Sensory Retraining

Overview
Sensory impairments are common after stroke but often not the focus of rehabilitation (Carey, 1995). There is
emerging evidence that sensation can be improved by active intervention post stroke, and that this improvement
may translate into improved function.
Principles of sensory retraining
The principles described by Carey et al (1993, p605) include:

Specific, graded stimulation tasks

Attentive exploration of the stimuli by the stroke survivor
Prevention of visual dominance
Comparison to the non-affected side
Quantitative feedback on outcome and performance
Use of anticipation
Summary feedback

Principles described by Yekutiel and Guttman (1993, p 242) include:

The nature and extent of the sensory loss are explored (verbally and physically) with the stroke survivor who
is often unaware of it
Emphasis is placed on sensory tasks the stroke survivor can do and these form the start and end of the
session
Sensory tasks are chosen which interest him/her and which promise to lead to sufficient failures and
successes to promote learning
Constant use is made not only of vision but also of the less affected hand to teach tactics of perception
Frequent rests and change of subject are needed to maximise concentration
No task or object used in the testing of sensation may be used in training

Whilst there are similarities between the two authors, there are two major differences the use of vision (or not)
and the use of assessment tasks as training tasks (or not).
Byl et al (2003, p177 and 180) reports principles based on neuroplastic processes in their sensory training program:

Supervised, rewarded, repetitive

Matched to the ability of the stroke survivor
Clear feedback on performance
Task-oriented
Sensory and motor practice
Stress free movement (relaxed)
Activities spaced over time
Progressed in difficulty always working at level of achievement
Reinforced by constraint of the unaffected limb and
Mental, mirror and specific task practice at home

Funded by the former Rural Stroke Outreach Service, Royal Brisbane and Womens Hospital, Queensland Health. The input of the Centre for
Allied Health Evidence, University of South Australia, is gratefully acknowledged.

Research
The research literature reflects two aspects of sensory retraining:

Sensory-specific training (Carey et al, 1993, Yekutiel and Guttman, 1993, Byl et al, 2003, Hillier and Dunsford
2006, Lynch et al 2007)
Sensory-related training (Carey and Matyas, 2000, Morioka et al 2007).

The distinction lies in the latter offering a more overt link between sensory appreciation and limb tasks during
training. This is argued to facilitate the transfer of enhanced sensory appreciation into real life functionality (Carey
and Matyas, 2000). The former is therefore directed more at the specifics of sensory strategies, awareness,
discrimination and recognition, with an expectation of transference.
There is evidence for both aspects (levels III-2 and 3) improving sensation (Carey et al, 1993, Yekutiel and Guttman,
1993, Byl et al, 2003, Hillier and Dunsford 2006, level II Lynch et al 2007, Morioka et al 2007) with some indication of
carryover into functional improvement.

Application for the upper limb

Example 1 (Carey et al, 1993):
The training tasks are based on the two assessment tasks texture discrimination (Tactile Discrimination Test) and
proprioceptive discrimination.

stroke survivors tactually explore a set of comparison surfaces with their preferred fingers, or the therapist
can support the weight of the hand, allowing the preferred finger to rest in an extended position, and
moving the hand as a unit, guiding the finger across the surface. The stroke survivor indicates which texture
is different (eg one will be different from the other four). Attentive exploration is encouraged and vision is
occluded. Feedback is provided on accuracy of judgements by showing stroke survivors the correct stimulus
and highlighting actual differences of textures. The stroke survivor compares how the stimulus felt with the
other hand and verbalises sensations from both hands.
The proprioceptive discrimination task uses a device to hold the wrist in predetermined angles. The stroke
survivor has their hand placed passively in one of 20 possible positions and is then asked to replicate the
angle with a protractor device. The training starts with relatively coarse distinctions between actual joint
angle and perceived joint angle and progresses with finer stimulus differences as dictated by successful
discriminations.

