Rivermead Assessment of Somatosensory

PerformanceRaiza Belarmino, Andy Phung,

Jessica Hoang, & Jasmine Vassel

Raiza Belarmino,

OTSCalifornia State University San

Marcos

BA Communication

Stanbridge University

MS Occupational Therapy

Andy Phung, OTS

California State University Fullerton

BA Health Science

Stanbridge University

MS Occupational Therapy

Jessica Hoang, OTS

California State University Long Beach

BA Psychology

Stanbridge UniversityMS Occupational Therapy

Jasmine Vassel, OTS

Azusa Pacific UniversityBA in Psychology w/

concentration in Health Psychology

Stanbridge UniversityMS in Occupational Therapy

IntroductionWhat is the somatosensory system?

Concerned with conscious perception of touch, pressure, pain, temperature, position, movement, and vibration which arises from the muscles, joints, and skin.

Who would have somatosensory impairments?

Stroke

Multiple Sclerosis

Head Injury

Spinal Cord Injury

What is the RASP?Standardized battery test designed to provide an quantifiable and

reliable assessment of somatosensory functioning

Includes standardized instruments that provide comprehensive measures of various somatosensory functions to inform and monitor rehabilitation and recovery

What is the RASP?Comprised of Seven Subtests

5 Primary Subtests

Sharp/dull discrimination

Surface pressure touch

Surface localization

Temperature discrimination

Movement and direction proprioceptive discrimination

2 Secondary SubtestsSensory extinction

Two point discrimination

RASP Instrument: NeurometerUsed to test

Sharp/dull discrimination

Surface pressure touch

Surface localization

Sensory extinction

2 parts

Top = sharp/ dull discrimination

Lower = surface pressure touch, surface localization and sensory extinction

RASP Instrument: NeurotempRed and blue colored instruments with liquid crystal displays

Blue instrument displays temperatures from 6-10°C

Red instrument displays temperatures from 44-49°C

RASP Instrument: NeurodiscFour-pointed, fixed-distance, two-point discriminator

Used to establish extent of two-point discrimination on finger pads

Applied perpendicular to skin surface and parallel to the finder axis and depressed approximately 1 mm briefly

Three fixed distances: 3, 4, and 5 mm

Patient and Control SampleReliability and validity for RASP established

Inclusion Criteria: Patients with diagnosis of first ever unilateral stroke

Exclusion Criteria:Evidence of bilateral signs, noncompliance, severe visual/hearing impairment,

cognitive impairments

The presence of another neurological condition

100 patients used in standardization

Control Group:50 non brain damaged subjects

Test ReliabilityReliability established by comparing 15 different patients scored

independently by 2 different raters and the original research therapist

Patient ReliabilityAssumes that sometimes information provided can be inaccurate

Controls possible sources of unreliabilitySeries of sham trials on 2 of the 5 primary subjects

Sharp/dull discrimination

Surface pressure touch

Sham trials, also known as “non-touch” trials, are performed to control patient reliability

Sham TrialThe examiner pretends to give a stimulus when in fact none is applied

Six sham trials are conducted for each side

Helps identify patients whose performance demonstrates unreliability

Improves patient reliability by enabling the examiner to exclude those that are consistently reporting sensations on sham trials

Who uses the RASP?Medical doctors

Neurologists

General Practitioners

Physiotherapists

Occupational therapists

Speech and language pathologists

Nurses

Research Psychologists

Other clinically qualified staff

Used when health care practitioners wish to document sensory loss in a patient for clinical or research purposes

Provides a comprehensive picture of the patient’s performance

Findings can be used to inform and monitor rehabilitation and recovery.

