Sensation Flashcards
Why would you do sensory testing?
-Identify a problem interfering with occuapation
–impairments hinder movement
–impairments increase the risk of injury
-Assist with diagnosis (assess type and extent of sensory
loss)
-Provide information about return of neurological function
–Evaluate and document sensory recovery
-Determine a treatment plan and approach
–Compensation (adaptation)
–Sensory re-education (remediation)
–desensitization (remediation)
T/F: Sensation is particularly important for hand function
True. E.g., Fine motor coordination, manipulation, judging force for grasp…
Clients with which diagnosis would most likely NOT need a sensory assessment?
a. C5-6 tetraplegia
b. Multiple sclerosis
c. Myocardial infarction
d. Carpal tunnel syndrome
C. Myocardial infarction: need to evaluate sensory for all others
What clients are appropriate for Sensory Assessments?
- Any client with potential neurological involvement
- Diagnosis determines expected sensory picture
- Clients with:
- -Cortical lesions
- -LMN lesions
- -PNI
- -Other neurological diagnoses
T/F: Any client with potential neurological involvement would be appropriate for sensory assessment
True!
T/F: Diagnosis determines sensory deficits in a patient
False. Diagnosis determines what is expected in a sensory picture, but not always true
This condition results in a total absence in dermatomes below the level of lesion
A complete spinal cord injury. May have paresthesia (tingling or pins and needles) at level of lesion
This condition relates to damage within specific spinal tracts.
Incomplete spinal cord injury.
Anterior=pain and temperature (usually coms back before light touch and proprioception
Posterior=light touch, vibration, proprioception
T/F: Peripheral nerve injuries relate to dermatomes of the body while Spinal cord injury pattern varies with nerves involved and extent of damage
False. Spinal Cord Injuries relate to consistent dermatomes while peripheral nerve injury patterns vary with nerves involved and extend of damage
Damage to this area in a PNI affects a dermatome on one side of the body
Damage to a single nerve root affects a single dermatome on one side of the body.
Damage to this region in a PNI affects sensation within peripheral nerve distribution
Damage to a peripheral nerve affects sensation within peripheral nerve distribution
T/F: Sensory loss severity can very widely in a peripheral nerve injury
True.
- Mild compression: increased sensitivity for light touch or vibration (slightly elevated threshold)
- Complete transection: total loss of tactile sensation within the region
- peripheral neuropathies: (diabetes, alcoholism) “glove and stocking distribution”…distal to proximal with possibly paresthesia/pain
Complete vs incomplete SCI
- Complete: total absence in dermatomes below level of lesion. Might have paresthesia (tingling or pins and needles) at level of lesion
- Incomplete: relates to damage within specific spinal tracts.
- -Anterior=pain and temperature (usually come back before light touch and proprioception)
- -Posterior=Light touch, vibration, proprioception, etc
Types of PNIs that affect sensation
- Single nerve root
- -affects dermatome on one side of body
- Damage to peripheral nerve
- -affects sensation within peripheral nerve distribution
Expectations for sensation in CVA and Brain injury (cortical lesion)
- Contralateral sensory loss
- perception of light touch and proprioception are most affected
- generalized inattention/lack of awareness
- breakdown in sensory processing-sensorimotor problem
T/F: In CVA and brain injuries, pain is the most affected, temperature is less affected, and fine touch/proprioception is least affected
False. Fine touch/proprioception is most affected, temperature is less affected, and pain is the least affected
T/F: Loss of proprioception and pain are more common following right CVA than left
True
What are expectations for sensory recovery in a CVA/TBI?
Decreased edema, increased vascular flow, plasticity and relearning
What are expectations for sensory recovery in a LMN injury?
decreased ischemia and edema with first 6 months (any recovery usually within first year)
What are the expectations for sensory recovery in a PNI?
Very likely to fully recover if compression was brief and mild:
-mild compression: full
-prolonged compression: full but not usually normal
-total transection: only with surgical intervention and adequate regrowth (pain and temp usually return first, then touch; moving before light touch and accurate localization recovers last)
-chronic conditions (peripheral neuropathy): usually not
expected
T/F: with PNI sensory recovery, touch usually returns before pain and temperature
False. Pain and temperature usually returns before touch. Moving touch returns before light touch and accurate localization recovers last
T/F: with PNI sensory recovery, moving touch returns before light touch
True. Pain and temperature usually returns before touch, moving touch returns before light touch, and accurate localization recovers last
T/F: Normally, you would be Sensory testing before ROM/MMT/Cognition/Vision
False! Normally, you would do sensory testing after ROM/MMT/Cognition/Vision testing. You may need to alter the sequence based on abilities, limitations, impairments, etc
Sensory Assessment is done when in the sequencing of assessing a pt?
