Sensation

Clients Appropriate for Sensory Assessment

any client with confirmed or potential neurological involvement

diagnosis determines the expected sensory picture

Injuries to Spinal Cord

SCI: dermatomes at and below the level of injury

injuries or conditions affecting the nerve roots: corresponding dermatitis

Incomplete Spinal Cord Injury

relates to damage within specific spinal tracts

anterior: pain and temperature 

posterior: light touch, vibration, proprioception, etc

Complete Spinal Cord Injury

total absence in dermatomes below level of lesion

might have paresthesia at the level of lesion 

Paraesthesia

tingling or pins and needles

Peripheral Neuropathy/Nerve Injury

peripheral nerve distribution

pattern varies with nerves involved and extent of damage 

at nerve root: affects dermatome on one side of body 

damage to peripheral nerve: affects sensation within peripheral nerve distribution 

severity can vary widely 

Cortical Lesions

contralateral sensory loss

perception of stereognosis and proprcoetion are most affected

testing is completed on the anterior and posture aspects of the upper arm, forearm and hand (6 regions)

generalized inattention/lack of awareness

breakdown in sensory processing (sensorimotor problem)

Procedures for Sensory Testing

observe skin: thickness, calluses, bruises

obtain client’s subjective report

stabilize part/limb being tested 

state instructions and demonstrate in an intact area 

test less involved side first 

test proximal to distal 

occlude client’s vision 

apply stimulus at irregular intervals 

avoid inadvertently cues 

be sure to test all areas of sensory distributions 

observe accuracy and speed of responses 

note and record areas of hypersensitivity 

added UE should be supported on a table (depending on assessment) 

Intact

normal sensation

Impaired

able to detect some but not all stimulus presented

perception of stimulus is different from that of intact areas (or can related to speed of precessing) 

Absent

total loss of sensation

inability to detect a specific sensory modality 

Touch Awareness (Light Touch)

examines cutaneous sensation

Touch Awareness (Light Touch): Procedure

lightly brush/touch: stimulate a few hairs

ask of client can feel anything and client responds 

randomize: alter timing and location of stimulation (5 responses per area → 5 × 6 areas = 30)

Touch Awareness (Light Touch): Scoring

intact (+): consistently recognizes touch 

impaired (-): recognizes some but not all stimuli in a specific area 

absent (0): unable to recognize stimulus 

score: number o correct responses 

sometimes done with localization 

Pain Awareness (Sharp/Dull Discrimination)

examine ability to differentiate between sharp and dull stimuli 

protective sensation 

Pain Awareness (Sharp/Dull Discrimination): Procedure 

use new/sterilized paper clip or safety pin

touch client intermittently and randomly with lead and point of pin (perpendicular to skin)

tap skin lightly: enough pressure to deflect skin

client indicates “sharp” or dull” 

Pain Awareness (Sharp/Dull Discrimination): Scoring

intact

impaired 

absent 

Pain Awareness (Superficial Pain)

examines response to the superficial application of a painful stimulus

protective sensation

Pain Awareness (Superficial Pain): Procedure

hold the pinwheel between the thumb and index finger in the indentation in the handle and roll lightly over the skin 

test first in a known area of intact sensation such as face or neck 

can be tested in deratomal pattern or according to peripheral nerve distribution 

client indicates whether they feel the stimulus the same as in the intact area, less than the intact area or not at all 

Pain Awareness (Superficial Pain): Scoring

intact: feels the same as a uninvolved area

impaired: feels the individual pins but not as sharp

absent: feels a line or feel nothing 

Temperature Awareness

examines ability to differentiate between warm and cool stimuli

protective sensation

Temperature Awareness: Procedure

use test tubes filled with warm/cool water or spoons in water

touch client intermittently and randomly with different temperature  

Temperature Awareness Scoring

intact

impaired 

absent 

Proprioception 

awareness of joint position in space

assessing the shoulder, elbow, wrist, and index finger is usually sufficient

Proprioception: Procedure

hold the lateral aspects of the extremity, with one hand proximal and the other hand distal to the joint being tested 

randomly move the joint being tested into flexion or extension 

ask client to identify direction of motion: “up” or “down” 

Proprioception: Scoring

intact 

impaired: delayed/nearly correct 

absent: incorrect or no response 

describe client’s response  

Kinesthesia

awareness of joint motion

need decent motor control to perform this test (to mirror position with other extremity)

alternative: position the affected limb and have the patient replicate the position with the unaffected limb 

Kinesthesia: Procedure

occlude the client’s vision

move the unaffected limb into a certain position by grasping only the lateral aspects of the limb 

ask client to move the affected limb into the same position 

Kinesthesia: Scoring

intact

impaired 

absent 

normal responses are very rapid/ 100% expected

Stereognosis

examines ability to recognize objects tactually

requires interpretation of sensory input 

motor functions is a prerequisite 

Stereognosis: Procedure

place various familiar items in a client’s hand

ask client to identify item through touch 

client names items or identifies item properties 

examiner may assist client with manipulation 

adapt for speech deficits: clients point to items 

Stereognosis: Scoring

number correctly identified out of total 

intact if assisted to manipulate: document 

note if client able to correctly identify properties 

normal: within 2-3 seconds 

Touch Pressure Threshold 

measures threshold of light touch sensation 

Touch Pressure Threshold: Procedure

Semmes-Weinstein Test

begin testing with filament marked 2.83

tested on the fingertips only 

hold filament perpendicular to skin 

apply to skin until filament bends (bend is according to length/thickness, not pressure)

apply in 1.5 seconds, hold 1.5 seconds, remove in 1.5 seconds 

repeat 3 times at each testing site (use thicker filaments if the client does not perceive thin ones)