Example 2 (Yekutiel and Guttman, 1993, p242):

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Stroke survivors are asked to identify the number of touches or lines and the numbers and letters drawn on
the arm and hand
They are asked to find their thumb whilst blindfolded (therapist moves the limb to new positions)
discriminate the shape, weight and texture of objects or materials placed in their hand
passive drawing where the therapist holds the stroke survivors hand (whilst they hold a pencil) and draws
simple figures (four different figures which they are familiar with from the same figures on prompt cards)
and the stroke survivor then has to identify which figure has been drawn
This latter can be progressed as proprioception improves to writing messages the two hands are used
alternately.

These and like activities are performed for 45 mins x 3 per week, for 6 weeks.

Example 3 (Byl et al, 2003, table 2, p180):

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Use stress-free hand strategies in all functional activities

o Use the hand in a functional position (palm and fingers rounded gently, palm off surface)
o Let the sensation of objects open the hand (shape the hand around the object)
o Hold objects with the least force possible and feel everything about the object with different fingers
o Perform common functional activities with the eyes closed to heighten sensory part of task
o Thread the fingers together (one hand over the other while the palm is down) and facilitate the
maintenance of the carpal and oblique arches of the hand by feeling the fingers in the palm
Improve sensory discrimination
o Watch videotape demonstrating sensory activities (common motor tasks where sensation is
important)
o Play games/fine motor activities with eyes closed to force you to feel the shape that you need (play
dominoes, dice, pick up sticks, Scrabble, Solitaire with Braille cards)
o Learn to read Braille books
o Place coarse and unusual surfaces on objects frequently handled to help control excessive force (eg
put sand paper or rough Velcro on pens, toothbrush, eating utensils, keyboard)
o Place hand into box filled with rice/beans and objects retrieve/match objects (eg safety pins)
Improve accuracy by having another person do the following with the stroke survivor:
o Graphesthesia replicate drawings of letter, numbers, figure drawn on the skin of hand/digits
o Localisation touch stroke survivor on the digit and hand and have them put finger on the spot
where touched (eyes closed)
o Stereognosis eyes closed, interpret information about an object through exploration and touch
with the glabrous aspects of the finger (match it, play a game with object, play cards)
o Proprioception move the stroke survivors upper limb from a starting place to a new place, keeping
the index or the middle finger for pointing and have the stroke survivor replicate the movement; on
own, stroke survivor practices moving accurately from different positions to different targets with
eyes closed.
Quiet the nervous system
o Facilitate normal movements following light sensory stimuli (eg light touch)
o Put on a t-shirt without putting the arms through the sleeves (keeping the arms inside next to the
trunk) or wrap up in a blanket and rock in a rocker to quiet the nervous system
o Place the elbow, wrist and fingers in shortened positions to discourage excessive firing
o Put cloth tape on the skin to increase sensory information
Reinforce learning with mental rehearsal
o Put the unaffected hand in front of a standing mirror and put the affected hand behind the mirror;
look at the mirror image and imagine it is your affected hand.
o Feel different objects with both hands and make them feel the same
o Find a quiet place and mentally practice and rehearse how things feel when they are being used in
normal movements (15 min. a day).
This program runs for four weeks, 1.5 hours supervised plus home program per week.

Application for the lower limb

Example 1 (Hillier and Dunsford 2006, Lynch et al 2007)
The training tasks are based on the hierarchy of assessment tasks. The inclusion of sensory retraining protocols
within stroke rehabilitation is recommended where the overall clinical assessment indicates sensory impairment is a
major contributing factor in the activity restriction/s of the stroke survivor.
These may take the form of

education (the stroke survivor learns to understand the nature and implications of their sensory loss),
specific practise in the hierarchy of sensory appreciation (detection, discrimination, recognition,
proprioception) and
related functional tasks that require the use of sensory input to complete mobility functions. The focus is on
mastery of each stage, immediate feedback and reinforcement, reiteration of all components and goal
setting. Sensory retraining techniques which are carried out in an enriched environment, are interesting,
active and demanding, and are socially stimulating are far more likely to result in neuroplastic changes
(Yekutiel, 2000). When practising sensory tasks, the aim is to assist the client with their own discovery of
different sensations. The unaffected limb is often used to facilitate this learning process. The focus is also on
the abilities rather than the disabilities of the stroke survivors; working collaboratively with them to achieve
client-focused goals; and to share knowledge and control.

