sensory testing peripheral nerves

mixed sensation

ulnar n. at elbow (wartenberg sign)

motor only

AIN and PIN

sensory only

DSRN and DSUN

CNS

cannot regenerate

PNS

can regenerate

sensibility

the way our brain perceives us

CNS lesions

show motor spasticity/flaccidity and whole limb

Sensory changes

with CNS contralateral to the injury site

spinal segment lesions

show myotomal and dermatomal

PNS lesions

show sensory or motor loss specific to the involved nerve with symptoms and signs distal to the site of injury

CNS

contralateral damage

PNS

ipsilateral damage

acute compression

on and off again

chronic compression

lypoma and hematoma

ischemic injury

reduced blood flow

laceration injury

complete or incomplete

neuropraxia

A conduction block; no anatomical disruption-all components intact. (complete recovery in days/mos)

MILD

Radial tunnel (on and off again)

axonomesis

Disruption of axons and myelin sheaths, but endoneurial tubes are intact. (recovery is an inch a mos)

MODERATE

More damage, longer to heal

May not get all the way back to where it was before

neurotmesis

Complete severance or serious disorganization: no spontaneous recovery. (requires surgery with severe functional loss)

SEVERE

1.0 to 1.5 mm per day

1.0 inches per month

usually takes a month to begin

the rate of nerve regeneration in the forearm and hand is...

8.5 mm per day

the rate of nerve regeneration in the upper arm

distance

the rate of nerve regeneration is proportional to the _________ from the cell body

tinel sign

the ___________ is one way to measure a regenerating axon (nerve gets irritated when it is healing)

- pain and temperature

- 30hz vibration

- moving touch

- constant touch

- 256hz vibration

- touch localization

- stereognosis

order of sensory return

pain and temperature

sharp and dull, hot and cold

30hz vibration

speaker at a concert

moving touch

2pt vs 1pt

constant (static) touch

being able to tell the fingers are being touched

256hz vibration

higher frequency

touch localization

close eyes and tell me where i touch you

stereognosis

quarter, dime, wood, steel, usually occluded sensibility

surgeon

it is the job of the ___________ to prepare as precise of a repair after a nerve injury as possible

therapist

it is the job of the ________ to assist the patient in the maintenance of the end-organs by:

- protective orthotic positioning

- ROM therapy

- massage

- modalities as indicated

to achieve the best FUNCTIONAL results after nerve injuries and repair

critical

educate

time is _________ after a nerve repair

always ________

sharp/dull testing for crude sensation

There is NO standardization for this test. It simply identifies one nerve fiber is functioning.

pain sensation

pinching the digit firmly or by pin prick

sterilized safety pin or paper clip

intact

absent protective

using a _______________, assess the amount of pressure needed to elicit pain on the UNINVOLVED side

alternate randomly sharp/dull

the client will respond:

correct response to sharp/dull is ___________ sensation

incorrect response to sharp/dull is ______________ sensation

test tubes

intact

impaired

temperature awareness

protective sensation

Many clinicians use only the pinprick test as sufficient of protective sensation

Apply _______________ with hot or cold fluid randomly to areas of involved hand

Patient responds hot or cold

Correct response: to both indicates _________ protective sensation

Incorrect response: to both indicated __________ temperature awareness

monofilament testing

semmes-weinstein is the _______________ threshold testing

light touch

one

SW is a graded light-touch testing instrument consisting of a kit of twenty nylon monofilament probes. This allows one to map light-touch sensibility.

We will use the abbreviated kit.

We are testing the health of ________ nerve ending!

three ; lightest

_______________ applications of the _________________ monofilmanets are used in clinical testing even though the patient usually responds to the first application. (count "one thousand and one"

When calibrated correctly, it is one of the few, if not the only, sensibility measurement instrument that approaches requirements for an objective test.

5

there are a total of _____ critical monofilaments

soft elbow orthotic at night in extension

patient education

patient presents with symptoms consistent with cubital tunnel

ot treatment is...

disk- criminator

two point testiing is done using what tool

fine motor function

moving; static

wind a watch.

handling precision tools.

A good indicator of _________________ following a peripheral nerve injury is 2 point function.

Testing ability to discriminate between one point and two points of pressure.

__________ two point returns before ____________ two point.

6mm of two point is needed to __________________

12mm is needed for ____________________

nerve density

when using the two point discrimination test we are testing for __________________- in an area

disk-criminator

The weight of the instrument improves control on force of application but does not totally eliminate variable force from hand-held application.

