ASSESSING ABILITIES AND

CAPACITIES: SENSATION

GUIDED BY:
Ms. S. Kiruba Pricilla, Assistant Professor
SRMCOT

PRESENTED BY :
Beauty Podder, MOT- 1ST Year (Paediatrics)
SRMIST
 OUTLINE
Introduction
Importance of assessing sensation with effect of sensory loss on
ot function
Role of sensation in occupational functioning
Neurophysiological foundations of tactile sensation
Patterns of sensory loss
Types of sensation
Principles or steps to perform sensory test
Appropriate sensory testing tools.
Testing procedure
Interpretation of results for treatment planning.
 INTRODUCTION

Sensation is the neurophysiological process that perceives

sensory stimuli from environment to brain.

Sensation is stimulated by receptors in the periphery of the

body (PNS),and the sensory information then travels through

afferent neurons carrying nerve impulses from the receptors to
the brain (CNS).
IMPORTANCE OF ASSESSING SENSATION
Determine types and extent of sensory loss.
Evaluate sensory modalities.
Evaluate sensory recovery
Provide direction for occupational therapy intervention.
Determine impairments and functional limitations.
Determine time to begin sensory re-education and
desensitization.
Shows a controlled use of splints and use of
compensatory techniques.
Prevents further injury.
ROLE OF SENSATION IN OCCUPATIONAL
FUNCTIONING
Awareness of position of hands,legs,or body.
Enables one to carry out ADL activities like feeding,
dressing or any functional activity requiring motor
control of movement.
Provides proper sensory feedback.
Impairment in the somatosensory system does not
only hinder movement but also increases the risk of
injury while performing various occupation.
NEUROPHYSIOLOGICAL FOUNDATIONS
OF TACTILE SENSATION
 PATTERNS OF SENSORY LOSS
SOMATOSENSORY DEFICIT PATTERNS
It includes directly to the involved neuroanatomical
structures like central or peripheral nervous system.
CORTICAL INJURY
Patients with brain lesions caused by stroke or acquired
brain injury usually show sensory losses related to loss
of functioning of specific neurons within CNS.
Mostly perception of fine touch and proprioception are
affected, temperature is affected less, pain sensibility is
affected least,(Fredericks,1996)
  MIDDLE CEREBRAL ARETERY OCCLUSION:
1. Contralateral impairment of sensation, face, arm and leg.

 ANTERIOR CEREBRAL ARTERY OCCLUSION:

1. More loss of sensation in contralateral leg than in face and arm.
 POSTERIOR THALAMUS LESION:
1. Impaired cold sensation and cold response

Partial recovery of sensation following cortical injury is

associated with: (Carr &Shepherd,2010)
1. Decreased edema
2. Improved vascular flow
3. Cortical plasticity
4. Relearning.
Sensory area’s of brain
SPINAL CORD INJURY:
Complete lesion: total absence of sensation dermatomes
below the level of lesion.
PARAESTHESIA may occur in the dermatome associated
with the level of lesion
Incomplete lesion: sensory losses related to damage within
specific spinal tracts.
ANTERIOR PART OF SPINAL CORD DAMAGE:
Leads to loss of pain and temperature sensation below the
level of lesion, whereas touch, vibration, proprioception
remains intact.
 POSTERIOR PART OF SPINAL CORD DAMAGE:
Loss of light touch and vibration but temperature and painful
stimuli are preserved.
BROWN SEQUARD SYNDROME:
Loss of touch, vibration, proprioception, on the side of lesion
and loss of temperature and pain sensation on the opposite
side of the lesion.
CENTRAL SPINAL CORD DAMAGE:
Bilateral loss of pain and temperature sensation below the
level of lesion.
 PERIPHERAL NERVE INJURY:
Damage to single nerve root affects sensation on one side
of body within a single dermatome.
Damage to peripheral nerve distal to brachial plexus
affects sensation within the nerve distribution.
(example- carpal tunnel syndrome)
A complete damage to peripheral nerve results in total
loss of tactile sensation within the region, loss of 2PD
and cutaneous pain sensibility.
PERIPHERAL POLYNEUROPATHY:
Bilateral and symmetrical usually beginning in feet and
hands(glove stocking distribution) and proximally
spreading.
Paraesthesia and pain accomapanies peripheral neuropathy.

