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.
Purpose: The purpose was to evaluate the effects of a sensory
re-education programme on the somatosensory and motor function of the
upper limb in subacute stroke.
Participant: The participant was a subacute stroke patient with radiological evidence of first unilateral stroke, with motor and sensory impairments.
Procedures: Following a baseline period to establish a pattern of sensory function, a sensory re-education programme was delivered over 10 sessions. The treatment occurred three times a week on set days and was administered by a trained assistant.
Main outcome measures: The Rivermead Assessment of Somatosensory Performance (RASP) and the Upper Limb--Motor Assessment Scale (UL-MAS) were completed throughout the baseline phase and then at weekly intervals until the final day of the study. The Functional Independence Measure was completed at the start and end of the intervention phase.
Results: Surface pressure touch and surface localisation were the most impaired during the baseline phase. Proprioceptive movement and proprioceptive direction showed gradual improvement throughout the intervention phase. Conclusion: The results suggest that there may have been an effect on proprioception in the upper limb following intervention. The inconsistency during the baseline phase makes definitive conclusions difficult to draw. The change in proprioception did not have any effect on motor recovery. Further discussion is needed on the implementation of sensory re-education in the subacute stroke population.
Key words: Sensation, upper limb, subacute stroke.
(Care and treatment)
Occupational therapy (Practice)
Occupational therapy (Usage)
Proprioception (Physiological aspects)
|Publication:||Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 College of Occupational Therapists Ltd. ISSN: 0308-0226|
|Issue:||Date: Dec, 2009 Source Volume: 72 Source Issue: 12|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Sensory loss is a significant problem after stroke, with a recorded incidence of between 11% and 60% of patients (Carey 1995). The detrimental effect of somatosensory loss, particularly on motor function, is well documented (Kusoffsky et al 1982, Kandel et al 2000) and is of key importance to therapists. Taub et al (1999) suggested that learnt non-use may occur as a consequence of sensory loss and that this may lead to further deterioration in motor ability. Other consequences of reduced sensation include negative implications for functional outcome and safety (Carey 1995) and longer length of stay (Bohannon 2003).
Sensory re-education consists of the specific training of somatosensory modalities. Yekutiel (2000) described sensory re-education as 'a process in which the patient learns with the therapist's help to discover and use whatever ... sensations are available to them.' The first referenced study of sensory re-education in stroke was by Forster and Shields (1959). They described a sensory programme focusing on position sense and discrimination of objects using mirrors to maximise sensory feedback. This was a single case study that made recommendations for further work. Vinograd et al (1962) modified this programme and made an attempt to evaluate sensory and functional gain by using a subjective scoring of normal, good, fair, poor, trace and zero. The assessment measurements were identical to the treatment given and the improvements made could have been as a result of practice effect (Carey 1995). These factors compromise the validity of the positive results. Van Deusen Fox (1964) conducted the first study that was a controlled trial (AB/BA design). This study investigated the effects of pressure and cutaneous stimulation to the forearm, hand and fingers. Some improvement in finger localisation was evident; however, no statistically significant change was recorded in sensory outcome.
In the 1990s, more robust studies using control mechanisms suggested that clinical differences could be achieved through the use of sensory re-education programmes (Carey et al 1993, Yekutiel and Guttman 1993, Carey and Matyas 2005), although no randomised controlled trials exist. The control was achieved through either baseline stability measurements (Carey et al 1993, Dannebaum and Dykes 1998, Carey and Matyas 2005) or through a control group (Yekutiel and Guttman 1993).
Carey et al (1993) conducted two studies using four multiple baseline, single case experimental designs. In the first study, each stroke participant received 10 sessions of training in texture discrimination, which led to marked improvement in three out of four patients. In study 2, participants received 10 training sessions in texture discrimination and 10 in proprioceptive discrimination, whilst both sensations were measured. The results showed a significant improvement but only in the discriminative modality that was being trained at that time, concluding that the training effect appears to be stimulus specific and not transferable. A further study (Carey and Matyas 2005) showed that these skills were not transferable unless the stimuli were very similar to those used in training. The limitations of these studies are the small sample size and lack of randomisation of participants. The authors also developed specific equipment for their research, making the studies hard to reproduce (Carey et al 1993, Carey and Matyas 2005).
