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RehabMeasures Instrument

Nottingham Assessment of Somato-Sensations

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Purpose

The NSA has been used in clinical trials following stroke to test interventions such as electrical stimulation and task specific training.

Link to Instrument

Instrument Details

Acronym NSA

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

Cost not known

Diagnosis/Conditions

  • Stroke Recovery

Populations

Key Descriptions

  • Multi-modal sensory examination includes tests of:
    1) Tactile sensation (light, touch, touch localization, temperature discrimination, pinprick sensation, bilateral simultaneous stimulation)
    2) Kinesthesia
    3) Stereognosis
  • Tactile scoring:
    0) Absent – fails to identify the test sensations on 3 trials
    1) Impaired – identifies the test sensation, but not on all 3 trials in each region of the body of feels duller
    2) Normal – correctly identifies the test sensation on 3 trials
  • Stereognosis scoring:
    2) Normal – item is correctly named or matched
    1) Impaired – some features of object identified or attempts descriptions of objects
    0) Absent – unable to identify the object in any manner
  • Kinesthesia scoring:
    0) Absent – no appreciation of movement taking place
    1) Appreciation of movement taking place – indicates on each movement that a movement takes place but the movement direction is incorrect
    2) Direction of movement sense – able to appreciate and mirror the direction of the test movement, but is inaccurate in its new position
    3) Joint Position Sense – accurately mirrors the test movement to within 10 degrees of the new test position

Number of Items

3

Equipment Required

  • For tactile sensation: blindfold, cotton ball, Neurotip, 2 test tubes for hot and cold water, talcum powder.
  • For sterognosis assessment: blindfold, 2 different coins, pen, pencil, comb, scissors, sponge, piece of flannel cloth, cup, glass.

Time to Administer

60 minutes

Entire test can take up to 60 minutes, depending on client's sensory impairment.
Kenesthesia and Sterognosis tests takeapproximately 15 minutes each.

Required Training

Training Course

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jane Sullivan, MPT, DHS and the Stroke EDGE task force in 2011.

ICF Domain

Body Structure
Body Function

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

UR

UR

UR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

NR

NR

NR

NR

NR

StrokEDGE

NR

UR

UR

UR

UR

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

NR

NR

NR

NR

 Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

No

No

Yes

StrokEDGE

No

Yes

Yes

Yes

Considerations

It is unlikely that the entire test will be performed in any of these practice settings, however components of the test may be appropriate if the systems review/screening exam indicates sensory loss and/or if sensory loss is hypothesized to underlie the patient’s movement dysfunction. 

Clinical utility is poor due to the time to complete the entire test and the need for specific equipment that may not be available in the clinic (e.g. neurotip). The stereognosis and kinesthesia subscales have better clinical utility (equipment and time). Those two tests may be more appropriate for use in the clinic that they use standardized equipment procedures and have some acceptable psychometric data available. 

The inclusion of sensory outcome measure in clinical trials could advance knowledge by identifying those intervention that are associated with sensory improvement as well as helping to determine those client characteristics (beyond motor and functional status) that are associated with improvement following selected interventions. This information would assist clinicians to target appropriate interventions based on client baseline characteristics.

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Stroke

back to Populations

Interrater/Intrarater Reliability

Stroke:

(Lincoln NB et al, 1991; n = 20 acute stroke patients)

Inter-rater

  • Assessed by two physical therapists within 2-52 days of each other. Kappa coefficients = 0.01-0.89; only 1 item k >0.7

Intra-rater

  • One physical therapist tested patients on two occasions between 2-52 days apart. Kappa coefficients = -0.13-0.92; k >0.7 for 17/54 items

 

(Lincoln NB et al, 1998; n = 27 stroke patients)

  • Kappa coefficients showed acceptable agreement on 12 out of the 86 items for inter rater reliability. Light touch and pressure scales were most reliable and pin-prick and temperature scales were least reliable
  • For inter rater reliability of the stereognosis subtest reported kappa coefficients 0.38 to 1.0. Coefficients were higher on the unaffected side and for certain items (scissors, sponge, cup) Intracranial Disorders: 

 

(Stolk-Hornsveld F et al, 2006; = 18 inpatients; mean age = 57.7 years; diagnosed with intracranial disorder)

  • Intra rater and inter rater reliability of the Erasmus MC modifications to the Nottingham Sensory Assessment (EmNSA), kappa coefficients 0.58 to 1.00. Two-point discrimination was less reliable 0.11 to 0.63. Inter rater reliability of EmNSA, kappa coefficients of 0.46 to 1.00. Two-point discrimination was less reliable of 0.10 to 0.66

Stroke: Stereognosis Assessment

(Gaubert CS and Mockett SP; 2000, n = 20 stroke patients ( 3.85±2.78 weeks post-stroke)

  • The stereognostic ability of the subjects was assessed using the NSA procedures by 2 of 3 examiners within a 24-hour period.

