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Sensory Reeducation

& Desensitization
SENSATIONS…
 Moberg – “Hands without sensation is like
eyes without vision”

 The Disembodied Lady


- from the book, “The Man Who Mistook His Wife for a Hat” – by Oliver
Sachs (Sachs 1985, p.43-54)
Sensation…
 Entails the ability to transduce, encode, and ultimately perceive
information generated by stimuli arising from both internal and
external environments

 Five Basic Senses:


 Somatic
 Vision
 Vestibular
 Auditory
 Chemical Senses

 The Sixth Sense - proprioception


A Little Review of Neuro…
 In a patient with a specific sensory
deficit can one determine which
spinal segment is affected? And
where the lesion might occur?
– Yes. By using dermatomal maps.
– Especially pain and temperature
rather than touch, pressure and
vibration. The dermatomal maps for
pain and temperature do not overlap
as much.

 Are these maps the same in each


person.
– No.

 Do proprioceptors follow the


dermatomal maps.
– No, they follow muscle innervation
patterns.
A Little Review of Neuro…
 The Somatic Sensory System has 2 Major Components:

1. Subsystem for mechanical stimuli


- light touch, vibration, pressure, cutaneous tension (mechanoceptors)

2. Subsystem for painful stimuli (nociceptors) and temperature

 Mechanosensory processing of external stimuli initiated by a diverse


population of cutaneous and subcutaneous mechanoreceptors at the body
surface.

 Additional receptors are located in muscles, joints, and other deep


structures and monitor mechanical forces generated by the musculoskeletal
system called proprioceptors (spindles, GTOs, joint receptors).
Neuro pa rin…
 Medial Lemniscal Tract/Dorsal column
 Fine touch and proprioception
 Affects ipsilateral side

 Ventral Spinothalamic Tract


 Crude Touch
 Affects contralateral side 2-3 segments
below level of lesion

 Lateral Spinothalamic Tract


 Pain and Temperature
 Affects contralateral side

 Dorsal Horn
 “the gate”
 Lamina I-VI
- Substantia gelatinosa – lamina 2 (what
gives it distinction?)
3 Types of Primary Afferent Fibers:

1. Large Myelinated A β fibers


- Mechanoceptors - Touch, pressure

2. Small Myelinated A δ fibers


- Mechanoceptors, Nociceptors (fast pain), Cold receptors

3. Small Unmyelinated C fibers


- Nociceptors (slow pain), Warm and Cold receptors,
Mechanoceptors
Types of Somatic Sensations
 Protective sensations
 Pressure – warns of deep pressure or repetitive pressure that can lead to injury;
if touch sensation is impaired, pressure sensation can aid in performance of
ADL and substitute for touch feedback in some activities

 Thermal sensation

 Superficial Pain

 Discriminative sensations – fine motor functions


 Touch sensation

 2-pt discrimination – static and moving (measures innervation densities)

 Stereognosis

 Movement and posture sensations


 Proprioception

 Kinesthesia
Sensory Evaluation & Testing
 Light touch
 Pressure
 Position/Motion Sense
 Thermal
 Superficial Pain
 Functional Tests

Functional
Implications?????
Two-Fold Objective
 Sensory acuity – potential to function
 Function with acuity – actual ability to function
Principles of Treatment
 Treatment is always based on Learning Principles

 Tailored to interest and ability of the patient.


 Activities are graded to ensure success for improved performance
 The patient must find relevance and importance of treatment – motivation!!!
 Attention, concentration, judgment

 Good assessment and reassessment is crucial

 Clear picture of the diagnosis


 CNS or PNS dysfunction?
 Prognosis?
 Hypersensitive?
 Diminished sensation?
 Loss of Sensation?
 Pain syndromes?
 Presence of paresthesias?
Intervention Strategies

Loss of Sensation
Compensation Techniques

Diminished
Sensory Re-Ed/Retraining

Hypersensitive
Desensitization
COMPENSATION TECHNIQUES
Compensation Techniques

 Loss or impairment of protective sensation


 Goal: PREVENT INJURY
 safety first!
 increase awareness of deficit
 minimize risks of tissue damage (Brand 1979)
1. Continuous low pressure
2. Concentrated high pressure
3. Excessive heat or cold
4. Repetitive mechanical stress
5. Pressure on infected tissue
Compensation Techniques
 Use other senses
 Vision - observe motion and location of body parts; check skin condition
 Hearing – rubbing sounds