COMPLEX REGIONAL PAIN SYNDROME:

Pain is revealed in a distinct pattern of generalized
bilateral sensory loss and hyperalgesia.
Sensory loss can also be seen in burn injuries involving
the peripheral nerve
Sensory loss can also be seen in amputation injuries
involving peripheral nerve.
Sensory loss in peripheral nerve can also be found in
cancer as a result of neurotoxicity.
 TYPES OF SENSATION

SUPERFICIAL DEEP CORTICAL SPECIAL

1. TOUCH 1. VIBRATION 1. STEREOGNOSIS 1. OLFACTORY

2. PAIN 2. PROPRIOCEPTION 2. BAROGNOSIS 2. VISUAL
3. TEMPERATURE 3. KINAESTHESIA 3. GRAPHESTHESIA 3. GUSTATORY
4. PRESSURE 4. MUSCLE PAIN 4. TWO-POINT 4. AUDITORY
DISCRIMINATION 5. EQUILIBRIUM
5. TACTILE
LOCALIZATION
6. RECOGNITION OF
TEXTURE
 PRINCIPLES OF SENSORY
TESTING

1. Choose a minimal distraction environment.

2. Patient should be comfortable and relaxed.
3. Ensuring patient’s understanding and producing
language. If not then modify the testing procedures.
4. Determine the areas to be tested.
5. Stabilize the body part to be tested.
6. Note any difference in skin thickness except decreased
sensation.
 PRINCIPLES OF SENSORY
TESTING
7. State the instructions and demonstrate the test stimulus
on the intact side.
8. Occlude the patient’s vision for the test.
9. Apply stimuli at irregular intervals.
10. Observe confidence and correct response.
11. Observe any discomfort like hypersensitivity.
12. Doing reassessment.
 THE SENSORY EXAMINATION
 Knowledge of skin segment (dermatome) innervation by the dorsal roots and

peripheral nerve innervation is required for making sound, accurate

diagnostic and prognostic judgments. hey serve as critical references during
testing as well as provide a framework for documenting results.
 Sensory tests are typically performed in a distal to proximal direction.

 It is generally not necessary to test every segment of each dermatome;

testing general body areas is sufficient.

 During testing, the application of stimuli should be applied in a random,

unpredictable manner with variation in timing

 TESTING PROCEDURES
2 tools for testing:
1. Non-standardized – May be less costly ( doesn’t require specific
trademarked materials )
- Doesn’t require sensitive training.

2. Standardized - Published procedures for administration and scoring

reliability and validity studies objectivity.
-Quantification ( numerical precision of performance and
characteristics )
 NON-STANDARDIZED
SENSORY TEST TEST INSTRUMENT
Touch awareness- Measures general Cotton ball , Fingertip , Pencil eraser
awareness of light touch input
Pinprick- Measures discrimination of Safety pin
sharp and dull stimuli, which indicates
protective
sensation
Temperature awareness- Measures Hot and cold discrimination Kit or glass test
discrimination of warm and cool stimuli tubes filled with warm and cool water

Vibration awareness- Measures Tuning forks-30 cycles per second

awareness of input to rapidly adapting
fibers
Stereognosis- Measures the ability to
identify objects, which requires
interpretation of sensory input
256 cycles per second
A number of small objects known to the
patient

Moberg Pick-Up Test- Measures the An assortment of small objects and a small
function of slowly adapting fibers in box
medial nerve injury
 CONTD.
SENSORY TEST TEST INSTRUMENT

Proprioception- Measures sense of joint none

position, which relies on input from an
unknown combination of muscle, joint,
and skin receptors

Kinesthesia- Measures sense of joint none

motion, which relies on input from an
unknown combination of muscle, joint,
and skin receptors
 STANDARDIZED
SENSORY TEST TEST INSTRUMENT
Touch threshold- measure of threshold of Semmes-Weinstein monofilaments or
light touch sensation Weinstein Enhanced Sensory test
Static two-point discrimination- Disk- criminator or aesthesiometer
measures innervations density of slowly
adapting fibers of hand
Moving two-point discrimination- Disk- criminator or aesthesiometer
measures innervations density of quickly
adapting fibers of fingertips

Touch localization- measures spatial Semmes-Weinstein monofilament (4.17,

representation of touch receptors in the pen or pencil eraser
cortex

Touch localization- measures ability to Semmes-Weinstein monofilament (6.65 or

localize touch black filament on WEST grid
superimposed on the hand or hand zones
 CONTD.
SENSORY TEST TEST INSTRUMENT

Vibration threshold- measures threshold of Biothesiometer , vibration , automated

rapidly adapting fibers tactile tester

Modified pick up test- Dellon’s A small box and 12 standard metal objects :
modification of the Moberg’s pick-up test- Wing nut , screw , key , nail , large nut ,
measures the interpretation of sensation in nickel , dime, washer , safety pin , paper
distribution of median nerve clip, small hex nut and square nut

Erasmus MC revised Nottingham sensory A blind fold , cotton wool balls , neurotips ,
assessment cockatail stick , aesthesiometer
Quantitative functional measures of
sensation after stroke, sensation assessed
includes : light touch , pin prick , pressure,
two-point discrimination and proprioception
 CONTD.

