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In all higher order motor behaviors,

the brain must correlate sensory
inputs with motor outputs to
accurately assess and control the
bodys interaction with the
environment.
A. Jean Ayers, PhD

SENSORY INTEGRATION

is the ability of the brain to organize,

interpret, and use sensory
information.
Provides an internal representation of
the environment
Provide the foundation on which motor
programs for purposeful movements are
planned, coordinated, and
implemented.

SENSORY INTEGRATION

the neurological process that

organizes sensation from ones own
body and from the environment and
makes it possible to use the body
effectively within the environment.
developed by A. Jean Ayers (19201989)

SENSORY INTEGRITY
SOMATOSENSATION (SOMATOSENSORY)
refers to sensation received from the skin
and musculoskeletal system
SENSORY EXAMINATION OF SENSORY
INTEGRITY
By determining the patients ability to
interpret and discriminate among
incoming sensory information.

SENSORY INTEGRITY

The Guide to Physical Therapist

Practice definition:
the intactness of cortical sensory
processing, including proprioception,
pallesthesia, stereognosis, and
topognosis.

SENSATION AND MOVEMENT

Feedback control uses sensory
information received during the
movement to monitor and adjust
output.
Feedforward control is a proactive
strategy that uses sensory information
obtained from experience.

SENSATION AND MOVEMENT

The primary role of sensation in movement is to:
(1) guide selection of motor responses for
effective interaction with the environment
(2) adapt movements and shape motor
programs through feedback for corrective
action.
Sensation also provides the important function of
protecting the organism from injury.

SENSORY DYSFUNCTION
Nerve damage
Metabolic disturbances (diabetes,
hypothyroidism, alcoholism);
Infections (Lyme disease, leprosy, human
immunodeficiency virus [HIV]);
Impingement or compression (arthritis, CTS);
Burns;
Toxins (lead, mercury, chemotherapy);
Nutritional deficits (vitamin B12).
SCI, CVA, TIA, tumors, multiple sclerosis (MS),
TBI

AGE-RELATED SENSORY CHANGES

Neurons are replaced at a declining rate

Degeneration of neurons
Decrease in the number of enzymes
Depletion of the neuronal dendrites
Gradual reduction in conduction velocity of
sensory nerves
Reduction of Meissner's and Pacinian
corpuscles
Decrease in the distance between the
nodes of ranvier

F M
O E
N ST
O Y
I
T S
A
Y
C
R
I
F SO
I
S
S EN
A S
L
C HE
T

SENSORY RECEPTORS

AKA sensory nerve endings

At the distal end of an afferent nerve fiber
Once stimulated specific sensation
RECEPTOR SPECIFICITY
highly sensitive to the type of stimulus for
which they were designed.

This specificity of nerve fiber sensitivity to a

single
modality of sensation is called the labeled line
principle.

SENSORY RECEPTORS
(1)SUPERFICIAL SENSATIONS
EXTERORECEPTORS receive stimuli from the external
environment via the skin and subcutaneous tissue.
>> Pain, Temperature, Light touch and pressure
(2) DEEP SENSATIONS
Proprioceptors receive stimuli from muscles, tendons,
ligaments, joints, and fascia
>> Position sense and awareness of joints at rest, movement
awareness (kinesthesia), and vibration.
(3) COMBINED (CORTICAL) SENSATIONS
Exteroceptive + Proprioceptive + intact function of cortical sensory
association areas.
>> Stereognosis, Two-point Discrimination, Barognosis,
Graphesthesia, Tactile Localization, Recognition Of Texture, Double
Simultaneous Stimulation

TYPES OF SENSORY RECEPTORS

A. CUTANEOUS RECEPTORS
1. Free Nerve Endings
Found throughout the body.
. perception of pain, temperature, touch, pressure, tickle, and itch
2. Hair Follicle Endings (Hair End-Organs)
.Hair follicle + FNE
.sensitive to mechanical movement and touch.
3. Krauses End-Bulb
. bulbous encapsulated nerve endings in the dermis and conjunctiva
of the eye
. function not clearly understood.
. They are believed to be low threshold mechanical receptors that
may play a contributing role in the perception of touch and
pressure.

