SENSORY INTEGRATION

Part 1

Ayers defined sensory integration as “the neurological process that organizes sensation
from one’s own body and from the environment and makes it possible to use the body
effectively within the environment.”
Sensory integration is a theory developed by A. Jean Ayers (1920–1989).
The theory states that disordered sensory integration directly affects both motor and
cognitive learning and that interventions designed to enhance sensory integration will
improve learning.
Motor learning and performance are linked to sensations
Sensations form the network for feedback and feedforward mechanisms in the brain.

SENSORY INTEGRITY: The intactness of cortical sensory processing including proprioception,

pallesthesia, stereognosis and topognosis.

Causes of loss of sensory integrity:-

I. Pathology/pathophysiology in the following systems (ICF: Health conditions):
• Cardiovascular (e.g., cerebral vascular accident, peripheral vascular disease)
• Endocrine/metabolic (e.g., diabetes, rheumatological disease)
• Integumentary (e.g., burn, frostbite, lymphedema)
• Multiple systems (e.g., AIDS, Guillain-Barré syndrome, trauma)
• Musculoskeletal (e.g., derangement of joint; disorders of bursa, synovia, and tendon)
• Neuromuscular (e.g., cerebral palsy, developmental delay, spinal cord injury)
• Pulmonary (e.g., respiratory failure, ventilatory pump failure)
II. Impairments in the following categories (ICF: Body structures/functions [impairments]):
• Circulation (e.g., numb feet)
• Integumentary integrity (e.g., redness under orthotic)
• Muscle performance (e.g., decreased grip strength)
• Orthotic, protective, and supportive devices (e.g., wears ankle-foot orthosis)
• Posture (e.g., forward head)
III. Functional limitations in the ability to perform actions, tasks, or activities in the following
categories (ICF: Activity/activity limitations):
• Self-care (e.g., inability to put on trousers while standing because of loss of feeling in foot)
• Home management (e.g., difficulty with sorting change because of numbness)
• Work (job/school/play) (e.g., inability as a day care provider to change child’s diaper
because of loss of finger sensation, inability to operate cash register because of clumsiness)
• Community/leisure (e.g., inability to drive car because of loss of spatial awareness,
inability to play guitar because of Hyperesthesia)
IV. Disability, that is, the inability or restricted ability to perform actions, tasks, or activities
of required roles within the Individual’s sociocultural context, in the following categories
(ICF: Participation/participation restriction):
• Self-care
• Home management
• Work (job/school/play)
• Community/leisure
V. Risk factors for impaired sensory integrity (ICF: Personal Factors and Environment):
• Lack of safety awareness in all environments
• Risk-prone behaviours (e.g., working without protective gloves)
• Smoking history
• Substance abuse
VI. Health, wellness, and fitness needs (ICF: Personal Factors):
• Fitness, including physical performance (e.g., inadequate balance to compete in dancing
competition, limited perception of arms and legs in space during ballroom dancing)
• Health and wellness (e.g., inadequate understanding of role of proprioception in balance)