SENSORY TEST TEST INSTRUMENT

Hand active sensation test Objects of various weights and textures

Quantitative functional measures of haptic
perception the hand

Quick DASH none

Self report tool for people with musculo
skeletal disorders of the UE measures
perceived abilities to do tasks requiring
sensory feedback
 SUPERFICIAL SENSATION
Pain sensation:

Pain is an unpleasant sensory and perceptual experience

that is associated with either actual or potential cellular
damage.

Pain can be tested by pinching the digit firmly or by

pinprick.

Intact pain sensation is indicative of protective sensation.

 TEST FOR PAIN(Protective sensation)
PROCEDURE:-
-Using sterilized safety pin , asses the amount of pressure
required to elicit a pain response on the uninvolved hand .
This is the amount of pressure that the examiner will use on
the involved side.
-Alternate randomly between the sharp and dull sides of the
safetypin and ensure the each spot has one sharp and one dull
application.
RESPONSE:-
The client indicates “sharp” or “dull” following
application.
SCORING-
A correct response to both sharp and dull indicates intact protective
sensation . An incorrect response to both sharp and dull indicates absent
protective sensation.
*TOUCH AWARENESS-
Measure general awareness of light touch input.
TEST IN INSTRUMENT- Cotton ball or swab ,finger tip , pencil eraser.
STIMULUS-Light touch to a small area of patient’s skin.
RESPONSE-Patient says ‘YES’ or makes agreed upon nonverbal signal
each time stimulus is felt.
SCORING & EXPECTED RESULT- Scoring is a number of correct
responses in relation to number applied stimuli . Expected score is
100%.
 TEMPERATURE AWARENESS
Temperature Awareness

 Temperature awareness is a test for protective sensation.

 Thermal receptors detect warmth and cold.

 It is important to test temperature sensation before

applying heat or cold modalities to avoid burn injuries.
Test for Temperature Awareness (Protective
Sensation)
Procedure
Apply test tubes or metal cylinders filled
with hot or cold fluid randomly to areas of
the involved hand.
Response
The client indicates “hot” or “cold”
following application.
Scoring
A correct response to both cold and hot
indicates intact temperature awareness.
An incorrect response to either or both
indicates impaired temperature awareness.
 DEEP SENSATION
Proprioception:
Conscious proprioception derives from receptors
found in muscles, tendons, and joints and is
defined as awareness of joint position in space.
It can be identified by tactile cues and pressure.
If proprioception is impaired, it may be difficult to
gauge how much pressure to use when holding a
paper cup.
 Test for Proprioception
Procedure
Hold the lateral aspect of the elbow, wrist, or
digit.
Move the body part into flexion or extension.
Response
The client duplicates the position with the
opposite extremity.
Scoring
An accurate response indicates intact
proprioception.
The term kinesthesia is sometimes used
interchangeably with the term proprioception
but can also be defined as awareness of joint
movement.
 Kinesthesia
Measures sense of joint motion, which relies
on input from an unknown combination of
muscle, joint, and skin receptors (Ropper &
Samuels, 2009).
Stimulus
Hold body segment being tested on the lateral
surfaces; move the part through angles of
varying degrees.
Response
Patient indicates whether part is moved up or
down.
Scoring and expected results
Graded as intact, impaired, or absent.
Nearly 100% correct identification is expected.
 Vibration awareness:
Measures awareness of input to rapidly adapting
alpha-beta fibers (Dellon , 1988).
Test instrument
Tuning forks: 30 cycles per second
256 cycles per second
Stimulus
Strike tuning fork with force to cause vibration;
place prong on injured and then uninjured hand;
ask patient, “Does this feel the same or different?”
Response
Patient responds same or different
and describes difference in
perception.
Scoring and expected results
Scoring is normal if stimuli to both
hands feel the same, altered if stimuli
feel different.
The 30 cycles per second tuning fork
is used to test the Meissner afferents,
and the 256 cycles per second tuning
fork is used to test the Pacinian
afferents.
 CORTICAL SENSATION
Two point discrimination:
Two-point discrimination and touch pressure
testing with monofilaments are tests of different
aspects of sensation.

Two-point discrimination is a test for receptor

density and is a good test to use for mapping
improvement following nerve repair.
 Test for Static Two-Point Discrimination
Procedure
Use a device such as the Disk-Criminator or Boley gauge
with blunt testing ends.
Test only the fingertips because this is the primary area of
the hand used for exploration of objects.
Begin with a distance of 5mm between the testing points.
Randomly test one or two 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.
Response
The client will respond “one” or “two” or “I don’t know”
following application.
 Test for Moving Two-Point Discrimination
Procedure
Begin with distance of 8mm between points.
Randomly select one or two points, and move
proximal to distal on the distal phalanx .The pressure
applied is just enough for the client to appreciate the
stimulus.
If client responds accurately, decrease the distance
between the points and repeat the sequence until you
find the smallest distance that the client can perceive
accurately.
Response
The client responds “one”, “two”, or “I don’t know”.
 Stereognosis :
Stereognosis is the use of both
proprioceptive information and touch
information to identify an item with the
vision occluded.
Without stereognosis, it is impossible
to pick out a specific object such as a
coin or a key from one’s pocket, use a
zipper that fastens behind you, or pick
up a plate from a sink of sudsy water.
The Dellon modification of the Moberg
Pickup Test is a good test for
stereognosis for clients with injuries
involving the median and/or ulnar
nerves.
Graphesthesia
The ability of person to identify (with the eyes closed) letters
or numbers written on the dorsum of the skin.
Barognosis :
 The ability to differentiate different weights.
 Two different weights on either hands to be given.
 Ask the patient to differentiate which is heavier with eyes
closed.
 Tactile localization:

Localization of touch is an important test to

perform following nerve repair since it helps
determine the client’s baseline and projected
functional prognosis.
This test can be done with a constant (static) touch
or a moving touch.
Localization of touch is thought by many to reflect
a cognitive component of the client’s abilities.
Test for Localization of Touch
Procedure
Apply the finest monofilament that the client can
perceive to the center of a corresponding zone on
the hand grid.
Once the client feels a touch, have him or her open
his or her eyes and use the index finger to point to
the exact area where the stimulus was felt.
Place a dot on the hand grid for a correct response.
Response
The client attempts to identify the exact location
of a stimulus.
Scoring
Correct identification of the area within 1cm of
actual placement indicates intact touch
localization.
SENSORY EVALUATION TOOLS
 INTERPRETATION OF EVALUATION
FINDINGS
Touch threshold testing with monofilaments can be
interpreted based on the categories of sensory loss.
For example:
1. Decreased light touch, patients often do not realize that
they have loss of sensation.
2. There is no motor effect on motor use of hand, but
patients can identify temperatures, textures and objects
by touch.
3. Diminished protective sensation results in decreased
motor coordination like dropping objects from grasp
but whereas intact temperature and painful stimuli.
MONOFILAMENTS
SCORING OF MONOFILAMENT
Response
 The client says “touch” when he feels
Scoring
 The client responds to at least one of the three
applications of the monofilament.
Norms are as follows:
 Green (1.65 to 2.83) indicates normal light touch.
 Blue (3.22 to 3.61) indicates diminished light touch.
 Purple (3.84 to 4.31) indicates diminished protective
sensation.
 Red (4.56 to 6.65) indicates loss of protective
sensation.
 Untestable indicates an inability to feel the largest
monofilament.
 TREATMENT PLANNING
Patient education to use vision and adapted
environment to compensate for lost sensation and
avoid injury.
If hypersensitivity or hyperesthesia of body part,
sensory desensitization is indicated.
If there is decrease but not total loss of sensation
within an area, sensory retraining can be done for
improvement.
Sensory re-education for patients.
CASE

 Blessing is a 48-year-old woman who recently underwent

carpal tunnel release of her right dominant hand.
 She works as a customer service representative for a large
insurance company.
 Her sensory loss is interfering with her ability to
type, to manipulate small fasteners, and to quilt by hand.
 She lives alone and is particularly concerned about not being
able to put on her earrings or a necklace. This is difficult
because she cannot feel or manipulate earring backs or
necklace hooks.
 She states that she is very independent and
does not want to burden others by asking for help. Her hand
surgeon has told her that she anticipates excellent sensory
recovery.
QUESTION
1.What tests would be appropriate for BLESSING?
2. Describe a sensory re-education program that would
be appropriate for BLESSING.
3. What will you tell BLESSING regarding typical
sensory recovery following carpal tunnel release?
ANSWER
1. The most appropriate sensory tests for Blessing would be
touch pressure, two-point discrimination, and the Dellon
modification of the Moberg Pickup Test. Test for touch
pressure first since light touch must be intact for two-point
discrimination to be tested. The Dellon modification of
the Moberg Pickup Test is particularly appropriate for her
because it looks at sensory function of the digits that carpal
tunnel syndrome is affecting.
2. She is a good candidate for both desensitization of the
hypersensitive incision scar and sensory re-education to
stimulate neural recovery.
CONTD

For instance, blessing could practice putting her earrings on

in front of a mirror and grading the size of
the earrings/fasteners.

3.Her that typical recovery after successful carpal release

includes decreased hypersensitivity as the desensitization
program progresses. She should expect improving ability
to feel and manipulate small objects and sensory recovery
proceeds proximally to distally, with the fingertips being
the last to recover. Deeper pressure will be felt before
lighter pressure; this will progress as two-point
discrimination improvement.
REFERENCES
Occupational Therapy and Physical Dysfunctions (7th
edition , Trombly )
Pedretti Occupational Therapy (7th edition )
Pedretti occupational Therapy(3rd edition)
THANK YOU