A. CUTANEOUS RECEPTORS
4. Merkels Discs
located below the epidermis in hairless smooth (glabrous) skin with a
high density in the fingertips.
sensitive to low-intensity touch, as well as to the velocity of touch,
and respond to constant indentation of the skin (pressure).
They provide for the ability to perceive continuous contact of objects
against the skin and are believed to play an important role in both
two-point discrimination and localization of touch and contribute to
recognition of texture.
5. Ruffini Endings
Located in the deeper layers of the dermis, and in joint capsules and
assist with joint position sense.
perception of touch and pressure
slowly adapting and particularly important in signaling continuous
skin deformation such as tension or stretch

A. CUTANEOUS RECEPTORS
6. Meissners Corpuscles
low-threshold, rapidly adapting and in high concentration in the
fingertips, lips, and toes, areas that require high levels of
discrimination located at dermis.
These receptors play an important role in discriminative touch
(e.g., recognition of texture) and movement of objects over skin.
7. Pacinian Corpuscles
located in the subcutaneous tissue layer of the skin and in deep
tissues of the body (including tendons and soft tissues around
joints).
stimulated by rapid movement of tissue and are quickly adapting.
Perception of deep touch and vibration.

B. DEEP SENSORY RECEPTORS

located in muscles, tendons, and joints and
include both muscle and joint receptors.
They are concerned primarily with posture,
position sense, proprioception, muscle tone,
and speed and direction of movement.
The deep sensory receptors include the
muscle spindle, Golgi tendon organs, free
nerve endings, Pacinian corpuscles, and joint
receptors.

B1. MUSCLE RECEPTORS

1. Muscle Spindles
The muscle spindle fibers (intrafusal fibers) lie in a parallel arrangement to the
muscle fibers (extrafusal fibers).
They monitor changes in muscle length (Ia and II spindle afferent endings) as
well as velocity (Ia ending) of these changes.
plays a vital role in position and movement sense and in motor learning.
2. Golgi Tendon Organs
located in series at both the proximal and distal tendinous insertions of the
muscle.
monitor tension within the muscle.
provide a protective mechanism by preventing structural damage to the
muscle in situations of extreme tension. by inhibition of the contracting
muscle and facilitation of the antagonist.
3. Free Nerve Endings
These receptors are within the fascia of the muscle
respond to pain and pressure.
4. Pacinian Corpuscles
Located within the fascia of the muscle, these receptors respond to vibratory
stimuli and deep pressure.

B2. JOINT RECEPTORS

1. Golgi-Type Endings
These receptors are located in the ligaments, and function to detect
the rate of joint movement.
2. Free Nerve Endings
Found in the joint capsule and ligaments, these receptors are
believed to respond to pain and crude awareness of joint motion.
3. Ruffini Endings
Located in the joint capsule and ligaments, Ruffini endings are
responsible for the direction and velocity of joint movement.
4. Paciniform Endings
These receptors are found in the joint capsule and primarily monitor
rapid joint movements.

SPINAL PATHWAYS
ANTEROLATERAL SPINOTHALAMIC
Responds to stimuli that are potentially harmful in
nature.
(+) slow-conducting fibers of small diameter, some of
which are unmyelinated.
thermal and nociceptive information
Mediates NONDISCRIMINATIVE SENSATIONS:
Pain
Temperature
Crudely localized touch
Tickle
Itch
Sexual sensations

SPINAL PATHWAYS
ANTEROLATERAL SPINOTHALAMIC
Activated primarily by:
Mechanoreceptors
Thermoreceptors
Nociceptors
3 MAJOR TRACTS OF ST SYSTEM:
ANTERIOR STT Crude touch and
pressure
LATERAL STT Pain and temperature
SPINORETICULAR TRACT with diffuse
pain sensations

SPINAL PATHWAYS
DORSAL COLUMNMEDIAL LEMNISCAL
SYSTEM
Responses to more discriminative
sensations from specialized
mechanoreceptors
(+) fast-conducting fibers of large
diameter with greater myelination
thermal and nociceptive
information
Mediates:
Discriminative touch and pressure
sensations
Stereognosis
Barognosis
Graphesthesia
Recognition of texture
Two-point discrimination
Vibration
Movement
Position sense
Awareness of joints at rest

