Graphesthesia Somatosensory

 Graphesthesia is the ability of the patient to identify characters that are written on
the kin using a dull pointed object (or your finger, perhaps). Examination
 What to do? The examiner demonstrates the test by writing single numbers on the Definition of terms
ALGESIA: PAIN
palm of the hand while the patient is watching. The patient then closes their eyes
Analgesia- total loss of sensation
and identifies numbers that are written by the examiner. Hypalgesia- partial loss of sensation
 You say: “Mr/Ms… I’m going to write some numbers on your palm and ask you to Hyperalgesia- increased sensitivity to pain
Allodynia- abnormal perception of pain from a nonpainful stimulus, with delayed perception and after
identify them just like this.. please close your eyes.” sensation
 To the examiner: “The patient exhibits graphesthesia.” Neuralgia- multiple, very severe, electric shock-like pains that radiate into a specific root or nerve
distribution
Pain of Nociceptive- divided into somatic and visceral and arises from some local lesion, such as an
Stereognosis invasive carcinoma or trauma that stimulates local pain ending
Pain of Neurogenic- arises from some form of heightened sensitivity poor overactivity from a lesion that
affects the PNS or CNS, apart from stimulation of local pain endings.
Referred Pain- site at which the Pt feels the pain may not correspond to the site of lesion
 Stereognosis is the ability to identify objects that are placed in the hand when the Trigeminal Neuralgia- characterized by repetitive excruciating schocks of pains in one/more branches of
eyes are closed. Use small objects like a coin, keys, etc CN V.
Causalgia/ Reflex Sympathetic Dystrophy- unbearable, burning, relentless hyperesthesia and
 What to do? The patient is given common objects and asked to identify them with hyperalgesia that ensue after injury to a peripheral nerve
pt’s eyes closed Test each hand separately. ESTHESIA: TOUCH or FEELING
 You are testing here the Parietal lobe. Hypesthesia- partial loss of temperature
Anesthesia- total loss of pain/ lack of pain
 If the pt has lost the sense of form because of a lesion in the pathway- periphery, Pallanesthesia- loss of vibration sense
spinal cord, brainstem, or thalamus, it is called stereoanesthesia. If it refers to the Hyperesthesia- increased sensitivity to touch
Hyperpathia- extreme overresponse to pain
lost of sense of form because of a lesion of the association cortex, it is Anesthesia dolorosa- raised pain threshold
asterognosis. Hyperthermesthesia- increased sensitivity to temperature
Paresthesia- sensations when they accompany a normal external stimulus to the skin
 You say: “Mr/Ms… I’m going to ask you to feel some objects I will place on your Dysesthesia- spontaneous occurrence without any external stimulus
hand and ask you to identify them, please close your eyes.” Uncomfortable sensations of numbness, tingling, pins & needles, or burning pain of neuralgia/
causalgia
 To the examiner: “The patient exhibits stereognosis.
GRAPHO: WRITING
Agraphagnosia- loss of graphic sense
NOSO: DISEASE
Autopagnosia- ability to discern or identify body Anosognosia- loss of disease awareness
Nosognosia- sense of awareness disease
parts Nosology- science of disease classification
THERM: HEAT
Thermhypesthesia- partial loss of temperature sensation
 Ask the patient what is the name of particular body part. Sa upper extremities test Thermanesthesia- total loss of temperature sensation
each fingers and let the patient close their eyes. TOPO: PLACE
Topognosia- sense of localization of skin stimulus
PROPRIOCEPTION- sense of movement, of position, and of skeletomuscular tension provided by deep
mechanical receptors in muscles, joint, connective tissues, & vestibular system.
