At Which Stage of Sensory Recovery Can a Tingling
Sign Be Expected?
A Review and Proposal for Standardization and Grading
C. Spicher, OTR
Department of Rheumatology, Physical Medicine,
and Rehabilitation
H6pital Cantonal
Fribourg, Switzerland
G. Kohut, MD
Orthopaedic and Hand Surgery
Department of Orthopaedic Surgery
H6pital Cantonal
Fribourg, Switzerland
J. Miauton, PhD (Mech Eng)
HES Fribourg
Fribourg, Switzerland
n March 1915, Hoffmann l- 3 published a
I
method to evaluate the success of a surgical
nerve repair. He observed that "durch Reizung des
Nerven eine Empfindung hervorgerufen werden
kann [by the stimulation of a nerve, a sensation can
be procured]."l He called this test "Klopfversuch
[the tapping trial]."z In October 1915, Tinel4 ,5 stated
that pressure applied to an injured nerve trunk fre-
quently produces a sensation of tingling, and he
called this "Ie signe du fourmillement [the tingling
sign]." In 1948, Henderson6 had already written
that the present-day use of the sign differed from
that of Tinel's original test description. At that time,
it was uncommon to describe a test with the four
criteria we now use? -standardization, grading, re-
liability, and validity. Presumably because of the
tingling sign's lack of standardization,8-1o there has
been little or no mention of this sign in articles on
sensibility testing and re-education over the last ten
years. l l - 16
Patients are referred to therapy for sensory re-
education at different stages of sensory recovery.
Correspondence and reprint requests to C. Spicher, OTR, De-
partment of Rheumatology, Physical Medicine, and Rehabilita-
tion, H6pital Cantonal, 1708 Fribourg, Switzerland.
298 JOURNAL OF HAND THERAPY
ABSTRACT: The phenomenon of paresthesia elicited by per-
cussion of regenerating axons is usually associated with Tinel
and Hoffmann, who both described it separately in 1915, al-
though the same phenomenon had been described previously,
in 1909, by Trotter and Davies. This sign is used widely, but its
standardization is almost completely lacking, its grading is sel-
dom used, and its reliability or validity is scarcely mentioned
in the literature. The authors present a method of standardi-
zation and grading of the tingling response by means of a vi-
brostimulator, which permits precise localization of the trigger
point and uniform stimulation. The tingling response may then
be classified according to its location and to the magnitude
threshold at which the response is triggered. In the distal part
of the nerve, after neurotmesis repair, the tingling sign is graded
T++ (tingling after a weak stimulus) and T+ (tingling only
after a strong stimulus). At the site of the injury, the initial tin-
gling sign is graded TO. The sign is graded TOO if, independent
of recovery, a slight positivity persists at the initial site of injury.
Grading of sensory recovery is poorly standardized, since dif-
ferent authors use different variations and modifications of ex-
isting classifications. The authors of this paper present a cross-
matching of these classifications and propose to use Dellon's
modification of Zachary'S classification in eight stages, from SO
to S4. A discussion of the probability of eliciting a tingling sign
during axonal regeneration concludes that the clinician can ex-
pect to trigger a T + + sign when sensory recovery evolves from
stage SO to stage Sl and should no longer expect to trigger one
when sensory recovery improves from stage S2 + to stage S3.
J HAND THER 12:298-308,1999.
For more effective treatment, it would be valuable
to know whether to expect a tingling sign and how
to look for it if it is present.
The first aim of this article is, therefore, in the
context of neurotmesis repair, to propose a method
of standardization and grading of the tingling sign,
in view of its history and of present-day test re-
quirements, as a first step toward the creation of a
valid clinical test. The reliability and validity of
such a test will need to be established in future
studies. The second aim is to discuss the likelihood,
at each stage of sensory recovery, that a tingling
sign will be present.
HISTORY OF THE TINGLING SIGN
In 1873, Letievant, a surgeon and professor of
physiology, published-in a remarkable book of
548 pages and 226 references17 - a review of the re-
generating nerve theory and proposed a new the-
ory of interterritorial sensory takeover. The first
phase was sensory takeover by an adjacent intact
nerve, and the second phase was regeneration of
the injured nerve, which could take as long as 12
to 24 months. He observed that pressure over the
median nerve at the site of repair or at a point distal
to the repair caused painful tingling in the fingers.
Unfortunately, he misinterpreted this phenomenon
and included it in his new theory of motor and
sensory substitutions, not in the theory of the re-
generating nerve.
In 1907, the surgeons Trotter and Davies l8 pro-
posed a standardized method of localizing the larg-
est area of altered sensibility following nerve injury.
They called it "the stroking method." In 1909, they
published a little-known article of 122 pages/9 in
which they studied the stroking method in 14 in-
jured and repaired nerves. In fact, their numerous
observations of the regeneration of these nerves
were drawn from data gathered using themselves