Yekutiel and Guttman (1993) performed a non-randomised controlled study of 20 chronic stroke participants and showed that the re-education of sensory function was transferable to modalities not actually trained. The treatment group received lessons of 45 minutes, three times a week for 6 weeks. Treatment consisted of exercises to re-educate touch, proprioception and object recognition (published in Yekutiel 2000), which shared only a few aspects with the outcome measures. The specific lessons were chosen according to the ability of the individual and from across the three categories. The exercises required the participation of the individuals in describing what they could feel. After the treatment period, the control group showed negligible changes in sensory testing whereas the treatment group showed statistically significant improvement. The identified weaknesses of the study were the lack of randomisation of the participants and the possibility of observer bias.
Yekutiel and Guttman (1993) also acknowledged that a limitation of the study was that there was no evaluation of the functional ability of the hand. It would appear that no recent studies on sensory re-education have evaluated the clinical significance of improvement in sensory ability on motor/functional outcome (Vinograd et al 1962, De Jersey 1979). Given the influence of sensation on motor function, the need for motor ability and overall function to be measured alongside sensation seems essential. Only treatment programmes that include a motor or functional component assess this effect (Byl et al 2003, Smania et al 2003).
The rationale for sensory re-education is based on the concept of neuroplasticity (Carey 1995, Dannebaum and Dykes 1998, Yekutiel 2000). The goal of sensory re-education is to increase the cortical representation of the damaged areas within the sensory cortex post-stroke (Dannebaum and Dykes 1998). Research shows functional reorganisation of the sensorimotor cortex following a 'motor' intervention (Jenkins et al 1990, Nudo 1997, Nelles et al 1999, 2001); however, no published human studies look directly at the reorganisation of the cortex as a result of sensory re-education.
The majority of the research on the effectiveness of sensory programmes uses a chronic client population. This aims to minimise the potential confounding variables, for example, the effect of spontaneous recovery, and to maximise the validity of the results (Carey et al 1993, Yekutiel and Guttman 1993, Dannebaum and Dykes 1998, Smania et al 2003, Carey and Matyas 2005). However, the recovery of somatosensory function post-stroke is greatest within the first 3 months (Carey et al 2002, Julkunen et al 2005) and further research is required to assess the response of acute / subacute patients to sensory re-education (Carey 1995).
The research question for this study was as follows:
* Does the use of a sensory re-education programme increase the somatosensory and motor function of the upper limb in subacute stroke?
The study was carried out within the inpatient setting of an acute stroke rehabilitation unit. A single case experimental design was used to allow a detailed analysis of the effect of the sensory re-education programme on an individual patient (Sunderland 1990, Domholdt 2005). This design follows that of other published research on sensory re-education (Carey et al 1993). A summary of the methods is available in Fig. 1. Ethical approval was received from the Hertfordshire Research Ethics Committee.
Recruitment criteria and process
The inclusion criteria for the study were:
* Radiological and clinical evidence of first unilateral stroke
* Within one month of onset of stroke (subacute)
* Motor and sensory impairments
* Adequate cognition and comprehension to give informed consent and participate with the intervention and outcome measures
* Patient to be an inpatient on unit for 5 weeks to enable treatment and outcome measurements to take place. An inpatient environment would be used to try to reduce the number of variables influencing the patient.
[FIGURE 1 OMITTED]
Patients who had visuospatial neglect, as shown on the Star Cancellation test (Halligan et al 1991), were excluded because this could have influenced the results of the study. Pre-existing sensory and motor problems were also exclusion criteria.
Consecutive stroke admissions were screened over a 6-month period against the inclusion and exclusion criteria. The aim of recruitment was to complete three single case experiments to allow a closer investigation of any trends in results. However, of those patients that had sensory and motor problems, 94% had inadequate communication or cognition, which excluded them from the study. Only one subacute stroke patient completed the study and is presented below. One other participant deteriorated within the baseline phase following an extension of his stroke. The participant was withdrawn from the study because the inclusion criteria were no longer met due to the development of cognitive impairments.