 Use less affected part


 In checking temperature
 Handling sharp objects

 Use of adapted devices


 Built up handles for tools – distribute pressure

 Frequent position change


 rest or relieve pressure over affected area

 Skin care
 prevention – cushions, in-soles, straps, protective mitts
 wound care
Methods of Compensation
Brand (1979)
 Avoid exposure of the involved area to heat, cold, and sharp
objects.

 When gripping a tool or object, be conscious of not applying more


force than necessary

 Beware that the smaller the handle, the less distribution of


pressure over the gripping surfaces. Avoid small handles by
building up the handle or by using a different tool whenever
possible.

 Avoid tasks that require use of one tool for long periods of time,
especially if the hand is unable to adapt by changing the manner
of grip.
Methods of Compensation
Brand (cont’d)
 Change tools frequently at work to rest tissue areas.

 Observe the skin for signs of stress, that is, redness,


edema, and warmth, from excessive force or repetitive
pressure, and rest the hand if these signs occur.

 If blisters, lacerations, or other wounds occur, treat


them with the utmost care to avoid further injury to the
skin and possible infection.

 To keep skin soft and pliant, follow a daily routine of


skin care, including soaking and oil massage to lock in
moisture.
SENSORY REEDUCATION
FOR
PERIPHERAL NERVE INJURIES
(PNI)
Sensory Reeducation for PNI
 FOCUS: the HAND esp. fingertips
 Cortical maps - reorganization
 Reinnervation (nerve repair and recovery)
 Time

 Limited by scar tissue

 Atrophy of sensory receptors

 Malalignment of axonal fibers

 PURPOSE: help learn to recognize the


distorted cortical impression

 Outcome dependent on:


 cognitive capacities – learning abilities and
visuospatial cognition
 motivation
 compliance
General Principles of SR
 Implementation before adequate regeneration
 No benefit, causes frustration
 Semmes-Weinstein 4.56-6.65

 Active exploration is encouraged

 General sequence: Eyes closed – eyes open – eyes closed

 May begin when the patient first can appreciate deep, moving touch
 Matching sensory perception with visual perception

 Perception of light non moving touch with good touch localization


 Functional tasks of object identification through touch
 Semmes-Weinstein 4.31 or lower
 The better return of touch perception, the better the prognosis for
retraining in fine discrimination.
General Principles of SR
 Localization:
 Use of grid
 May be graded – dull to light
 Proximal to distal strokes or
transverse
 Constant touch is at the center of
each zone

 Discrimination:
 Gross to fine discrimination
 Moving/exploring
 Use of grid
 Progression:
Matching - Same or different?
In what way?
Identify texture, object, etc…
Sensory Modalities Used
 Eraser end of pencil - graphesthesia

 Dowels with different textures

 Fabrics

 Objects with different rough/smooth


edges

 Objects embedded in Putty

 Games and Puzzles

 Containers with different background


mediums

 ADL with Vision Occluded

 Work simulated tasks


Sensory Modalities Used
SR Protocols - PNI
 Different protocols for different facilities
 Principles are generally similar

1. Dellon
2. Wynn Parry
3. Turner
4. La Croix and Helman
5. Callahan
6. Nakada and Uchida
SR Protocols - PNI
 Dellon (Pedretti, 5th ed, p.440; Trombly, 5th Ed, p.589)
 Early phase
 Reeducation of moving touch, constant touch, pressure, and touch localization
 Use of pencil eraser
 4x a day at least 5 mins each
 Procedure: 1. Patient observes the stimulus
2. Vision occluded (verbalizes sensation felt)
3. Eyes open to verify

