Occupational therapy programs tables of content

Insert upper extremity gross sensory evaluation sheet here - pages one and two.
UPPER EXTREMITY GROSS SENSORY EVALUATION PROCEDURES
Fill in all blanks.

Chart review: Self-explanatory.

Perform testing in a quiet environment.

Describe the reason for the sensory test to the patient before testing begins.

Demonstrate each sensory test with vision to increase the patient’s understanding.

Test the uninvolved extremity first to ensure the patient’s understanding and to establish a norm for that patient. You may also determine that some sensory loss exists bilaterally.

Do all actual testing of the extremities with vision occluded.

Provide the testing stimulus at random with no consistent timing, to ensure accurate results. Give the patient at least 2 seconds to respond to each stimulus.

SHARP/DULL DISCRIMINATION
Use a safety pin with sharp end for sharp sensation and blunt end for dull. Be careful not to break the skin.

Absent: Patient does not respond to any stimulus: does not know when touched.

Impaired: Patient responds to stimulus but is unable to distinguish sharp from dull: responds inconsistently or noticeably slower than expected.

Intact: Patient consistently distinguishes sharp from dull.
HOT/COLD
Use test tubes, one containing hot water, the other cold. To avoid patient’s interpretation of the stimuli as painful, use hot water 104" to 113" and cold water 41" to 50"F. Apply tubes in random order to areas of the skin.

Absent: Patient does not respond to any stimulus: does not know when touched.

Impaired: patient responds to stimulus but is unable to distinguish hot from cold; responds inconsistently or noticeably slower than expected.

Intact: Patient consistently distinguishes hot from cold.
LIGHT TOUCH
Lightly touch the patient in a specific area with a cotton ball.

Absent: Patient does not respond to any stimulus: does not know when touched.

Impaired: Patient responds to stimulus but cannot localize or distinguish deep pressure from light touch: responds inconsistently or noticeably slower than expected.

Intact: patient consistently distinguishes and localizes deep pressure and light touch.
POSITION SENSE
Passively position a joint of the involved extremity and ask the patient to imitate the position with the opposite extremity.

Absent: Patient is unable to identify body part being moved or in what position it is placed.

Impaired: Patient is able to identify body part being moved or its position but is unable to identify both; responds inconsistently or noticeably slower than expected.

Intact: Patient consistently identifies body part moved and in what position it is placed.

Upper Extremity Gross Sensory Evaluation Procedures (cont.)

STEREOGNOSIS
Use of the following objects is recommended: coin, paper clip, safety pin, 1-inch cube, cotton ball, pencil, toothbrush, key. Place each object individually in the patient’s hand. If necessary, assist the patient in manipulation of the object. Then ask the patient to name the object. It is preferable that the objects. It is preferable that the objects initially not be shown to the patient.

Absent: Patient is unable to identify any object placed in hand.

Impaired: Patient is unable to identify objects but may identify some property of an object (“round, hard, etc.”) Patient is able to identify some, but not all objects.

Intact: Patient is consistently able to identify all objects placed in hand.
Complete the evaluation form and sign and date the document.

Information adapted from Trombly & Scott.

DESENSITIZATION EVALUATION PROCEDURES

This evaluation tool helps patients identify their specific tolerance to pain so that an individualized desensitization program based on the patient’s hierarch of hypersensitivity for contact and immersion textures can be established.

Fill in all blanks.

Check whether first or second evaluation and the date the evaluation is being performed.
SYMPTOMS

Check the description that best describes the hypersensitivity the patient is experiencing.

DESCRIPTION OF PAIN

Circle the words that the patient uses to describe the hypersensitivity. Write in any additional descriptions the patient uses.

RESPONSE TO TEXTURES
Textures as listed on the evaluation form are glued to dowels.

Light stroke: The patient is asked to lightly stroke the texture over the hypersensitive area.

Minimal pressure: The patient progresses to minimal pressure or “rolling” over the area.

Deep Pressure: The patient continues to progress to deep pressure or “rubbing.”

Comments: Use the key to describe the patient’s tolerance to each texture, using the various amounts of pressure: light stroke, minimal pressure, and deep pressure. Add any comments that will increase the readers’ understanding.

RESPONSE TO PARTICLE IMMERSION
The contact and immersion particles listed on the evaluation form are contained in 3-pound coffee containers or similar containers.

Surface contact: The patient is instructed to just lightly touch over the particles with the hypersensitive area of the extremity.

Total immersion: The patient progresses to total immersion, or sinking the hand into the particles.

Applied pressure: The patient takes the particles and presses or rubs them over the hypersensitive area.

Comment: Use the key to describe the patient’s tolerance to each particle immersion with the various levels of immersion: surface contact, total immersion, applied pressure. Add any comments that will increase the readers’ understanding.