PATTERN OF SENSORY DISTRIBUTION

Knowing the dermatomes is important as it tells us about the sensory distribution of the
nerves and thus helpful in diagnosis.
Considerable variation exists in the clinical presentation of sensory impairments. This
variability is typically associated with the nervous system involved (CNS vs. PNS), the type of
injury, pathology, or disease, as well as the severity, extent, and duration of involvement .
For example, if a patient presents with complaints of numbness on the ulnar half of the ring
finger, the little finger, and the ulnar side of the hand, the therapist would be alerted to
carefully address ulnar nerve (C8 and T1) integrity during the sensory examination.
Complaints of sensory disturbances on the palmar surface of the thumb and the palmar and
distal dorsal aspects of the index, middle, and the radial half of the ring finger would be
indicative of median nerve (C6–8 and T1) involvement.
Other patterns of sensory loss may be associated with specific pathology. For example, with
peripheral neuropathy (e.g., diabetes), sensory loss is often an early symptom and presents
in a glove and stocking distribution (referring to the typical involvement of the hands and
feet). In contrast, MS frequently presents with an unpredictable or scattered pattern of
sensory involvement.
Spinal cord injury (SCI) often presents with a more diffuse pattern of sensory involvement
below the lesion level that is typically bilateral, although not necessarily symmetrical and
also helps determine degree of impairment.
SPINAL CORD TRACTS
Examination of sensory function provides data to reflect integrity of spinal cord.
For example, contralateral loss or impairment of pain and temperature perception is
suggestive of lesions in the anterolateral tracts. Deficits in discriminative sensations such as
vibration and two-point discrimination suggest lesions of the dorsal column.
Evidence of both sensory and motor loss is usually indicative of nerve root involvement
(recall that the dorsal and ventral roots converge to form the spinal nerves).
CNS lesions (e.g., CVA, brain injury) may produce significant sensory impairments
characterized by a diffuse pattern of involvement (e.g., head, trunk, and limbs) and can
result in significant motor dysfunction (sensory ataxia) and impairment of fine motor control
and motor learning, as well as present a significant threat of injury to anaesthetic limbs
(e.g., an inability to determine the temperature of bath water).
Age related sensory changes
The neurons are placed at declining rate and this, may account for decline of average weight
of brain with ageing.
Other changes in the brain include degeneration of neurons with presence of replacement
gliosis, lipid accumulation in the neurons, loss of myelin, and development of neurofibrils
(masses of small, tangled fibrils) and plaques on the cells. There is also a decrease in the
number of enzymes responsible for synthesis of dopamine, norepinephrine, and to a lesser
degree acetylcholine, as well as depletion of the neuronal dendrites in the aging brain.
Electrophysiological studies have identified a gradual reduction in conduction velocity of
sensory nerves with advancing age, and this may reflect degenerative changes in myelin
sheaths or loss or reduction in size of sensory axons.
Evoked potentials provide a quantitative measure of sensory function and have been found
to decrease in amplitude with age.
A reduction in the number of Meissner’s corpuscles has also been identified. These
corpuscles, responsible for touch detection, are limited to hairless areas, and become
sparse, take on an irregular distribution, and vary in size and shape with age.
Age-related changes in morphology and decreased concentrations of Pacinian corpuscles,
responsive to rapid tissue movement (e.g., vibration), have also been reported.
Degenerative changes in myelin have been documented in both the central and peripheral
nervous systems.
Damage in myelin sheath causes decline in the conduction velocity. In PNS the decrease of
distance between the nodes of Ranvier causes slowing of salutatory conduction. Destruction
of myelin sheaths has been linked to a reduced expression of primary myelin proteins,
axonal atrophy, and to reduced expression and axonal transport of cytoskeletal proteins.
Changes in postural instability, exaggerated body sway, balance problems, wide-based gait,
diminished fine motor coordination, tendency to drop items held in the hand, and difficulty
in recognizing body positions in space. Age-related sensory changes include altered postural
stability and control, diminished response to tactile stimuli, reduced vibratory and
proprioceptive acuity, decreased cutaneous temperature thresholds and two-point
discrimination, and altered ability to adapt to sensorimotor responses to task demands.
EXAMINATON OF SENSORY SYSTEM
The two general categories of preliminary tests include the patient’s (1) arousal level,
attention span, orientation, and cognition; and (2) memory, hearing, and visual acuity.
alert

lethargic

arousal obtunded

attention stupor

coma

time
1
orientation place

person

fund of knowledge
(learning+experience)

tests for cognition(awareness calculaton

sensory and judgement) ability
integration
proverb
interpretation

long term
memory
short term
hearing
2 snellen chart
for vision

peripheral
visual acuity
vision

depth
perception
 classificaton of
sensory system

spinal pathway(by
sensory
which they r
receptor(divided by
mediated to higher
those they mediate)
centre- 2
interdependent
systems)
superficial deep combined cortical
sensation(exterocep sensation(proprioceptors sensation(combo of
tors by skin and s.c. in muscle, tendon, ligs, anterolateral
superficial and deep) DCML (Fast large
tissue) joint, facia ) spinothalamic
system (Slow condu- diameter fibres)
cting small diameter
fibres some
pain propriception stereognosis unmyelinated)
thermal and
discriminative touch
nociceptive

2 point
touch vibration discrimination
pain
pressure

temperature kinesthesia barognosis

temp
vibration

pressure graphesthesia
crude touch
proprioception

tactile localization
tickle kinesthesia

texture recognition
itch

double simultaneous
stimulation
sexual sensation

Classification of sensory system