 Directional Scratch Test Testing for Proprioception
Materials: Tongue Depressor broken longitudinally / butt of tuning fork/ finger tip  With one hand, support the pt’s hand or foot and ask the pt to remain completely
 Make a 2 cm long stroke between the two lines (distal shin and dorsum of the hand), relaxed.
randomly alternating between a proximal (up) and distal down (direction)  With the other hand, grasp the digit by its side and wiggle it up and down, stopping
 Ask the patient to state whether the object moved up or down. randomly in one direction or the other. Separate the digit being test so that you do
 Start with practice trials with pt’s eyes open to establish communication. Then with not touch other digits.
eyes closed, 10 trials in random up and down directions.  Orient/ Ask the pt to report whether the finger is up or down.
 If pt errs, increase the distance to 5 cm then to 10 cm to get a quantitative estimate  Then for actual testing: Have the pt’s eyes closed and not to move the digits at all.
of the deficit. Tell the pt “Ma’am ako lang po ang gagawa ng movement”
This test is superior to the standard tests of position and vibration. It correlates well  Make sure to apply the same pressure all throughout the test.
with abnormal evoked responses.
 Use the fourth digit in testing position sense (lesser space covered in the human
Reporting: Patient was able to determine the direction of the stimuli accordingly.
homunculus.
 First, Second, Fifth digits of the hands and feet have the richest innervation and
Two-point Discrimination Test largest cortical representation
Reporting: Pt was able to correctly identify the motion and direction of the specific
extremity tested.
Materials: Calipers/ Ruler/ Paper Clip
 Start with the device wider than the expected distance to establish communication Testing of Position Sence by Romberg
and gain pt’s cooperation.
 Randomly alternate touching one or two points of the calipers. Test
 Have the pt identify if they feel one or two points. “Ma;am/ Sir, sabihin niyo po sakin
ilan po yung nararamdaman niyo”  Ask the pt to stand with feet together. Note whether the Pt sways.
 Move the two points closer together across consecutive trials until the pt cannot  Then ask the Pt to close eyes, note whether swaying increases.
distinguish the 2 points as separate  Stand behind the pt with arms held up ready to catch the pt, but do not touch pt.
 Touch the client on fingertips, forearm, and dorsal hands Reporting: Pt’s position sense is intact.
 Pt should discriminate two points at a distance 2 to 4 mm on the finger tips, 4 to 6 Pts w/ acute unilateral vestibular disease tend to sway to the side of the lesion, but the
mm on the dorsum of the fingers, 8 to 12 mm on the palm, and 20 to 30 mm on the nervous system compensates in chronic vestibulocerebellar disease, uni- or bilateral.
dorsum of the hand Pts w/ dorsal column lesions or severe sensory polyneuropathies, sway much most with
eyes closed and fall unless supported.
Children >7 years can respond reliably. It decreases somewhat with aging
Pts w/ hysteria cause the most difficulty in interpreting swaying tests.
Peripheral nerve, central pathway, parietal lobe lesions impair two-point Sensory dystaxia would distinctly worsen w/ Pt’s eyes closed because visual guidance
discrimination substitutes for proprioceptive guidance, eye closure increases sensory dystaxia much more
than cerebellar dystaxia.
Clinical Finding Sensory dystaxia Cerebellar dystaxia
Loss of vibration and position sense +
Areflexia +
Nystagmus +
Hypotonia +
Dystaxia much worse with eyes closed +
Overshooting on release +
 Testing for Pain Sensation
Materials: pin/ broken tongue depressor/ neurohammer
 Open tongue depressor in front of the patient, then break it into half.
 Show the pt a straight pin/ broken tongue depressor with its sharp and dull ends.
Orient the patients by having it done first in the dorsum of the hand with eyes open.
“Ma’am/ Sir eto po yung blunt, eto po yung sharp.”
 Have the pt shut his eyes to prevent visual cues.
 Alternate touching the patient with two ends of the pin randomly to monitor Pt’s
attentiveness and reliability.
 Make sure that you apply both stimulus with the same pressure. Make about 3
successive pricks for each stimulus.
 Start with the normal area to establish communication, so that patient know what to
expect.
 Test the face and dorsum of the hands and feet. (Avoid horny skin of the palms and
soles)
 If needed, quantify the sensation “Maam kung 100% po sa right, ilan percent po sa
left?”