client says “yes” upon feeling stimulus 

Touch Pressure Threshold: Scoring

standardized

number of the thinnest monofilament felt at least 1/3 trials 

normal adult: 2.83 in upper extremity 

recorded using standard color code

Interpretation of Sensory Findings 

diminished light touch

diminished protectie sensation

loss of protective sensation

hypersensitivity 

Diminished Light Touch

person might not be aware of loss of sensation

no effect on movement on hand

able to identify temperatures, textures and objects by touch 

Diminished Protective Sensation

decreased motor coordination: slower manipulation/dropping objects

identification of temperatures and pain intact 

at risk for injury 

Loss of Protective Sensation

inability to use hand without vision

feel pinpricks and deep pressure 

less able/unable to determine temperatures 

at risk for injury 

Hypersensitivity

candidate for desensitization

Two Point Discrimination

examines discrimination between one or two points on the skin

Two Point Discrimination: Function

highly sensitive

predicts good hand function independent of sight 

predicts precision grasps 

Two Point Discrimination: Procedure

start with points at 5mm distance

test only the finger tips because this is the primary area of the hand used for object exploration 

randomly apply either 1 or 2 points placed longitudinally on the radial aspect of the distal phalanx for a total of 10 applications. then apply either 1 or 2 points placed longitudinally on the ulnar aspect of he the distal phalanx for a total of 10 applications, this can be tested on each finger individually 

pressure is applied lightly; stop just when the skin begins to blanch 

ask client if one or two points are felt 

gradually adjust to find smallest correct level 

Two Point Discrimination: Scoring

client responds accurately to 7 of 10 applications 

1-5mm: normal static 

6-10mm: fair static 

11-15mm: poor static

one point preceded indicates protective sensation only 

no points perceived indicates an anesthetic area 

Touch Localization 

examines spatial representation of touch receptors in cortex 

Touch Localization: Procedure

use Semes-Weinstein Monofilament 4.17 or pen, pencil eraser

apply touch to client’s skin (vision occluded) and ask client to identify the location of stimulus (should open their eyes)

client uses their index finger or marking pen to point to the spot that was touch 

Touch Localization: Scoring

intact: localizes touch within 1cm

impaired: difficulty with localization

absent: unable to localize a stimulis 

Touch Localization: Standardized Assessment Outcomes

fingertips: within 3-4mm

palm: 7-10mm

forearm: 15-18mm 

typically therapists combine touch awareness and non-standardized localization 

Sequencing and Prioritizing: SCI

assess sensation in each dermatome 

additionally: proprioception, stereognosis, 2 point discrimination 

known complete lesions: make no assumptions upon admission

incomplete or unknown lesion: test multiple sensory modalities 

test bilaterally: results may differ 

key sensory points within each dermatome has been identified by American Spinal Injury Association (ASIA)

Sequencing and Prioritizing: PNI

peripheral neuropathy: general testing with focus on protective sensation

single peripheral nerve involvement: establish accurate map of body area and severity of loss 

nerve compression and recovery: use measures that are highly sensitive (monofilament) to show small changes in sensory function 

functioning at C6, C7, C8 nerve roots and/or median nerve: functional tests of sensation requiring objects or texture identification with thumb, index, and middle fingers 

recovery sequence: pain → moving touch → light touch → touch localization 

Sequencing and Prioritizing: CVA

assess light touch, proprioception, pain awareness, temperature and stereognosis

note observation during ADL that appear to be loss of proprioception: proprioception assessment 

possible risk for injury: protective sensation (pain and temperature)

Desensitization

intervention for hypersensitivity

conditions: nerve trauma, soft tissue injury, amputation, burns

3 types of materials: dowels textures, immersion textures, vibration 

patient organizes their own hierarchy of noxious stimuli in terms of discomfort 

treatment starts with stimulus that is slightly irritating

applies stimulus 10 minutes, 3-4 times daily 

increase in force, duration, and frequency 

also: continuous pressure, tapping, rolling, weight bearing, massage, activities 

Volumeter

edema assessment

fill volunteer with water 

position beaker

place hand in and rest middle/ring fingers in dowel 

measure amount of water displaced 

use opposite side as norm if not involved 

measures changes overtime/with intervention 

Circumferential Measurement 

edema assessment 

tape measure

measure some place on each finger, hand, etc

figure of eight technique

use opposite side as norm if not involved 

measures changes overtime/with intervention 

Tinel’s Sign

nerve degeneration

used to track how far a sensory nerve has regenerated (after nerve repair)

tap along course of nerve (distal to proximal)

when tapping elicits tingling sensation: indicates, the location of compression or where sensors axon growth has stopped 

rate of recovery: 1mm/day; 1in/1 month 

Water Test

sympathetic recovery

de-innervated skin does not wrinkle 

submerge hand in water for 5 minutes 

look for drinking 

patterns according to PN distributions 

Ninhydrin Test

sympathetic recovery

de-innervated skin does not sweat

use iodine and heat lamp 

iodine will bead up under heat lamp in portions of skin that are innervated

patterns according to PN distributions 

Grip Strength Testing

calibrated instruments: dynamometer

a composite measure (beyond the strength of the individual muscles)

standardized methods and norms 

client is seated with shoulder adducted, neutrally rotated, elbow flexed at 90 degrees, forearm neutral, wrist slightly extended

handle of dynamometer at second position

therapist “ready, squeeze as hard as you can”

therapist urges client through 3 trial attempts, 2-3 mint rests in-between

Pinch Strength Testing

calibrated instruments: pinch dynamometer

a composite measure (beyond the strength of the individual muscles)

standardized methods and norms 

3 trials for tip, lateral, and three point pinch

Grip and Pinch Strength: Scoring

average of 3 trials is recorded