as test subjects. In particular, they observed "the
earliest phenomenon of recovery," called "periph-
eral reference." It can be summarized as follows-
a gentle stroking touch with the finger near the
proximal boundary of the anesthetized area and in
line with the nerve trunk produces a local, numb,
vague sensation of pressure and a sensation having
the characteristics of true touch at the edge of the
most distal part of the area. More precisely, the 15th
point of their summary is that, "during regenera-
tion, stimulation of the nerve trunk below the sec-
tion produces peripherally referred sensations of
cold, pain, or touch according to the stimulus, even
when the nerve is stimulated outside the formerly
anesthetic area." This was truly the first step to-
ward the identification of a tingling sign.
In 1978, Kaplans published Tinel's famous ar-
ticle 4 in English and translated, as other English
speaking authors already had},9 the term "Ie signe
du fourmillement" as "the tingling sign." Other au-
thors 3,16,2o referred to the sign as "the Hoffmann-
Tinel sign." We prefer to use the anonymous and
original term-"the tingling sign" in English,
"signe du fourmillement" in French, and "Paras-
thesien Zeichen" in German.
To propose a method of standardization and
grading of the tingling sign, in view of its history
and of present-day test requirements, we have clas-
sified the historical information on the tingling sign
into four sections-a review of the standardization
of the tingling sign, grading, reliability, and va-
lidity.
Standardization
Many different types of stimuli that trigger a
tingling sign in an injured nerve ~ave been de-
scribed, including a "gentle stroking touch with the
finger,"19 "tapping,"21 "tapping with a straight fin-
ger,,,1-3 "gentle tapping with a finger,"22 a "von
Frey hair tapped repeatedly,"18,19 "pressure,,,4,17,23
"percussion,"6,24,25 "pressure with a foam instru-
ment 2 to 3 mm in width,,,26 or even "gentle per-
cussion with a home-made instrument of a rubber
eraser fixed at the end of a pencil."20 Already in
1909, Trotter19 suggested recording and comparing
the effects of "stimuli which are constant or directly
measurable." In 1952, Sunderland24 suggested a
"uniform" stimulus.
It is easier to find a standard starting point for
stimulation on the nerve trunk than a standard type
of stimulus to apply. Many authors 20 - 22 ,24,27,28 follow
the recommendation of Hoffmann2,3 and Tinel4 ,5 to
commence mechanical stimulation along the course
of expected regeneration from distal to proximal.
Another important component of the sign is
the location at which this sensation is triggered by
the stimulus. Among the many descriptions of this
location, Callahan's29 is perhaps the easiest to un-
derstand-"The most distal point at which the pa-
tient experiences a tingling sensation that radiates
peripherally in the cutaneous distribution of the
nerve is the point of a positive Tinel's sign." Del-
lon 21 ,3o described this as an advancing Tinel's sign.
According to present-day use of the term, the
Tinel sign also includes a nerve impulse gener-
ated ectopically at the site of a nerve injury/l as
in a carpal tunnel, cubital tunnel, or tarsal tunnel
syndrome. Dellon27 described it as a static Tinel
sign. But this impulse is not the historical Tinel
sign. 4 - 6,9,25
"Tinel was careful to draw a distinction be-
tween 'formication' produced by pressure over a
nerve and referred distally, and the 'sensibility of
nerve on pressure' found in neuralgic irritations,
which is always a local sensation."9 This distinction
between the quality of the tingling responses
obliges us to describe this sensation. The most com-
mon term used to describe it is "tingling sensa-
tion.,,5,6,8,9,22,29 In French, we use the term "sensation
de fourmillement,,4,26 or "sensation dysesthesique,
a type de fourmillement ou d'electricite [dyses-
thesic sensation, as in tingling or electric cur-
rent].,,32 In German, Hoffmann2 used the terms
"Stechen [tingling or prickling]" and "heftige Par-
asthesien [intense paresthesia]."3 Head 33 first pro-
posed the terms "protopathic" and "epicritic" in
1905. He observed "a curious widespread formi-
cation" produced by a von Frey's hair, "that radi-
ates widely over the affected area." Some authors3,25
use the confusing English term "pins and needles,"
which is not really a tingling sensation. In fact,
Wynn-Parry28 used this term for the sensation that
a patient usually describes as persisting for some
minutes after sensory testing.
Is the tingling response painful or not? Mel-
zack, in the McGill pain questionnaire/ 4 ranked
"tingling" at pain level 1. In the French version of
the McGill pain questionnaire/ 5 Boureau described
"fourmillement" at pain level 2. Letievane 7 de-
scribed "a sensation of painful tingling." Tubiana 20
described the response as follows: "The reaction
can be compared to that produced by a weak elec-
tric current, unpleasant but not painful." Trotter's
description l9 is similar: liThe sensation produced is
almost exactly like that of faradic current of a
strength just below the pain threshold." He indi-
cated, as did Tinel/,5 that "pain is a sign of irritation
of the nerve; tingling is a sign of regeneration ....
The tingling of regeneration is not a painful sensa-