RESPONSE TO VIBRATION
Use low-speed vibration at 83 cycles and high-speed vibration at 100 cycles. Each tactile input is experienced by the patient at both speeds of the vibrator.

Indirect: The patient is instructed to move the vibrator over the hypersensitive area, which is covered with a towel.

Direct: The patient is instructed to move the vibrator directly over the hypersensitive area with no covering.

2" from the sensitive area: The patient moves the vibrator around the surrounding tissue within 2 inches of the border of the hypersensitive area.

Use the key to describe the patient’s tolerance to each level of vibration and each level of tactile sensation. Add any comments that will increase the readers’ understanding.

Complete the evaluation form and sign and date the document.

RESPONSE TO PARTICLE IMMERSION: Key: (+) patient can tolerate (-) patient cannot tolerate

	Surface Contact		Total Immersion		Applied Pressure		Comments
Eval	1^st	2^nd	1^st	2^nd	1^st	2^nd
cotton
popcorn
beans
rice

COMMENTS:__________________________________________________________________________

RESPONSE TO VIBRATION: Key: (+) patient can tolerate (-) patient cannot tolerate

		Low Speed		High Speed		Comments
	1^st		2^nd	1^st	2^nd
Indirect (shielded)
2" from sensitive area
Direct contact

COMMENTS:__________________________________________________________________________

___________________________________________ ______________________

Therapist’s Signature Date
Source: Courtesy of Downey Community Hospital, Downey, California

DEPARTMENT OF OCCUPATIONAL THERAPY REPORT

DESENSITIZATION EVALUATION
Patient:_______________________________________ Date of 1^st Evaluation:_________________

Date of 2^nd Evaluation:_________________

SYMPTOMS: _____ Itching near wound or suture site

_____ Trigger point of pain can be elicited/localized

_____ Burning pain

_____ Pain causes withdrawal of hand to contact

_____ Pain interferes with use of hand in ADL
DESCRIPTION OF PAIN: Tingling, burning, throbbing, shooting pain, aching, positive Tinel’s sign (electric

shock)

Other:___________________________________________________________
RESPONSE TO TEXTURES: Key: (+) patient can tolerate (-) patient cannot tolerate

	Light Stroke		Minimal Pressure		Deep Pressure
Eval	1^st	2^nd	1^st	2^nd	1^st	2^nd
moleskin
cotton
gauze
crew sock
terry cloth
velvet
yarn wrap
satin
felt
denim
corduroy
burlap
wool
sandpaper
wire wrap
Velcro pile
Velcro hook
suede
leather
trash bag
foil
wood
nylon net
sheet
paper towel

PROGRAM: SENSORY STIMULATION
DESCRIPTION/PURPOSE:
Sensory stimulation involves the use of controlled sensory input with all the comatose or semi-comatose residents to increase their level of response and overall awareness. Coma is an unresponsive state of consciousness from which a person cannot be aroused even after vigorous and repeated stimulation.
OBJECTIVE/GOALS:

To provide structured input in order to maximize the ability to process the response to stimuli.

To facilitate recovery of the nervous system to improve the ability to process information of increasing variety and complexity.

To provide a level of sensory input within the optimal range to prevent deterioration in the functional efficiency of information processing mechanisms.

To prevent sensory deprivation.

INDICATIONS:

A comatose or semi-comatose resident who displays a lack of response or inconsistent response to environmental stimulation.
CONTRAINDICATIONS:

Someone who is hyperactive and maladaptive behavior to stimulation
PRECAUTIONS:

Observe for signs of overstimulation.

All team members should use a consistent approach to avoid increasing resident disorientation.

EQUIPMENT:

Large gauge needle.

Hot and cold packs.

Stiff bristled brush

Sandpaper

Various fabrics of different textures

Radio, television, and tape recorders.

Salt, sugar, and vinegar.

Sensory Stimulation (cont.)

ASSESSMENT:

Reflexes

Muscle tone, especially spasticity

Range of Motion

Balance and postural control

Sensory registration

Sensory processing

EVALUATION TOOLS:

Glascow Coma Scale

Ranchos Los Amigos Cognitive Functioning Scale

PROCEDURES:

General principles.

Input must be well structured, timed and broken down into simple steps.

Allow enough time between each stimuli for a response since the response will often be delayed.

Limit the use of television, radio, or other continuous background stimulation.

Reduce the ambient noise levels in the environment to reduce the information processing load.

Regulate the way in which staff communicate with residents, using key words and slow delivery of such words to facilitate understanding.

Best responses to stimulation may occur in the high interpersonal contact conditions (verbal/emotional enthusiasm).

Assume that at least some information is being received and relate to all residents, regardless of level of response in an appropriate manner.

A consistent, repetitive and appropriately structured approach to the resident by all members of the treatment team will yield optimal results.

