Huerta Exam 2: Sensory Screening and Evaluation

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purposes of screening and evaluations

• Assess the extent of sensory loss

• Evaluate and document sensory recovery

• Assist in diagnosis

• Provide prognostic information

• Determine impairment and functional limitations

• Provide directions for OT treatment

tests that evaluate function:

1) functional hand tests

2) simulated activities

3) ADL and IADL performance

basics of sensory assessment: cognition

client must have adequate cognition

basics of sensory assessment: vision

must be occluded

*can first show how to do it with vision but then test without it

basics of sensory assessment: body parts

supported without providing stimuli

basics of sensory assessment: environment

reduce environmental stimuli

basics of sensory assessment: concentration

ensure clients ability to concentrate

basics of sensory assessment: assessment tools

we must determine the appropriate assessment tools

basics of sensory assessment: methods

use standardized methods of administration

Basics of Sensory Assessment

• Client must have adequate cognition

• Vision occluded

• Body part supported without providing stimuli

• Reduce environmental stimuli

• Ensure client's ability to concentrate

• Determine appropriate assessment tools

• Use standardized methods of administration

general sensory test procedures

1) make sure the client understands the procedure

2) perform trial with vision

3) occlude vision

4) test unaffected side first

5) test affected side second

what side will we test first

a) affected

b) unaffected

unaffected

timesaving method to determine if sensation is abnormal

screening

... sites can be used to reflect larger points of the hand innervated by the same peripheral nerve.

specific sites

For screening median nerve function, what do we test?

test the thumb tip, index tip, and index proximal phalanx.

For screening ulnar nerve function, what do we test?

test the distal and proximal ends of the small finger and the proximal ulnar aspect of the palm.

For screening the radial nerve, what do we test?

test the radial back of hand, dorsal part of the thumb web space

if the distal aspect is intact, what does this mean?

everything else is intact

when conducting a sensory screening of the hand, we must note and document the appearance of:

- blisters

- altered sweat patterns

- calluses

- shiny or dry skin

- scar

- wounds

- atrophy of thenar and hypothenar eminences

sensory assessments: standardized tests

1) touch pressure

2) moving and static 2 pt discrimination

3) point localization

4) vibration threshold

sensory assessments: non standardized tests

1) awareness of touch, pain or pinprick

2) temperature

3) vibration

4) stereognosis

5) Moberg pick up

6) proprioception

7) kinesthesia

the least stimulus needs to elicit a response

stimulus threshold

stimulus threshold

the least stimulus needs to elicit a response

examples of stimulus thresholds

- light touch

- vibration

- cutaneous pressure

refers to the number of sensory receptors in one area

tactile discrimination

tactile discrimination

the number of sensory receptors in an area

distinguish different textures by touch

moving and static two point discrimination tests assess what?

tactile discrimination

proprioception evaluation

1) occlude vision

2) move the joint being tested into flexion or extension

3) ask the client to identify the position of the joint or ask them to replicate the position with their other limb

proprioception screening

test distally, move proximally if deficit is noted

uses both touch and proprioception to identify an object in-hand

stereognosis

stereognosis test

1) use familiar objects and place them in the client's hand

2) show the objects and tell them what they are

3) client manipulates object with vision occluded and is asked to identify objects or its characteristics

*client must have adequate motor function and communication skills

what assessment assesses pressure threshold?

semmes-weinstein monofilaments

where can the semmes-weinstein monofilaments be used?

on the entire body but mostly used for hands

Light touch is perceived by receptors in the

superficial skin

Light touch is important for ..., whereas deep pressure is important for...

light touch ->fine discriminatory hand use

deep pressure -> protective sensation.

Touch pressure testing examines the spectrum from

light touch to deep pressure.

.... is a good test to use for clients with nerve compression, such as carpal tunnel syndrome.

Touch pressure testing - semmes-weinstein monofilaments

Having intact ... is an indicator of better sensation than having only ....

a) light touch pressure awareness

b) deep touch pressure awareness

light touch pressure awareness

intact deep touch pressure awareness

what must be intact for two-point discrimination to be testable

Light touch pressure awareness

because the two-point discrimination test uses light touch.

semmes-weinstein monofilaments: green

normal

Semmes-Weinstein Monofilaments: blue

diminished touch

semmes-weinstein monofilaments: purple

diminished protective sensation (poses safety risk!!)