tion. It is a vaguely disagreeable feeling; the patient
compares it with a sensation of electrical shock."
October-December 1999 299
Grading
Many articles discuss the rate of regenera-
tion. 6,9,24,3o,36-4o Regeneration depends on several fac-
tors, including the type of nerve injured, the type
of injury, the location of the injury, and the age of
the patient. Sunderland24 observed regeneration in
the arm to be faster the more proximal the site of
injury. For example, the rate of median nerve re-
generation after a crush injury is 8.5 mml day in
the upper arm but only 2 mml day at the wrist.
More recently, Gable and Xenard 20 published a
very interesting concept practiced in Nancy, France.
They describe the distinctions made between three
different tingling signs, based on Henderson's
work. 6 Henderson described, in 1948, four different
stages of regeneration as fIno regeneration, negli-
gible regeneration, partial regeneration, and com-
plete regeneration." Seddon23,29,41 further described
Henderson's stages (Table 1), and Gable and Xe-
nard 20 grade them Tl, T2, and T3. They make a pre-
cise distinction between a tingling sign triggered at
the level of the injury (Tl), which is a sign not of
regeneration but rather of the presence of a neu-
roma, and a tingling sign triggered in the distal part
of the nerve (T3 or T2), which is a proper sign of
regeneration.
Reliability
In 1954, Seddon23 reported that "most workers
at the British centers were more concerned with the
unreliability of TineI's sign.... " It was more a prob-
lem of standardization than a problem of reliability.
Without standardization of the sign,B-lO its reliabil-
ity could not be tested. In our review of the litera-
ture, the only study of the reliability of the tingling
sign was by Wynn-Parry.28 In 1966, he reported that
"TineI's sign is the classical way of assessing the
progressive regeneration of a peripheral nerve ....
In our experience, if it is performed carefully, in
most cases it is reliable."
Validity
In our review of the literature, we found no
information on the validity of the tingling sign. In
other words, we did not find any evidence of
whether a correlation exists between a tingling sign
and the location of distally regenerating axon
sprouts. In this context, Hoffmann1,3 estimated that
flit is certainly of the utmost importance, for the
physician as well as the patient, to establish if con-
duction is possible at the site of the injury, that is,
whether or not there is growth of the nerve fibers."
Trotter19 noted, "In the first place, it is necessary to
say that while peripheral reference is invariably
present in an early stage of recovery, it does not,
except possibly in the very earliest stages of all, ac-
company sensations elicited by stimulation of everx
reappearing sensitive spot of the area." Tubiana
also noted the great interest of the tingling sign:
300 JOURNAL OF HAND THERAPY
The prognostic value of this sign is not absolute.
... Interrupted progress [of the sign] must be re-
garded as alarming, and when this persists, and the
absence of other signs of regeneration [to be
discussed] confirms it, surgical exploration is
indicated .... Too much should not be expected of
Tinel's sign, which must be interpreted only in con-
junction with other clinical findings.
PROPOSAL FOR STANDARDIZATION
AND GRADING OF THE
TINGLING SIGN
The first aim of this article is to propose, in the
context of neurotmesis repair, a method of stan-
dardization and grading of the tingling sign as a
first step toward the creation of a valid clinical test,
whose validity and reliability can be examined.
Definition
A tingling sign is a sensation triggered by a
mechanical stimulus in the distal part of an injured
nerve or at the site of an injury. This sensation ra-
diates peripherally, from the point where it is trig-
gered to the cutaneous distribution of the nerve.
This tingling response can be compared with that
produced by a weak electric current, as in transcu-
taneous electrical nerve stimulation. This unpleas-
ant sensation is not Ita severe pain"* and does not
persist.
Standardization and Grading
To make a precise distinction between an ad-
vancing tingling sign in the distal part of the nerve
(a sign of regenerating axon sprouts) and a static
tingling sign at the level of the injury (a sign of the
presence of a nerve injury, as in carpal tunnel syn-
drome lO,27), we propose the following grades:
• Grade TO to represent a tingling sign triggered at
the site of the acute injury ("T" for tingling re-
sponse and "0" for the absence of a sign of re-
generation)
• Grade T + + to represent a tingling sign of tan-
gible regeneration triggered in the distal part of
the nerve ("T" for tingling response and "+ +"
for a sign of tangible regeneration; Table 1 and
Figure 1)
• Grade T + to represent a tingling sign of negli-
gible regeneration triggered in the distal part of
the nerve, as discussed below ("T" for tingling
response and "+" for a sign of negligible regen-
eration; Table 1 and Figure 1)
Distinction has to be made between a tingling sign
at the site of an injury that initially presents no sign
'Patients usually rate the pain of this tingling response between
3 and 5 (from slight to moderate) on a visual analog scale42 of
10.
 TABLE 1. Signs of the Stages of Regeneration According to Various Authors

