EXAMINATION OF SENSE OF TOUCH

Principle:
Sense of touch can be assessed by voluntary stimulation of tactile receptors in skin and noting the response.

Apparatus:
Fine touch aesthesiometer, crude touch aeshesiometer, cotton wool, webers compass, key , pencil and subject.

Method of e a!ination "procedure#:

Introduce yourself to the subject whose sensory system is to be examined. xplain the procedure to the subject and take consent. !he part of skin to be examined should be ade"uately exposed. #sk the subject to close the eyes. !o test fine touch, take a fine aesthesiometer or wisp of cotton and touch the identical parts of the body of the subject starting from face, lips, back of neck, fingertips, hand and forearm. !he patient should be asked to reply $yes$ or raise the index finger each time a stimulus is applied. !actile locali%ation can be tested by having the patient point to the area stimulated or to describe the area tested. #nd we can test all the dermatomes and the cutaneous innervation areas of all the nerves by this method.

To test coarse or crude touch, coarse aesthesiometer is used to touch the same areas as we tested for fine touch.

Stereo$nosis& this is ability to recogni%e and identify objects by feeling them. !he absence of this ability is termed astereognosis. !his is tested by putting an object e.g. key in the hand of patient when his eyes are closed and he is asked to reply what it is.

Graphesthesia: this is ability to recogni%e symbols written on the skin. !he absence of this ability is termed graphanesthesia. !his is tested by making a circle or writing some digit on the palm of subject and asking him what has be drawn.

Two-point discrimination: this is ability to recogni%e simultaneous stimulation by two blunt points. 'easured by the distance between the points re"uired for recognition. !his is tested by using (ebers compass. !wo pointed ends of this compass are separated apart gradually and are touched to the skin of patient simultaneously. !he patient is asked whether he has felt two points or one. !he minimum distance at which he can appreciate two points as two is called as minimal separable distance. !his distance is very less on lips and finger tips )*+,mm- but much larger on the back )./+0/mmof our body. !his distance is inversely proportional to the number of receptors present in some area of skin and also inversely proportional to the representation of that area in sensory cortex of brain.

Precautions and other i!portant considerations:

1. Before starting the examination, the patient should be questioned as to whether abnormal sensations are experienced subjectively.
.. It must be performed carefully with optimal patient cooperation to achieve reliable results. ,. !he patient should be physically and mentally relaxed and in comfortable surroundings. 1. 2are must be taken to explain the patient what is expected of him or her and to assure anxious patients that the examination will not be painful. 0. #ccurate results are difficult to obtain if the patient is distracted or exhausted. In such cases, the examination should be repeated when the patient is rested. 3. #reas of abnormal sensation should be outlined on the patient with a skin pencil.

TESTIN% THE FINE AN& C'U&E TOUCH:

Part to (e touched)

Nu!(er of ti!es touched

Nu!(er of ti!es felt "ri$ht#) */ */ */ */

Nu!(er of ti!es felt "left#) */ */ */ */

Nu!(er of ti!es felt "ri$ht#) */ */ */ */

Nu!(er of ti!es felt "left#) */ */ */ */

4ips.

*/

Fingertips. */ 5and. Forearm, hairy area Forearm, non+hairy area. */ */

*/

*/

*/

*/

*/

TESTIN% THE TACTI*E *OCA*I+ATION:

Part to (e touched 4ips. 7alm. Fingertips. 8ack of hand. Forearm, hairy area. Forearm, non+hairy area.

Error or not 6ormal 6ormal 6ormal 6ormal 6ormal normal

&iscussion:
!he sensory system provides information that places the individual in relation to the environment. # sensation is any change in external or internal environment detected by receptors. 9eceptors may be located superficially in skin and mucous membranes or deeply in tendons, muscles, ligaments and joints. Sensations may be classified on the basis of location of receptors to exteroceptive and proprioceptive sensation. # third sensory modality re"uires cortical analysis to provide interpretation of sensory information. #ll three types of sensation should be evaluated in every patient examined.

A#) E terocepti,e sensation: )also termed superficial sensation-& receptors

in skin and mucous membranes. !hese sensations are tactile or touch sensation, pain sensation, and temperature sensation. So!e i!portant clinical definition related to Tactile or touch sensation:

Anesthesia: absence of touch appreciation Hypoesthesia: decrease of touch appreciation Hyperesthesia: exaggeration of touch sensation, which is often unpleasant

)!erms above are unfortunately used indiscriminately to apply to losses of all types of sensation. !hey are not specific for loss of tactile sensation.-

So!e i!portant clinical definition related to Pain sensation "al$esia#: Analgesia: absence of pain appreciation Hypoalgesia: decrease of pain appreciation Hyperalgesia: exaggeration of pain appreciation, which is often unpleasant So!e i!portant clinical definition related to Te!perature sensation- (oth hot and cold "ther!esthesia#: Thermanalgesia: absence of temperature appreciation Thermhypesthesia: decrease of temperature appreciation Thermhyperesthesia: exaggeration of temperature sensation, which is often unpleasant So!e Sensor. per,ersions: Paresthesia: abnormal sensations perceived without specific stimulation. !hey may be tactile, thermal or painful: episodic or constant. Dysesthesia: painful sensations elicited by a non+painful cutaneous stimulus such as a light touch or gentle stroking over affected areas of the body. Sometimes referred to as hyperpathia or hyperalgesia. ;ften perceived as an intense burning, dyesthesias may outlast the stimulus by several seconds.

