Professional Documents
Culture Documents
Dr.A.P.P.Pavani
PG in medicine
OVERVIEW
Introduction
Anatomy of sensation
Examination
Requires great concentration and cooperation from the patient and from the
examiner.
EXTROCEPTIVE PROPRIOCEPTIVE
PRIMARY SENSATIONS
1.Extroceptive sensations:
Derived from sources outside the body
Light touch
Pain
Temperature
2.Proprioceptive sensations:
Derived from body itself
Sense of position and passive movement
Vibration
Deep pressure pain
COMBINED AND CORTICAL SENSATIONS
Stereognosis
Two point discrimination
Graphaesthesia
Barognosis
Localisation of touch(topognosis)
ANATOMY OF SENSATION
POST CENTRAL CORTEX
THALAMUS
FIBRE TRACTS
SENSORY AFFERENTS
SENSORY RECEPTORS
ANATOMY OF SENSATION
and lateral columns of the spinal cord, through the brainstem, to the
Although the fiber types and functions that make up the spinothalamic
and lemniscal systems are relatively well known, many other fibers,
This explains why a complete lesion of the posterior columns of the spinal
Positive symptoms.
Negative symptoms.
SYMPTOMS
pathways, they are not necessarily associated with a sensory deficit (loss)
on examination.
SYMPTOMS
sensory symptoms.
except pain; it sometimes implies that the abnormal sensations are perceived
spontaneously.
evident.
Another set of terms refers to sensory abnormalities found on examination.
vibratory sensibility and absent deep tendon reflexes in the affected limbs.
• Origin of aberrant sensations
• OBJECTIVES
• This requires that sensory thresholds , particularly in the feet and legs, be
assessed in relation to age standards.
RULES OF EXAMINATION
Care should be taken not to tire the patient out or prejudice his mind by
suggestions.
In order to ensure accuracy , the patient’s eyes must be kept close or covered.
Patient is instructed to make his response prompt ,as soon as the artificial
stimulus is percieved,by uttering the word “yes”to indicate his ability to feel
the stimulus.
• RULES OF EXAMINATION
The time elapsing between the stimulus and response , under normal
circumstances ,is one-tenth of a second.
Patient under no circumstance must be asked “did you feel that ” , when a
stimulus is applied.
Tested with a wisp of cotton or a fine , soft paint brush touched lightly to
the skin , or a mere touch of a finger tip , the patient being instructed to
say “ yes “ on immediately feeling the touch.
PAIN
A sharp pin with a rounded head is generally sufficient to produce uniform
and graduated stimuli.
1 .The shaft of the pin should be long enough to allow the examiner’s index finger
and thumb to slide downwards on impact.
2 .A short pin held with index finger on the head of the pin usually produces an
indelicate and variable stimulus.
4. Hollow needles should never be used . Puncturing the skin is heavy handed and
does not produce an accurate response in an alarmed patient . Also poses the risk
of transmitting disease.
EXTROCEPTIVE SENSATIONS
PAIN
PAIN.
• A commonly used technique is asking the patient to compare
one side to the other in monetary or percentage terms.
• For example, “If this (stimulating the apparently normal side) side is
a rupee’s worth (or 100%), how much is this (stimulating the
apparently abnormal side) worth?”.
• PAIN
• If testing is done too rapidly, the area of sensory change may be misjudged.
• Applying the stimuli too close together may produce spatial summation;
stimulating too rapidly may produce temporal summation. Either of these
may lead to spurious findings.
EXTROCEPTIVE SENSATIONS
TEMPERATURE
• Temperature sensation may be tested with test tubes containing warm and
cool water, or by using various objects with different thermal conductivity.
• Ideally, for testing cold, the stimuli should be 5°C to 10°C (41°F to 50°F),
and for warmth, 40°C to 45°C (104°F to 113°F).
• The extremes of free flowing tap water are usually about 10°C and 40°C.
• Temperatures much lower or higher than these elicit pain rather than
temperature sensations.
TEMPERATURE
• Testing temperature may be useful when the patient does not tolerate
pinprick stimuli, has confusing or inconsistent responses to pain testing,
or to help map an area of sensory loss.
• The examiner should hold the sides of distal phalanx with the right hand ,while
the left hand is used to steady the interphalangeal joint.
• He is asked to shut his eyes during the test and state the direction of toe in
relation to neutral position.
• To begin with, the test movements have to be somewhat large,once the idea of
the test becomes clear to the patient , the smallest possible movements that are
detectable should be employed,avoiding sudden or quick jerks at all times
PROPIOCEPTIVE SENSATIONS
PSEUDOATHETOSIS
• Patients with impaired joint position sense in their fingers may exhibit
so called pseudoathetosis
ROMBERG’S TEST
• Ask the patient to stand with his feet side by side.
VIBRATION SENSE
• A low frequency tuning fork of 128 Hz is used to test the vibration sense.
• It must be first demonstrated to the patient by pressing the base of the tuning
fork on the sternum, both during and after the cessation of vibration.