A suggested program incorporating the following aspects has been adapted from the upper limb protocols by
Yekutiel 2000 and Carey 1993 for each task a map of the foot is recorded to feed back to the client.

Light touch detection: via Semmes-Weinstein monofilaments to deliver known pressure do you feel this (yes/no). Can increase sensitivity using full range of monofilaments, or can simplify and
just use a tissue.
Localisation: same stimuli but different request - where do you feel this (point or describe). Can include
sensory inattention/extinction by including bilateral stimuli randomly throughout this level response
should acknowledge two sites.
Temperature discrimination: via two test tubes of icy water and hot tap water (35-40) is this hot or cold
(hot/cold)
Light touch discrimination: via toothpick and tissue is this sharp or blunt (sharp/blunt)

More advanced training can include:

Surface recognition: offer stroke survivor five different floor surfaces including tiles, sand, pebbles, carpet
and linoleum what is this surface and/or what temperature/texture/material.
Proprioception: Distal proprioception test is your big toe pointing up or down (externally manipulate toe
into flexion or extension, randomly five times). Alternatively a flat board can be applied to the foot o move
the ankle into varying degrees of plantar and dorsi-flexion with the client instructed to copy the angle on the
other ankle or to describe if the foot is pointing more up or down (more DF or PF).
Limb Copying can you put your other foot/leg in this position (externally manipulate affected lower limb
into five random positions for less-affected lower limb to copy).

Example 2 (Morioka and Yagi, 2003)

In this protocol, clients are asked to stand on different rubber mats these have different densities and the client is
instructed to determine the relative hardness of the surface.

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Example 3 (Chung et al 2006)

Clients follow a computer generated variable frequency to signify to increase or decrease knee flexion practice leg
standing on wooden box and the other on digital scales to monitor weight bearing

Considerations

Stroke survivors with right sided CVA potentially will respond less well than stroke survivors with left CVA, as
the sensory disturbance of the former may be part of a wider perceptual disturbance or hemi-neglect.
Monitor for functional carry-over
Cognition of stroke survivor and motivation levels: stroke survivors will need to be motivated and able to
attend to, and articulate, the sensory impressions if this therapy is to be successful,
Intensity of time required to have a successful outcome.

Readings and references

Byl N, Roderick J, Mohamed O, Hanny M, Kotler J, Smith A, Tang M, Abrams G. Effectiveness of sensory and motor
rehabilitation of the upper limb following the principles of neuroplasticity: patients stable after stroke. Neurorehabil
Neural Repair. 2003;17: 176-191.
Carey LM. Somatosensory loss after stroke. Critical Rev Phys Rehabil Med 1995; 7: 51-91.
Carey LM, Matyas, TA & Oke, LE. Sensory loss in stroke patients: Effective training of tactile and proprioceptive
discrimination. Arch Phys Med Rehabil 1993; 74: 602-611.
Carey L, Matyas T. Somatosensory discrimination after stroke: Stimulus specific versus generalisation training. In:
Bennett K, Gregory S, editors. Perception for action: proceedings from the Third Annual Perception for Action
Conference. Melbourne: Cleveland Digital Printing; 2000: 61-72.
Hillier SL, Dunsford AF. A pilot study of sensory retraining for the hemiparetic foot post stroke. International Journal
of Rehabilitation Research 2006: 29(3): 237-242.
Lynch EA, Hillier SL, Stiller KS, Campanella RR, Fisher PH. Sensory retraining of the lower limb after acute stroke: A
randomised controlled pilot trial. Arch Phys Med Rehabil 2007: 88: 1101-7.
Morioka S, Yagi F. Effects of perceptual learning exercises on standing balance using a hardness discrimination task in
hemiplegic patients following stroke: a randomized controlled pilot trial. Clin Rehabil. 2003:17(6):600-7.
Yekutiel M & Guttman E. A controlled trial of the retraining of the sensory function of the hand in stroke patients. J
Neurol Neurosurg Psychiatry. 1993; 56: 241-244.
Yekutiel M. Sensory re-education of the hand after stroke. 2000;Whurr Publishers, London.

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