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ADULT PHYSICAL DYSFUNCTION REHABILITATION - WEEK 2

LEARNING OBJECTIVES

  • Recognize the supporting role of the Occupational Therapy Assistant (OTA) in the evaluation of sensation, perception, and cognition.

  • Define and describe various functions and deficits in the sensory, perceptual, and cognitive systems.

  • Recognize tests and evaluation principles related to sensory, perceptual, and cognitive dysfunction.

  • Describe the interrelationship among sensory, perceptual, and cognitive functions in the performance of everyday activities.

EVALUATION AND OBSERVATION OF DEFICITS IN SENSATION, PERCEPTION, AND COGNITION

  • Sensation

    • Concerned with the somatosensory system, which includes:

    • Touch: Perceived through skin or hair receptors.

    • Deep Pressure: Tactile sensation of force applied to skin (e.g., feeling ischial tuberosities pressing into a chair seat).

    • Pain: Unpleasant or noxious tactile sensation.

    • Thermal Sensation: Tactile sensation of heat or cold.

    • Proprioception: Information about joint position and motion, conveyed unconsciously by receptors in muscles, joints, ligaments, and bones.

ROLE OF SOMATOSENSORY SYSTEM IN TASK PERFORMANCE

  • Example: Brushing Teeth

    • The sense of touch helps feel the toothbrush.

    • Deep pressure helps grip the toothbrush correctly.

    • Pain sensation alerts to avoid brushing sensitive areas in the mouth.

    • Proprioception guides the arms and hands through the brushing motion.

    • Thermal sensation helps determine the appropriate water temperature for rinsing.

CONTROL OF SOMATOSENSORY SYSTEM

  • The somatosensory system is managed by peripheral receptors in the skin and other sensory organs.

  • Proprioceptive receptors are found in:

    • Muscles

    • Tendons

    • Joint capsules

  • All sensory information is processed through the spinal cord and brain.

  • Some sensations can trigger motor responses prior to brain perception (e.g., reflex withdrawal from a hot object).

SENSATION AND MOTOR PERFORMANCE

  • Sensation functions as the primary means to learn about the external world.

  • Roles of Sensory Information:

    • Controls movement.

    • Modulates/regulates actions.

    • Provides feedback about motion effectiveness through various sensory systems.

  • Ongoing movement sensations send information to the Central Nervous System (CNS) where a comparison between intended and actual actions is made.

CONTROL PROCESSES: FEED-FORWARD AND FEEDBACK

  • Feed-Forward Control

    • Operates swiftly compared to feedback; used to plan movements before execution.

    • Anticipates sensory experiences (e.g., skiing: considering slope, snow condition, speed).

  • Feedback Control

    • Operates continually during movement execution to correct errors.

    • Reevaluates required actions and plans responses.

IMPACT OF SENSORY LOSS ON MOVEMENT

  • Impaired proprioception and tactile sensation adversely affect both feedback and feed-forward systems.

  • Consequences for Clients:

    • Cannot sense joint position/motion (proprioceptive dysfunction).

    • Cannot sense object contact (tactile dysfunction).

    • Motor dysfunction may lead to coordination problems.

    • Visual input may partially compensate for lost tactile and proprioceptive sensations.

POTENTIAL SCENARIOS AFFECTED BY SENSORY DEFICITS

  • Activities impacted include:

    • Dressing

    • Feeding

    • Toileting

    • Transfers

    • Bed mobility

    • Functional mobility

  • Suggested resources for examples: Check YouTube.

SENSATION EVALUATION, INTERVENTION AND THERAPEUTIC ACTIVITIES

  • Sensory dysfunction affects performance in daily activities (ADLs and education).

  • Evaluating occupational impact is essential for all clients with sensory dysfunction.

  • Specific tests and interventions vary by diagnosis and prognosis.

TESTING AND EVALUATION OF SENSORY FUNCTION

  • Test selection may depend on whether the origin is central nervous system (CNS) or peripheral nervous system (PNS):

    • Patients with CNS injuries often show deficits in proprioception, kinesthesia, and stereognosis.

    • Patients with PNS injuries commonly exhibit deficits in pressure thresholds and two-point discrimination.