The Patient Should BeAppropriately dressed so the examiner is able to assess all 10 areas of

the body

Have the purpose of each assessment explained to them

Always shown what the test involves prior to administration

Made aware they will first be assessed on the unaffected side

Informed they will need to keep their eyes closed for all tests

Discouraged from guessing

Reassured not to be surprised if sometimes they cannot feel anything

The Tester ShouldBe aware that altered body functions may affect test procedures and

limit access to certain test regions

Always allow for a few practice trials

Carry out testing in a quiet setting and ensure the participant is comfortable

Record relevant participant details on the score sheet

Use clinical judgment in deciding the number and types of subtests to employ

Scoring10 anatomically referenced test regions

Alternating pattern from unaffected side → affected side; head → feet

Each test region is approximately 25mm squared● Scoring is recorded on specific table/body chart

● Total score represents patient’s ability to detect and discriminate sensory stimulation

● Sham trials scored separately

False positives = 1

Maximum sham score = 2

Anatomical Reference

LimitationsAll tests require verbal responses

Subjects with speech or language difficulties will need accommodations

Examiner has 2 options for verbally impaired patients:

1. Point to pictures, objects, or words on designated cards

2. Use hand signals

Test Sequence1.Sharp/dull discrimination

2.Surface pressure touch

3.Surface localization

4.Sensory extinction

5.Two point discrimination

6.Temperature discrimination

7.Proprioception

a. Movement

b. Direction

Sharp/Dull DiscriminationEquipment needed:

2 neurometers, 2 neurotips, scoring sheet

Regions on the body to be tested:

Face (1 and 2), hand (3-6), foot (7-10)

Procedure:

Subtest administered with patient’s eyes closed

Work from unaffected to affected side, neurometer is applied to test area pseudo-randomized order (designated trial sequence)

Neurometer is applied to the subject’s skin

60 trials (30 left, 30 right) and 20 shams (10 left and 10 right)

10 test regions → 6 stimuli presented: 3 dull, 3 sharp, 2 sham in following order: S § D D S S § D

Sharp/Dull Discrimination●Explanation to patient:

○ Patient is shown two neurometers with sharp and dull ends pointed out

○ Examiner tells patient that he/she is going to test whether patient can feel sharp or dull

●Scoring:

○ Only correct detections are noted

○ Record each response for stimulus on scoring sheet

○ Test provides single score representing patient’s ability to detect sharp/dull discrimination

Sharp/Dull Scoring

Surface Pressure TouchTest equipment needed:

1 neurometer, scoring sheet

Regions on the body to be tested:

Face (1 and 2), hand (3-6), foot (7-10)

Procedure:

Subtest is administered with patient’s eyes closed

Neurometer is set to level one throughout testing

Neurometer applied to designated testing area briefly (until thick white filament tip disappears before releasing

60 trials (30 left and 30 right) and 20 shams (10 left and 10 right)

10 test regions → 6 touch (T) stimuli and 2 (§) sham trials are presented in following order: T § T T T T § T

Surface Pressure TouchExplanation to Patient:

Patients are informed that Neurpen will be used to touch areas of face, arms and legs

Examiner will say, “I want to see if you can feel this light touch. Before each trial I’m going to say “Do you feel this?”

Scoring:

Only correct discriminations are noted

Record each response on scoring sheet

Surface Pressure Touch Scoring

Surface LocalizationTest equipment needed:

1 neurometer, scoring sheet

Regions on the body to be tested:

Face (1 and 2), hand (3-6), foot (7-10)

Explanation to Patient:

Patient is requested to identify where on their body they have been touched

Responses can be verbal or on the body chart

If the patient indicates they have not felt the stimulus, it can be repeated once

Surface LocalizationProcedure:

Test is administered with the patient’s eyes closed

Neurometer is set to level one

Total of 60 trials (30 left and 30 right) are administered

Sequence of touches: 1 (unaffected side), 2 (affected side), 3 (unaffected side), 9 (affected side), 2 (unaffected side), 3 (affected side)

No sham trials

Surface Localization ScoringOnly correct localizations are recorded

Sensory ExtinctionTest equipment needed:

2 neurometers, scoring sheet

Regions on the body to be tested:

Face and hand

Explantation:

Explain to the patients that they may feel one or two touches on similar area either by itself or at the same time (e.g. hands and face)

Procedure:

Examiner sets the neurometer to level two and see if the patient can feel the stimulus on the affected side. If not, the test is discontinued.

When testing only affected arm, the individual closes their eyes and the examiner apply the neurometer until the tip just disappears before releasing.

When testing both arms, the examiner apply both neurometers simultaneously with the same testing condition.