 Late phase
 Initiated when moving and constant touch are perceived at the fingertips with good
localization
 Usually 6-8 months after nerve repair at the wrist
 Goal: recovery of tactile gnosis
 Procedure: Same as above
 Progression:
1. Large objects different from one another (common household items)
2. Objects with more subtle differences
3. Different textures
4. Smaller objects requiring discrete discriminations
5. Incorporate activities that simulate occupational roles
SR Protocols - PNI
 Wynn Parry (Pedretti, 5th Ed., p.441)

 Begins approximately 6-8 months after a nerve suture at the wrist


 2-4x a day for 10 minutes
 Reevaluation done 1,3,6 months after IE
 Time to recognize objects
 Time to recognize textures
 Time for correct localization

 Initial phase
a. Place block in affected hand with vision occluded – feel block,
describe shape, compare weight with block in UA
b. Look at the block and repeat manipulation if incorrect/different
c. Compare sensory experience with UA hand
d. Continue until various shaped blocks have been mastered
e. Differentiate textured from wooden surfaces – blocks with
sandpaper or velvet
SR Protocols - PNI
 Next phase
a. Identification of several textures with vision occluded
b. Identification of common objects with vision occluded

 Incorrect responses: allow to perform manipulations while


looking at the objects - relate what is felt to what is seen

 Progression: large to small objects

 Variations: burying objects in bowl of sand


form boards
identifying wooden letters

 Training of Touch Localization


1. Vision occluded
2. OT touches several places on volar surface
3. Patient locates each stimulus with index finger of UA hand
 Incorrect response – patient is directed to look and relate
SR Protocols - PNI
 Turner (Pedretti, 5th Ed., p.441)
 Peripheral Nerve Lesions
 Retraining begins with return of protective sensation (deep pressure,
pinprick) and touch perception
 Same principles of identifying objects, shapes, textures with vision
occluded
 If incorrect – look at the object and compare sensation for integration
 Use different textured dominoes or checkers, finding large to small sized
objects in rice or lentils
 3-4x a day for 45 minutes
 Encourage bilateral activities in functional tasks
 Pottery, bread-kneading, weaving, macrame
 Compare the feelings of the tools and materials – A vs. UA
SR Protocols - PNI

 La Croix and Helman (Pedretti, 5th Ed., p.441)


 Purpose is to help patient to correctly interpret different sensory
impulses
 Sessions are done several times a day for short periods
 UA => A
 Vision => vision occluded
 Graded stimuli are used in treatment
 Least stressful stimuli are presented first
 Constant pressure, movement, light touch, vibration
 Hypersensitive areas are noted
 Stroking, deep pressure, rubbing, maintained touch with different textures and
shapes
SR Protocols - PNI
 Callahan (Trombly, 5th Ed., p. 588)

 Moving and constant touch sequence


 eyes closed =>open => close again
 Use of smaller and lighter stimulus as patient improves
 Goal: localization of a touch that is near the light-touch threshold
 Progression:
 Discrimination of similar and different textures using sandpaper, fabrics,
and edges of coins – introduced early
 Practice graphesthesia, Identify shapes or letter blocks
 Later stages: pick objects from containers filled with sand or rice and
practice identification of common objects
 Recommends practice of daily living activities with vision occluded
 Variety of tasks – games, puzzles are more beneficial
SR Protocols - PNI
 Nakada and Uchida (Trombly, 5th Ed., p. 588)
 5 stage Sensory Reeducation program
 Patient had total impairment of vision and very limited sensation in
her left hand
 Good functional outcome (ADL performance) – drying dishes,
putting on socks, and holding dentures while brushing
 Stages:
1. Object recognition - feature detection strategies
2. Prehension of various objects – grasping
3. Control of prehension force while holding objects
4. Maintenance of prehension force during transport of objects
5. Object manipulation
SENSORY REEDUCATION
FOR
CNS Dysfunction
Sensory Reeducation - CNS Dys
 Recovery of motor function depends on sensation (Dannenbaum &
Jones, 1993)
 Low priority - ranked 9th (Neistadt and Seymour, 1995)
 Less-defined than protocols for PNI – “still in infancy”
 Limited studies measuring outcomes in occupational performance

 Concept of Neural Plasticity


 Carr & Shepherd (1998) – reorganization appears to be related to frequency of use

 Goal: gain larger cortical representation for the areas from which
sensory feedback is crucial to performance of daily tasks

