Annie Witte Occupational Therapy Student The Ohio State University Monday July 20 th 12:00pm

Sensory Re-Education (SRE) Therapy techniques to re-train sensory pathways Made possible by neuroplasticity – Dynamic potential of the central and peripheral nervous systems to reorganize during development, learning, or after being damaged

Why SRE Matters 50-85% of patients present with sensory deficits after stroke 2 Re-training sensation can permit normal cortical representations to be maintained. 3 – Down-side to neuroplasticity: When input is eliminated, adjacent cortical regions take over the unused areas Sensation impacts function 3

How Sensation Impacts Function – Safety concerns (e.g., detecting hot temperatures, stereognosis, proprioception) 3 – Impaired spontaneous use 3 – Inability to sustain grasp and manipulate objects; pinch grip 3,4 – Impaired ability to reacquire skilled movements for activities of daily living 3

Carey and Matyas (2005) 1 Stimulus-specific training (SST) vs. stimulus- generalization training (SGT) SST: designed to maximize improvement of specifically trained sensory discriminations (e.g., 1 specific texture) SGT: designed to facilitate transfer of training to untrained/novel stimuli

Results of SST vs. SGT Stimulus-specific training (SST): Success for trained texture and proprioceptive discriminations, but failed to show spontaneous transfer to related but untrained stimuli. Stimulus-generalization training (SGT): Success for intramodality transfer for texture discriminations. Most effective/efficient and practical for rehab after stroke.

How to make SGT work? Transfer tasks selected matter! Same sensory-perceptual dimension Same body location Same tactile domain Same exploration technique (e.g., fingertips) Same limb-position discrimination

Carey, Macdonell, and Matyas (2011) 2 Sensory discrimination training vs. repeated, non-stimulus exposure to sensory stimuli (exploration) Experimental group: Subjects trained on sensory task in random sequence with texture discrimination, limb position sense, and tactile object recognition (discrimination of shape, size, weight, texture, hardness, & temperature) Control group: Subjects experienced a wide variety of textures, shapes, sizes, weights, and hardnesses with grasping or passive movements of the UE

Results of Sensory Discrimination Training vs. Sensory Exploration Significantly greater improvement in experimental group vs. control group Both groups improved by 6-week and 6-month follow-ups, but experimental group maintained improvement more at follow-ups and achieved transfer of training effects to novel stimuli

Schabrun and Hillier (2009) 3 Systematic review of SRE literature to: – Compare quality of available evidence for passive and active SRE – Compare passive vs. active SRE 118 studies identified, only 14 included due to study design, focus on motor, not specific to limb function, and not active vs. passive training

Active and Passive SRE Defined Passive: when electrical stimulation is used to activate cutaneous nerves when no muscular contraction is available Active: participatory practice with exercises designed specifically to re-educate sensory function

Examples of Passive/Active SRE Passive Sensory Re-Training – Sending constant message from peripheral nervous system (PNS) to central nervous system (CNS) re- builds the pathway for feeling into the limbs – E-stim, pneumatic compression, thermal stimulation, massage and self-massage, and vibration Active Sensory Re-Training – Practice of localization of sensations, discrimination, proprioception, stereognosis, graphesthesia, and kinesthesia.

Results of Active vs. Passive Passive SRE has some evidence of improvement for hand function and dexterity post-status stroke. Many studies measured function (shows net improvement) Active SRE does not have sufficient data Individual studies report positive effects, but lower level of evidence Measuring impairment rather than function (more difficult to detect) More research necessary (higher power, subject homogeneity, and reliable outcome measures)

SRE Principles Graded progression of discriminations from easy to difficult 1,2 Attentive exploration of stimuli with vision occluded 1,2 Use of anticipation trials 1,2 Feedback on salient sensory features of the stimuli, accuracy of judgments, and method of exploration 1,2 Summary feedback and intensive training 1,2 Use of vision to facilitate intermodal calibration of sensory information 1,2

SRE Principles (continued) Repeated presentation of target discrimination tasks 1 Comparison of sensation with other hand 1 Self-checking of accuracy 2 A variety of stimuli within each sensory dimension trained 2 Feedback on ability to identify distinctive features in novel stimuli 2 Tuition of training principles 2

Accuracy in Sensory Evaluation 6 Environment: background noise reduced, secluded room if possible Client: ability to concentrate, anxiety, skin calluses, Instrument: able to grade up/down or calibrate, quality Method: standard instructions, support/immobilize hand, varying timing & spacing of application Examiner: skill, experience, and concentration

References 1.Carey, L. M., & Matyas, T. A. (2005). Training of somatosensory discrimination after stroke: facilitation of stimulus generalization. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, 84(6), 428– Carey, L., Macdonell, R., & Matyas, T. A. (2011). SENSe: Study of the effectiveness of neurorehabilitation on sensation: A randomized controlled trial. Neurorehabilitation and Neural Repair, 25(4), 304– Schabrun, S. M., & Hillier, S. (2009). Evidence for the retraining of sensation after stroke: a systematic review. Clinical Rehabilitation, 23(1), 27–39. 4.Blennerhassett, J. M., Matyas, T. A., & Carey, L. M. (2007). Impaired discrimination of surface friction contributes to pinch grip deficit after stroke. Neurorehabilitation and Neural Repair, 21(3), 263–272.

References 5.Pumpa, L. U., Cahill, L. S., & Carey, L. M. (2015). Somatosensory assessment and treatment after stroke: An evidence-practice gap. Australian Occupational Therapy Journal, 62(2), 93– Pedretti, L., Pendleton, H. & Krohn, W. (2006). Pedretti's occupational therapy: Practice skills for physical dysfunction. St. Louis, Mo: Mosby/Elsevier.

Please contact me for references or if you have any questions. Annie Witte Occupational Therapy Student The Ohio State University