CVA Examination sensation and Reflexes

Question 1

Sensory deficits post CVA

Answer 1

*Type and extent of impairment are related to the location and size of the vascular lesion

*Localized dysfunction is common with cortical lesions

*Diffuse dysfunction involvement suggests deeper lesion involvement

Question 2

Why is Sensory important?

Answer 2

*Sensory impairments will negatively affect motor performance, motor learning and rehabilitation outcomes

*Sensory impairments can contribute to unilateral neglect and learned nonuse of limbs

*Sensory impairment can be associated with pressure sores, abrasions, shoulder pain and subluxation

Question 3

What is the purpose of a sensory screen vs exam?

Answer 3

*A screen identifies need for further investigation

*A gross sensation screen is part of the neurologic evaluation which examines a patient’s somatosensation

*The sensory exam involves testing sensory integrity by determining the patient’s ability to interpret and discriminate among incoming sensory information

Question 4

What are sensory receptors?

Answer 4

*Located in the distal end of an afferent nerve fiber

*They give rise to perception of a specific sensation once stimulated

*Three divisions include:
-Superficial sensations
-Deep sensations
-Combined (cortical) sensations

*Systems that mediate to higher centers:
-Spinal pathways

Question 5

What are the type of sensory receptors?

Answer 5

*Mechanoreceptors: respond to mechanical deformation of the receptor or surrounding area

*Thermoreceptors: respond to change in temperature

*Nociceptors: respond to noxious stimuli and result in the perception of pain

*Chemoreceptors: respond to chemical substances

*Photic (electromagnetic): respond to light within the visible spectrum

Question 6

Other Sensory receptors are

Answer 6

*Cutaneous Receptors
located at the terminal portion of the afferent fiber

*Deep Sensory Receptors
located in muscles, tendons and joints

Question 7

What Pathways for Transmission of Somatic Sensory Systems

Answer 7

*Information enters the spinal cord through the dorsal roots

*Sensory signals are carried to higher centers via ascending pathways

Question 8

What is the anterolateral spinothalamic system?

Answer 8

*Initiates self-protective reactions and responds to stimuli that are potentially harmful

*Slow-conducting fibers of small diameter, some are unmyelinated

*Transmission of thermal and nociceptive information, pain mediation, temperature, crudely localized touch, tickle, itch, sexual sensations

*Route: dorsal roots  immediate crossing to ascend the spinal cord through the medulla, ponds and midbrain  VPL of the thalamus  projections are sent to the somatosensory cortex via the internal capsule

Question 9

what does the spinothalamic tract carry?

Answer 9

Pain and temperature

Question 10

the Dorsal column medial lemniscal system

Answer 10

*Involved with responses to more discriminative sensations

*Fast-conducting fibers of large diameter with greater myelination

*Mediates the sensations of discriminative touch and pressure sensations, vibration, movement, position sense, and awareness of joints at rest

*Route: enter through the dorsal column  ascend to the medulla and synapse with dorsal column nuclei (nuclei gracilis and cuneatus)  cross to the opposite side and pass up to the thalamus (via medial lemniscus) to the VPL  somatosensory cortex

*Projections to the sensory association areas allow for the perception and interpretation of combined cortical sensations

Question 11

the dorsal column medial lemniscal tract is carrying what

Answer 11

discriminative sensations such as kinesthesia and touch

Question 12

what is Somatosensory Cortex

Answer 12

*Most complex processing of sensory information

*Divided into three main divisions:

-Primary somatosensory cortex
—–Post central gyrus

-Secondary somatosensory cortex
——Posterior parietal cortex

Question 13

What is Homunculus?

Answer 13

*Somatotopic map that represents either the motor (pre-central gyrus) or sensory (post-central gyrus) and identifies the relative size of the cortex devoted to specific body parts

—Represents the density of sensory input from the body region

—Represents the importance of sensory information from the area as it relates to function

Question 14

what are Superficial Sensations

Answer 14

*Exteroceptors are responsible for superficial sensations.

*Information is received from the external environment via the skin and subcutaneous tissue.

Question 15

What are superficial sensation

Answer 15

pain perception, temperature awareness, touch awareness

Question 16

what is deep sensations

Answer 16

*Proprioceptors are responsible for the deep sensations.

*These receptors receive stimuli from muscles, tendons, ligaments, joints and fascia.

*These receptors are responsible for position sense.

Question 17

what are deep sensations

Answer 17

kinesthesia awareness, proprioceptive awareness, vibration perception

Question 18

what is combined cortical sensations?

Answer 18

*This is the combination of both the superficial and deep sensory mechanisms.

*Information comes from both exteroceptive and proprioceptive receptors as well as intact function of cortical sensory association areas in the brain.