Gable and
Henderson" Xenard 20 Seddon29,., This Paper
No regeneration T1 "If [the tingling sign] was strongly positive at TO
the level of the lesion but persistently absent be-
low, spontaneous regeneration could not be ex-
pected,"
Negligible regeneration T2 "If the sign was strongly positive at the site of T+
damage and also appeared weak distal to it, the
quality of regeneration would be poor."
Partial regeneration T3 "But a strongly positive sign at the level of the T++
lesion that gradually faded as response moved
peripherally and became stronger in the distal
part of the nerve indicated that satisfactory re-
generation was in progress,"
Complete regeneration: ND ND TOO
"If recovery is not quite perfect
slight tingling may persist from the
neuroma."

NOTE: ND indicates "not discussed."

TABLE 2. Comparison of Mechanical Stimulators That Trigger a Tingling Sign

Area of Discrimination
Uniform Localization Ease of Between T++
Stimulator Stimulus (mm 2 ) Pain Use and T+ Cost
Tip of finger No 100 Moderate Easy to Impossible None
to severe difficult
Semmes-Weinstein Yes 02 Slight to Difficult Possible Expensive
monofilaments moderate
(Rolyan)
Von Frey electronic Yes 1 Slight to Difficult Possible Very
esthesiometer moderate expensive
(Bioseb)
Tuning fork, 30 Hz No 20 Severe Difficult Impossible Inexpensive
Mini-massager (Hitachi) Yes 2 Severe Very easy Impossible Inexpensive
N eurothesiometer Yes 130 Slight to Easy Possible Expensive
(Scientific Laboratory moderate
Supplies)
Biothesiometer Yes 130 Slight to Easy Possible No longer
(Bio-medical) moderate available
Vibrameter (Somedic) Yes 3-130 Slight to Easy Possible Very
moderate expensive
Vibratory Sensory Yes 122 Slight to Easy Possible Very
Analyzer (Medoc) moderate expensive
Vibralgic (Ikar) Yes 3 Slight to Very easy Possible Expensive
moderate

of regeneration, and the tingling sign of an injury
that, after a period of weeks, months, or years, pre-
sents no more sign of regeneration. We propose, in
addition to the previous grades:
• Grade TOO to represent a tingling sign triggered
at the site of an old injury, which has since par-
tially or fully recovered (Figure 1)
For example, we observed longstanding post-
traumatic nerve injuries43,44 that had ceased their
spontaneous regeneration but presented a tingling
response on stimulation of the neuroma. Since there
had been no spontaneous regeneration for years,
we used to write that the patient had "a negative
Tinel sign." Now, to avoid confusion, we propose
to grade this TOO.
To find a standard starting point for stim-
ulation on the nerve trunk, we propose to initi-
ate the mechanical stimulation along the course
of expected regeneration, from distal to prox-
imal. This approach has been advocated in previ-
ous studies. 2 - 5 ,20-22,24,27,28
To provide a mechanical stimulus to the nerve
we need:

October-December 1999 301

 TINGLING SIGN

At the site of the inj un:' In the distall2art of the nerve

Grade Description Illustration} Grade Description Illustration

A positive sign of T++

51 =;f4s; lszl®
TO No sign of regeneration, - -- -'" T+ + tangible regeneration:
"
<k1
but a tingling sign is
present at the site of So with a weak stimulus
the acute injury or
with a strong response IItutoma

A positive sign of

s;?§7
TOO No more T+ negligible regeneration:

~ 71+s,l~
sign of regeneration.
but a slight tingling may with a strong stimulus
persist at the site of or
an old injury with a weak response
TOO aeurom..

FIGURE 1. The grading of a tingling sign. The illustrations provide examples of what could be observed after the repair of a
digital proper palmar nerve injury at the proximal phalanx.

• A "uniform" stimulus, which is necessary as a plitude of the mechanical vibration.