Have to have a higher level of return.

static (constant)

prick with disk-criminator on DIP

moving

start from DIP crease and move to PIP

blind people

_________________ have good telling between 1 and 2 because they have high sensation in their fingertips to be able to read braille.

normal

1-5mm disk-criminator reading

fair

6-10mm disk-criminator reading

poor

11-15mm disk-criminator reading

protective sensation only

one point only felt disk-criminator reading

anesthetic

no points felt disk-criminator reading

fingertips

With common scoring methods, two-point discrimination testing is most accurate at the _______________. (keep in mind that the ring finger has split innervation)

Studies have found subjects with entrapments and compressions in which two-point discrimination is normal, but monofilament and nerve conduction testing are abnormal.

Two-point discrimination testing has been clinically useful despite the lack of control of the application forces.

Limitations: difference between the way people do it.

Different instruments vary in weight and configuration, and the test probes vary. For this reason the examiner should always use the same instrument for repeated testing.

what is a limiation with disk-criminator testing

functional ability to locate touch

pencil eraser

The localization test is utilized to determine __________________. This deficit can result in difficulties performing many task.

This test can be done with a _____________________ or the smallest monofilament determined to be intact.

It is crucial to use the same item for retest.

localization

TQ: ______________ is one of the last things that will come back because it takes a higher level of cognitive abiity

early

sensory reeducation

Localization _____________ after nerve repair is poor and generally improves with time and use of the affected part. Poor localization after nerve repair can seriously limit function.

Localization may vary with the cognitive ability of a patient to adapt to new sensory pathways more than as a result of the actual level of return of the nerve and its response to touch stimuli.

Loss of localization can be improved with ________________________, suggesting that the change is in part relearning, rather than solely a physiologic change in the nerve. Research regarding the plasticity of the brain supports this concept.

NCV (nerve conduction velocity)

- to help define site of involvement and severity of slowed or absent conduction

semmes-wienstein-style monofilament hand screen or mapping

- to determine the touch-presssure threshold involved in that area

static and moving 2-pt disc.

stress testing with provocative activity or positioning (for pt w/ intermittent symptoms)

- followed by repeat NCV or SW

functional tests

what tests would be do for nerve lesion in continuity

(nerve is not transected)

Examination of the hand

- for evidence of sympathetic dysfunction.

Tinel's test distal to the repair

- to determine distal progression of regenerating axons

Semmes-Weinstein-style monofilament hand screen or mapping

- to assess level and area of touch - pressure return and to reveal changes over time

Pinprick test if tested areas are unresponsive to the thickest diameter

- (6.65 marking number), 300-g+ level Semmes-Weinstein-style monofilament

Static and moving two-point discrimination tests on the fingertips (if indicated)

Touch localization

- testing distal to nerve repair

Dellon modification of the Moberg pickup test - - for median or median and ulnar nerve dysfunction

functional/outcome test

what tests would you perform for nerve laceration (nerve is not intact requires surgery)

4

NOTE: for a child younger than ____, the wrinkle test, possibly the ninhydrin sweat test, and the Moberg pickup test may provide the best information.

desensitization

When the patient is hypersensitive to certain textures. Something like a sensitive scar after carpal tunnel, we would use something noxious like cotton balls and they would build up to corn and peas, etc. we can also use things like fluidotherapy

For hypersensitivity of scars or skin.

tolerate; adverse

Desensitization should begin at the level of vibration, texture or medium that the patient can ___________, but are slightly ___________.

sensory re-education

When the patient's brain is perceiving something in the wrong way and we have to re-train the brain and nerves to feel the right thing. Have the patient touch their hair with both hands. They say to the left hand it feels like sandpaper but to the right is feels soft. Their left hand is their involved hand and even though they know their hair should be soft their brain perceives it as rough like sandpaper, so we are working to retrain the brain.

Stimulation and use of a body part affect the cortical map.

Children have a greater capacity for neural regeneration and neuroplasticity than older individuals.

Protective sensory re-education:

people who lack protective sensation are at risk for injury secondary to their sensory loss (blisters, burns, etc.)

discrimination sensory re-education

If the pt has intact protective sensation with recognition of 4.31 on light touch (do not have to localize only feel 4.31)

Stimulation is graded from that requiring gross discrimination to that requiring fine discrimination.

Same or Different

How are they the same or different?

Identification of the material or object.

Within the somatosensory cortex there is a capacity for plasticity.

Habituation, learning, memory, and cellular recovery are processes of neuroplasticity.

Promoting normal use may stimulate new receptors and facilitate neuroplasticity.

When the we have the opportunity to use neuroplasticity to rebuild receptors in the brain, we are able to retrain it in things like habituation, learning, memory, and cellular recovery. This is what allows healing in patient's who have nerve injuries or brain injuries. It is the ability for us to re-learn learn new things after injury.

Neuroplasticity (WRITE OUT WHY IT IS IMPORTANT)

- nerve glides

- pain management

- patient education

- orthosis

- occupation based interventions

what are other treatment intervention for nerve damage

nerve glides

Motion is lotion and allows the nerves to glide in a controlled manner within pain tolerance.

pain management

TENS, superficial heat, manual therapy, visualization, etc.