FEATURES OF PATHWAYS FOR TRANSMISSION OF

SOMATIC SENSORY SIGNALS

SOMATOSENSORY
CORTEX

1.Primary
somatosensory
cortex (S-I)
2.Secondary
somatosensory
cortex (S-II)
3.Posterior parietal
cortex

S1 NEURONS
POSTCENTRAL GYRUS
identify the location of stimuli as well as discern the size,
shape, and texture of objects.
S-II
Superior aspect of the lateral sulcus
innervated by neurons from S-I.
POSTERIOR PARIETAL LOBE
Behind S1, Consists of Area 5,7
Area 5 - integrates tactile input from mechanoreceptors of the
skin with proprioceptive input from muscles and joints.
Area 7 - integrates stereognostic and visual information from
visual, tactile, and proprioceptive input.

BRODMANNS AREA (47 AREAS)

PARIETAL LOBE
BRODMAN
N
AREAS
Area 3,1,2
Area 43

Area 5,7

GYRUR
S
Postcentral
gyrus

Superior
Parietal

Area 40

Area 39

Inferior
Parietal
Gyrus

NAME

FUNCTION

LESION

Primary
Somesthetic
Area

Proprioceptiv
e and tactile
sensation

Hemianesthesia,
Pain, temperature
and touch

Gustatory Area

Taste

Difficulty identifying
taste

Secondary
Somesthetic
Area

Interprets
proprioceptiv
e and tactile
sensation

Difficulty
interpreting
sensations

Supramarginal

Speech
language
processing

L: Ideomotor
Apraxia

Angular

Gerstman
Initial
Syndrome
processing of Cannot make
written visual meaning out of

BRODMANNS AREA (47 AREAS)

FRONTAL LOBE
BRODMANN
AREAS

GYRURS

NAME

FUNCTION

LESION

Area 4

Precentral
Gyrus

Primary Motor Area

Voluntary
movement

Weakness
(flaccid/spastic)

Pre-motor Area/
Motor Association
Area

Planning
Initiation of
motor movement
Coordination

R: Problem in planning
and initiation

Frontal Eye Field

Conjugate Eye
movements
CL Head and Eye
turning

Prefrontal Areas

Intelligence
Personality
Behavior
Insight
Judgment and
Decision-making

Area 6
Superior
Frontal
Gyrus
Area 8

Area 9-12
Inferior
Frontal
Gyrus
Area 44

Primary Motor
Speech Brocas
Area

Fluency

L: Incoordination
R frontal eye field,
affected pt turns head
and eye toward the R

Flow of speech is slow

and hesitant, vocabulary
is limited, and syntax is
impaired.
Speech production is
labored or lost

CLASSIFICATION OF APHASIA

FLUENCY

GOOD

COMPREHEN
SION
REPETITION

TERMINOLOG
IES

POOR

GOOD
G

ANOM
IC

POOR
P

CONDUCTI
ON

TRAN
SCOR
TICAL
SENS
ORY

GOOD

POOR

WERNICKE
S

TRAN
SCOR
TICAL
MOTO
R

BROCAS

TRANSCORTI
CAL MIXED

GLOBAL

BRODMANNS AREA (47 AREAS)

TEMPORAL LOBE
BRODMANN
AREAS

GYRURS

Primary Auditory
Area

Area 41
Superior
Temporal
gyrus
Area 22,42

BRODMAN
N
AREAS

NAME

GYRUR
S

Cuneus
Lingual

LESION

Auditory
input

Unilateral: partial
deafness
Bilateral: Cortical
deafness

Secondary
Interprets
R Auditory Agnosia
Auditory Area/
sound and
L Aphasia: Fluent/
Auditory
speech
Sensory/ Posterior/
Association/
comprehensi
OCCIPITAL LOBE
Receptive
Wernickes Area
on

NAME

Primary Visual
Area

Area 17

FUNCTION

FUNCTION

LESION

Visual Input

Unilateral: CL
Homonymous
Hemianpsia
Bilateral: Cortical
blindness
18: color blindness/
color agnosia/

PATTERN (DISTRIBUTION) OF SENSORY IMPAIRMENT

Dermatome (or skin segment) refers to the

skin area supplied by one dorsal root.
* Dermatome map

PRELIMINARY TESTS
2 GENERAL CATEGORIES:
(1)Arousal level, attention span,
orientation, and cognition
(2) Memory, hearing, and visual acuity

Arousal is the physiological readiness of the human

LEVEL
OF for PATIENT'S
LEVEL OF
system
activity
INTERACTIO
CONSCIOUSN
ESS

AROUSAL
LEVEL

STIMULATIO
N

N WITH PT

Alert.