Question 19

how do you prepare for the sensory exam

Answer 19

*Prepare testing environment
-Quiet, well-lit area

*Patient positioning: sitting, recumbent, supine or prone

*Equipment: safety pin/paper clip, test tubes with stoppers, piece of cotton/tissue, tuning fork (with headphones to reduce auditory cues), variety of small, commonly used objects, a small hand-held object (aesthesiometer) to measure two-point discrimination, and a variety of fabrics

Question 20

What are preliminary considerations of sensory exam

Answer 20

*Promotes/reduces reliability of your testing and alters accuracy
-Arousal
-Attention
-Orientation
-Cognition
-Memory

*Impairments may warrant adaptations to maintain test accuracy
-Hearing
-Visual acuity
-Speech

Question 21

what are some important things to consider with sensory exam

Answer 21

*Fully explain the purpose of the test and provide expectations

*Stimulus application should be random, unpredictable and with variation in timing

*Skin condition should be considered (calloused areas, etc.)

*A ”trial run” or demonstration should be performed

*Occlusion of the patient’s vision should occur

*Clothing should not obstruct the area being tested

*Sequencing: superficial  deep  combined cortical
Ex: lack of touch sensation would limit object recognition within the hand

*Test distal to proximal

Question 22

What information is generated( with sensory exam)? How do you document your findings?

Answer 22

*The modality tested

*The quantity of involvement of body surface areas affected (pattern identification)

*The degree or severity of involvement (absent, impaired, normal, not testable)

*Localization of the exact boundaries of the sensory impairment

*The patient’s subjective feelings about these changes

*The potential functional impact of sensory loss

Question 23

what is the problem with sensory exam?

Answer 23

Deficits can occur at any point within the system:
Sensory receptors
Peripheral nerves
Spinal nerves
Spinal cord nuclei and tracts
Brain stem
Thalamus
Sensory cortex

Question 25

what are example of sensory patterns

Answer 25

*Peripheral nerve injury
Ex: ulnar half of the ring finger

*Peripheral neuropathy secondary to Diabetes
Glove and stocking distribution

*Multiple Sclerosis
Unpredictable/scattered pattern

*SCI
Diffuse pattern below the lesion level that is typically bilateral

Question 26

what are other considerations of sensory exam

Answer 26

*Spinal cord tract integrity

*Nerve root involvement has evidence of motor and sensory loss

*CNS lesions (e.g., CVA) may result in significant sensory impairments with a diffuse pattern (e.g., head, trunk, and limbs)

Question 27

What are Superficial Sensations: Pain Perception

Answer 27

*Sharp/dull discrimination

*Indicates function of protective sensation

*Random perpendicular application of sharp and dull ends of a safety pin/paper clip

Question 28

What are superficial sensations: temperature awareness

Answer 28

*Test the ability to distinguish between warm and cool stimuli

*Two test tubes with stoppers are required

*Ideal cold temperatures are between 41-50 deg F

*Ideal warm temperatures are between 104 and 113 deg F

*The side of the test tube should be placed in contact with the patient’s skin in a random fashion

*Difficult test to perform as the tube temperature changes rapidly when exposed to air

Question 29

what are Superficial Sensations: Touch Awareness

Answer 29

*Determines perception of tactile input

*Often a piece of cotton or tissue is used

*The tested area is lightly touched or stroked

Question 30

What Deep Sensations: Kinesthesia Awareness

Answer 30

*Examines the awareness of movement

*The extremity/joint is moved passively through a small ROM

*The patient is asked to state up, down, in, out, etc.

Question 31

What is Deep Sensations: Proprioceptive Awareness

Answer 31

*Test joint position sense and the awareness of joints at rest

*The extremity or joint is moved through the ROM and held statically

*The patient should verbally describe or demonstratively (on the contralateral extremity) duplicate the position

Question 32

what is Deep Sensations: Vibration Perception

Answer 32

*This test requires a turning fork that vibrates at 128 Hz

*The base of the vibrating tuning fork is placed on a bony prominence

*Random application of vibrating and non-vibrating stimuli is required to identify if sensation is intact or impaired

*Auditory clues can reduce accuracy of test results

*The patient is asked to verbally identify if the stimulus is vibrating or non-vibrating upon each contact

Question 33

What are the Combined Cortical Sensations: Stereognosis Perception

Answer 33

*The test determines the ability to recognize the form of objects by touch

*Items used should be small, easily obtainable and culturally familiar

*Items should be of differing sizes and shapes

*An item is placed in the patient’s hand, he or she can manipulate the object and then verbally identify the item

Test samples can be given during explanation and demonstration of the test

Question 34

the Combined Cortical Sensations: Tactile Localization

Answer 34

*This test determines the ability to localize touch sensation on the skin (topognosis)