Reporting: Patient was able to identify and localize pain sensation accordingly.
Testing for Delayed Pain & Deep Pain
Sensation
Do not use these tests on the face!
Testing for delayed pain: Pinch the dorsum of the Pt’s foot briskly between the
fingernails of your thumb and index finger. Look for a delayed response
Testing for deep pain: Test by squeezing very hard on Achilles tendon (Abadie’s sign
when the pt feels no pain) or a muscle or by compressing very hard over a bony
surface.
Reporting: Patient was able to identify and localize pain sensation accordingly.
Testing for Vibration Sense
Dorsal Column Tract Function
Material: Tuning fork (128 Hz)
 Pallanesthesia : loss of vibration sense
 Start with Pt’s eyes open and show the pt what you will do, but do the test with Pt’s
eyes closed.
 Hold a tuning fork by the round shaft and strike the tines a crisp blow against the
ulnar side of your palm to set the pork vibrating.
 Apply the free end of the shaft to the Pt’s fingernails and toenails or just proximal to
the nail bed.
 Inquire: “Ma’am nafefeel niyo po ba yung buzz?
 If patient fails to feel vibration at the nails for as long as you can, apply the fork to
proximal bony prominences: ulnar styloid process or distal radius and internal
malleolus or shin.
 Sometimes apply the tuning fork when it is not vibrating to test Pt’s attentiveness
and reliability
Aging increases the threshold to vibration and reduces the sensitivity. Normally, the
hands feel vibration better than the feet at all ages.
Interruption of the Dorsal Column Pathway from the Peripheral receptors up
through the thalamus reduces vibratory perception.
Reidel-Seiffer tuning fork is the most practical for routine use
Reporting: Patient was able to detect the initial vibration and accurately determine
when it has stopped.
 Testing for Light Touch Testing for Temperature
Sensation Lateral Spinothalamic Tract Function
Materials: Tuning Fork and Hand
Posterior Colum and Spinothalamic Tract Function  Instruct the pt, “Ma’am/ Sir ipikit niyo po ang inyong mata at may ipaparamdam po
Materials: Cotton or Tip of tissue ako sa inyo, sabihin nyo po sa’kin kung warm or cold”
 Start with warm first to avoid inducing numbness.
 Instruct the pt, “Ma’am/Sir ipikit niyo po ang inyong mata. May bagay na  Using tuning fork or finger test: Apply metal shaft of a tuning fork to the side of the
ipaparamdam po ako sa mukha niyo, sabihin niyo po kung may nararamdaman po Pt’s check for a few seconds and then remove it then apply side of your little finger
kayo.” TEST BOTH SIDES then ask, “Pantay po ba?” to the same spot
 Sequence: Face, Dorsum of the hand, if not able to identify proceed to forehand  Alternate tuning fork or finger test as you proceed over 3 trigeminal sensory areas
w/in dermatome. For Lower Ex, start with the feet same sequence as Upper Ex. and dorsum of both hands and feet
 Start with the normal side  To sharpen ambiguous results, say “Saan po yung mas malamig- number 1:
Left Right tuning fork or number 2- finger?
Ophthalmic branch (V1)  If the Pt discriminates temperature normally & history does not suggest neurologic
Maxillary branch (V2) disease, you do not need to prick PT with a pin.
Mandibular branch (V3) Left Right
Forearms (C6, T1) Ophthalmic branch (V1)
Thumb and Little Finger Maxillary branch (V2)
(C6, T8) Mandibular branch (V3)
Calves (L4, L5) Forearms (C6, T1)
Little toes (S1) Thumb and Little Finger
(C6, T8)
Reporting: Patient was able to feel and have equal sensation on (bilateral or unilateral) Calves (L4, L5)
part of ____. Hence light touch is normal. If abnormal or walang nafeel- “Light touch is Little toes (S1)
deficit” then sabihin mo kung saan part.
Reporting: Patient was able discriminate correctly between warm and cold upon
presenting stimuli.