first step toward the creation of a valid test for The Vibralgic consists of a signal generator and
the tingling sign. The use of a uniform stimulus a vibrostimulator (Figure 2). The generator pro-
should improve the interobserver reliability of duces a sinusoidal signal with a frequency between
documenting the tingling sign. 30 and 1,000 Hz and a voltage between 0.1 and 4.8
• A vibrostimulator probe with a contact area V. The electrical signal is converted to a mechanical
small enough to localize exactly the point that displacement by the stimulator in the same manner
triggers a tingling sign. Consequently, it will be as in a loudspeaker.
possible, as time passes, to follow the path of the The vibrostimulator manufacturer unfortu-
advancing tingling sign precisely, millimeter by nately does not indicate explicitly the relationship
millimeter. between the amplitude of the mechanical displace-
• A mechanical stimulus that is strong enough for ment and the electrical signal. However, it is well
the therapist to trigger a tingling sign but weak known so that the acceleration of the movable part,
enough not to provoke severe pain. which is applied to the injured tissue, is propor-
tional to the amplitude of the electrical signal. The
For these reasons, we chose to provide a mechani- frequency of the mechanical displacement is obvi-
cal stimulus with a vibrostimulator. The choice be- ously the same as the electrical one.
tween the numerous vibrostimulators available on
the market was difficult, since no systematic com-
parison between them has been made. A large
number of models are available, from the more ex-
pensive and sophisticated to the cheapest and sim-
plest ones. A number of vibrostimulators used in
previous studies 4s - 49 (e.g., TVR model, HV-13 D,
Biothesiometer) are no longer available. On the
other hand, the displacement, speed, and accelera-
tion characteristics of the vibrostimulators have not
been clearly characterized by the different authors
of the publications. We have been using the Ikar
Vibralgic Vibrostimulator (LMT, Ecublens, Switzer-
land) for the last eight years. Thisi instrument is
used in about 500 sensory re-education centers in
French-speaking Europe. The various technical
characteristics of eight vibrostimulators available
on the European market today are reported in Table
2. The limits of our finger testing to trigger a tin-
gling sign are also reported; it is difficult to localize
a tingling sign of a digital proper palmar nerve at
the proximal phalanx by percussion, but it is easy
with the Vibralgic. It is our belief, and our sugges-
tion in this paper, that the vibrostimulator permits FIGURE 2. The generator and stimulation head of the Vi-
the adjustment of the excitation frequency and am- bralgic stimulator.

302 JOURNAL OF HAND THERAPY

 The peak-to-peak value of the acceleration a is TABLE 3. Peak-to-Peak Amplitude of the Displacement, in
thus given by Microns, for Various Vibralgic Vibrostimulators, Measured
at a Fixed Frequency of 160 Hz

a = C-V Voltage (V)

Vibrostimulator 1.0 2.0 3.0 4.0 4.8
where V is the peak-to-peak voltage and C is a con- A 53 91 127 166 193
stant that depends on the vibrostimulator design. B 58 99 143 176 208
The peak-to-peak amplitude of the displacement x C 51 81 121 155 180
is then given by D 49 91 139 175 203
E 50 81 126 152 176
CV F 46 86 122 157 182
X=-2 G 46 80 114 145 173
W
H 57 97 142 175 201
I 50 86 121 153 183
where w is the pulsation measured in rads per J 53 91 127 162 191
second. 51
To check the vibrostimulator, we chose a me-
chanical stimulus with a unit on which we have TABLE 4. Peak-to-Peak Amplitude of the Displacement, in
performed a series of measurements. lO We have Microns, for Various Vibralgic Vibrostimulators, Measured
tested the Vibralgic in various Swiss rehabilitation at a Fixed Excitation Voltage of 4.8 V
centers. A first set of tests has shown that the gen-
Frequency (Hz)
erated electrical signal, in both amplitude and fre-
quency, does correspond to the displayed value on Vibrostimulator 160 140 120 100 90 80 70 60
the instrument to better than ±5%. To check exper- A 193 244 343 514 660 894 1270 2040
imentally the relationships we have presented B 208 291 436 768 1100 1620 2670 1600
above, we used the following measurement proce- C 180 242 338 517 675 914 1360 2170
dure: We placed an accelerometer on the stimulator D 203 280 431 775 1150 1914 3550 3240
tip and measured with the help of an oscilloscope E 176 231 314 466 579 740 967 1320
the acceleration at a fixed frequency of 160 Hz. In F 182 244 348 514 654 851 1160 1760
another set of experiments, the voltage was kept at G 173 237 339 514 679 962 1570 2550
4.8 V and the frequency was swept. The experi- H 201 280 403 654 847 1230 1950 3380
mental results are reported in Tables 3 and 4. As I 183 234 323 479 613 815 1150 1710
shown in Table 3, the vibrostimulators have peak- J 191 255 369 572 760 1020 1650 2550
to-peak output displacements within ±10% of each
other. This is perfectly normal for this type of in-
strument. The amplitude of the displacement for
the various vibrostimulators remained more or less 1. Localization of a tingling sign (subjective)
the same down to a frequency of 120 Hz, below
which the values started to diverge. This behavior A. The patient holds the stimulation head of
is to be expected, since the natural resonance fre- the vibrostimulator (magnitude of vibra-
quency of these devices is around 70 Hz. The am- tion, 3.0 V, 160 Hz) and applies its probe
plitude of the displacement is greatly enhanced for to the skin at the site of the injury, making
frequency close to the resonance frequency. small, gentle, circular movements. When
From these measurements, we deduced an av- the tingling response (TO or TOO) appears,
erage value of 320,000 for the coefficient C in the patient holds the head of the vibro-
stimulator still and the therapist marks the
center of the contact area (3 mm)2 on the
10- 4 m ·S2
patient's skin with a pen.
V
B. The therapist places the stimulation head
of the vibrostimulator (magnitude of vi-
Therefore, the relationship between the peak-to- bration, 3.0 V, 160 Hz) at the distal part of
peak amplitude of the displacement of the vibro- the injured nerve. Using slight to moderate
stimulator in 1O-4m versus voltage and fre- application force, the therapist moves the
quency is head of the vibrostimulator along the
course of expected regeneration from dis-
320,000· V tal to proximal. The patient indicates when
x = ------::--
(27rff the tingling response (T + +) appears by
saying "stop." The therapist marks this
second point on the skin with a pen.
where V is the voltage and f the frequency, in hertz,
displayed by the generator. e. The therapist measures the distance be-
We use the following procedure to look for a tween these two points and consequently
tingling sign: is able to follow the evolution of the ad-