/#)Propriocepti,e sensation: )also termed deep sensation-& receptors

located in muscles, tendons, ligaments and joints Joint position sense )arthresthesia-& #bsence is described as such Vibratory sense )pallesthesia-& #bsence is described as such Kinesthesia: perception of muscular motion. <sually not measured in routine clinical evaluation.

C#) Cortical sensor. functions: interpretative sensory functions that re"uire

analysis of individual sensory modalities by the parietal lobes to provide discrimination. Individual sensory modalities must be intact to measure cortical sensation. Stereognosis: ability to recogni%e and identify objects by feeling them. !he absence of this ability is termed astereognosis. Graphesthesia: ability to recogni%e symbols written on the skin. !he absence of this ability is termed graphanesthesia. T o!point "iscrimination: ability to recogni%e simultaneous stimulation by two blunt points. 'easured by the distance between the points re"uired for recognition. #bsence is described as such. To#ch locali$ation )topognosis-& ability to locali%e stimuli to parts of the body. Topagnosia is the absence of this ability. Do#ble sim#ltaneo#s stim#lation: ability to perceive a sensory stimulus when corresponding areas on the opposite side of the body are stimulated simultaneously. 4oss of this ability is termedsensory extinction.

Another 0a. to classif. the sensations:

#-. S7 2I#4 S 6S#!I;6S& visual sensation )vision-, auditory sensation )hearing-, olfactory sensation )sense of smell- and gustatory sensation )sense of taste-. 8-. S;'#!I2 S 6S#!I;6S&

*. mechanoreceptive sensations& !actile sensation )fine and crude touch, pressure, tickle, itch and vibration-. Sense of position )proprioception-.

.. !hermal sensation )heat and cold sensation-. ,. 7ain sensation )fast and slow pain-.

1arious path0a.s of the fi(ers and the sensations carried (. the!:

a#) Spinothala!ic s.ste! "or anterolateral s.ste!#& #nterior or ventral spinothalamic tract carries& crude touch, tickle, itch, pressure and sexual stimulation. 4ateral spinothalamic tract carries& pain and temperature sensation.

(#) &orsal colu!n !edial le!niscus path0a. 2conscious3 proprioception: =oint position )proprioception-, vibration, deep pressure, two point tactile discrimination, graphaesthesia and stereognosis. c#) &orsal and ,entral spinocere(ellar path0a. >unconscious? proprioception

Afferent fi(ers that carr. tactile sensation:

'yelinated fibers& #+ beta fibers )velocity of conduction@ ,/+A/ mBsec-, #+ delta fibers )velocity @ 0+,/ mBsec.<nmyelinated fibers& !ype 2 fibers )velocity of conduction@ /.0+ . mBsec-.

Touch sensiti,it.:
Caries from part to part.

Depends on number of receptors. 'aximum sensitivity& at tip of tongue, lips, finger tips, then hands, forearm and arm. 'inimum sensitivity& on the back of body

Sensor. path0a. of Fine touch:

!ouch receptors are present in large numbers in the skin of fingers and lips and less number in the skin of trunk. !he first order of neurons carrying the fine touch sensation enters the spinal cord via posterior root and then ascend in the ipsilateral dorsal column of the spinal cord. !hey terminate in the nucleus gracilus and cuneatus of medulla. !he second order neurons arise from the nuclei, cross to the opposite side in medulla and ascend up in the contralateral medial leminiscus, to terminate in the ventral posterior nucleus and related specific sensory nuclei of the thalamus. !he third order of the neurons arises from the thalamus and reach the sensory cortex via thalamic radiations. !he sensations that are carried in the posterior column of the spinal cord are fine touch, proprioception, and sense of vibration, tactile locali%ation, two point discrimination and stereognosis.

Sensor. path0a. of Crude touch:

!he first order neurons after entering the spinal cord synapse with the second order neurons in the dorsal horn of spinal cord. the second order neurons cross to the opposite side at that spinal segment and ascend up in the contralateral ventral spinothalamic tract to terminate in the specific sensory relay neurons of the thalamus.the third order neurons arise in the thalamus and end in the sensory cortex through thalamic radiations.

Appendi no 4: &orsal colu!n path0a.5!edial le!niscus path0a.:

Appendi

no 6: Spinothala!ic path0a.:

Pain perception 2 fibers& thin, unmyelinated # delta& thinly myelinated Te!perature # delta& thinly myelinated

Appendi

no 7:

Appendi no 8: Spinal cord 9 ,arious i!portant sensor. tract

Appendi

no ::

Appendi

no ;: Sensor. ho!unculus: