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OTJXXX10.1177/1539449216643941OTJR: Occupation, Participation and HealthCarey et al.

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OTJR: Occupation, Participation and

The State-of-the-Science on
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2016, Vol. 36(2S) 27S­–41S
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on Daily Life in Adults and Older Adults, DOI: 10.1177/1539449216643941

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and Following Stroke: A Scoping Review

Leeanne M. Carey1,2, Gemma Lamp1,2, and Megan Turville1,2

Abstract
The aim was to identify and synthesize research evidence about how adults and older adults process somatosensory
information in daily activities, and the interventions available to regain somatosensory function following stroke. We
developed two interacting concept maps to address the research questions. The scoping review was conducted from
2005 to 2015 across Web of Science, AMED, CINAHL, Embase, Medline, and PsychInfo databases. Search terms included
somatosensory, perception, performance, participation, older adult, stroke, intervention, discrimination, learning, and
neuroplasticity. Contributions from 103 articles for Concept 1 and 14 articles for Concept 2 are reported. Measures of
somatosensory processing, performance, and participation used are identified. Interventions available to treat somatosensory
loss are summarized in relation to approach, outcome measures, and theory/mechanisms underlying. A gap exists in the
current understanding of how somatosensory function affects the daily lives of adults. A multidisciplinary approach that
includes performance and participation outcomes is recommended to advance the field.

Keywords
somatosensation, adult, stroke, performance, participation, rehabilitation

Introduction categories of measures to be used in clinical settings, and

Without touch, we cannot fully process the world around us.
Our senses, and in particular our body sensations, help shape
our interactions with objects and the environment around us.
They allow us to feel and recognize everyday objects in our
hands, know where our limbs are in space, be alerted to dan-
ger through touch, and perform controlled reach and manipu-
lation of objects. Moreover, people who experience loss of
body sensations, such as following stroke, report difficulty
with a range of everyday activities and life roles.
Despite the apparent importance of somatosensation in
our daily lives, the relationship between somatosensory pro-
cessing and how it supports performance of daily tasks and
participation outcomes is not well known. In particular, we
need to identify and synthesize (a) current evidence of how
adults and older adults process somatosensory information in
daily activities, and (b) the impact of somatosensory impair-
ment on performance and participation outcomes. The pur-
pose of this review is to summarize the available literature
that informs our understanding of the role of somatosensa-
tion in an individual’s performance of daily activities, and
the impact of impaired body sensations and somatosensory
interventions on such performance and participation out-
comes. It is envisioned that the findings will help inform
somatosensory interventions available to improve outcomes
at processing, performance, and participation levels. The
identification of gaps in the current knowledge base will help
guide future research in the field.
Somatosensory function refers to the detection, discrimi-
nation, and recognition of body (somato) sensations. These
include submodalities of touch, such as light touch (on the
surface of the skin), firm pressure, and texture discrimina-
tion; proprioception involving sensing the location and
movement of body parts; temperature sensation; pain (noci-
ception); and the integration of sensations in the active rec-
ognition of objects through touch (haptic object recognition;
1
Occupational Therapy, School of Allied Health, La Trobe University,
Melbourne, Victoria, Australia
2
Neurorehabilitation and Recovery, Florey Institute of Neuroscience and
Mental Health, Heidelberg, Victoria, Australia
Corresponding Author:
Leeanne M. Carey, School of Allied Health, College of Science, Health
and Engineering, La Trobe University, Bundoora, Victoria 3086; and
Neurorehabilitation and Recovery, Stroke Division, The Florey Institute
of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg,
Victoria 3084, Australia.
Email: l.carey@latrobe.edu.au

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28S OTJR: Occupation, Participation and Health 36(2S) 
Dunn et al., 2013). Models of somatosensory processing
highlight that sensation is important for perception and for
action (Dijkerman & de Haan, 2007). Both will influence
how somatosensory information is sought and processed.
The process is dynamic and is influenced by a range of fac-
tors, such as attention and movement (Carey, 2015). It is
intrinsically linked with our goals when interacting with the
world around us.
One in two stroke survivors loses the sense of touch
(Carey, 2012a; Carey & Matyas, 2011). However, despite the
high prevalence and potential impact on daily activities, this
problem is often not addressed in clinical practice settings
(Kalra, 2010). A few reviews have been conducted over the
last two decades to summarize the evidence in relation to
impairment, assessment, and treatment of somatosensory
impairment after stroke (Bohannon, 2003; Borstad &
Nichols-Larsen, 2014; Carey, 1995, 2006, 2012; Connell,
Lincoln, & Radford, 2008; Connell & Tyson, 2012a, 2012b;
Dannenbaum & Jones, 1993; Doyle, Bennett, Fasoli, &
McKenna, 2010; Schabrun & Hillier, 2009; Sullivan &
Hedman, 2008). These provide the foundation literature for
comparison with the current scoping review that spans from
2005 to 2015.
A range of interventions has been described to treat
somatosensory loss after stroke (e.g., Carey, Macdonell, &
Matyas, 2011; Dannenbaum & Jones, 1993; Yekutiel &
Guttman, 1993). However, the impact of these interventions
on performance and participation is unclear. Although
improved somatosensory processing is an important outcome
in its own right, the impact of improvements in sensory capac-
ity needs to also be aligned with performance of everyday
activities that require somatosensory information processing,
as well as with participation in valued activities and life role.
The International Classification of Functioning, Disability
and Health (ICF; World Health Organization, 2001) is a
framework commonly used to classify body function/struc-
ture (impairment), activity, and participation outcomes in
health and disease. Furthermore, the language of rehabilita-
tion science described by Baum (2011) provides a frame-
work to better understand the continuum of, and relationship
between, rehabilitation outcomes. These frameworks may be
used to characterize outcome measures and may help to
inform our understanding of somatosensory processing and
how it supports everyday activities.
Measures at the somatosensory processing (body func-
tion/structure), performance (activities), and participation
levels will be identified, together with relationships investi-
gated. Measures of somatosensory processing/function are
defined consistent with measures classified at the level of
body structure/body function (Baum, 2011; World Health
Organization, 2001). Measures of body structure/function
were categorized on the basis of the main purpose of the
measure, that is, somatosensory processing, motor execu-
tion, or sensorimotor function that involves integrated motor
and somatosensory processing. “Performance” refers to an
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Figure 1.  Conceptual model for linking measures of
somatosensory processing, performance of daily actions/activities,
and participation in valued activities.
individual’s capacity to perform daily actions or activities,
consistent with the “functional limitations” category
described by Baum (2011) and the “activities” category
described by the ICF (World Health Organization, 2001) and
Baum (2011). Here we focus on measures of performance of
daily actions, particularly of the upper limb, and indepen-
dence in common daily activities at the person level. The
“participation” category refers to measures that quantify the
extent to which a person engages in valued life activities,
including household, social, work, and leisure activities,
consistent with ICF (World Health Organization, 2001) and
the language of rehabilitation (Baum, 2011). Participation is
in part dependent on environmental influences (Baum, 2011).
Quality-of-life measures are considered separate to partici-
pation measures and may be linked with a secondary health
condition (Baum, 2011) and thus are not the focus of this
review. The potential relationship between somatosensory
processing, performance, and participation outcomes is
depicted in Figure 1.
The objective of this state-of-the-science scoping review
is twofold: (a) to identify and synthesize the available
research evidence about how adults and older adults process
somatosensory information in daily life and (b) to identify
the interventions available to help regain somatosensory
function following brain injury, in particular following
stroke. We ask two related research questions to address the
breadth and depth of the topic:
Research Question 1: What is the current and contribut-
ing body of knowledge available to inform our under-
standing of somatosensory function and how it supports
performance of daily actions/activities and participation
in valued activities and life roles in adults, older adults,
and stroke survivors?
Carey et al. 29S
Figure 2.  Concept maps depicting key variables searched and the relationship between them.
Research Question 2: What intervention approaches are
available to treat somatosensory impairment after stroke:
Do outcomes affect somatosensory capacity, performance
and/or participation, and do current approaches have an
underlying knowledge base/mechanism of action consis-
tent with evidence from neuroscience and learning?
Current understanding of somatosensory function and its
impact on daily life may be informed by different literatures,
including psychology, neuroscience, and rehabilitation sci-
ence. We will scope these literatures to address the research
questions. For Research Question 1, the current knowledge
base that supports our understanding of the processing of
body sensations, such as touch, limb position sense, and hap-
tic object recognition, will be identified. In particular, we
will identify measures used to investigate the relationship
between somatosensation and (a) performance of component
skills/actions that support use of the upper limbs in daily
activities, (b) independent and successful completion of
daily activities, and (c) participation in valued life activities
and life roles. The current knowledge base will be reviewed
in adults and older adults to determine the nature of the rela-
tionship in healthy individuals as a baseline for comparison
with adult stroke survivors. It will also be reviewed in stroke
survivors with or without somatosensory loss to determine
the impact of somatosensory loss on the relationship. For
Research Question 2, we will identify the evidence for inter-
ventions available to treat impaired body sensations in adult
stroke survivors. The impact of these interventions on out-
comes that span somatosensory processing, performance,
and participation will be reviewed.
Method
We followed five stages in our scoping review. These stages
are consistent with those recommended by Levac, Colquhoun,
and O’Brien (2010).
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Stage 1: Development of Concept Maps That
Link the Purpose With Research Questions
In Stage 1, a conceptual model was developed, with interact-
ing concept maps, to address the research questions. The
concept maps are depicted in Figure 2 and described below:
Concept 1: Somatosensory function and its impact on daily life in
adults, older adults, and stroke survivors with somatosensory
loss.  For Concept 1, we focused on studies which examined
processing of body sensations involving touch, propriocep-
tion, and recognition of objects through the sense of touch. In
particular, we reviewed how these somatosensory functions
support (a) performance of actions of the upper limb and
daily activities, and (b) participation in activities that adults
and stroke survivors need and want to do (how we use our
senses) and life roles they want to play. The target population
had adults, older adults, and stroke survivors with and with-
out somatosensory loss. Health outcomes were focused on
somatosensory function in daily life.
Concept 2: Interventions available to address impaired somato-
sensory function and its impact on daily life.  For Concept 2, we
focused on studies that examined impaired somatosensory
function in adult stroke survivors, and the interventions
available to treat this loss and its impact on daily life. In par-
ticular, the focus was on somatosensory function across the
continuum of sensory processing and its impact on perfor-
mance and participation in daily activities at baseline and in
response to therapy. We also considered the potential for
improvement and rationale for current interventions in the
context of current theories, mechanisms of action, and neural
plasticity. The target population was adults and older adults
who have experienced impairment of body sensations fol-
lowing stroke. Health outcomes span somatosensory pro-
cessing to performance of everyday actions and activities,
and participation in valued activities and playing life roles.
30S OTJR: Occupation, Participation and Health 36(2S) 

Table 1.  Concepts, Topics, and Search Terms.

Concept/component topic Search terms

Concept 1
  Somatosensory processing
  Performance OR daily activities OR
participation
  AND Adults OR older adults OR
stroke
Concept 2
  Output from Concept 1 AND stroke
  Somatosensory interventions
  Capacity to regain lost function
Tactile, touch, proprioception, somatosensory, sens*, feeling, “limb position sense,”
perception, discrimination, haptics, stereognosis, “form perception,” “size perception,”
“touch perception,” “weight perception,” “upper limb function,” “object recognition”
Loss, reduced, altered, impaired, deficit, deficiency
Hand, arm, “upper limb,” “upper extremity”
Capacity, activit*, function, “daily life,” performance, sensorimotor performance, daily
activit*, activities of daily living, participation
Adult, “older adult,” elderly, aging, stroke, “brain injury,” CVA (cerebrovascular
accident), infarct, lesion, neurological, “cerebrovascular disease,” “cerebrovascular
disorder,” infarct*, MCA (“middle cerebral artery”).
As above
Intervention, therapy, treatment, “sensory train*,” “regain sensory function,” “sensory
relearn*,” “sensory retrain*,” rehabilitation, physiotherapy, “occupational therapy,”
“discrimination learning,” “sensory integration,” “physical therapy modalities,”
therapeutics, “sensory rehab*,” “neuro rehab*,” “neurorehab*,” train*, learn*,
somatosensory “sensory education,” “sensory re-education”
“recovery of function,” “brain activity,” “neural plasticity,” neuroplasticity

Stage 2: Scope of Search
We conducted a combined search to address the research
questions, as defined in the concept maps. We first searched
for articles on somatosensory processing or impaired somato-
sensory processing, and separately for articles on perfor-
mance, daily activities, or participation (Table 1). These
searches were then limited to adults, older adults, or stroke
survivors. For Concept 1, we were interested in identifying
articles that did or did not include performance or participa-
tion outcomes in addition to somatosensory processing in
adults, older adults, or adult stroke survivors. For Concept 2,
we used the output from Concept 1, limited it to stroke survi-
vors, and added separate search terms for somatosensory
intervention and capacity to regain lost function. Our review
focus was on somatosensory interventions that reported on
performance or participation outcomes in addition to somato-
sensory processing and whether these interventions provided
theoretical or mechanism of action justification for the
approach taken. The scoping review was conducted to iden-
tify peer reviewed research published from January 2005 to
26 March 2015 and included the following databases: Web of
Science, AMED, CINAHL, Embase, Medline, and PsychInfo.
Search terms for Concepts 1 and 2 are outlined in Table 1.
Search parameters were also set to include only English stud-
ies and exclude non-research articles.
Stage 3: Study Selection
Selection of studies for inclusion in the scoping review
involved a two-step process and an iterative team approach.
A total of 14,147 articles were initially found. After screen-
ing for duplicates, this was narrowed down to 6,525 articles
(see Figure 3). These were then sorted and reviewed relative
to inclusion and exclusion criteria. Two authors indepen-
dently reviewed title and abstracts of remaining studies to
identify potentially relevant studies. A further 4,644 studies
were excluded based on the following criteria: not in English,
non-human participants, children participants, involving
drugs or surgery, impairments caused by a condition other
than stroke (such as multiple sclerosis, Parkinson’s, etc.), not
a sensory topic, involving other sensory modalities (such as
auditory or olfactory), and other (such as unable to access the
full text). A subset, referred to as “subcategories” was identi-
fied as addressing related issues but was not the focus of the
current review, and thus excluded. Subcategory papers
included topics such as pain, lower limb somatosensory loss,
neglect, motor, and visuomotor. They were saved in a sepa-
rate category for future reference or review. The remaining
studies were identified as potentially relevant for Concept 1
(N = 260) or Concept 2 (N = 111). We did not exclude studies
on the basis of research quality.
The next step involved two authors independently review-
ing the full text of the articles categorized for Concepts 1 and
2 to decide whether they met concept specific inclusion/exclu-
sion criteria. For Concept 1, studies were required to meet the
main inclusion criteria listed above. Review of the full texts
identified 103 articles that met these inclusion criteria. For
Concept 2, further details related to inclusion/exclusion are
provided in Table 2. Where there was uncertainty in relation to
meeting inclusion/exclusion criteria, these studies were
reviewed with the senior author and a consensus achieved.
Uncertainty only occurred for Concept 2 and the senior author
reviewed all final articles included for Concept 2.
Of the 111 intervention articles assessed for inclusion for
Concept 2, 97 (87%) articles were excluded for reasons

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Carey et al. 31S
Figure 3.  Flow diagram outlining selection process of articles for
scoping review.
documented in Table 3. Review of these intervention articles
revealed that many studies had aims that broadly encom-
passed upper limb recovery or functioning, and although they
may have mentioned somatosensation, typically the study did
not focus on somatosensation. For studies, where it was deter-
mined that somatosensation was not the primary focus of
treatment, the focus of treatment was classified as relating to
the following: motor/upper limb movement (N = 39; 58%),
upper limb or hand recovery/function (N = 21; 31%), spastic-
ity and/or motor (N = 3), gait/balance/postural control (N =
3), and global stroke recovery focus (N = 1). The most chal-
lenging inclusion criteria related to determining if the popula-
tion investigated had somatosensory impairment. Although
many studies mentioned somatosensation or sensorimotor
recovery, they often did not identify if somatosensory impair-
ment was present or not in the sample. All studies measured
somatosensory functioning at baseline, yet half of the studies
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did not state somatosensory loss as an inclusion criterion for
their investigated sample.
Stage 4: Data Extraction and Analysis
Data were extracted according to predefined data extraction
rules. Two authors independently extracted data. Data
extracted were cross tabulated, reviewed, and a consensus
for inclusion/exclusion reached where possible. In cases
where a consensus was not reached, the senior author
reviewed the study, together with the other authors, to
achieve consensus of final decision. Data extracted included
field of research, journal information, and country of
research for all articles. For Concept 1, all outcome mea-
sures were extracted. For Concept 2, data extracted included
study design, population characteristics, nature of interven-
tion, control intervention, outcome measures, and theory/
mechanisms underlying the intervention. Theory refers to
the knowledge base from which a particular intervention
arises or is justified relative to, for example, learning
theory.
Data categorization and analysis.  Data on source and focus
of contributing literature were tabulated and quantitatively
summarized. We categorized and grouped outcome mea-
sures identified for Concept 1 consistent with categories
described by the ICF (World Health Organization, 2001)
and with the language of rehabilitation science (Baum,
2011). The authors’ description was taken into account
when available. The number of measures used in each arti-
cle was summarized. The frequency of use of different
types of measures and the number of measures within each
category were quantified across studies. The nature and
extent of use of measures across the different categories
was also reviewed and investigation of relationships
between measures identified.
For Concept 2, interventions available to treat somatosen-
sory loss after stroke were categorized and reviewed accord-
ing to (a) type of intervention, (b) outcome measures used,
and (c) the theory and/or mechanisms articulated in support
of the treatment. In relation to measures used, outcomes were
categorized at the body function, performance, and participa-
tion levels (as for Concept 1). Types of interventions and the
knowledge base and/or mechanisms of action provided as
justification for the approach were summarized according to
themes.
Results
We report on the breadth of the literature contributing to the
research question articulated in Concept 1 and provide a
comprehensive summary and thematic review of the research
question for Concept 2. This is consistent with the purpose
and activities outlined for Stage 5 (Levac et al., 2010).
32S OTJR: Occupation, Participation and Health 36(2S) 

Table 2.  Inclusion and Exclusion Criteria for Somatosensory Intervention Studies.

Inclusion Exclusion
Population
•  Adults with diagnosis of stroke • Children
• Upper limb somatosensation needed to be measured at • Pain
baseline, prior to intervention • Neglect
• Majority of sample needed to have reported measured
impairment in upper limb somatosensation following stroke
Intervention
• Had primary focus on treating somatosensory loss after • No reported specific focus on somatosensation
stroke as the direct target of treatment
Outcomes
• Specific somatosensory outcomes. Objective outcomes that •  No somatosensory related outcomes
relate to somatosensory functioning in adults.
Design
• Inclusive of a range of study designs where sample was •  Case study where N = 1
greater than N = 1.

Table 3.  Reasons for Exclusion of Somatosensory Intervention Studies.

Exclusion reason N = 97
Somatosensation was not primary focus of treatment 32
Somatosensation was not primary focus of treatment and no specific somatosensory outcomes 31
Majority of population did not have somatosensory loss after stroke or unclear if majority of population had 7
somatosensory loss. These studies did focus on somatosensation and have somatosensory outcomes
Case study 7
Not stroke population or not all stroke population 6
Somatosensation not primary focus of treatment and majority of population did not have somatosensory loss 4
after stroke or unclear if majority of population had somatosensory loss
Focus on treating neglect after stroke 3
No specific somatosensory outcomes. These studies did focus on somatosensation and have population with 2
somatosensory impairment
Focus on treating pain after stroke 2
Conferences or theses 2
Not intervention study 1

Stage 5: Quantitative Summary and Thematic
Analysis
Concept 1: Somatosensory function, performance, and
participation.  Our quantitative summary and thematic analysis
for Concept 1 included three main outcomes as detailed below.
Knowledge base contributing to the somatosensory func-
tion and its impact on performance and participation in daily
life.  In addressing Research Question 1, our first outcome
was to (a) identify the knowledge base contributing to our
understanding of the concept of somatosensory function, and
(b) how it supports or limits performance of everyday activi-
ties and participation in valued activities in adults, older
adults, and in stroke survivors with somatosensory loss.
The results include articles retrieved for Concept 1, which
includes baseline information from intervention studies
retrieved for Concept 2 (i.e., N = 103 articles in total).
The fields of research contributing to this knowledge
base included neurosciences/neurology, rehabilitation, and
psychology. Studies were published in over 50 different
journals. The top journals included Clinical Rehabilitation,
Neurorehabilitation and Neural Repair, Archives of Physical
Medicine and Rehabilitation, Frontiers in Human Neuroscience,
and Journal of NeuroEngineering and Rehabilitation. Studies
included adults, older adults, and individuals post-stroke with
and without sensory deficits. These populations were reviewed
to identify an evidence base for relationships both in healthy
individuals and following stroke-induced impairment. A word
frequency map based on full text of articles selected for
Concepts 1 and 2 combined summarizes the content and focus
of articles in the field (see Figure 4). Despite our focus being
on somatosensation in daily life, the relative prominence of
words like “somatosensory” and “performance” is low,
whereas “participation” is not present.

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Carey et al. 33S

Figure 4.  Word frequency map depicting content of studies contributing to the knowledge base that informs our understanding of
somatosensory function and its impact on performance and participation (Research Question 1).
Note. Studies include those identified for Concepts 1 and 2.

Measures used in studies of somatosensory function.  To bet-
ter appreciate the relationship between somatosensory func-
tion and its impact on daily life, we identified and categorized
the measures currently being used in studies of somatosen-
sory function in adults. From the 103 articles reviewed for
Concept 1, the outcome measures used were categorized as
follows: somatosensory processing/function (N = 193), motor
function (N = 89), sensorimotor function (N = 38), perfor-
mance of daily actions or activities (N = 69), participation in
daily activities (N = 3), quality of life (N = 5), brain (N = 42),
and other (N = 78). The total number of measures was N =
517 (Figure 5). Ninety-one different measures were used. The
performance category included performance of daily actions
of the upper limb, such as grasp/pinch and performance of
daily activities such as writing or dressing. The participation
category included measures such as the Canadian Occupa-
tional Performance Measure (COPM; Law et al., 2005) and
Reintegration to Normal Living Index (Wood-Dauphinee,
Opzoomer, Williams, Marchand, & Spitzer, 1988). Figure 5
represents the distribution and type of measures used across
the 103 articles identified for Concept 1.
Knowledge of somatosensory processing and its relationship with
performance and participation.  The measures contributing to
our knowledge base of somatosensory function and its impact
on daily life were mapped at the levels of: somatosensory pro-
cessing, performance of daily actions and activities, and par-
ticipation in valued activities and life roles. Figure 6 depicts
the number of measures used across the different categories
contributing knowledge to our understanding of somatosen-
sory function in this context. All studies included one or more
measures of somatosensory processing/function. Forty studies
included somatosensory and performance outcomes, using 18
different performance outcomes. Only three studies included
somatosensory and participation outcomes. No studies included
somatosensory, performance, and participation outcomes.
Most studies identified were designed to investigate
somatosensory processing alone, for example, in relation to
age-related changes, and/or its relationship with motor/sen-
sorimotor functions. This was evident through the inclusion
of measures consistent with the body function/body structure
category of the ICF. Our review did reveal some literature to
inform our understanding of the relationship between
somatosensory function and performance of daily actions
and activities of the upper limb. This included the role of
somatosensation in controlled pinch grip and use of the hand
in daily activities, such as picking up a glass, turning a key,
and writing. For example, Blennerhassett and colleagues

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34S OTJR: Occupation, Participation and Health 36(2S) 
Figure 5.  Frequency of outcome measures according to category.
Figure 6.  Relationship between number of outcome measures
across studies for somatosensory processing, performance, and
participation.
(Blennerhassett, Matyas, & Carey, 2007) investigated the
relationship between touch sensation following stroke and
the pinch-grip-lift-and-hold task, while controlling for motor
function. Others explored the relationship through the impact
of impaired somatosensory function on clinical measures of
hand function (Blennerhassett, Carey, & Matyas, 2008; Ng,
Tsang, Kwong, Tse, & Wong, 2011) or activities of daily liv-
ing (Tyson, Hanley, Chillala, Selley, & Tallis, 2008). Only a
few studies investigated the impact of somatosensory pro-
cessing on participation outcomes (N = 3/103). For example,
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Hill and colleagues (Hill, Fisher, Schmid, Crabtree, & Page,
2014) investigated the relationship between touch of the
affected hand of stroke survivors and the COPM. They found
a good to excellent relationship between performance and
satisfaction of valued activities and intact sensation.
Concept 2: Interventions available to address impaired somato-
sensory function and its impact on daily life.  For Concept 2, we
report on the somatosensory interventions identified, the out-
come measures used, and the theory/mechanisms purported
to underlie the intervention.
Interventions available to treat impaired somatosensory func-
tion after stroke. Fourteen (13%) intervention studies met
inclusion criteria. Review of these studies identified three
main types of intervention approaches: Nine (64%) stud-
ies involved stimulation paradigms; 4 (29%) involved dis-
crimination retraining and one used robotics. The majority
of interventions (72%) targeted one modality of somatosen-
sory functioning, being either tactile or proprioception. More
specifically, the study interventions targeted the following
somatosensory modalities: tactile (N = 6); tactile and pro-
prioception (N = 4); proprioception (N = 1); tactile, proprio-
ception, and temperature (N = 1); tactile, proprioception, and
haptic object recognition (N = 1); and tactile, temperature,
proprioception, and haptic object recognition (N = 1).
Stimulation approaches to somatosensory intervention
involved the application of temporary functional deafferen-
tation via anesthetic cream (N = 2), electrical stimulation
(N = 2), ice stimulation (N = 1), vibrotactile noise (N = 1),
Carey et al. 35S
Semmes–Weinstein monofilaments (N = 1), ischemic nerve
block to contralateral hand (N = 1), and neuromobilizations
(N = 1). In only three studies were the stroke patients required
to attend to and respond to the stimulation. In two thirds (N =
6) of the interventions, stroke patients were not required to
respond.
Discrimination training approaches involved discrimina-
tion of textures, limb position sense, and haptic object recog-
nition of graded discrimination tasks across three separate
training studies (Carey et al., 2011; Carey & Matyas, 2005,
2008), or sensorimotor training that included discrimination
of temperature, weights, textures, shapes, and objects with
vision occluded (Borstad et al., 2013). Core training princi-
ples in these approaches included attentive exploration, feed-
back, and graded progression of discriminations from easy to
difficult. Transfer enhanced training across multiple stimuli
was tested in a randomized controlled trial (N = 50; Carey
et al., 2011). A robotic based sensory retaining program tar-
geted kinesthetic discrimination of the upper limb, with aug-
mented feedback provided via use of a manipulandum (De
Santis et al., 2015).
Various study designs were used including: randomized
control trials (N = 2), control trials (N = 2), before and after
intervention studies (N = 4), single-group repeated measures
designs (N = 2), single-case experimental designs (N = 3),
and case series (N = 1). Five of the 14 intervention studies
were reported as pilot, feasibility, or preliminary studies.
Sample sizes ranged from 2 to 96 stroke survivors, with a
mean of 25 participants. Eight (62%) studies compared the
experimental interventions against a comparison interven-
tion. Of the studies that did have a comparison intervention,
typically the comparison was “traditional rehabilitation”
(N = 3).
Intervention outcomes: Somatosensory processing, perfor-
mance, and participation. A range of measures was used at
baseline to assess somatosensation, as outlined in Table 4.
The number of different measures of sensation used ranged
from 1 to 6. Six (43%) studies used one measure of somato-
sensation at baseline, 3 (22%) used two measures, 2 (14%)
studies used three measures, 1 (7%) used four measures, and
2 (14%) used six measures. In total, 19 different measures
were used to assess somatosensory outcomes. The most
common measures of baseline sensation were: Wrist Position
Sense Test (Carey, Oke, & Matyas, 1996), Semmes–Wein-
stein Monofilaments (Bell-Krotoski, Fess, Figarola, & Hiltz,
1995), Grating Orientation Test (Van Boven & Johnson,
1994), Two-Point Discrimination Test (Mackinnon & Del-
lon, 1985), Hot/Cold Discrimination Test, Tactile Discrimi-
nation Test (Carey, Oke, & Matyas, 1997), Fabric Matching
Test (Carey, 1995), and Weinstein Enhanced Sensory Test
(Weinstein, 1996).
In half of the studies, clear improvements in stroke survi-
vors’ somatosensory capacity following treatment were
reported. In the majority of studies, this was identified as the
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primary outcome. These studies involved the following treat-
ment focus: stimulation (N = 3; Sens et al., 2012; Voller
et al., 2006; Wolny, Saulicz, Gnat, & Kokosz, 2010), dis-
crimination retraining (N = 3; Carey et al., 2011; Carey &
Matyas, 2005, 2008), and robotics (N = 1; De Santis et al.,
2015). Somatosensory modalities targeted during treatment
in these studies with improvements were tactile and proprio-
ception (N = 3); tactile (N = 2); proprioception (N = 1); and
combination of tactile, proprioception, and haptic object rec-
ognition (N = 1). In four other studies (29%), improvements
in somatosensation were reported, but for limited sample or
outcomes (Borstad et al., 2013; Enders, Hur, Johnson, & Seo,
2013; Sens et al., 2012; Valentini, Kischka, & Halligan,
2008). Two studies found no significant improvement in
somatosensation for stroke survivors who participated in
stimulation treatments (Bohls & McIntyre, 2005; Yozbatiran,
Donmez, Kayak, & Bozan, 2006).
The majority of studies (71%) did not have performance-
related outcome measures. Studies that did have performance
measures (Borstad et al., 2013; Carey et al., 2011; Smith,
Dinse, Kalisch, Johnson, & Walker-Batson, 2009; Yozbatiran
et al., 2006) included Wolf Motor Function Test, Motor
Activity Log, Sequential Occupational Dexterity Assessment,
and Hand Function Test. In relation to performance mea-
sures, these measures were used to investigate upper extrem-
ity motor function, subjective upper extremity function, hand
function, grasp, and manipulation. Two out of four studies
demonstrated clear improvements in grasp, manipulation,
and upper extremity functional use. One study found a trend
in performance outcomes and one did not include results of
performance measures. No somatosensory intervention study
included participation-based outcome measures.
Nearly half of the studies (43%) included the assessment
of other component behaviors following treatment. These
primarily related to sensorimotor and/or motor functioning.
Sensorimotor function was assessed using the Nine Hole Peg
Test, force feedback task, shape-sorter-drum task, and peg-
board activities. Outcome measures of motor functioning
included, Box and Blocks Test, motor performance using
robotics, motor tapping task, and hand movement test. For
three studies that assessed sensorimotor outcomes following
treatment, the results were ambiguous: One study demon-
strated a trend in improvement of sensorimotor capacity
(Smith et al., 2009) and two were assessed as mixed in their
findings (Borstad et al., 2013; De Santis et al., 2015). Two
out of six studies that assessed motor outcomes showed
improvements in motor behavior following stimulation inter-
vention (Sens et al., 2013; Sens et al., 2012). One study dis-
played a trend to improvement in motor capacity (Smith
et al., 2009), two were unclear in their results (Borstad et al.,
2013; De Santis et al., 2015), and one study found no signifi-
cant difference in motor outcomes (Yozbatiran et al., 2006).
Two studies had brain-related outcome measures involv-
ing functional magnetic resonance imaging and somatosen-
sory evoked potentials (Borstad et al., 2013; Sens et al.,
36S OTJR: Occupation, Participation and Health 36(2S) 

Table 4.  Somatosensory Measures Used in Somatosensory Intervention Studies at Baseline and Post-Intervention.

Somatosensory modality
Proprioception
Touch (threshold)
Touch (tactile resolution)
Touch (discrimination)
Temperature
Touch (discrimination)
Touch (discrimination)
Touch (threshold)
Touch (threshold)
Somatosensory (screening)
Texture and weight discrimination
Haptic object recognition
Touch (discrimination)
Haptic object recognition
Proprioception
Somatosensory (self-report)
Somatosensory (screening)
Haptic object recognition
Proprioception
Light touch and temperature
discrimination
Proprioception
Haptic object recognition
Baseline Post-intervention
Somatosensory measure N = 37 N = 36
Wrist Position Sense Test 5 4
Semmes–Weinstein Monofilaments 4 4
Grating Orientation Test 3 4
Two-Point Discrimination Test 3 2
Hot/cold Discrimination 3 3
Tactile Discrimination Test 3 3
Fabric Matching Test 3 3
Weinstein Enhanced Sensory Test 2 2
Von Frey Monofilaments 1 1
Fugl–Meyer upper extremity sensory subscales 1 0
Hand Active Sensation Test 1 1
Haptic Object Recognition Test 1 1
Grid Matching Test 1 2
Functional Tactile Object Recognition Test 1 1
Nottingham Assessment Scale: kinesthetic sensation 1 0
Self-report of somatosensory loss 1 0
National Institute of Health Stroke Scale–“Sensory” 1 0
item
Stereognosis: identify 10 common objects 1 1
Proprioception: position and kinaesthesia sense of the 1 1
thumb flexion, extension, opposition, 2nd, 3rd, 4th and
5th digit flexion, as impaired, normal or absent
Rivermead Assessment of Somatosensory Performance 0 1
Subtests 2 and 6
Measure of proprioception using robotics involving two- 0 1
alternative forced choice discrimination test
Haptic object recognition with 3 Lego objects 0 1

2012). The two studies demonstrated improvements using
these outcomes (Borstad et al., 2013; Sens et al., 2012). In
summary, outcomes used in the intervention studies included
37 measures of somatosensory processing, four measures of
motor function, five sensorimotor measures, and six perfor-
mance measures, but no participation or quality-of-life
measures.
Foundations for somatosensory interventions. Nearly all
intervention studies (N = 13) described a theoretical basis or
mechanism of action underlying the somatosensory interven-
tion. The dominant theoretical basis identified across all inter-
vention types was neuroplasticity or cortical reorganization
(N = 12). Interhemispheric cortical connections or interac-
tions (N = 5) were described as being important mechanisms
underlying stimulation somatosensory interventions. Stimu-
lation interventions were also linked with mechanisms such
as bombardment (N = 1), action potentials (N = 1), enhanced
signal detection (N = 1), and interneuron connections (N =
1). The discrimination training interventions used learning
theories, such as perceptual learning (N = 4), in addition
to theories of neural plasticity. Somatosensory discrimina-
tion training programs also highlighted the importance of
neurophysiology (N = 4) to guide treatment principles. The
robot-mediated training mechanisms included neuroplasticity
and skill learning with augmented feedback. Of the four dis-
crimination training and one robotic training studies that were
founded on principles of neural plasticity and learning, all of
the five studies reported positive training outcomes (Borstad
et al., 2013; Carey et al., 2011; Carey & Matyas, 2005, 2008;
De Santis et al., 2015). In comparison, only three of the nine
studies that used stimulation approaches reported positive
training effect (Sens et al., 2013; Voller et al., 2006; Wolny
et al., 2010).
Discussion
The purpose of this scoping review was to identify and synthe-
size the current research evidence supporting the processing of
somatosensory information in daily activities, and the inter-
ventions available to address impairment in somatosensory
processing following stroke. Our review for Concept 1 indi-
cated that most studies measured the processing of somatosen-
sory information alone in adults. A few studies that included
performance measures investigated the relationship between
somatosensory processing and performance, focusing on

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Carey et al. 37S
pinch grip and/or hand function in healthy individuals or fol-
lowing stroke-related somatosensory loss. However, despite
our extensive search, we found very few studies that investi-
gated the relationship with participation in daily activities.
Thus, though observation and comments from people with
impaired somatosensation suggest the importance of sensation
in daily activities, our review indicated that there is currently
limited empirical evidence to quantify the presence and/or
nature of a relationship and the implications for participation
in daily activities.
Review of available somatosensory interventions for
Concept 2 revealed three main approaches: stimulation, dis-
crimination training, and use of robotics. Again outcomes
focused on improvement in somatosensory processing
capacity. Very few studies investigated outcomes in perfor-
mance of upper limb actions or daily activities, and/or par-
ticipation in valued activities following somatosensory
training in stroke survivors. Rather the focus was on compo-
nent body function behaviors of somatosensory processing
and/or motor and sensorimotor functions. The rationale for
different intervention approaches was linked with concepts
such as neuroplasticity and learning.
Concept 1: Somatosensory function and its impact on
daily life in adults, older adults, and stroke survivors with
somatosensory loss.
A strength of the current state-of-the-science scoping
review was the identification of the different research fields
potentially available to contribute to our understanding of
how somatosensory function supports daily life in adult-
hood and older adulthood. Our findings highlight input from
the fields of neurosciences and rehabilitation. However, the
number of studies that investigated relationships between
somatosensation and daily life was limited. The review tar-
geted adults and older adults when somatosensory function
is well established or may show some deterioration with
age. This population provides a point of comparison with
stroke survivors who span these ages and commonly experi-
ence somatosensory impairment. Although the populations
are heterogeneous, together they permit insights into the
impact of somatosensation on daily activities through com-
parisons with age-related deterioration and impairment fol-
lowing stroke.
Our main finding was a gap in the literature relating
impairment in somatosensory processing to participation
outcomes. The identified gap in the knowledge base linking
somatosensation and participation is not surprising given
potential complexity of a relationship and the multiple fac-
tors that affect participation. Participation is a multidimen-
sional construct and measures used, such as the Activity
Card Sort and COPM, are known to capture much more than
measures of body function impairment (Tse, Douglas,
Lentin, & Carey, 2013). Yet, if outcomes at the level of per-
formance and participation are considered important, we
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either need to assess outcomes at all of these levels sepa-
rately for each individual or learn from the variation across
individuals the presence and nature of the relationship
between these variables.
The relationship between somatosensory function and
daily life is potentially complex and multidimensional.
Measures across the ICF and rehabilitation continuum may
help to better understand this relationship relative to the pur-
pose and impact of somatosensory function. For example, the
purpose of somatosensory processing has been identified for
perception and for action (Dijkerman & de Haan, 2007), con-
sistent with measures at the body function and performance
level. Furthermore, goal-directed action of the upper limb is
based on models that link the goal, somatosensation, and
movement (Frey et al., 2011). The current scoping review
adds to the existing body of knowledge (e.g., Flanagan,
Bowman, & Johansson, 2006) supporting the important role
of somatosensory processing in sensorimotor function and
action of the upper limb. In particular, it has identified studies
that investigate the relationship between performance out-
comes in the upper limb and daily activities.
Participation in valued activities is multidimensional,
shaped by the individual’s goals and motivations as well as
personal, environmental, and social factors. Although multi-
dimensional, our review indicates that there may be a rela-
tionship between somatosensation and performance and
satisfaction with valued activities, as measured using the
COPM (Hill et al., 2014). To fully appreciate somatosensory
function in the context of daily life, it is important that we
understand how it is used, the goals that drive it, and the
environment that shapes it. We need to be able to identify the
thread that links sensory function with performance and par-
ticipation. We also need to better understand the interaction
with other person factors such as attention, and environmen-
tal factors affecting. This will require a multi-discipline
approach.
Scoping reviews are designed to identify and synthesize
the available literature, and through review of this literature
help build a conceptual model to provide direction for future
research in the field. Figure 1 depicts a chaining between
somatosensory processing, performance, and participation,
while acknowledging the other factors at each of these lev-
els. This model and frameworks such as the ICF (World
Health Organization, 2001) and the language of rehabilita-
tion science (Baum, 2011) may help to better understand
how sensory function supports performance and participa-
tion outcomes in people’s lives. Using a multidimensional
perspective, researchers and clinicians are in a key position
to impact the field.
Concept 2: Interventions available to address impaired
somatosensory function and its impact on daily life.
A major gap in the literature was identified regarding out-
comes of somatosensory retraining that extend beyond the
38S OTJR: Occupation, Participation and Health 36(2S) 
level of sensory information processing. Although the cur-
rent scoping review limited the search to the past decade,
reviews of prior research in the field (Bohannon, 2003;
Carey, 1995, 2006; Connell & Tyson, 2012b; Sullivan &
Hedman, 2008) support our current finding. Thus, our under-
standing of how therapy may improve somatosensory func-
tion in daily lives across the continuum of information
processing to performance and participation is currently
limited.
Use of somatosensory capacity outcomes is appropriate
and likely to be the most sensitive outcome to detect improve-
ment when training somatosensory function (Carey, 2012a).
However, whether improvements translate to improved par-
ticipation in activities and life roles valued by the individual
is important in the context of client-centered rehabilitation
(Baum, 2011). It is recommended that stroke survivors are
also able to apply improvements in sensory capacity in the
performance of daily actions, and improve the frequency and
satisfaction of participation in valued activities requiring
somatosensory processing. Valid and reliable measures, such
as the COPM (Law et al., 2005) and Activity Card Sort
(Baum & Edwards, 2008), are available to measure these
outcomes. For example, in our current intervention studies,
participants rate their performance and satisfaction in five
valued tasks that they perceive are affected by their somato-
sensory impairment using the COPM (Carey, 2012b). They
are trained on two activities and outcomes are measured
across all five.
Most intervention studies identified in our scoping review
described the somatosensory stimuli used and how they were
applied or presented to the patient (e.g., stimulation or as a
discrimination task). In addition, the rationale for interven-
tions was often suggested by association or broad reference
to bodies of knowledge that support rehabilitation, cortical
reorganization, or neural plasticity in general. However,
many did not clearly articulate how the process of training
may help the person to make sense of the stimuli or regain a
sense of touch in the context of current knowledge (e.g., in
relation to neural plasticity) and/or in the context of learning
opportunities afforded.
Only a few provided explicit operationalization of inter-
vention strategies used relative to robust evidence from bod-
ies of knowledge such as neural plasticity and perceptual
learning. For example, Carey et al. (2011) described core
training principles of attentive exploration with vision
occluded; feedback on sensation, accuracy of discrimination,
and method of exploration; calibration of the altered sensa-
tion through the other hand and via vision; anticipation trials;
graded progression of discrimination difficulty; and inten-
sive training. In addition, to achieve transfer of training
effects, variation in stimuli, intermittent feedback, and tuition
of training principles are described. Each of these principles
is directly linked with robust evidence from neuroscience
and/or learning theories and operationalized in training
(Carey, 2012a; Carey & Matyas, 2005). Positive
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training outcomes were found for all discrimination and
robotic training studies based on principles of neural plastic-
ity and learning, highlighting the potential benefit of these
skill-based learning approaches.
Recommendations for Clinical Practice and
Research
Clinical practice. This state-of-the-science scoping review
highlights a gap in the current literature available to support
our understanding of the importance of body sensations and
their impact on daily life. As yet, it is not fully understood
how somatosensory function maps onto daily life, for adults
or older adults. Moreover, it is difficult to appreciate the
impact of loss of body sensations in people following brain
injury, such as stroke. Until this relationship is better under-
stood, it is recommended that clinicians include measures of
somatosensation, performance, and participation in their
clinical practice so that outcomes at each of these levels can
at least be appreciated separately. This approach will allow
clinicians to better appreciate the impact of somatosensory
function on daily life in individual clients.
In relation to somatosensory interventions, we identified
current interventions available as well as gaps in the litera-
ture. A number of approaches to intervention were identified
with positive outcomes in somatosensory capacity.
Furthermore, we found that somatosensory interventions that
involve discriminative training were consistently successful
in improving somatosensory discrimination capacity and
have potential to affect performance in daily activities. It is
recommended that discrimination training interventions,
such as these that show positive outcomes and are aligned
with principles of neuroplasticity and learning theory, be
considered for use in clinical practice. Findings from our
review also highlighted major gaps in the intervention litera-
ture in relation to the impact of somatosensory interventions
on performance and participation. It is therefore recom-
mended that therapists carefully consider the outcomes of
therapy targeted and the type of intervention most suited to
their client.
Research.  A gap exists in our current understanding of how
somatosensory function supports daily life in adults. System-
atic investigation of the relationship between somatosensory
function, performance and participation is required in older
healthy individuals as well as in people who experience loss
of body sensations. It is recommended that researchers use
outcome measures across more than one level of the contin-
uum described in the language of rehabilitation (Baum,
2011). In particular, it is recommended that researchers use
measures that span somatosensory processing, to perfor-
mance of daily activities, and participation in valued activi-
ties. Figure 1 depicts how researchers and clinicians could
conceptualize the chaining of somatosensory function to per-
formance and participation in valued activities, both in
Carey et al. 39S
relation to the relationship between measurement outcomes
and in relation to outcomes targeted in therapy. Investigation
of the relationship between these outcomes will be critical to
advance our knowledge in the field.
Environment and human capacity, or functional limita-
tion, combine to support participation (Baum, 2011). If we
are to advance our understanding of this potential relation-
ship, we need to use measures of participation that can be
linked with impairments (Baum, 2011; Gray, Hollingsworth,
Stark, & Morgan, 2006) and/or test conceptual models relat-
ing these outcomes using statistical methods such as struc-
tural equation modeling (Hollingsworth & Gray, 2010). For
example, engagement in daily activities linked with capacity/
impairment can be measured using constructs like time, fre-
quency, effort, support, satisfaction, meaning, control,
importance, and expectations (Baum, 2011; Gray et al.,
2006). Participation linked with somatosensation may be
measured, for example, with objective tools that measure fre-
quency of use of the limb, subjective self-report of impor-
tance of specific tasks involving somatosensory processing,
and indirectly through reported levels of difficulty, assistance
required, or barriers experienced (Baum, 2011).
It is also recommended that researchers clearly articulate
how the strategies or principles of training used in their inter-
ventions are operationalized relative to the theoretical con-
structs and/or underlying mechanisms that they purport to
support them. This will support systematic development of
science-based interventions, consistent with recommenda-
tions for the development of complex interventions (Medical
Research Council, 2008). If somatosensory rehabilitation is
to affect daily life, it is also important that studies systemati-
cally investigate the interaction between the intervention
approach and transfer of training effects to performance and
participation outcomes. This will provide new insights in
relation to how somatosensory function supports perfor-
mance and participation as well as how the therapeutic
approach may contribute to improved capacity/skill and how
this is used by the individuals in their daily activities. A fur-
ther area of research worthy of attention is how current inter-
vention strategies are situated in the context of the learning
opportunities they afford and their impact on neural plastic
changes in the brain. This will help provide new insights into
the mechanisms underlying therapy-facilitated recovery and
contribute to building science-driven models of rehabilita-
tion, such as a learning-based model of rehabilitation (Carey,
Polatajko, & Baum, 2012).
Summary and Conclusion
In conclusion, this scoping review revealed a knowledge gap
in the literature available to inform our understanding of
somatosensory function in relation to its impact on perfor-
mance of daily activities and in relation to participation in
valued activities and life roles in adults, older adults, and in
people who experience loss of body sensation following
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stroke. This was evident not only in relation to current under-
standing of how somatosensation supports or limits partici-
pation in daily activities (Research Question 1), but also in
the context of somatosensory interventions available and the
outcomes targeted (Research Question 2). The results high-
light the need to look beyond somatosensation as a body
function only, to how it is used in daily activities and life
roles in adults and older adults with and without somatosen-
sory loss. It is also recommended that we better target and
critically evaluate the impact of somatosensory interventions
on processing, performance, and participation outcomes fol-
lowing stroke.
A conceptual framework in which research priorities can
be focused and contribute meaningfully to the wider
research field has been suggested. To advance the field we
will need to integrate knowledge from a range of research
fields and disciplines, including rehabilitation therapists,
cognitive neuroscientists and physiologists. It is only
through the bringing together of scientists and bodies of
knowledge from several related fields that we may be able
to address the core research question that has driven this
state-of-the-science review: how does somatosensory pro-
cessing relate to daily activities in adults, older adults, and
stroke survivors.
Acknowledgments
We would like to thank the American Occupational Therapy
Foundation for the invitation to prepare this state-of-the-science
scoping review. The review was presented at the inaugural State-of-
the-Science symposia at the American Occupational Therapy
Association 2015 Annual Conference, in celebration of the 50th
Anniversary of the Foundation. We would particularly like to thank
Dr. Scott Frey for his role as respondent and Drs. Frey and Baranek
for their contributions as discussion moderators.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: The authors have no relevant affiliations or financial
involvement with any organization or entity with a financial interest
in or financial conflict with the subject matter or materials dis-
cussed in the manuscript apart from those disclosed. No writing
assistance was utilized in the production of this manuscript.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
authors would like to acknowledge the financial support provided
from the National Health and Medical Research Council of
Australia (Grants 307905, 1022694, 1077898 to L.M.C.), an
Australian Research Council Future Fellowship (#FT0992299 to
L.M.C), a James S. McDonnell Foundation 21st Century Science
Initiative in Cognitive Rehabilitation–Collaborative Award (Grant
220020413 to L.M.C.), a La Trobe University Post-Graduate
Research Award (to M.T.), and the Victorian Government’s
Operational Infrastructure Support Program.
40S OTJR: Occupation, Participation and Health 36(2S) 
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