Arousal, Attention, Cognition and the Sensory Integrity Examination

what are the cognitive domains that are screened in the mental status examination?

alertness, orientation, attention, memory, and executive function

what are the possible precipitating factors for altered mental status?

• CNS injury or disorder

• medication side effects

• metabolic disturbance

• chronic systemic diseases

• systemic infections

• toxin exposure

what is the impact of the mental status on exam and plan of care?

helps to determine the

• duration of session

• treatment environment

• type and amount of feedback

• communication with client

• safety concerns

which test, MMSE or the MoCA, is more sensitive to early cognitive decline?

The Montreal Cognitive Assessment (MoCA) is more sensitive to early cognitive decline compared to the Mini-Mental State Examination (MMSE). It is designed to detect mild cognitive impairment.

what is the cutoff score for the MMSE?

less than 24/30 (*heavily weighted in orientation and verbal cognition)

what is the cut off score for the MoCA?

less than 26/30, has more items related to executive function

what are some conditions that involve sensory impairment?

peripheral nerve injuries, metabolic disturbances, infections, burns or toxins, nutritional deficiencies (B12), brain injury, spinal cord injury, tumors, MS

what is the pattern of sensory involvement associated with peripheral nerve injury?

follows PN distribution

what is the testing method for peripheral nerve injury?

light touch, pinprick, temp, vibration sense within that nerve’s cutaneous distribution

what is the pattern of sensory involvement associated with peripheral neuropathy

follows stocking glove distribution

what is the testing method for peripheral neuropathy?

vibration with tuning fork, monofilament testing, light touch, proprioception in distal extremities

what is the pattern of sensory involvement associated with spinal cord injury?

depends on the level and extent of injury, often resulting in a loss of sensation below the injury site in dermatomal levels, can be complete or incomplete (sensory sparing),

what is the testing method for spinal cord injury?

dermatomal mapping with light touch, pinprick, proprioception, vibration sense, assess sensory level

what is the pattern of sensory involvement associated with multiple sclerosis?

patchy, scattered sensory loss, may involve proprioception, vibration, or light touch

what is the testing method for multiple sclerosis?

vibration sense, joint position sense, light touch, temp and compare bilaterally to detect patchy deficits

what is the pattern of sensory involvement associated with nerve root involvement?

sensory impairment follows a dermatomal pattern

what is the testing method for nerve root involvement?

light touch and pinprick across dermatomes, compare sides for sharp/dull discrimination

what is the pattern of sensory involvement associated with brain injury (stroke, TBI)?

contralateral sensory loss, may involve the face, arm, leg depending on lesion location (cortical, thalamic, brainstem)

what is the testing method for brain injury/TBI?

light touch, pinprick, sterognosis, graphesthesia, proprioception, vibration, extinction with double simultaneous stimulation

what is the pattern of sensory involvement associated with sensory ataxia?

loss of proprioception and vibration sense, leading to poor coordination, worsens in the darks or when eyes are closed

what is the testing method for sensory ataxia?

rhomberg test with eyes closed, proprioception tests/joint position sense, and vibration sense with tuning fork, coordination tasks

describe the instructions for sensory integrity testing

• explain the sensory test to the patient

• do a trial run in area of intact sensation with patient eyes open

• test general areas sitting or lying down, once deficit notes, testing becomes more discrete and exact boundaries of involvement are identified

• apply stimuli in random and unpredictable manner with variation in timing

• for each test, consider and document the sensory modality tested, body surface area affected, quantity and severity of involvement, localization of exact boundaries of loss, impact on function

will you follow a dermatomal pattern with all neurological patients?

NO

what are the superficial sensations that are tested?

• pain (sharp-dull)

• temperature (rare in clinical practice but use water when is done)

• light touch (cotton ball or monofilament testing for bottom of feet for protective sensation)

• pressure perception

which pathway can be examined by testing pain and temperature?

the spinothalamic tract (STT)

what are the deep sensations tested?

• proprioception

• kinesthesia (awareness of movement, dynamic)

• vibration on bony prominences (use tuning fork)

which modality may be the first sensory modality affected by peripheral neuropathy?

vibration

what are the combined cortical sensations that may be tested?

stereognosis, tactile localization, two point discrimination, double simultaneous stimulation, and graphesthesia

what is stereognosis?

ability to use light touch, proprioception, and movement to ID object placed in hand

what is graphesthesia?

ability to ID letters written on the skin with the eyes closed, test not typically used clinically

what does double simultaneous stimulation test?

tests whether the patient is aware of stimuli presented at the same time on opposite sides of the body

what is a critical component of treatment in patients with sensory loss?

patient and family education critical! plan of care is guided by compensatory approach or sensory integration approach depending on the type of deficit

what are walkasins?

wearable prosthetic device that helps people with peripheral neuropathy regain mobility and reduce falls risk