*The patient is asked to identify the specific point of application of a touch stimulus (e.g., tip of ring finger, medial malleolus, etc.), and not simply the perception of being touched

*This test is often combined with pressure perception or touch awareness

*Use of a cotton swab or fingertip is used to touch different skin surfaces

The patient is asked to verbalize description of the location of the stimuli or point to the area

The distance can be recorded between the application site and the site indicated by the patient

Question 35

What is Combined Cortical Sensations: Two-Point Discrimination

Answer 35

*This test determines the ability to perceive two points applied to the skin simultaneously

*It is the measure of the smallest distance between two stimuli that can still be perceived as two distinct stimuli

*Results can be negatively influenced by fatigue

*Values vary for different individuals and by gender and body part
-The most refined location is the distal upper extremity

*To increase validity testing should occur with some application of two- and one-point stimuli

*The patient is asked to identify the perception of ”one” vs. “two” stimuli

Normative values do exist

Question 36

what is Combined Cortical Sensations: Double Simultaneous Stimulation

Answer 36

*This test determines the ability to perceive simultaneous touch stimuli

*The therapist simultaneously touches:
-Identical locations on opposite sides of the body
-Proximally and distally on opposite sides of the body
-Proximal and distal locations on the same side of the body

*The extinction phenomenon is the term used to describe a situation in which only the proximal stimulus is perceived with “extinction” of the distal

*The patient is asked to verbalized when and how many stimuli are felt

Question 37

what does the Combined Cortical Sensations: Graphesthesia consist of

Answer 37

*This test determines the ability to recognize letters, numbers, designs “written” on the skin

*A fingertip or pencil eraser are used to trace on the palm of the patient’s hand

*An orientation of drawings should be agreed upon during the trial

*Between each separate drawing, the palm should be wiped with a cloth indicating changes in figure to the patient

*This can be a useful test is paralysis limits grasp of an object such as required for stereognosis testing

*The patient is asked to verbally identify the figures drawn on the skin

*A series of drawing can be present to a patient for pointing if language or speech impairments are present

Question 38

Combined Cortical Sensations: Recognition of Texture

Answer 38

*This test determines the ability to differentiate various textures

*Suitable textures may include cotton, wool, burlap, silk, etc.

*The items are placed within the patient’s hand and he or she is asked to manipulate the texture

*The patient is asked to identify the individual texture as they are placed within the hand

Question 39

Combined Cortical Sensations: Barognosis

Answer 39

*This test determines the ability to recognize different weights

*A set of discrimination weights consisting of objects of the same size and shape but of graded weight is used

*The therapist may place a series of different weights in the same hand, place a different weight in each hand, or ask the patient to use a fingertip grip to pick up each weight

*The patient responds by indicating if an object is “heavier” or ”lighter”

Question 40

Why is sensory testing important?

Answer 40

Learning motor behavior is dependent on the patient’s ability to take in sensory information from the body and the environment (sensory intake), process it (sensory integration), and use it to plan and organize behavior (output).”

Question 41

what is Deep Tendon Reflexes

Answer 41

*A reflex is an involuntary, predictable, and specific response to a stimulus that is dependent on an intact reflex arc (sensory receptor, afferent neurons, efferent neurons, and responding muscles or gland).

*A muscle contraction is produced as a result of stimulation of the stretch-sensitive IA afferents of the neuromuscular spindle

*Reflexes are tested by tapping sharpely over the muscle tendon with a standard reflex hammer or with the tips of the therapist’s finger

*The muscle should be positioned in midrange and the patient should be instructed to relax

Question 42

what are commonly tested myostatic reflexes stretch

Answer 42

jaw, biceps, brachioradialis, triceps, finer flex, hamstrings quads achilles

Question 43

DTR Grading

Answer 43

0 absent no response

1+ low normal, diminished

2+ normal

3+ brisker or more reflexive than normal

4+ very brisk, hyperreflexive with clonus

5+ sustained clouns

Question 44

Upper Motor Neuron Injury
Lower Motor Neuron Injury
Type of paralysis
Spastic: UMN
Flaccid:LMN

Atrophy
No disuse atrophy: UMN
Severe atrophyLMU

Deep tendon reflexes
Increased:UMN
Absent:LMN

Pathological reflexes
Present:UMN
Absent:LMN

Fasciculation and fibrillation
Absent:UMN
May be present:LMn

Question 45

Superficial Cutaneous Reflexes

Answer 45

*These reflexes are elicited with a light stroke applied to the skin

*The expected response is a brief contraction of muscles innervated by the same spinal segments receiving the afferent inputs from the cutaneous receptors

Examples:
-Plantar reflex: abnormal sign would be a Babinski reflex

-Abdominal reflex: an abnormal response would be a loss of a response or asymmetry

-These may be absent in individuals who are obese or who have had abdominal surgery