  • Evaluation Example:

    • A patient with a history of CVA and a wrist fracture should be tested for proprioception, stereognosis, pressure threshold, and two-point discrimination.

TYPES OF SENSORY RECEPTORS (GUTMAN 2008)

  • Exteroceptors: Receive stimuli from the external world.

    • Examples: Visual, auditory, tactile, olfactory, gustatory receptors.

  • Interoceptors: Receive sensory information from within the body (e.g., internal organ sensations).

  • Proprioceptors: Detect body position and movement located in joints, muscles, tendons, and the inner ear’s labyrinths.

SOMATOSENSORY SYSTEM

  • Handles input from both superficial sources (skin) and deep sources (musculoskeletal system).

  • Sensations are stimulated at peripheral receptors and sent to the brain via the spinal cord.

  • Receptor types: mechanoreceptors, chemoreceptors, thermoreceptors.

SPECIAL SENSE RECEPTORS (GUTMAN 2008)

  • Visual Receptors: Rods and cones in the retina (exteroceptors).

  • Olfactory Receptors: Hair cells in nasal mucosa (exteroceptors).

  • Auditory Receptors: Hair cells in the cochlea (exteroceptors).

  • Gustatory Receptors: Taste buds in the tongue (exteroceptors).

  • Equilibrium Receptors: Semicircular canals, utricles, saccules of the inner ear (proprioceptors).

SOMATOSENSORY RECEPTORS (GUTMAN 2008)

  • Mechanoreceptors: Detect touch, pressure, stretch, and vibration.

  • Chemoreceptors: Activated by cell damage or injury, important for olfaction and gustation.

  • Thermoreceptors: Respond to temperature changes. Subset includes nociceptors, which sense pain.

  • Photoreceptors: Detect light (retina).

SUPERFICIAL SENSATION (GUTMAN 2008)

  • Also called cutaneous sensation; distal body parts have a higher density of receptors and smaller receptive fields than proximal parts, enhancing touch sensitivity (fine discrimination).

  • Normal two-point discrimination allows recognition of fine details (e.g., edge sensations).

  • Aspects of Superficial Sensation:

    • Touch: Fine or coarse; includes pressure and vibration.

FINE TOUCH RECEPTORS

  • Superficial Fine Touch Receptors:

    • Meissner’s Corpuscles: Sensitive to light touch and vibration.

    • Merkel’s Disks: Responsive to pressure.

  • Subcutaneous Fine Touch Receptors: Larger fields and less discriminative.

    • Pacinian Corpuscles: Respond to touch and vibration.

    • Ruffini’s Corpuscles: Senses skin stretch.

COARSE TOUCH SENSATION

  • Free nerve endings throughout skin provide sensations such as itch and tickle.

  • Pain: Perceived by nociceptors providing painful sensations. Thermal receptors sense cold (A-delta fibers) and warmth (C fibers).

IMPORTANCE OF TEMPERATURE SENSATION

  • Critical for determining safe temperature for bathing, washing, and cooking.

  • Test temperature sensation before applying heat/cold modalities to prevent burns.

  • Use unaffected body part to assess temperature safety.

PAIN CONCEPTS

  • Pain is an unpleasant sensory experience associated with actual or potential cellular damage.

  • Types of Pain:

    • Somatic Pain: Occurs from skin, skeletal muscles, bones. Superficial somatic pain is well-localized, while deep somatic pain is poorly localized.

    • Visceral Pain: From internal organs; dull and diffuse, often with autonomic nervous responses (e.g., heart rate changes).

QUALITIES OF PAIN (GUTMAN 2008)

  • Dull Ache: Diffuse, carried by slow-conducting C fibers, tends to last longer.

  • Sharp Pain: Well-localized, carried by fast A-delta fibers, tends to be short-lived.

PAIN SCALE - Universal Institute for Rehabilitation and Fitness Center

  • Numerical Scale:

    • No pain (0) to worst pain imaginable (10).

  • Visual Analog Scale: Patient indicates their pain on a continuum.

  • Categorical Scale:

    • None (0), Mild (1-3), Moderate (4-6), Severe (7-10).

  • Pain Faces Scale: Ranges from ”very happy, no hurt” to “hurts as much as you can imagine.”