Awake and
attentive

Normal

Normal and
appropriate

Lethargic.

Drowsy and
may fall
asleep if not
stimulated in
some way

DIFFICULTY

Should be
stimulated in
some way

May get
diverted

in focusing or
maintaining
attention
on a question
or task.

Obtunded.

Somnolent
state

Repeated

May
be largely
unproductive

Confused
when awake

Stupor
(semicoma).

returns to the
unconscious
state when
stimulation is
stopped

strong,
generally
noxious
stimuli

Coma (deep
coma).

cannot be
aroused
by any type
of stimulation

Unable

Reflex motor
responses
may or may
not be seen.

Attention is selective awareness of the

environment or responsiveness to a stimulus or
task without being distracted by other stimuli.
REPEAT ITEMS
repeat a series of numbers, letters, or words.
begin with 2 or 3 items and gradually
progress to longer lists.
SPELL WORDS BACKWARDS
longer words
Attention deficits will be apparent when the
order of letters is confused or inability/
difficulty to perform tasks

Orientation refers to
the patients
awareness of time,
person, and place.
oriented 3,
(T,P,P)
Partial orientation:
domains of
disorientation within
parentheses.

oriented 2
(time)
oriented 1
(time, place).

Cognition is defined as the process of knowing

and includes both awareness and judgment
Fund of knowledge sum total of an
individuals learning and experience in life
Calculation ability examines foundational
mathematical abilities; verbal or written
Acalculia inability to calculate
Dyscalculia difficulty in accomplishing
calculations
Proverb interpretation the patients ability
to interpret use of words outside of their
usual context or meaning.

FUND OF KNOWLEDGE:
Who became president after Kennedy was shot?
Who is the current vice president of the United
States?
Which is morea gallon or a liter?
In what country is the Great Pyramid?
CALCULATION ABILITY:
4 + 4 = ____; 10 + 22 = ____; 46 8 = ____; 13 7
= ____; 4 3 = ____; 6 6 = ____; and so forth.).
SAMPLE PROVERBS
People who live in glass houses shouldnt throw
stones.
The early bird catches the worm.
The empty wagon makes the most noise.

MEMORY
Long-term (remote) memory
date and place of birth,
number of siblings,
date of marriage,
schools attended, and
historical facts
Short-term memory
PT provides series of words or numbers; pt will repeat
sequence immediately.
car, book, cup
Seven-digit number
Short sentence
Normal memory function should be able to recall the list 5
minutes later and at least two of the items from the list
after 30 minutes.
RECALL : ALL ITEMS 5 MINS AFTER
REPEAT 2 ITEMS AFTER 3O MINS

HEARING
Observing the patients response to
conversation can provide a gross
assessment of hearing.
Note should be made of how alterations
in voice volume and tone influence
patient response.

VISUAL ACUITY
Pt wear corrective lenses
Dx that directly affect vision such as
multiple sclerosis, hypertension, and
diabetes.
- standard Snellen chart mounted on the
wall
. recorded at 20 feet (6 m) from the
Snellen chart
. N: 20/20
- visual acuity cards for use at bedside.

Peripheral field vision

R
C

N
E
E

G
IN

FUNCTION OF SCREENING:
Determine the need for further or more
detailed examination
Determine in a timely manner if referral to
another health care practitioner is warranted
Focus the search for the origin of symptoms
to a specific location or body part
Identify system-related impairments that
contribute to activity limitations or disability

NEUROLOGIC PIN

EQUIPMENT
SENSATION

EQUIPMENT

1. PAIN

Large-headed safety pin

Large paper clip that has one segment bent
open

2. TEMPERATURE

Two standard laboratory test tubes with

stoppers.

3. LIGHT TOUCH

A camel-hair brush, a piece of cotton, or a

tissue.

