Introduction to Sensory Examinations PDF

Introduction to Sensory Testing PT 8311 Fall 2021 Jolene Walsh PT, MPT Contributions By: Keith Cole, PT, DPT, PhD, MBiomedE, OCS, Dhinu Jayaseelan, PT, DPT, OCS, FAAOMPT and Joseph Signorino, PT, DPT, OCS, FAAOMPT ...

Introduction to Sensory Testing PT 8311 Fall 2021 Jolene Walsh PT, MPT Contributions By: Keith Cole, PT, DPT, PhD, MBiomedE, OCS, Dhinu Jayaseelan, PT, DPT, OCS, FAAOMPT and Joseph Signorino, PT, DPT, OCS, FAAOMPT  Objectives 1. Describe the purpose(s) for performing a sensory examination 2. Classify and differentiate between superficial, deep, and combined sensation 3. Describe the guidelines for completing a sensory examination and testing protocols for specific sensory tests 6. Apply clinical decision-making skills to application of sensory examination data Purposes of Sensory Examination To determine location and quality of sensory impairment To determine how sensory deficit affects movement To provide a justification for therapeutic intervention To assure patient safety To establish goals and select intervention strategies To re-evaluate the effectiveness of interventions  Sensory Integration “The neurological process that organizes sensation from one’s own body and from the environment and makes is possible to use the body effectively within the environment” - A. Jean Ayers Intact system = automatic & unconscious Affects both motor and cognitive learning Non-intact system 1. Identify impairments 2. Assists in establishing POC 3. Predicts expected outcomes of interventions  Examples of Conditions Affecting Sensation Pathology, disease or injury Metabolic disturbances to peripheral nerves (ie (ie DM) ALS) Infection Injury to nerve roots or spinal cord Toxins Tumor TIA and CVA Many more… Nutrient deficits Brain injury or disease http://www.lower-back-pain-toolkit.com/image-files/body-chart- peripheral-neuropathy.jpg  Sensory Distributions Pattern: all sensation has “relatively” specific boundaries Examples: Dermatome: skin area supplied by one dorsal nerve root - Larger area Peripheral Nerve Distribution: skin area supplied by one peripheral nerve - Smaller area http://www.raynersmale.com/blog/2015/1/17/sensation-testing-for- person-with-peripheral-lesion  Peripheral Sensory Nerves https://coreem.net/core/common-forearm-nerve-blocks/ https://aneskey.com/lower-extremity-landmarks-2/ Sensory Distribution If sensation impaired….pattern will suggest location of lesion Single dermatomal (radiculopathy) or nerve branch (mononeuritis) Patchy motor, sensory, https://www.academia.edu/ 26345290/STTModule_v2.ppsx reflex deficits on a limb (brachial or pelvic plexus) Sensation impaired below a dermatomal level (spinal cord) Saddle area sensory loss https://clinicalgate.com/the-cranial-nerves-and- understanding-the-brainstem-the-rule-of-4/ (cauda equina) Crossed face-body pattern https://www.merckmanuals.com/professional/neurologic- disorders/neurologic-examination/how-to-assess-sensatio  Other Specific Patterns of Sensory Impairment Diabetes: “glove and Multiple Sclerosis: stocking” “scattered pattern”  Age Related Sensory Changes Alterations in sensory function occur with normal aging Need to be clearly differentiated from illness, disease or pathology Examples: reduction in touch detection, vibration & reaction time, decreased 2-pt discrimination, reduced performance in timed balance testing http://geroscience.com/wp-content/uploads/2017/01/aging.jpg  Terminology Associated with Sensory Disturbances Anesthesia – loss of sensation Paresthesia – abnormal sensation without apparent cause Hyperesthesia – increased sensitivity to sensory stimuli Hypoalgesia – decreased sensitivity to pain Hyperalgesia - increased sensitivity to pain Pallanesthesia – inability to perceive/recognize vibratory stimuli Dysesthesia - abnormal, unpleasant sensation Astereognosis - inability to recognize the form & shape of objects by touch Classifications of Sensory System  Another classification of Type… Mechanoreceptors, Muscle and Joint Deep Receptors, Thermoreceptors, Nociceptors, Electromagnetic, Chemoreceptors http://www.bowenworkmaui.com/how-does-it- Receptors we will test Mechanoreceptors – Touch & pressure – Deep: muscle and joint movement, position, vibration Nociceptors – Pain Stimulated by potentially damaging mechanical, chemical or thermal stimuli  More about Pathways… Anterior Spinothalamic- signals do not require discrete localization of source or precise gradations in intensity – Crude, more primitive system – Fibers immediately cross midline at spinal cord to thalamus then