The participant was a 78-year-old lady, 21 days post-stroke. Her CT scan showed a left middle cerebral artery infarct, affecting her dominant side. In addition to the motor and sensory impairments, she had mild dyspraxia and mild expressive dysphasia; however, she was deemed to meet the inclusion criteria. She scored 52/54 on the Star Cancellation test and had no significant past medical history. Prior to admission, the participant was independent with mobility and all activities of daily living. Informed written consent was obtained.
The sensory re-education progamme developed by Yekutiel (2000), consisting of exercises aimed at improving touch, proprioception and object recognition, was used. The exercises were selected according to the ability of the participant and involved the whole of the upper limb. The principles of motor relearning were incorporated into the treatment, such as feedback, patient participation and motivation (Yekutiel 2000). Exercises were given as homework to the participant and relative, and compliance was recorded in an exercise diary (Yekutiel 2000). The programme was delivered over 10 sessions, lasting about 45 minutes each. The treatment occurred on Mondays, Wednesdays and Fridays at the same time to minimise variability, and over a 4-week period. The re-education programme was performed by a therapy assistant who had been trained in the programme. Examples of the exercises used appear in Appendix 1.
The participant continued to receive routine therapy because it would have been unethical to remove this treatment. The principles were based on the Bobath concept, with techniques documented and monitored so as not to include any specific sensory re-education.
The Rivermead Assessment of Somatosensory Performance (RASP) is a standardised test battery that provides a reliable and valid method of assessing sensory function (Winward et al 2002). The 'primary' subtests of the RASP were used. The assessment areas were 25mm square, at described points on the lateral aspect of the shoulder, forearm, palm and dorsum of hand. Each sensory modality was tested six times per body part, and the number of correct answers recorded per subtest. The maximum score for subtests 1-4 and subtests 5a-5b is 24 and 18 respectively.
The Upper Limb section of the Motor Assessment Scale (UL-MAS) measures the function of the upper extremity and has been researched to demonstrate its validity and reliability in stroke (Carr et al 1985, Loewen and Anderson 1988, 1990, Lannin 2004). Each upper limb item (Upper Arm Function, Hand movements and Advanced Hand Activities) contains six hierarchical tasks, with scoring ranging from 0 (unable to perform task 1) to 6 (optimal performance as patient can perform all six tasks). The maximum total UL-MAS score is 18 (Lannin 2004).
The Functional Independence Measure (FIM) is an 18-item measure that is well established in research to evaluate functional ability in stroke (Ottenbacher et al 1996, Timbeck and Spaulding 2003). It covers a wide variety of components of motor function, activities of daily living, communication and cognition. The maximum FIM score is 126.
During the baseline phase, the six subtests of the RASP were recorded on five consecutive working days over a 7-day period. This identified the participant's level of sensory function pre-intervention to act as a control mechanism. A short baseline phase was required to ensure that the participant completed the full programme of intervention prior to discharge. The UL-MAS was also recorded throughout the baseline phase. Any pattern of change would be used to identify if there was a relationship between sensory and motor function.
During the intervention phase, the RASP and the UL-MAS were recorded on a weekly basis (Thursday) and on the day after the last treatment session. The FIM was completed at the beginning and end of the intervention phase.
The measurements were collected by the researcher who followed the procedural guidelines of each measure. Potential bias was minimised by a colleague completing the scoring at the same time as the researcher, on one occasion per outcome measure, and the results compared. The outcome measures were collected at the same place and time each assessment day.
A visual analysis of the graphs and charts was used to assess any change in the data. The raw data were converted into percentage of correct responses to allow comparison between each subtest. The median values of the baseline data and of the data collected on the final assessment day were also calculated to provide a broad indication of change. Further evaluation was performed with the use of the 'slope value' to establish the rate of change. The slope value is the ratio of the change in the y-value over the change in the x-value (Domholdt 2005). Two slope values were calculated: a baseline value (from baseline day 1 to 7) and an intervention value (from intervention assessment day 10 to the final assessment day 31). The higher the positive value, the more the improvement over time; a negative value indicates deterioration.
Somatosensory results (RASP)
The baseline data of the six subtests of the RASP were converted into a percentage of correct responses and are illustrated as a line graph in Fig. 2. Table 1 shows the rate of change (slope values).