4. VIBRATION

Tuning fork and earphones

5. STEREOGNOSIS (OBJECT
RECOGNITION)

A variety of small, commonly used articles such

as a comb, fork, paper clip, key, marble, coin,
pencil, and so forth.

6. TWO-POINT
DISCRIMINATION

two-point discrimination aesthesiometer

7. TEXTURE RECOGNITION

Samples of fabrics of various

texture such as cotton, wool, burlap, or silk

PATIENT PREPARATION
1. Explain purpose
2. Cooperation is necessary
3. Try not to guess
4. Pt should be well rested
5. Do demonstration
6. Occlude patients vision using Blindfold/ folder

THE SENSORY EXAMINATION

The superficial (exteroceptive) sensations are usually examined
first deep combined cortical
Distal to proximal
The modality tested
The quantity of involvement or body surface areas affected
(pattern identification)
The degree or severity of involvement (e.g., absent, impaired, or
delayed responses)
Localization of the exact boundaries of the sensory impairment
The patients subjective feelings about changes in sensation
The potential impact of sensory loss on function (i.e., activity
limitation, disability)

COMMON ELEMENTS OF SENSORY

EXAMINATION FORMS
(1)a dermatome chart to graphically display findings;
(2)a grading scale
0absent;
1impaired;
2normal;
NTnot testable
(3) a section for narrative comments

SOME THINGS TO REMEMBER:

1. Hands should always be washed prior to and after
patient contact.
2. Random pattern
3. Varied timing
4. Consider skin condition

A
I
S
C
N
I
F IO
R T
E
P SA
U
S EN
S

PAIN PERCEPTION

sharp/dull discrimination

indicates function of protective sensation.

STIMULI: Not too close not too rapid

Maintain UNIFORM PRESSURE: with each successive

application of stimuli, the pin or reshaped paper clip should
be held firmly and the fingers allowed to slide down the
pin or paper clip once in contact with the skin.

Response
The patient is asked to verbally indicate sharp or dull when a
stimulus is felt. All areas of the body may be tested.

TEMPERATURE AWARENESS

ability to distinguish between warm and cool stimuli.

Two test tubes with stoppers

Cold are between 41F (5C) and 50F (10C)

Warmth, between 104F (40C) and 113F (45C).

The side of the test tube should be placed in contact with the skin
The test tubes are randomly placed in contact with the skin area to
be tested.
Response
The patient is asked to reply hot or cold after each stimulus
application

TOUCH AWARENESS

determines perception of tactile touch input.

A camel-hair brush, piece of cotton (ball or swab), or tissue

is used. The area to be tested is lightly touched or stroked.

Response
The patient is asked to indicate when he or she recognizes
that a stimulus has been applied by responding yes or
no.
can be obtained by dividing the number of correct responses
by the number of stimuli

PRESSURE PERCEPTION
fingertip or a double-tipped cotton swab is used
to apply a firm pressure on the skin surface
FIRM ENOUGH to indent skin
Response
The patient is asked to indicate when he or she
recognizes that a stimulus has been applied by
responding yes or no.

DEEP SENSATIONS
Kinesthesia is the awareness of movement.
Proprioception includes position sense and
the awareness of joints at rest.
Vibration refers to the ability to perceive
rapidly oscillating or vibratory stimuli

KINESTHESIA AWARENESS

The extremity or joint(s) is moved passively through a relatively

small range of motion (ROM).

Small increments in ROM are used as joint receptors fire at specific

points throughout the range.

The therapist should identify the range of movement being examine

Response
The patient is asked to describe verbally the direction (up, down, in,
out, and so forth) and range of movement in terms previously
discussed with the therapist while the extremity is in motion.
Or simultaneously duplicating the movement with the contralateral
extremity.

PROPRIOCEPTIVE AWARENESS
The extremity or joint(s) is moved through a ROM and
held in a static position. Again, small increments of
range are used.
Response
While the extremity or joint(s) is held in a static position
by the therapist, the patient is asked to describe the
position verbally or to duplicate the position of the
extremity or joint(s) with the contralateral extremity
(position matching)

VIBRATION PERCEPTION

tuning fork that vibrates at 128 Hz.

Ability to perceive a vibratory stimulus is tested by

placing the base of a vibrating tuning fork on a bony
prominence (such as the sternum, elbow, or ankle).