DERMATOME AND MYOTOME DISTRIBUTIONS

  • Understanding of body’s sensory and muscle distributions is crucial for diagnosing and assessing sensory and motor deficits.

SENSORY TESTING: SEMMES-WEINSTEIN MONOFILAMENT

test

  • Monofilament Testing Instruments utilized to assess light touch sensitivity.

  • Interpretation of Filament Results:

    • 1.65 - 2.83 (Green): Normal

    • 3.22 - 3.61 (Blue): Diminished light touch

    • 3.84 - 4.31 (Purple): Diminished protective sensation

    • 4.56 (Red): Loss of protective sensation

    • 6.65 (Red): Deep pressure sensation

TWO-POINT DISCRIMINATION

  • Assesses the ability to perceive two distinct touch points.

  • Interpretation:

    • Less than 6 mm: Normal

    • 6 to 10 mm: Fair

    • 11 to 15 mm: Poor

  • Clinical Importance: Helps in assessing sensory nerve function and recovery understanding.

SENSORY DOWELS FOR THERAPEUTIC ACTIVITIES

  • Rolyan® Sensory Re-Education Wands offer a graduated sensory re-education system across various textures.

VISION IN SENSORY FUNCTION

  • Components Assessed:

    • Visual acuity, peripheral vision, scanning, tracking, accommodation.

    • Importance of assessing visual perception in relation to cognitive and perceptual functions.

APHASIA, APRAKIA, AND AGNOSIA

  • Apraxia: Impairment in voluntary movement not due to muscle or comprehension deficits.

    • Example: Difficulty performing tasks despite understanding them fully.

  • Agnosia: Impairment in object recognition despite intact sensory functions.

    • Example: A client can describe but not identify an object visually.

  • Aphasia: Speech/language disorders, impacting word choice and comprehension without motor deficits.

    • Divided into expressive (Broca’s aphasia) and receptive types (Wernicke’s aphasia).

TERMINOLOGIES FROM ARNADOTTIR’S A-ONE EVALUATION

  • Conceptual Definitions (CD): Generalized, abstract ideas about terms, often found in dictionaries.

  • Operational Definitions (OD): Specific measurements or observations utilized in tests for quantifiable assessments.

COMMON PSYCHOLOGICAL TERMINOLOGIES

Aggression

  • CD: Hostile behaviors intended to injure someone physically or emotionally.

  • OD: Hostility exhibited towards therapists during activities requiring participation.

Anomia

  • CD: Difficulty retrieving names of objects or people; fluent speech.

  • OD: Inability to name familiar objects, often resorting to descriptions instead.

Anosognosia

  • CD: Denial of a body part as one’s own, typically following paralysis.

  • OD: Clients may refer to their paralyzed limbs as "someone else's."

Apathy

  • CD: Lack of interest in activities or surroundings highlighted by minimal emotional response.

  • OD: Exhibits indifference during activities, indicating a lack of motivation or concern.

IMPAIRED COGNITION AND BEHAVIORAL DIFFICULTIES

  • Disorientation: Confusion regarding time, place, and personal information without correlated language issues.

  • Distractibility: Attention diversion due to irrelevant stimuli, which may impair task performance.

  • Dysarthria: Difficulty in speech production due to muscle control impairments.

  • Echolalia: Repetition of heard speech instead of spontaneous communication.

  • Right-Left Discrimination Impairment: Inability to differentiate left from right, affecting navigation and task execution.

  • Initiative Impaired: Lack of proactive involvement in necessary tasks despite understanding.

THERAPY APPLICATIONS AND CONSTELLATIONS OF SKILLS

  • Evaluation Activities: Incorporating games and therapeutic activities targeted at cognitive function improvement such as problem-solving cards, memory games, and tactile stimulation using sensory wands.

  • Ongoing assessment and adaptation of activities based on individual client needs and performance feedback.

REFERENCE MATERIALS

  • Early, M. B. (2013). Physical Dysfunction Practice Skills for the Occupational Therapy Assistant. Elsevier, Mosby. ISBN: 978-0-323-05909-1

  • Gillen, G. (2009). Cognitive and Perceptual Rehabilitation. Elsevier, Mosby. ISBN: 978-0-323-04621-3