[FIGURE 2 OMITTED]
Fig. 2 shows that there were varying levels of impairment in the different subtests on assessment with the RASP. The most impaired sensations during the baseline phase were surface pressure touch (median = 38% correct responses) and surface localisation (median = 42%). Proprioceptive movement was less impaired than proprioceptive direction, with median scores of 72% and 50% respectively. There was no impairment of temperature on assessment with the RASP (median = 100%).
During the baseline phase, there were different patterns of change across the subtests. Sharp / dull discrimination had scores between 62% and 71% correct responses, with a median of 67% and a slope value of 0.830. Surface pressure touch showed significant variation, with considerable improvement overall. The slope value shows that the participant was improving by, on average, 5.123% of correct answers per day during the baseline phase. Surface localisation was very stable through this period, with scores of 42-46%. No impairment of temperature was demonstrated. The two proprioception subtests followed a similar pattern to each other, with negative slope values. Deterioration was most evident in the proprioception subtests on day 7.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
The compliance of the participant and relative to complete the homework exercises once a day was variable, with an average of three times each week. Noncompliance was recorded by the relative in an exercise diary and was due to fatigue or to the participant being anxious and unable to concentrate on the exercises.
The results of the intervention phase are shown in Table 2. This includes the median of the five baseline assessment days to allow analysis of the effect of the intervention. The slope values in Table 1 illustrate the rate of change during the intervention phase.
A more detailed presentation of the results of the baseline and intervention results per subtest is illustrated in Figs 3 and 4. The data have been converted into a percentage of correct responses.
Sharp/dull discrimination showed minimal change throughout the intervention phase, with values of correct responses between 63% and 67% and a slope value of 0.057. Further analysis of the sharp /dull discrimination data showed that it was the dull sensation that was significantly impaired. The maximum percentage of correct responses in identifying the dull sensation was 50%, compared with 100% for the sharp sensation. Surface pressure touch and surface localisation showed inconsistent results within the intervention phase. The slope values of 0.186 and 0.029 respectively suggest little change in sensory function.
The results for temperature discrimination (subtest 4) were at the ceiling level in all outcome measurement sessions, showing no change within the scores.
Proprioceptive movement and direction showed a positive effect during the intervention phase, with slope values of 1.5 and 1.029 respectively. There was a gradual improvement over the full intervention phase in both subtests, with proprioceptive movement achieving full recovery after 2 weeks of treatment.
Overall, the sensory function of the participant, as assessed by the RASP, improved through the intervention phase, with median scores of 11.5 at baseline and 17 at final assessment. The sensations that improved the most were the two proprioceptive subtests.
Motor function results (UL-MAS)
During the baseline assessments, the participant had no motor activity as detected using the UL-MAS, with a median total UL-MAS score of 0. At the end of the study, there was an improvement of 1 point in Upper Arm Function, giving a total UL-MAS score of 1.
Disability results (FIM)
The FIM score improved, with a pre-intervention score of 54 and a post-intervention score of 74.
The results of this single case experiment show that there was variation between the different types of sensation during the baseline and intervention phases. Surface pressure touch and surface localisation were the most impaired subtests during the baseline phase. Surface pressure touch improved throughout the study; however, the change was greatest pre-intervention. The proprioceptive subtests both showed gradual improvement throughout the intervention phase, with proprioceptive movement achieving full recovery after 2 weeks of treatment. The rate of change in the proprioceptive subtests was greatest within the intervention phase, suggesting a potential benefit of the sensory programme in this participant. The lack of stability during the baseline phase makes definitive conclusions difficult to draw as spontaneous recovery may also have had an effect.
Winward et al (2007) found differences in the recovery pattern of somatosensory function in the first 6 months post-stroke (n = 18). The inconsistency was seen between patients and also within patients. In this single case experiment, there was variation in surface pressure touch and the proprioceptive subtests during the baseline phase. Surface pressure touch showed inconsistency, with overall improvement throughout the baseline phase. This change cannot be linked to the intervention and may be due to spontaneous recovery. Another possible explanation is that there was a practice effect from the frequent use of the RASP within the baseline phase. This trend was not demonstrated within any of the other subtests or in previous research using the RASP (Bohls and McIntyre 2005, Winward et al 2007). The results of the two proprioceptive subtests followed a similar course to each other, with deterioration at day 7. The proprioceptive subtests were the last to be performed when completing the RASP, therefore fatigue may have been a feature; however, the decline was only evident on this day. Winward et al (2007) also found that there was no association between modalities that travelled in the same sensory pathway. The results from the present study follow this, with impairment of sharp/dull but not temperature.