 Functional use is possible but spontaneous use is limited


 NO training => Learned non-use => further loss of sensory & motor fxns

 recovery of pain and temperature perception usually precedes


recovery of proprioception and light touch

 Weight-bearing is used to increase proprioceptive feedback


Sensory Reeducation – CNS Dys
 Eggers
 Advocates integrating sensory retraining with motor retraining using
NDT approach
 Focus on tactile and kinesthetic reeducation
 Stimulate sensation without increasing spasticity
 Repetition and variation is necessary
 Prerequisite: normalize muscle tone
find optimal position
 Progression:
1. with vision => vision occluded => use of padded surface
2. gross discrimination => fine
3. estimate quantities through touch
4. discriminate large and small objects hidden in sand
5. discriminate between 2-3 dimensional objects
6. pick a specific small object from among several objects
Sensory Reeducation – CNS Dys
 Dennenbaum & Jones (1993)
 Success = awareness of tactile stimulation
+ basic motor skills
 ES 100Hz
 With vision => eyes closed
 Identify finger that was stimulated
 Textured moving stimuli => stationary stimuli
 Early incorporation of hand into functional activities
 Textured surfaces, enlarged handles to help with tactile
contact and tactile feedback
Sensory Reeducation – CNS Dys
 Yuketiel & Guttman (1993)
 Identification of the number of touches
 Graphesthesia tests

 “Find your thumb” without looking

 Identification of shape, weight, and texture

 Passive drawing and writing


 OT moves patient’s hand while holding a pencil and
patient identifies a letter, number, or drawing made
Sensory Reeducation – CNS Dys

 Carr & Shepherd (1998)


 Sensory relearning concurrent with motor
relearning
 Advocate use of bimanual tasks

 Object identification without vision


DESENSITIZATION
Desensitization
 PNI,crush injuries, wound/scar management,
burns, amputations
 Guarding = Learned non-use
 Phantom limb sensation vs. Phantom Pain
 Poor success – cumulative trauma and RSD

 Progressive stimulation => progressive


tolerance
 Begins at patient’s level of tolerance 3-4x daily
 Structured practice within the context of
functional activities – better outcomes
Desensitization
Goal:
 Increasing the pain threshold of a nerve
 Decrease the discomfort
 Usually 7-8 weeks

Progression:
 soft => coarse => rough
 Increase in force, duration, and frequency of application
Sensory Modalities Used
 Massage
 Percussion/tapping or
rolling/stroking with different
textures
 Vibration
 Immersion in materials - styrofoam
balls, rice, beans, popcorn and
plastic squares
 Weight-bearing
 Pressure/Compression
 TENS
 Heat
 Fluidotherapy
 Therapy putty
Treatment Protocols
 Hardy, Moran and Merritt Desensitization Protocol
Treatment Protocols

 Three-Phase Desensitization Treatment Protocol


Sensory Modalities Used

• Patients arrange dowel texture and


immersion textures in the order of least
to most irritating
• Uncomfortable but tolerable for 10
minutes 3-4x daily
GROUP DISCUSSION
Skills Practice
6 groups
 Discuss different cases given (15 minutes)
 Presentation 15 minutes each

 Principles of treatment
- Suggest treatment intervention
- progression?
- possible functional activity/activities in outpatient clinic

 Home program/instructions to be given to patient or


caregivers – give 3-5.
Cases:
1. Stroke – bedridden elderly overweight, requires positional splints
for flaccid extremities, lethargic

3. Peripheral Nerve Injury – car mechanic; median nerve repair; has


loss of sensation on fingertips only of dominant hand; needs to go
back to work in a week

5. Diabetic – in her 50’s; primary income earner - cooks for a living


(cart), always up and about

7. Amputee – motor cycle accident; radial 3 digits, wounds healing but


c/o phantom pain; late 30’s teacher

9. Hand burn contractures – skin grafting over digits, wounds healing;


diminished sensation

11. Spinal Cord Injury – 30’s, wants to live independently in Baguio,


incomplete hemi-section of spinal cord at C7 level
DO WELL ON YOUR EXAMS!!!
God bless!