Sensory Extinction ScoringScores are obtained for left and right brain damaged patients and are

divided into face and hand

Two-point DiscriminationTest equipment needed:

Discriminator, scoring sheet

Regions on the body to be tested:

Fingertip of index finger on both hands

Explantation:

Show the patient the discriminator and explain how it will be used to find out whether they can feel one or two points on the tip of their index finger

Procedure:

Test is administered with patient closing their eyes and other parts of the hand does not come in contact with the discriminator

Discriminator is applied to the fingertip either a single point or one of the two points within the range of 3mm - 5mm

Testing starts on the unaffected side first

Testing is discontinued if the patient fails between one and two points between the three distances

Two-point Discrimination ScoringPatients that failed to detect within 3-5 mm range are considered to

show impairment.

Temperature DiscriminationTest equipment needed: 2 Neurotemps, scoring sheet

Regions on the body to be tested: face (1 and 2), hand (3-6), foot (7-10)

Temperature Discrimination Procedure●Explanation to patient: “I am going to use these Nuerotemps to test whether

you can feel warm or cold. Just before the trial I am going to say “What’s this?” Don’t worry if you don’t feel all the trials and remember to indicate only warm or cold”

●Procedure:○ Ensure Nuerotemps are at the end of the temp window (Warm = 44-49°C, Cold =

6-10°C) prior to administering the test

○ Place Neurometer for up to 1 second on patient

○ For each of the 10 test regions 6 stimuli are presented (for a total of 60 trials)

■ 3 warm and 3 cold in the following order - WCCWWC

○ Each of the patient’s response are recorded in the corresponding box

Temperature Discrimination Scoring

Proprioception Movement/Direction Discrimination

Test equipment needed:

Scoring sheet

Joints to be tested:

Elbow (L/R), wrist (L/R), thumb or finger (L/R), ankle, toe (L/R)

Explanation to patient:

Say: “I am going to move your [elbow, etc] up and down and I want you to tell me whether you can feel me moving this joint and in which direction. Up is towards your head and down is towards your feet. Before each trial I am going to say ‘What’s this?’ Don’t worry if you don’t feel all the trials and remember only to indicate when you’re actually feel something.

Proprioception Movement/Direction Discrimination

Procedure:

Patient is given several practice trials and instructed to close their eyes

Each joint should be held by lateral surfaces

Starting position may be up to 20° either side of the mid-joint

Only move each joint approximately 20°

Each joint is moved 6 times in the following order: up, down, down, up, up down

Wait 1-2 seconds between movements

No sham trials

Proprioceptive Movement Discrimination ScoringScoring depends on the detection of movement

Movement or no movement

Proprioceptive Direction Discrimination Scoring Scoring depends on the detection of direction of movement

Up or down

References Busse, M. & Tyson, S.F. (2009). How many body locations need to be tested when assessing sensation after stroke? An investigation of redundancy in the Rivermead Assessment of Somatosensory Performance. Clinical rehabilitation, 23, 91-95. doi: 10.1177/0269215508097296Connell, L.A., Lincoln, N.B., & Radford, K.A. (2008). Somatosensory impairment after stroke: frequency of different deficits and their recovery. Clinical Rehabilitation, 22, 758-767. doi: http://dx.doi.org/10.1177/0269215508090674Helliwall, S. (2009). Does the use of a sensory re-education programme improve the somatosensory and motor function of the upper limb in subacute stroke? A single case experimental design. The British Journal of Occupational Therapy, 72(12), p. 551-558. doi: https://doi.org/10.4276/030802209X12601857794853Winward, C.E., Halligan, P.W., & Wade D.T. (2002). The Rivermead Assessment of Somatosensory Performance (RASP): standardization and reliability data. Clinical Rehabilitation, 16, 523-533. doi: http://dx.doi.org/10.1191/0269215502cr522oaWinward, C.E., Halligan, P.W., & Wade D.T. (2007). Somatosensory recovery: A longitudinal study of the first 6 months after unilateral stroke. Disability and Rehabilitation, 29(4), 293-299. doi: 10.1080/09638280600756489

Wu, C., Chuang, I., Ma, H., Lin, K., & Chen, C. (2016). Validity and responsiveness of the revised nottingham sensation assessment for outcome evaluation in stroke rehabilitation. The American Journal of Occupational Therapy, 70(2). doi:10.5014/ajot.2016.018390

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