D E R M A T O M E S V S P E R I P H E R A L C U T A N E O U S NE R V E S

What you may notice from the two images below is how the dermatomal pattern of a spinal level
differs from a peripheral cutaneous nerve. This is something we all learnt in our training but it is
easy to forget. There is no easy way of remembering all the nerve pathways, however, when
learning this different maps I have found it helpful to draw out the distributions/areas of skin
innervated on my own arm and leg. You can also keep a picture on your desk at work in case you
forget. 
 Cutaneous innervation of the upper limb……………

Cutaneous innervation of the lower limb

SENSAT IO N TESTING P RO CEDURES  

EQUIPMENT & SET-UP

 For all sensory assessment procedures test the affected side/area first then the unaffected
side. This prevents the retained memory of the last stimulus compromising the test. 
 Patient Position - supported long sitting, ensure the lower limb is exposed to the hip joint
and upper limb exposed to acromion. The trunk must be exposed for area tested.
 Equipment Required - cotton wool/tissue, 2 paper clips, test tubes filled with hot/cold
water.

It is generally recommended that you begin your assessment with light touch. This is a fine
discriminatory sense and if this sense is impaired then deeper sensations will often too be impaired
as they belong to the same sensory tract (dorsal medial lemniscus tract). For example, if you cannot
localise light touch, then the ability to localise joint position is often unlikely (proprioception). 
As you may have read from the previous blog on sensation, it is normally conducted in a distal-to-
proximal fashion as this saves time and allows for multiple dermatomes to be tested
simultaneously without testing the entire dermatome distribution. If a deficit is noted, then further
examination is required to specifically map out the impairment. Essentially the first aim is to
identify is sensation is intact or impaired, and the second aim is to map out the distribution of
sensory loss on the given limb and determine if this is in the distribution of a cutaneous nerve,
spinal nerve or multiple nerves. 

Let's go over some of the specifics of sensory testing in regards to three tests - light touch,
sharp/blunt and two-point discrimination. 

1 ) L I G H T T O U C H T E S T I N G - A B I L I T Y T O L O C A L I SE

Explanation to the Patient

 Explain procedure in general terms, including purpose of assessment.

 "I am going to test the feeling in your arm/leg/trunk, let me know what you feel by
responding with yes or no".

Testing Procedure

 Commence testing in area of suspected impaired sensation.

 Start distally in arm/leg, in a random sequence lightly but rapidly stroke a small area of
patient's skin on different surfaces using a cotton bud or tissue, use equal pressure
throughout all tests. (Light pressure means not being able to hear the stroke of the cotton
bud on the skin.) 
 After each stroke await a response from patient without prompting them.
 If the patient responds, ask them what it feels like and where (patient will point to the
location).
 Ensure when changing surfaces (and moving the limb for better access) you use as little
manual handling as possible to reduce sensation learning.
 Once you have assessed the affected side move to unaffected side & repeat.
 Then alternate between left and right sides in a random sequence.
 Documentation should include either a pictorial representation or a detailed description of
the absent sensation.
  If you are describing the change in sensation you may choose to ask the patient to rate the
intensity of what they feel compared to the unaffected side. Usually a difference of 20% i.e.
8/10 is considered within normal limits. 

1 ) L I G H T T O U C H T E S T I N G - T E S T I N G BE T W E E N A R E A S F O R
D I M I N I S HE D / A L T E R E D S E N S A T I O N

Explanation to the Patient

 "I will now test if any areas feel different than others" (indicates all types of sensations).
 "I will touch one area of skin then immediately touch another area".
 "I need you to tell me how one area feels compared to another".
 "You may keep your eyes open".
 During testing, I continually say "does that feel the same as that?"

Testing Procedure

 In a systematic way, moving from distal to proximal on all surfaces, lightly stroke one
area immediately followed by another area (either the same region on the opposite side, or
another area on the same side).
 Ask the patient what they feel, or "does that feel the same as that?"
 If the patient answers no, the further question the difference to understand if there is
paraesthesia, numbness, sensitivity or dysaesthesia (abnormal feelings like prickling,
crawling, burning etc.)

2) SHARP/BLUNT TESTING

Testing Procedures

 Start in the area where the patient had difficulties in sharp/blunt discrimination & using
equal pressure on both paper clips touch them 4 to 5cm apart.
 Ask the patient if they feel one or two points of pressure.
 Gradually lift & move the points closer together, each time asking if the patient feels one
or two points.
 Keep moving them closer until the patients reports feeling one point.
 Repeat at various spots in that area, documenting the distance between the two points.
  NB: it is normal to have differences at different parts of the body, however it is
important to note where responses are different between sides.

DO CUM ENTATIO N

The final aspect of sensory testing that I wanted to cover with this blog is terminology (O'Sullivan
et al., 2013). Here are a few words...

Words relating to pain:

 Analgesia - the complete loss of pain sensitivity.

 Dysesthesia - touch sensation experienced as pain.
 Hyperalgesia - increased sensitivity to pain
 hypalgesia - decreased sensitivity to pain.
 Allodynia - pain provoked by non-noxious stimulus.
 Causalgia - painful burning sensation (usually along the distribution of a nerve).

Words relating to sensation:

 Atopognosia - inability to localise a sensation.

 Hyperesthesia - increase sensitivity to a sensory stimuli
 hypesthesia - decreased sensitivity to a sensory stimuli.
 Paraesthesia - abnormal sensation such as pins and needles, numbness, tingling.
 Thigmanesthesia - loss of light touch sensibility .

Words relating to temperature:

 Thermanalgesia - inability to perceive heat.

 Thermanesthesia - inability to perceive sensations of heat or cold.
 Thermhyperesthesia - increased sensitivity to temperature
 thermhypesthesia - decreased temperature sensibility.

When I think back to my university days, I remember being quite overwhelmed with the number of
sensory tests we learnt in neurology and musculoskeletal subjects. Always remember that when put
in the context of a full neurological screen (deep tendon reflexes, strength and sensation) the
clinical patterns are much easier to recognise. However, it is definitely important to know the
purpose and method for these sensory assessments and the most common tests you will use such as
light touch, sharp/blunt discrimination, and temperature. The focus initially is to rule out any
sensory impairment during a neurological exam and once sensory impairment has been detected,
you can then be more specific in your mapping of the distribution and description of the
symptoms.