somatosensory Dorsal Column- Medial Lemniscal – Discriminative sensations from specialized mechanoreceptors – Fine gradations of intensity and localization – Fibers cross at medulla https://www.physio-pedia.com/Introduction_to_Neuroanatomy  The Somatosensory Cortex The Central Processing Unit of Humans for sensory info Blausen.com staff (2014). " Medical gallery of Blausen https://www.youtube.com/watch?v=8 hDoO0wcq8Q  Somatosensory Cortex divisions 1) S-I (postcentral gyrus) – Areas 1, 2, 3a, 3b – Identifies location of stimuli, size, shape and texture 2) S-II - tactile memory 3) posterior parietal lobe – Areas 5 and 7 – Area 5: integration of tactile from skin O’Sullivan Fig 5.6 with proprioception from muscles/joints – Area 7: integrates stereognosis and The Sensory Homunculus- somatotopic map https://fineartamerica.com/featured/ sensory-homunculus-natural-history- museum-london.html https://havenawright.weebly.com  Preliminary Considerations to Sensory Testing Measure patient’s ability to concentrate on and respond to the battery of sensory test items: 1.Arousal level, attention span, orientation, and cognition - Need to ensure appropriate communication capabilities - O’Sullivan Box 5.3 (Page 132) for sample questions on orientations - Sensory integration requires intact response to stimulus, arousal, attention, orientation, cognition and (short) memory to be properly tested ----------------Need to pass all above before assessing:-------- http://www.internetbusinessmastery.com/images/Course%2010-6.jpg  The Sensory Examination Superficial is the most primitive If a superficial sensation is impaired, then deeper/combined discriminate sensation will also be affected Primary modality of TOUCH must be intact to permit meaningful testing of cortical sensory function  What info do we get? For each sensory test, the following data is generated: Modality tested Quantity of involvement (pattern ID) Degree or severity Subjective feelings Potential functional impact  Patient Prep and Methods Preparation: 1. Full explanation of the purpose of the testing 2. Assist patient in finding relaxed comfortable position 3. Request that the patient refrain from “guessing” if they are uncertain of the correct response 4. “Trial run” demonstration prior to administration of test 5. Occlusion of vision but consider length of time with eyes closed Methods: Must know dermatomes and peripheral nerve patterns Typically test distal to proximal Not every dermatome required Random application, varied timing Once deficit noted, must ID boundaries of impairment  Superficial Sensory Testing Pain Perception Sharp/dull discrimination Temperature Awareness (we will not test this in our lab session) Warm (104° to 113° F) and cool (41° to 50° F) Touch Awareness Light tactile touch (with cotton ball, tissue, camel hair brush) Pressure Perception Firm pressure (to indent skin) Superficial Sensation Testing  Deep Sensation Testing 1. Kinesthesia 2. Proprioception 3. Vibration  Deep Sensation Testing Kinesthetic awareness Awareness of movement Patient describes direction of movement during PROM Proprioceptive awareness Joint position sense & awareness of joints at rest Joint held in static position Vibratory perception Use of tuning fork over bony prominence Deep Sensation Testing  Combined Cortical Sensation Require information from exteroceptors and proprioceptive receptors as well as intact cortical sensory association areas (ie the BRAIN) Stereognosis Tactile localization Two-Point discrimination Double simultaneous stimulation (DSS) *This is why sensory testing in System Review is done unilaterally Graphesthesia Texture Recognition https://www.ncmedical.com/item_747.html  Combined Cortical Sensation A B C D B  Clinical Example of Sensory Impairment Patient c/o numbness and pain in right hand Peripheral Nerve: median nerve Dermatome: C6-C7  Clinical Application: Loss of Protective Sensation in the Feet Threshold for detection of diabetic peripheral sensory neuropathy using a range of research grade monofilaments in persons with Type 2 diabetes mellitus Mary P Thomson, Julia Potter, Paul M Finch & Richard B Paisey Journal of Foot and Ankle Research volume 1, UseArticle of a 6,number: 8, 10-gram monofilament 9 (2008) 6 sites tested on foot The 6-gram monofilament was found to be the threshold of normal perception. Inability to sense a 10-gram monofilament is indicative of loss of protective sensation https://www.prohealthcareproducts.com/west-foot-monofilaments-tactile-sensitivity- test/  Questions? https://www.nsfinternationalfood.eu/services/sensory-testing/