semmes-weinstein monofilaments: red

loss of protective sensation

semmes-weinstein monofilaments: untestable

no discrimination of levels of feeling (nothing)

normal

a) green

b) blue

c) purple

d) red

e) untestable

green

diminished light touch

a) green

b) blue

c) purple

d) red

e) untestable

blue

diminished protective sensation

a) green

b) blue

c) purple

d) red

e) untestable

purple

loss of protective sensation

a) green

b) blue

c) purple

d) red

e) untestable

red

no discrimination of levels of feeling

a) green

b) blue

c) purple

d) red

e) untestable

untestable

nerve function tests

1) ninhydrin test - sweat

2) wrinkle test - deinnervation

3) nerve conduction studies - invasive

ninhydrin test

decreased sweat secretion

assesses sympathetic function

test that assesses sympathetic function

ninhydrin test

test that identifies areas of deinnervation

wrinkle test

areas that do not wrinkle

invasive test fo nerve function that requires special training to administer/interpret

nerve conduction studies (outside of our scope)

What are provocative tests?

tests that provoke symptoms

have a (+) result

types of provocative tests

1) Tinel's sign

2) Phalen's test

test: tapping skin over damaged peripheral nerve

tinel's sign

Tinel's sign

a way to detect irritated nerves.

It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.

Phalen's test is an essential test to detect

carpel tunnel syndrome

- compressed median nerve

Phalen's test

wrist flexion/extension provokes tingling in median nerve distribution

phalen's test vs tinel's sign

types of tests that ask the question: what is the minimum stimulus that the client is able to perceive?

threshold tests

types of threshold tests:

1) pinprick

2) temperature awareness

3) touch pressure

tests protective sensation

1) pinprick: sharp vs dull

2) temperature awareness: hot vs cold

sharp vs dull test

pinprick

pinprick test

Gently touch the skin with a pin & back end of pin and ask the patient whether it feels sharp or blunt

- intact

- impaired

- absent

- hyperalgesic (super pain)

temperature awareness test

- hot vs cold

- tests for protective sensation

- results = intact, impaired, absent

light touch is important for:

fine discrimination

deep touch is important for

protective sensation

touch pressure test

semmes-weinstein

tests vibration sense

tuning fork

what vibration returns first?

a) 30 hz

b) 256 hz

30 hz

if the client is able to successfully complete the 30 Hz tuning fork test, what does this mean functionally?

the client is ready for protective sensation treatment

if the client is able to successfully complete the 256 Hz tuning fork test, what does this mean functionally?

the client is ready for object recognition (discriminative touch)

if the client is not able to complete the 30 Hz tuning fork test, what does this mean functionally?

dont bother with protection sensation recovery

the nerve has not healed enough yet

transmitted though large, myelinated fibers

a) 30 hz

b) 256 hz

30

trasmitted through single quickly adapting nerve

a) 30 hz

b) 256 hz

256

loss of potential sensation in monofilament test means

they are at a big risk for injury

functional tests for touch sensation

1) static 2-point discrimination

2) moving 2-point discrimination

3) localization of touch

4) localization of moving touch

5) Moberg pick up test

6) 9 hole peg test

test that is considered the classic test of functional sensation

static 2-point discrimination

in the static 2-point discrimination, we only test what body area?

test only the finger pads

what mm do we start with in the static 2-point discrimination test?

5mm and move larger if needed

how many trials do you conduct in the static 2-point discrimination test? how many does the client need to get right?

7/10

what returns first?

1) static 2-point discrimination

2) moving 2-point discrimination

2) moving 2-point discrimination

what mm do we start with in the moving 2-point discrimination test?

8 mm

move proximal to distal

what test: touch an area and client indicates where they were touched

localization of touch

what test: touch and area and move to another and then the client indicates where you touched them

localization of moving touch

Localization of touch is an important test to perform after nerve repair because

it helps determine the client's baseline and projected functional prognosis.

Moberg pickup test (MPUT)

functional tests

placing common objects in a container

useful for median/ulnar nerve involvement

both hands with vision and then without

9 hole peg test

Measures finger dexterity

-the time fo each hand to place 9 pegs in a square board and remove them is the score

clients with sensory loss are either

1) hypersensitive

2) hyposensitivity

3) sensory loss

hypersensitive

normal stimulus is overbearing

hyposensitive

unable to sense normal stimulus

sensory loss

unable to discriminate sensation

tx for hypersensitivity

desensitization

grade stimulus from soft to harsh

The stimuli are upgraded to be slightly more noxious as the client's tolerance increases.

... is a decrease in a response after repeated benign stimuli.

Habituation

tx for hyposensitivity

discriminative sensory reeducation

grade stimulus from gross to fine

Discriminative sensory reeducation is graded by initially using grossly dissimilar objects, such as a spoon and a penny, and progressing over time to more similar objects, such as a dime and a penny.

sand paper vs silk

there are two types of clients who may benefit from sensory reeducation:

1) those who require reeducation to compensate for the dangers associated with sensory loss

2) those who may need to effect change on nervous systems that are either hypersensitive or more dormant.

Clients are candidates for discriminative sensory training if they

have intact protective sensation