October-December 1999 303


FIGURE 3. The stimulation head of the vibrostimulator in
contact with a patient's finger.
vancing tingling sign millimeter by milli-
meter.
2. Identification of a tingling sign (objective). To
verify the two tingling response points, the
therapist asks the patient to look away from
the hand. The therapist places the probe of the
stimulation head (Figure 3) on the tingling re-
sponse points with slight application force to
prevent the stimulation head from sliding on
the skint and asks if a tingling response is
elicited.
3. Discrimination between a tangible and a neg-
ligible tingling sign. If the therapist cannot
find this second tingling response again, he or
tThe stimulus we propose for identifying a tingling sign is a
vibration and not a pressure. Using an electronic aesthesiome-
ter, we determined that the slight application force needed to
prevent the stimulation head from sliding on the skin is equiv-
alent to that of a weight of 20 g.
she attempts to provoke it once more, but this
time with a stronger stimulus (magnitude of
vibration, 5.0 V, 140 Hz). Such a tingling re-
sponse would be graded T + .
The last advantage of a vibrostimulator is that
it offers mechanical stimuli with different magni-
tudes. Gable and Xenard 20 distinguish between a
patient who reports a strong tingling response (T3)
and a patient who reports a weak tingling response
(T2) (Table 1). The reason for making such a dis-
tinction is based on the hypothesis that the prog-
nosis for complete nerve regeneration should be
better if we find a T3 than if we find a T2 sign. This
has been observed over several years of practice by
Gable and her team in Nancy, France, and by our-
selves, in Fribourg, Switzerland. Those experienced
in the vibratory stimulation technique recognize
that the vibration can produce pain.14.52.53 The de-
gree of pain is in direct relation to the magnitude
of the applied vibration. 54 As we know, the stronger
you are beaten, the more severe is your pain. Wah-
ren45 uses the term "vibration-induced pain thresh-
old" to describe this phenomenon. Figure 4 shows
the degree of pain reported by a patient during the
procedure of looking for the tingling sign from a
collateral palmar nerve. The same therapist trig-
gered five times (on the same day) a tingling sign
with five different stimuli. It is not easy to evaluate
whether a tingling response is strong (T3) or weak
(T2). Melzack34 and Boureau et al.35 consider these
sensations painful. Instead of distinguishing be-
tween patients' reports of strong and weak tingling
responses, we propose to trigger a tingling re-
sponse with a weak stimulus or with a strong stim-
ulus (Table 5). In summary, we attempt to elicit a
tingling response first with a weak stimulus. If a
tingling response occurs, we call this a positive sign
of tangible regeneration, T + +. If a T + + response
disappears some weeks later, we then try to obtain
a tingling response using a stronger stimulus. If it
occurs, we call this a positive sign of negligible re-
generation, T+ (Table 1).

10

G)

.-
I: m 8
III
Co
en(.)
"0 ~ 6
CI) Cl
CI) 0
FIGURE 4. The degree of pain c, m
provoked by five different stimuli
during the procedure that looks for
~ ~
_
4 •
the tingling sign T + + from a dig- ~ •
ital proper palmar nerve. 2 •
--
III
> •
o •
o 50 100 150 200
Amplitude of vibration
(Microns, at 160 Hz)

304 JOURNAL OF HAND THERAPY

TABLE 5. Distinction Between Positive Signs of Tangible we consulted, the more complicated the criteria for
(T++) and Negligible (T+) Regeneration in the Distal Part
. of the Nerve
these stages appeared. In short, here is what we
discovered about the stages of sensory recovery:
Patient Vibrostimulator