Instruct the resident’s family in sensory stimulation techniques and confirm the reliability by occasional co-treatments.

Specific treatment techniques.

Tactile stimulation - If the patient responds appropriately to painful stimuli, i.e., withdrawal or facial grimace, discontinue the pain stimulus (from that session and thereafter) and note the response.

Touch: Touch the patient lightly on the hand and shoulder. Repeat with a firm touch once you have assessed the patient’s response to light touch.

Stiff brush: Rub a stiff brush over the right and left shoulder, and observe for response.

Sensory Stimulation (cont.)

Chest rub: Rub the sternum with knuckles at the nipple line.

Icing: Apply icing (icing of the A-size sensory fiber to activate a reflex reciprocal action of the superficial phasic or mobilizing muscles) by quick stokes of an ice cube along the forearm and upper arm to evoke a withdrawal response.

Pinprick: Prick the forearm and upper arm with a safety pin.

Pressure to nail bed: Apply pressure to the patient’s nail bed at the cuticle level with the thumb and forefinger.

Vibration: Apply vibration to muscle or tendon. Vibration is reciprocally inhibitory when it is applied to the weaker antagonist of the spastic muscle. Application of the vibrator to the tendon is more effective than application to the muscle belly, although a similar response can be obtained if the vibrator is applied to the belly and the amplitude is high. Caution: The vibration of a muscle or tendon should last at least 30 seconds but not more than 1 or 2 minutes because heat and friction produced by the vibrator may cause the patient discomfort.

Life support and monitoring lines: Observe the patient’s response to the life-support system. Note whether he or she attempts to pull on tubes or becomes agitated or shows any response to the sounds of the monitors or alarms.

Auditory Stimulation

Radio/television: Observe the patient’s response to these sounds: i.e., withdraws, turns head appropriately; shows changes in vital signs in response to familiar music, favorite shows, and the like. (During therapy sessions, unless used as treatment, radios, TVs, or other noises should be eliminated as much as possible so that voice commands for motor responses or the selected auditory stimuli are the most prevalent auditory input to the patient.)

Voice: Place the patient’s head in midline or stand opposite to the side that the patient’s head is turned toward. Call the patient by the name with which he or she is most familiar. Use a normal but firm voice.

Bell: Place the patient’s head in midline or stand opposite to the side that the patient’s head is turned toward. Ring bell 12 inches away from the patient’s ear (if the head is turned to the right, ring in the left ear, and vice versa).

Familiar voice: Play a tape recording of the voice of a familiar family member or friends, or observe the patient’s response to these individuals’ voice while they are present. “Familiar voices” can be pet sounds on tape.

Sensory Stimulation (cont.)
Olfactory Stimulation

Place a cotton ball saturated with the appropriate concentration of odor under the patient’s nostrils (a bottle of the odorant may used also). Be careful to avoid touching the patient’s face with the cotton ball, as this might cause an aversive protective response to the light touch. Allow the odorant to remain long enough to stimulate but not so long as to cause adaptation (about 10 seconds). Be alert to possible changes in level of consciousness, muscle tone, facial expression, verbalization, postural reflexes, feeding patterns, and affective state. If the patient’s initial response to banana/vanilla is reflexive sucking, it is considered an adaptive response. If the patient does not progress, the continued reflexive sucking is no longer considered adaptive.

Visual Stimulation

Shiny object moving horizontally; Use colored blocks or keys, but keep keys from jingling, if they do, note in comments.

Penlight: Use a small flashlight in a darkened room to observe for eye tracking.

Fast-moving object toward face: Use your hand.

Stationary object in visual field: Use colored blocks.

Pictures of familiar people: Use large prints if possible with only one to three people in a picture to encourage focusing on the familiarity of an individual.

Gustatory/Oral Motor Stimulation:

The taste buts are located on the tongue, palate, oropharynx, mucosa of the lips

and cheeks, and the floor of the mouth. Before using peppermint or popsicle,

obtain the physician’s approval. Toothettes may be dipped in various tastes:

make a note in comments section of this is done. The basic categories of taste

and the location of greatest acurity are as follows:

Sweet: anterior dorsal tongue

Bitter: posterior margin and tongue tip

Salt: anterior tongue margin

Sour: lateral tongue edges

DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the Sensory Stimulation program, present objective and measurable progress and the resident’s improvement as related to the functional abilities. Also include the resident’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.
Sensory Stimulation (cont.)
HANDOUTS:

Glasgow Coma Scale

Ranchos Los Amigo Cognitive Functioning Scale

Coma Evaluation Procedures

Sensory Awareness Evaluation and Flow Sheet Form

Stimulus/Response Flow Chart Form
RESOURCES:
Trombley, Catherine, (1995) Occupational Therapy for Physical Dysfunction. Baltimore: Williams and Wilkins.