Sensory Assessment follows:
-Interview, Observation of occupational performance, and ROM/MMT/Cognition/Vision
What might you have already observed that would provide you with information regarding a client’s sensory status?
Non-use
Positioning problems
Awkwardness with movement
clumsiness
How do you determine which sensory tests to do and the sequence to do them in?
- Look at diagnosis first…steers you toward certain tests
- General before discriminating: e.g., light touch/localization before sharp/dull. Most likely if they can’t feel anything, won’t be able to discriminate
- Don’t do all the tests with all clients
- For the most part the way we sequence them/present them is a rough order of general to discriminating
T/F: When performing sensory testing, it is typical to perform general before discriminating tests
True. E.g., light touch/localization before sharp/dull. Most likely if they can’t feel anything, won’t be able to discriminate.
T/F: With sensory testing, test the more involved side first
False. Test less involved side first
T/F: In sensory testing, you should test proximal to distal
True. Higher to lower dermatomes.
Why is it important to occlude vision during sensory testing?
Visual is a strong compensator
Procedures of sensory testing
- Observe skin: thickness, calluses, bruises
- Obtain client’s subjective report
- Stabilize part/limb being tested
- State instructions and demonstrate in an intact area
- Test less involved side first
- Test proximal to distal (higher to lower dermatomes)
- Occlude client’s vision
- Apply stimulus at irregular intervals
- Avoid inadvertent cues (auditory, facial expressions…)
- Be sure to test all areas of sensory distributions
- Carefully observe correctness, confidence, and promptness of responses
- Observe for hypersensitivity
- These procedures optimize reliability. The purpose is to eliminate non-tactile cues and ensure that client’s response accurately reflects actual sensation
How to score Sensory Assessments
-Intact: Normal sensation
-Impaired:
–Able to detect some but not all of stimuli
–Perception of stimulus is different from that of intact
areas (often relates to speed of processing)
–May want to add percentages (#correct/#given)
-Absent:
–Total loss of sensation or
–Inability to detect a specific sensory modality
-Document type of test, skin area tested, and response
How can you assess edema?
Volumeter or circumferential measurement
How can you test for nerve regeneration
Tinel’s Sign: lightly tap to elicit sensation of tingling/pins and needles in the distribution of the nerves
This assessment examines cutaneous sensation
Touch Awareness. Assesses general awareness of touch input.
Function: something brushes against your arm. Know when something is touching you
Touch Awareness Procesure
- Lightly brush/touch-stimulate a few hairs
- Ask if client can feel anything and client responds
- Randomize-alter timing of stimulation
- sometimes done with localization: Ask client to point to location of stimulation
Scoring for Touch awareness
- Intact (+): Recognizes/localizes touch
- Impaired (-): Recognizes only
- Absent (0): Unable to recognize or localize a stimulus
- Score=# of correct responses (expect 100%)
- Can be done in a standardized way-normal response is about within 3-4 mm of actual location in fingertips, 7-10 mm in palm, and 15-18 mm in forearm
Pain Awareness (Sharp/Dull) tests what?
Pain awareness (sharp/dull) examines differentiation between sharp and dull-superficial pain/protective sensation. Important to recognize superficial pain/pressure sores like scrapes, cuts. At risk for injury without.
Procedure for Pain Awareness testing (Sharp/Dull)
- Use new/sterilized safety pin
- Touch client intermittently and randomly with head and point of pin (perpendicular to skin)
- Tap skin lightly-enough pressure to deflect skin
- Client indicates “sharp” or “dull”
- Touch with amount of pressure necessary to elicit correct response on uninvolved side of body
- May use percentages to score
Scoring for Pain Awareness (Sharp/Dull)
-Intact
-Impaired
-Absent
(May be aware of pressure, but lack protective sensation)
What does pain awareness (pinwheel) test?
Examines response to the application of superficial pain stimulus. This is a protective sensation
Procedure and scoring for pain awareness (pinwheel) test
- Hold pinwheel between the thumb and index pinger in the indentation in the handle and roll lightly over the skin
- test first in a known area of intact sensation such as face or neck
- can be tested in a dermatomal pattern, or according to peripheral nerve distribution
- client indicates whether they feel the stimulus the same as in the intact area, less than in the intact area, or not at all
- Scoring: Intact, impaired, absent
Procedure and scoring for temperature awareness testing
- Examines discrimination between warm and cool-sensation of temperature
- Function: safety with cooking, bathing…
- Use test tubes filled with warm/cool water or spoons in water
- Touch client intermittently and randomly with different temperatures
- Scoring: Intact, impaired, absent
This assessment tests for sense of joint position
Proprioception. Unconscious information regarding position of joint, ligaments, muscles, tendons-in unknown combination
Function: body in space
Procedure and scoring for Proprioception testing
- Hold the lateral aspect of the elbow, wrist, or digit
- Move the body part into flexion or extension
- Ask the client to identify direction of motion: up or down
- Scoring can usually be done within a few degrees
- -Intact
- -Impaired: delayed/nearly correct
- -Absent: incorrect or no response
- -Describe client’s response!
This assessment examines sense of joint motion
Kinesthesia. Need decent motor control to perform this test to mirror position with other extremity
Function: postures, walking, writing without looking, any smooth/controlled movement; input from unknown combination of muscle, joints, and tendon receptors
Procedure and scoring for Kinesthesia testing
- Occlude the client’s vision
- move the unaffected limb into a certain posture by grasping only the lateral aspects of the limb
- ask the client to duplicate the position with affected limb
- Scoring:
- -In tact
- -Impaired
- -Absent in each joint
- -Normal responses are very rapid…100% expected
Stereognosis testing requires…
Interpretation of sensory input
Motor function as a pre-requisite
Procedure and scoring for Stereognosis Testing
-Place various items in client’s hand
-Ask client to identify item through touch
-Client names item and/or identifies properties
-May assist client with manipulation
-Adapt for speech deficits: client points to items
-Number of items is often 5…a number of small objects
known to the client
Scoring:
–Number correctly identified out of total
–Intact if assisted to manipulate
–Note if client able to correctly identify properties
–Normal=within 2-3 seconds
This is a standardized test that is more discriminatory for sensory testing than many of the other tests and is closely linked to other sensory areas and hand function
Touch Pressure Threshold. A hand therapist may do this to rule out others. Also a good test of protective sensation. But it is more time consuming.
Procedure and scoring of touch pressure threshold
Procedure-(Semmes-Weinstein test):
-Begin testing with filament market 2.83
-Hold filament perpendicular to skin
-Apply to skin until filament bends-bend is according to length/thickness, not pressure
-Apply in 1.5 seconds, hold 1.5 seconds, remove in 1.5 seconds
-Repeat 3 times at each testing site…use thicker filaments if the client doesn’t perceive thin ones
-Client says “yes” upon feeling stimulus
Scoring (Standardized)
-Number of thinnest monofilament felt at least 1/3 trials (normal adult=2.83 in UE)
-Pressure aesthesiometer
-20 graded monofilaments
-Different pressures-calibrated 1.65 to 6.66
-Recorded using standard color code
What is the filament thickness for a normal adult in UE?
- 83
- Clients who cannot feel the thickest monofilament may or may not be able to feel a pinprick, but have no other feeling and require visual guidance for all hand function
- Typically with PNI in outpatient settings
Interpretation of sensory findings for Diminished light touch:
Diminished light touch
- Person might not be aware of loss of sensation
- no effect on movement of hand
- able to identify temperatures, textures and objects by touch
- If decrease but not total loss – may be a candidate for sensory retraining…as long as prognosis indicates there is potential for improvement.
Interpretation of sensory findings for diminished protective sensation:
Diminished protective sensation:
- Decreased motor coordination-slower manipulation/dropping objects
- Identification of temperatures and pain intact
- At risk for injury
- If decrease but not total loss – may be a candidate for sensory retraining…as long as prognosis indicates there is potential for improvement.
Interpretation of sensory findings for loss of protective sensation
Loss of protective sensation
- Inability to use hand without vision
- Feel pinpricks and deep pressure
- Less able/unable to determine temperature
- At risk for injury
Pt with hypersensitivity is a candidate for…
Desensitization
Function of Two-Point Discrimination (static) testing
- Highly sensitive
- Predicts good hand function independent of sight
- Predicts precision grasp (how hard to hold)
Procedure for Two-Point Discrimination
-Start with points at 5 mm distance
-Test only the fingertips b/c this is the primary area of the
hand used for object exploration
-Randomly test 1 or 2 points on the radial and ulnar
aspects of each finger for 10 applications
-Pressure is applied lightly; stop just when the skin
begins to blanch
-Ask client if one or two points are felt
-Gradually adjust to find smallest correct level
-Usually done in hand, but there are norms for whole
upper body
-If no ability to do constant touch/vibration, cannot do this
-Longitudinal or transverse orientation is ok
-Use a disk-criminator or aesthesiometer
Scoring for Two Point discrimination (static)
-Clients responds accurately to 2/3, 4/7, or 7/10 trials
Norms for Two Point Discrimination (Static)
1-5 mm indicates normal static two-point discrimination
6-10 indicates fair static two-point discrimination
111-15 indicates poor static two-point discrimination
-One point perceived indicates protective sensation only
-No points perceived indicates an anesthetic area
Function of Two-Point Discrimination (Moving)
- Examines discrimination between one or two points on the skin
- Predicts manipulation skills
Procedure for Two-Point Discrimination Moving
- Starts with points at 8mm distance
- Randomly select one or two points and place in center of distal phalanx-parallel to longitudinal axis
- Move proximal to distal along distal phalanx
- Press until light indentation with equal pressure
- Ask client if one or two points are felt
- Gradually adjust to find smallest correct level
Scoring for Two-Point discrimination Moving
-Smallest distance at which client is correct 7/10 trials
Norms for Two-Point Discrimination Moving
2-4 mm for ages 4-60 indicates normal moving discrimination
4-6 mm for ages 60+ indicates normal moving two point discrimination
This assessment tests spatial representation of touch receptors in cortex
Touch Localization. General awareness of touch input
Procedure for Touch Localization
-Use Semmes-Weinstein Monofilament 4.17 or pen, pencil eraser
-Apply touch to client’s skin and ask client to remember/identify the location of stimulus (vision occluded)
-Client then uses index finger or marking pen to point to
spot just touched
-Typically therapists combine touch awareness and non-standardized localization
Scoring for touch localization
Intact (+): localizes touch
Impaired (-): difficulty with localization
Absent (0): unable to localize a stimulus
Score=# of correct responses (expect 100%)
What does a composite measure mean?
