow static and
two-point distance, by permission of Frank Kanatani). moving 2 P.D. to be reported at the force at which it is
applied.

Conclusion
the force at which the two prongs are applied. Bell,
working with Frank Kanatani, developed a prototype The sensational contributions of Erik Moberg have come
for this instrument (Fig. 12) which allows adjustment of full circle in that one of Moberg’s earliest and continuing
the force applied to the two wire prongs of their concerns was how hard to press the paperclip onto the
instrument by altering the length of the wire; the force is finger. His first efforts indicated that the prong should be
specified by the wire bending at the time it is applied. applied no firmer than is necessary to blanch the skin.
The space between the two wire prongs would be varied
by having a series of the test instruments. Most recently, tPost Office Box 26335, Minneapolis, Minnesota 55426, U.S.A.

Fig. 13 The force-defined two-point discriminator prototype. (a): A strain gauge at the base of each of the two prongs permits a continuous read-
out of the force required to deliver the stimulus at which the patient can determine whether one or two points are on the skin. The distance
between the two prongs is adjusted by the micrometer. (b): One of the two prongs may be “disengaged” to permit the use of the single
prong as a cutaneous pressure threshold measurement as well. The instrument can test both moving and static 2 P.D. and the final force at
which the determination was made. (By permission of N.K. Biotechnical Engineering Company)

22 THE JOURNAL OF HAND SURGERY

 THE SENSATIONAL CONTRIBUTIONS OF ERIK MOBERG

His concern was that pressing onto the surface of the DELLON, A. L., SCHNEIDER, R. J. and BURKE, R. (1983). Effect of Acute
Compartmental Pressure Change on Response to Vibratory Stimuli in
skin would deform the skin and create an error, in that Primates. Plastic and Reconstructive Surgery, 72: 2: 208&2!6.
you would be measuring not what occurred just beneath FESS, E. E. Documentation: Essential Elements of an Upper Extremity
the prong but over a greater area. This problem is solved Assessment Battery. In: Hunter, J. M., Schneider, L. H., Mackin, E. J. and
Callahan, A. (Eds.), Rehabilitation of the Hand, (2nd edn.), St. Louis, C. V.
now by being able to specify the force at which the 2 Mosby, 1984: 49978.
P.D. measurement is made. After all, Moberg’s chief LEVIN, S., PEARSALL, G. and RUDERMAN, R. J. (1978). Von Frey’smethod
concern was what the finger would do and it is therefore of measuring pressure sensitivity in the hand: An engineering analysis of the
Weinstein-Semmes pressure aesthesiometer. Journal of Hand Surgery, 3: 3:
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BERG, T. and PYYKKij, I. (1986). Digital vibrogram: A new diagnostic
Bunnell in saying that “Without sensation, the hand is tool for sensory testing in compression neuropathy, Journal of Hand Surgery,
blind”. Today, with appropriate evaluation of sensibility, 11A: 5: 693-699.
reconstructive surgery to restore sensation and sensory MACKINNON, S. E. and DELLON, A. L. (1985). Two-Point discrimination
tester. Journal of Hand Surgery, 10A: 6(l): 906-907.
re-education, we are confident that the future will permit MACKINNON, S. E. and DELLON, A. L. Surgery of the Peripheral Nerve,
us to say “even the blind hand can see”. York, Thieme, 1988.
McQUILLAN, W. (1970). Sensory recovery after nerve repair. The Hand, 2: I :
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24 THE JOURNAL OF HAND SURGERY