  • Kappa values ranged from 0.42 (moderate) to 0.85 (almost perfect) between Examiners 1 and 2

  • Kappa values ranged from 0.38 (fair) to 0.84 (almost perfect) between Examiners 1 and 3

  • Kappa values ranged from 0.40 (fair) to 0.80 (substantial) between Examiners 1 with Examiners 2 and 3.

For all 3 levels of comparison, the lowest Kappa value was for the pencil item.

Criterion Validity (Predictive/Concurrent)

Stroke:

(Connell LA et al, 2008; n = 70 stroke patients)

  • Upper limb tactile sensation at rehab admission (within 6 wks of stroke onset) predictive of upper limb tactile sensation at 6-months post-stroke (R2 =0.554; p < 0.001)

  • Lower limb tactile sensation at rehab admission (within 6 wks of stroke onset) predictive of lower limb tactile sensation at 6-months post-stroke (R2 =0.464; p < 0.001)

  • Stereognosis and proprioception at rehab admission (within 6 wks of stroke onset) predictive of stereognosis at 6-months post-stroke (R2 =0.709; p < 0.001)

  • Proprioception and upper limb tactile sensation at rehab admission (within 6 wks of stroke onset) predictive of proprioception at 6-months post-stroke (R2 =0.510; p < 0.001)

(Meyer et al, 2016; n = 32 acute stroke patients)

  • Proprioception (movement sense) as measured by the Erasmsus MC (revised) NSA at one week post-stroke, moderately predicted motor ability at 6-months post-stroke as measured by the UE Fugl-Meyer (Spearman ? = 0.27), the Motricity Index (Spearman ? = 0.27) and the Action Research Arm Test (Spearman ? = 0.26).

  • Stereognosis measured by the NSA at one week post-stroke moderately predicted motor ability at 6-months post-stroke as measured by the UE Fugl-Meyer (Spearman ? = 0.41), the Motricity Index (Spearman ? = 0.37) and the Action Research Arm Test (Spearman ? = 0.56).

Construct Validity

Stroke:

(Scalha et al, 2011; n = 20 stroke patients (> 2 yrs post-stroke)

  • Total Fugl-Meyer (FM) UE Sensation (proprioception and light touch) correlated with UE Nottingham Stroke Assessment (NSA) score; Spearman’s r=0.691; p<0.001)

  • UE FM arm light touch correlated with NSA tactile sensation subscale (p< 0.005)

  • UE FM palm light touch correlated with NSA tactile sensation subscale (p<0.005)

  • UE FM shoulder/elbow proprioception correlated with NSA proprioception subscale (r=0.586; p=0.007)

  • UE FM wrist/hand proprioception correlated with NSA proprioception subscale (r=0.75;p < 0.001).

Bibliography

Stolk-Hornsveld, F., Crow, J. L., et al. (2006). "The Erasmus MC modifications to the (revised) Nottingham Sensory Assessment: a reliable somatosensory assessment measure for patients with intracranial disorders." Clin Rehabil 20(2): 160-172. 

Lincoln, N., Jackson, J., et al. (1998). "Reliability and revision of the Nottingham Sensory Assessment for stroke patients." Physiotherapy 84(8): 358-365. 

Lincoln, N. B., Crow, J., et al. (1991). "The unreliability of sensory assessments." Clinical rehabilitation 5(4): 273-282. 

Meyer S, De Bruyn N et al. (2016). Associations Between Sensorimotor Impairments in the Upper Limb at 1 Week and 6 Months Post-Stroke. JNPT 40:186-195. .

 

Scalha TB, Miyasaki E et al. (2011). Correlations between motor and sensory functions in upper limb chronic hemiparetics after stroke. Arq Neuropsiquiatr 69(4): 624-629. .

 

Connell LA, Lincoln NB, Radford KA (2008). Somatosensory impairment after stroke: frequency of different deficits and their recovery. Clin Rehab 22: 758-767,

 

Gaubert CS and Mockett SP (2000). Inter-rater reliability of the Nottingham method of stereognosis assessment. 14: 153-159.