• Patient is asked to say “ buzzing” or “yes” when he feels the vibration and
• When this is made clear to the patient he is asked to close his eyes and
PRESSURE SENSATION
• Pressure or touch-pressure sensation is closely related to tactile sense, but
involves the perception of pressure from the subcutaneous structures rather
than light touch from the skin.
• It is also closely related to position sense and is mediated via the posterior
columns.
• Strong pressure over muscles, tendons, and nerves tests deep pain
sensibility.
CORTICAL OR COMBINED SENSATIONS
• Cortical sensations are those that involve the primary sensory areas of the
cortex to perceive the stimulus and the sensory association areas to interpret
of information from more than one of the primary modalities for the
STEREOGNOSIS
• Stereognosis is the perception, understanding, recognition, and identification
of the form and nature of objects by touch.
• STEREOGNOSIS
• Bunch of keys should not be used since the sound of rattling may betray its
nature to the patient.
• The test should be carried out simultaneously with both hands , using
identical objects.
• The patient’s eyes being closed , the points are placed on the skin ,
sufficiently wide apart to be recognised instantaneously as two points
(double contact) and then gradually brought together , until the patient
reports being touched with a single point only.
• The findings on the two sides of the body must always be compared..
CORTICAL OR COMBINED SENSATIONS
GRAPHAESTHESIA
• It is the ability to recognize letters or numbers written on the skin with a
pencil, dull pin, or similar object.
• Testing is often done over the finger pads, palms, or dorsum of the feet.
• Letters or numbers about 1 cm in height are written on the finger pads, larger
elsewhere.
BAROGNOSIS
• It is tested by using two coins of different weights but of equal or
nearly equal size.
• When objects of equal weight are placed in both hands , the one in the
affected hand always feel lighter in weight.
CORTICAL OR COMBINED SENSATIONS
TOPOGNOSIS
• Localisation of touch
• Consists of ability to localise stimuli applied to parts of the body with the
eyes shut.
SENSORY INATTENTION
• Sensory extinction, inattention, or neglect is loss of the ability to perceive
two simultaneous sensory stimuli.
• Testing for tactile extinction uses double simultaneous stimuli at homologous
sites on the two sides of the body.
• Light touch is most often used. Extinction occurs when one of the stimuli is
not felt.
• If using pinprick (with equally sharp pins), the stimulus on the abnormal side
may feel blunt compared to the normal side.
SENSORY LOCALISATION
Nerve roots
Spinal cord
Brainstem
nervous system.
• When the primary modalities are normal in a particular body region, but the
• When some primary modalities are involved more than others, the sensory
• When the pathways are remote from each other, such as in the
spinal cord and brainstem, a disease process may affect one type of
or Wallenberg’s syndrome.
• The pain and temperature loss involves the ipsilateral face, because of
involvement of the spinal tract of cranial nerve V, and the contralateral body,
because of damage to the lateral spinothalamic tract, sparing the light touch
DISTAL,SYMMETRIC DERMATOMAL
DERMATOMAL
SENSORY LOSS DUE TO SENSORY LOSS DUE SENSORY LOSS DUE
PERIPHERAL TO CERVICAL TO LUMBOSACRAL
NEUROPATHY RADICULOPATHY RADICULOPATHY
SENSORY LOCALISATION
SPINAL CORD
• If the spinal cord is transected, all sensation is lost below the level of
transection.
SPINAL CORD
• Lateral hemisection of the spinal cord produces the Brown- Sequard
syndrome, with absent pain and temperature sensation contralaterally and
loss of proprioceptive sensation and power ipsilaterally below the lesion
SPINAL CORD
spinal cord.
SPINAL CORD
• Anterior spinal artery infarction causes dissociated sensory loss.
• The anterior spinal artery infarction involves the anterior two-thirds of the
cord, sparing the posterior columns, which are perfused by the posterior
spinal arteries.
• The patients have dense motor deficits and dense sensory loss to pain and
temperature but normal touch, pressure, position, and vibration.
ANTERIOR SPINAL
ARTERY SYNDROME
SENSORY LOCALISATION
SPINAL CORD
• Dysfunction of the posterior columns in the spinal cord or of the
posterior root entry zone may lead to a band like sensation around
the trunk or a feeling of tight pressure in one or more limbs.
POSTERIOR COLUMN
SYNDROME
SENSORY LOCALISATION
BRAINSTEM
• Crossed patterns of sensory disturbance, in which one side of the face and
the opposite side of the body are affected, localize to the lateral medulla
(lateral medullary or wallenberg’s syndrome)
THALAMUS
• Hemi sensory disturbance with tingling numbness from head to foot is often
thalamic in origin but also can arise from the anterior parietal region.
CORTEX
• With lesions of the parietal lobe involving either the cortex or the subjacent
white matter, the most prominent symptoms are contralateral hemi neglect,
hemi-inattention, and a tendency not to use the affected hand and arm.