Grade Stimulus
Tingling
response Stimulus
Tingling
response
• adopted
"In 1942, the Medical Research Council (MRC)
a scheme for the assessment of recovery
T++ Uniform? 5trong Weak: 3.0 V, 160 Hz, Positive in peripheral nerve injuries as suggested by
about 0.1 mm Highet."38 This classification consisted of five
peak to peak stages-SO, 51, 52, 53, and 54. The description of
5trong Positive 54 is "Return of sensibility as in Stage 3, with
the addition that there is recovery of two-point
T+ Uniform? Weak Weak Negative
tactile discrimination within the autonomous
5trong: 5.0 V, 140 Hz, Positive zone."36
about 0.2 mm
peak to peak • In 1943, Highet and Holmes 36 published what
was to become the Highet classification.
• In 1946, Zachary and Holmes 38 modified the clas-
sification to consist of eight stages (Table 6). They
made a distinction between ulnar, median, and
ASSESSMENT AND GRADING OF radial nerve sensory recovery. The grade 54 is
SENSORY RECOVERY reserved for patients who have a complete recov-
ery.
The second aim of this article is to discuss the • In 1954, the Nerve Injuries Committee of the
likelihood of the presence of a tingling sign at each MRC published the Special Report Series No.
stage of sensory recovery. There are many different 282. 56 This book, edited by Seddon, contains
classifications of the stages of sensory recovery. For ten chapters. In Chapter 8, Zachary described
example, three French-speaking authors 14,16,55 report the Highet classification, which later became
that they have used the International British Re- the British Medical Research Council Report
search Council's grading, but unfortunately these (BMRCR) (Table 6).
three gradings, as reported, all differ. How is this • In 1957, Nicholson and Seddon37 observed that
possible? When we tried to understand the reason "it is even more probable in the present series
for this confusion, we found that, the more sources than in those described by Zachary in the Re-

TABLE 6. Some Classifications of Sensory Recovery

Grade Zachary and Holmes (1946),8
50 "No recovery of sensibility in the au-
tonomous zone of the median nerve."
51 "Recovery of deep cutaneous pain sen-
sibility."
51+ "Recovery of superficial cutaneous pain
sensibility."
52 "Recovery of superficial pain and some
touch sensibility."
52+ "Recovery of superficial pain and touch
sensibility throughout the median
area but with over-response,"
53 "Recovery of pain and touch sensibil-
ity with disappearance of over-re-
sponse."
53+ "Recovery as far as 53, but localization
of the stimulus is good and there is
imperfect recovery of two-point dis-
crimination."
54 "Complete recovery,"
NOTE: ND indicates not discussed.
Sensory Recovery
Highet's classification by
BMRCR (1954)56
"Absence of sensibility in the autono-
mous zone of the nerve."
"Recovery of deep cutaneous pain sen-
sibility within the autonomous zone."
ND
"Return of some degree of superficial
pain and tactile sensibility within the
autonomous zone."
ND
"Return of superficial pain and tactile
sensibility throughout the autono-
mous zone with the disappearance of
over-response."
ND
"Return of sensibility as in 53 with the
addition that there is recovery of two-
point discrimination within the au-
tonomous zone."
Zachary, Modified by Dellon (1988)'°
"No recovery of sensibility in the au-
tonomous zone of the nerve,"
"Recovery of deep cutaneous pain sen-
sibility with autonomous zone of the
nerve."
"Recovery of superficial pain sensibil-
ity."
"Recovery of superficial pain and some
touch sensiblity."
"As in 52 but with over-response."
"Recovery of pain and touch sensibility
with disappearance of over-response,
and there is a classical two-point dis-
crimination greater than 15 mm."
"As in 53 but localization of the stim-
ulus is good and there is a two-point
discrimination in 7- to lS-mm range."
"Complete recovery and there is a two-
point discrimination in 2- to 6-mm
range.