Trends in sensory deficit post-stroke do exist. The pattern within this study of greater impairment in tactile sensation than proprioception has been shown in research reviewing the recovery patterns of stroke patients (Kim and Choi-Kwon 1996, Julkunen et al 2005, Winward et al 2007, Tyson et al 2008). Tyson et al (2008) assessed the sensory function of 102 anterior circulation stroke patients within 2-4 weeks of onset using the RASP: 56% of patients had impairment of tactile sensation (subtests 2 and 3) compared with only 22% with impairment of proprioception. These results are particularly relevant to the participant within this study owing to the RASP being used and the identical pathology. Suggestions to explain this trend in impairment include the fact that the proprioceptive pathways may have inputs from multiple sources and are more diffuse (Winward et al 2007, Tyson et al 2008), and that the method of assessment of proprioception may not be sensitive enough to identify impairment (Kim and Choi-Kwon 1996, Tyson et al 2008).
The most improvement within the intervention phase was seen in the proprioception subtests. The slope values changed from negative to positive values. Proprioceptive movement achieved full recovery after 2 weeks of treatment. Although spontaneous recovery may have had an effect on the results, the slope values suggest a positive effect of the intervention on the rate of change.
An improvement in proprioception has been found in participants that have received routine rehabilitation (Julkunen et al 2005, Winward et al 2007) and in those that have received specific sensory re-education (Carey et al 1993, Yekutiel and Guttman 1993, Smania et al 2003, Carey and Matyas 2005). Winward et al (2007) questioned whether there was any need for specific sensory intervention because the natural recovery pattern in participants receiving routine rehabilitation was for proprioception to improve. The most commonly used neurological approach within the United Kingdom, and by the therapists treating the participant within this study, is the Bobath concept (Lennon et al 2001). This concept uses the facilitation of activity and movement through repetitive handling to re-educate normal function. The nature of this approach encourages the individual to sense movements and to practise movement tasks that may predispose to an increase in proprioception. However, evidence of the benefit of additional sensory training in participants that received routine rehabilitation does exist (Carey et al 1993). A larger randomised controlled study is required to establish the effect on sensation of sensory re-education versus traditional neurological rehabilitation approaches.
Despite an improvement in proprioception, there was minimal motor recovery in the upper limb of the participant. This is surprising considering that previous studies have shown good correlation between sensory function and motor control (Kusoffsky et al 1982). Few studies have looked at proprioception alone and its relationship with motor recovery. Tyson et al (2008) found a weak-to-moderate relationship between proprioception and mobility, recovery and independence in activities of daily living; this included upper and lower limb scores in the analysis. There was a greater correlation when proprioception and tactile modality scores were combined. Rand et al (1999) found no significant difference in the motor and functional recovery of patients with a pure motor stroke and patients with motor and proprioceptive impairments. These studies suggest that an improvement in both tactile sensation and proprioception may be required to have a positive effect on motor control.
The total FIM score increased as a result of an improvement in the feeding, grooming, dressing and transfer categories. With negligible change in the UL-MAS, it would be most logical to suggest that these tasks were completed by the use of the unaffected arm and the lower limbs.
The requirement for adequate communication and cognition significantly limited the number of patients that were suitable for recruitment to this study, and questions the feasibility of the intervention. Adequate communication and cognition enables patients to interact and attend within the sensory programme and home exercises, and is recognised as essential to maximise motor relearning (Yekutiel 2000). The inclusion criteria within this study mirrored those of other research (Carey et al 1993, Julkunen et al 2005) and are required to maximise internal validity. However, with the programme being suitable for such a small number of patients the relevance to the subacute stroke population as a whole is significantly reduced. Further work is required to establish which exercises of the Yekutiel programme may be more appropriate for those patients with communication and cognitive deficits and if they have a positive effect. For example, concentrating on the involvement of objects used in everyday tasks may be of more benefit in patients with cognitive deficits, or using different objects that are related to the patient's particular interests.