Beyond the strength of the individual muscles. In grip and pinch strength testing, a composite measure is taken
T/F: There may be a 40-55% difference between dominant and non-dominant UE in grip and pinch strength testing
False. It is normal to have 10%-15% difference between dominant and non-dominant UE
Procedures for Grip Strength Testing
- Client seated with shoulder adducted, neutrally rotated, elbow flexed at 90 degrees, forearm neutral, wrist slightly extended
- Handle of dynamometer at second position
- Therapist: Ready, squeeze/pinch as hard as you can
- Therapist urges client through 3 trial attempts
Pinch strength testing procedure
3 trials for tip, lateral and three-point pinch
How is scoring down for Grip and Pinch Strength Testing?
Average for 3 trials is recorded
Volumeter procedure
Edema Testing. Measures mas of body part by water displacement. Most often with hand
- Fill volumeter with water
- Position beaker
- Place hand in and rest middle/ring finger in dowel
- Measure amount of water displaced
Volumeter testing is contraindicated with…
Open wounds, plaster casts, vasomotor instability
T/F: Edema can be a cause of limited ROM
True
Circumferential Measurement procedures
-Use millimeter tape
-Measure same place on each finger, hand, etc.
–Important to measure at exactly same place from test
to test. Use anatomical landmarks
-Figure-of-eight technique
-Use opposite side as norm if not involved
-Measure changes over time/with intervention
T/F: With Circumferential Measurement for Edema, use the opposite side as norm if not involved
True
Tinel’s Sign is used for what
To track how far a sensory nerve has regenerated (after nerve repair)
Tinel’s Sign Procedure
- Tap along course of nerve distal to proximal
- When tapping elicits tingling sensation=indicates the location of compression or where sensory axon growth has stopped
What is the rate of recovery for nerve regeneration?
1 mm/day; 1 inch/1 month
What is the water test?
It is a sympathetic recovery test.
- De-innervated skin does not wrinkle
- Submerge hand in water for 5 min
- Look for wrinkling
- Patterns according to PN discributions
What is the Ninhydrin test?
It is a sympathetic recovery test.
- De-Innervated skin does not sweat
- Use iodine and heat lamp
- Iodine with bead up under heat lamp in portions of skin that are innervated
- Patterns according to PN distributions
With a SCI, you want to do sensory assessments for what purpose?
With an SCI, you want to know whether sensation is present or absent in each dermatome. Often touch awareness or pain awareness.
Minimum sensory testing for SCI would include:
Light touch, superficial pain, and proprioception (temperature in same track as pain)
- Vibration is not functional
- Test Bilaterally (results may differ)
T/F: If you are aware of the complete lesions upon admission, no additional sensory testing needs to be done.
False. Make no assumptions about whether sensation is present or absent
What sensory assessments should you do with a client with PNI
Assess protective sensation
With a single peripheral nerve involvement (with PNI), what do you need to make sure to do when assessing sensation?
Establish accurate map of body area and severity of loss
When dealing with nerve compression and recovery, what should you do when assessing sensation?
Use measures that are highly sensitive (monofilament) to show small changes in sensory function
What is the recovery sequence for PNI?
Pain –>Moving touch–>Light Touch–>Touch Localization
What sensory tests should you do with functioning at C6, C7, and C8 nerve roots and/or median nerve?
Functional tests of sensation requiring objects or texture identification with thumb, index, and middle fingers
What sensory assessments should you do with CVA?
- Assess light touch, proprioception, pain awareness, temperature, and stereognosis
- Note observations during ADL that appear to be loss of proprioception: proprioception assessment
- Possible risk of injury: protective sensation (pain and temperature)