October-December 1999 305


FIGURE 5. Three major fascicles of the digital nerve just
distal to the distal interphalangeal joint.
pore6 that this has resulted in an underestima-
tion of the proportion of recoveries, because ci-
vilians seem less likely to continue to report if
recovery is satisfactory than pensioners, who are
required to attend for periodic re-examination."
Consequently, Nicholson recommended using
the narrow classification of Zachary (1946) with
seven stages (without 51 +). For the same reason,
Delprat and Mansat,55 in 1982 in France, pro-
posed three stages-54a, 54b, and 54c-in the
achievement of functional sensory recovery.
• In 1975, in the second edition of Surgical Disorders
of the Peripheral Nerves,41 5eddon published a sim-
plified classification with six stages-50, 51, 52,
53, 53+, and 54-based on Zachary's original
classification. This is not the grading system of
the BMRCR. 56
• In 1988, in the third edition of Evaluation of Sen-
sibility and Re-education of Sensation in the Hand}O
Dellon chose the 1946 Zachary classification as
the most common international classification,
which he modified to include a classical two-
point discrimination (2PD) ranging as follows: 53
having a 2PD greater than 15 mm; 53+ having a
2PD in the range of 7 to 15 mm; and 54 having
a 2PD in the range of 2 to 6 mm. The two-point
discrimination test is carried out as described by
Dellon}O using the three-point (two mobile and
one fixed point) aesthesiometer. The minimal dis-
tance in millimeters at which the patient can cor-
rectly identify one- or two-point stimulation at
least seven times out of ten is recorded. 57
We have chosen the classification of Dellon's
well-known publication as a standard (Table 6),
even though we would prefer different values for
the static and moving two-point discrimination
tests 25.58 and modalities to make a distinction be-
tween deep and superficial cutaneous pain. We
would have liked to add light-touch -deep-pres-
sure testing59.6o and one-point localization testing61
as well.
50 at which stage of sensory recovery can a
tingling sign in the autonomous zone of the nerve
be expected?
The answer to this question is the core issue of
our hypothesis. Hoffmann and Tinel both spoke of
a nerve's regeneration but not of sensory recovery
and its quality, although Moberg62.63 and Wynn-
Parry28 are certainly correct when they insist on the
306 JOURNAL OF HAND THERAPY
importance of functional tests to evaluate the qual-
ity of sensory recovery. In keeping with the opin-
ions of Hoffman and Tinel, we chose to focus in
this article on the stages of sensory recovery.
To avoid any confusion, we would like to state
once more that the standardized and graduated tin-
gling sign has not been validated and shown to be
reliable to date. It is not the tingling test, but it is a
first step toward the creation of a valid clinical test.
In light of this reservation, we would like to discuss
now the hypothetical probability of the presence of
a tingling sign during axonal regeneration and the
reasons for the clinician to look for it.
• At the 50 stage, of course, we should not expect
a sign of regeneration, T + +, but we may observe
a tingling sign, TO.
• In 1948, Henderson6 stated that "the first few
inches of the advancing young sensory axons are
unmyelinated and sensitive to mechanical stim-
ulation." Yarnitsky and Ochoa64 stated that "a
tingling sign [T+ +] can be mediated by unmy-
elinated fibers (A, 0, and C)." Consequently, 51
is the earliest stage of sensory recovery at which
an advancing tingling sign, T + +, should be ex-
pected.
5econd, at which stage of sensory recovery
should the disappearance of the tingling sign be
expected? Generally, for injuries of the median and
ulnar nerves, its disappearance is observed after it
has reached the distal interphalangeal (DIP) joint,
because of the division of the nerve at this site (Fig-
ure 5).65 It is only at this stage that a response can
be elicited with a two-point discrimination test.
Therefore, we believe that an advancing tingling
sign, T + +, should no longer be expected at the 53
stage of sensory recovery, although a TOO sign may
persist.
On the other hand, the over-response to stim-
ulation in the 52 + stage does not permit two-point
discrimination testing even if it does permit one-
point localization testing. 61 Therefore, the disap-
pearance of the tingling sign also corresponds to
the disappearance of the over-response.
In summary, it is our feeling-based on our
experience and on the theoretical arguments put
forth in this paper, despite the presentation of no
conclusive data here-that the T++ sign should
appear when sensory recovery evolves from stage
50 to stage 51 and should disappear when sensory
recovery improves from stage 52 + to stage 53.
CONCLUSION
If we bear in mind that the prognostic value of
the tingling sign is not absolute, this sign can be a
very useful tool for the assessment of effective treat-
ment.
Primarily we hope that the method of stan-
dardization and grading that we have proposed
will permit anyone who frequently treats patients
with neurotmesis to determine whether the tingling
sign is valid and reliable. Only through further re-
search can this question be answered more defini-
tively.
Secondarily we hope that anyone will be able
to obtain an exact correlation between the tingling
test and the stage of sensory recovery. In particular,
it would be interesting to know whether the sud-
den disappearance of a T + + tingling sign has the
same prognostic value as the transformation of a
T++ into a T+ sign followed by its disappearance.
Finally, further research is necessary to deter-
mine whether there is any correlation between the
tingling test and different values of functional tests,
such as the Moberg pickup test. 62 ,63
In this way, the tingling sign may one day be-
come the tingling test.
Acknowledgments
The authors thank Valerie Debieux and Anne-Marie Serex, OTR,
for their assistance in the literature search; Francine Stettler,
OTR, Federico Balague, MD, Carmen Meyer, OTR, Michel
Jacques, OTR, and Evelyne Thommen, PhD, OTR, for reviewing
the manuscript; Janice Crausaz-Powell, OTR, Shirley Dawson-
Walkowski, PT, Prof. Jerome Faist, Phys Eng PhD, Gillian Le-
noir-Nutter, Mike McNichols, MD, Bryan I. O'Callaghan, MD,
BE, Rosalind Richards, RGN, Robin Mockli-Cowper, STAT, Irma
Stettler, OTR, and Sarah Ewald, OTR, for the English correc-
tions; Valerie Rappo-Simonet, OTR, for the drawings; and Ar-
thur James Grainger for the photography.
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