Another implication for practice is the impact of 45 minutes of pure sensory re-education three times a week on the time resource available for rehabilitation within some National Health Service units. Consideration needs to be given as to how aspects of the Yekutiel sensory programme may be incorporated into routine therapy to deliver the potential benefits. It makes the need to involve patients and carers in homework exercises even more essential and to ensure that compliance is maximised.
The Yekutiel programme retrains a wide variety of sensations; however, it does not include sharp /dull discrimination. This is important for users to consider, particularly if the minimal improvement in sharp/dull discrimination within this study is linked to the lack of specific re-education of this sensation.
One of the limitations of this study is that the study design assesses the effect of the sensory intervention on only one stroke patient and is not, therefore, generalisable. The fact that the participant had a middle cerebral artery infarct is, however, valuable because 50% of strokes are within that territory (Ng et al 2007). Other limitations include the confounding variables that could have had an influence on the results, for example, spontaneous recovery and the effect of the routine rehabilitation.
Future research to investigate the use of this sensory programme throughout the subacute stroke patient population would be useful to understand fully the use of this intervention within stroke care. A larger study could include patients with different motor abilities, which would provide information about any relationship between sensory and motor function. Significant work on how programmes could be modified for patients with dysphasia and cognitive deficits, and how exercises are integrated into routine therapy, is also required.
The results of this single case experiment suggest that there may have been an effect on proprioception in the upper limb of a subacute stroke patient following the use of a sensory re-education programme. The inconsistency during the baseline phase makes definitive conclusions difficult to draw because spontaneous recovery may also have had an effect. The change in proprioception did not have any effect on motor recovery. Although there appeared to be benefit to the patient within this study, the need for adequate comprehension and cognition to use this sensory re-education programme made recruitment difficult.
This paper is based on research completed as part of a dissertation for an MSc in Physiotherapy at Sheffield Hallam University.
* There may have been an effect on proprioception in the upper limb of a subacute stroke patient as a result of sensory re-education.
* Motor control did not change despite an improvement in proprioception.
What the study has added
This study prompts more discussion about the implementation of sensory re-education in the subacute stroke population.
Submitted: 30 September 2008.
Accepted: 16 July 2009.
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Correspondence to: Suzanne Helliwell, Therapy Team Lead, Physiotherapy Department, Watford General Hospital, Vicarage Road, Watford WD18 9HB. Email: firstname.lastname@example.org
Appendix 1. Examples of the exercises in the Sensory Re-education Programme (Yekutiel 2000) Category Name of Method exercise/ lesson Touch Lesson 3: Look at letters I, L and O on card. Letters Discuss and identify characteristics of letters. Trace letters onto the patient's arm and see if patient can recognise which letter it is. Lesson 4: Select rough or smooth objects. Get Discrimination patient to describe the distinctive of texture characteristics of texture of objects. Move object around within patient's hand if limited movement. Identify texture. Proprioception Lesson 6: Look at four figures written on card. Guided drawing Discuss features of each figure. Take affected arm and guide the arm/hand as if drawing the figure. Identify figure. Object Lesson 12: Select two different shapes and recognition Shapes discuss the differences, that is, and their a triangle has three sides and qualities points etc. Place shape within hand and identify shape. Lesson 18: Select themed objects, that is, Object those used in morning routine. recognition Discuss, feel and identify.
Table 1. The slope values of each subtest through the baseline phase and the intervention phase Sensory subtest Baseline value Intervention value (day 1 (day 10 [right arrow] 7) [right arrow] 31) 1: Sharp/dull 0.830 0.057 discrimination 2: Surface pressure 5.123 0.186 touch 3: Surface localisation -0.264 0.029 4: Temperature 0 0 discrimination 5a: Proprioceptive -5.745 1.5 movement 5b: Proprioceptive -2.377 1.029 direction Table 2. The raw data results of the intervention phase Sensory subtest Day of intervention assessment Baseline 10 17 24 31 median 1: Sharp/dull /24 16 15 15 16 15 discrimination 2: Surface pressure /24 9 21 19 22 21 touch 3: Surface /24 10 13 15 12 14 localisation 4: Temperature /24 24 24 24 24 24 discrimination 5a: Proprioceptive /18 13 12 17 18 18 movement 5b: Proprioceptive /18 9 12 13 14 16 direction Median 11.5 - - - 17
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