Response
The patient is asked to respond by verbally identifying or
otherwise indicating if the stimulus is vibrating or onvibrating each time the fork makes contact.

COMBINED CORTICAL SENSATIONS

1. Stereognosis Perception
2. Tactile Localization
3. Two-Point Discrimination
4. Double Simultaneous Stimulation
5. Graphesthesia (Traced Figure Identification)
6. Recognition of Texture
7. Barognosis (Recognition of Weight)

1. STEREOGNOSIS PERCEPTION
This test determines the ability to recognize the form of
objects by touch (stereognosis).
A variety of small, easily obtainable, and culturally familiar
objects of differing size and shape are required (e.g., keys,
coins, combs, safety pins, pencils, and so forth).
Response
The patient is asked to name the object verbally. For patients
with speech impairments, sensory testing shields can be
used

2. TACTILE LOCALIZATION

This test determines the ability to localize touch

sensation on the skin (topognosis).

The patient is asked to identify the specific point of

application of a touch stimulus (e.g., tip of ring finger,
lateral malleus, and so forth) and not simply the
perception of being touched.

Response
The patient is asked to identify the location of the stimuli by
pointing to the area or by verbal description. The
patients eyes may be open during the response
component of this test. The distance between the
application of the stimulus and the site indicated by the
patient can be measured and recorded.

3. TWO-POINT DISCRIMINATION

This test determines the ability to perceive two points

applied to the skin simultaneously.

It is a measure of the smallest distance between two

stimuli (applied simultaneously and with equal
pressure) that can still be perceived as two distinct
stimuli.

As this sensory function is most refined in the distal

upper extremities, this is the typical site for testing

3. TWO-POINT DISCRIMINATION

During the test procedure the two tips of the

instrument are applied to the skin simultaneously with
tips spread apart.

To increase the validity of the test, it is appropriate to

alternate the application of two stimuli with the
random application of only a single stimulus (the
purpose of the third tip on some aesthesiometers).

With each successive application, the two tips are

gradually brought closer together until the stimuli are
perceived as one.

Response
The patient is asked to identify the perception of one
or two stimuli.

4. DOUBLE SIMULTANEOUS
STIMULATION

This test determines the ability to perceive simultaneous

touch stimuli (double simultaneous stimulation [DSS]).

(1) identical locations on opposite sides of the body,

(2) proximally and distally on opposite sides of the body, and/or
(3) (3) proximal and distal locations on the same side of the
body.
Response
The patient verbally states when he or she perceives a touch
stimulus and the number of stimuli felt.

5. GRAPHESTHESIA (TRACED
FIGURE IDENTIFICATION)

This test determines the ability to recognize letters, numbers, or

designs written on the skin.

Using a fingertip or the eraser end of a pencil, a series of letters,

numbers, or shapes is traced on the palm of the patients hand

Orientation

Between each separate drawing the palm should be gently wiped

with a soft cloth to clearly indicate a change in figures to the
patient.

Response
The patient is asked to identify verbally the figures drawn on the skin.
For patients with speech or language impairments, the figures can
be selected (pointed to) from a series of line drawings.

6. RECOGNITION OF TEXTURE
This. test determines the ability to differentiate among
various textures.
Suitable textures may include cotton, wool, burlap, or silk.
The items are placed individually in the patients hand.
The patient is allowed to manipulate the sample texture
Response
The patient is asked to identify the individual textures as they
are placed in the hand. They may be identified by name
(e.g., silk, cotton) or by texture (e.g., rough, smooth).

7. BAROGNOSIS (RECOGNITION OF
WEIGHT)

This test determines the ability to recognize different weights. A

set of discrimination weights consisting of small objects of the
same size and shape but of graduated weight is used

The therapist may choose to place a series of different weights

in the same hand one at a time, place a different weight in each
hand simultaneously, or ask the patient to use a fingertip grip
to pick up each weight.

Response
The patient is asked to identify the comparative weight of objects
in a series (i.e., to compare the relative weight of the object
with the previous one); or when the objects are placed (or
picked up) in both hands simultaneously the patient is asked to
compare the weight of the two objects. The patient responds by
indicating that the object is heavier or lighter.