The effects of aging on sensory parameters of the hand and wrist
Background & aims. It is generally accepted that there arises a decrease in sensory integrity with aging. Despite so much emphasis on the lower extremity, studies have not focused sufficiently on agerelated sensory changes in the hands and wrists. The aim of our study is to evaluate the hand and wrist sensory parameters of young and geriatric people and to reveal the sensorial differences in young and geriatric hands.
Methods. 60 elderly and 60 young individuals were included in our study. The 3D Motion Sensor mOOver® was used to assess joint position sense. Baseline Pneumatic Bulb Dynamometer® device was used to assess the grip sensitivity. The hand pressure sensitivities was evaluated with Stabilizer Pressure Biofeedback®. The vibration senses, sensory threshold and two-point discrimination were evaluated. Results. Joint position sense error rates of all movements of dominant and nondominant wrists and errors of grip and pressure sensitivity, sensory threshold and two points discrimination distance were found lower in youths (p = 0.000). Sense of vibration’s duration was found higher in youths (p = 0.000).
Conclusions. Our results are of great importance in terms of demonstrating how aging affects sensory changes in the hand and wrist. Adequate and accurate assessment of the sensory parameters in the hand and wrist will be able to enable the accurate detection of pathologies that may be encountered in this region. This data will help professionals working in the fields of geriatric rehabilitation and hand rehabilitation to predict changes in sensory parameters and to design protective rehabilitation and treatment programs.
The hand and wrist commonly use in our daily and occupational lives. With the combination of motor and sensory parameters of the hand and wrist, more effective movements come out in our daily living activities. In order to maintain their social lives and daily living activities, the hand and wrist senses are just as important for geriatric group as the young individuals. It is known that the sensory continuity of the hand and wrist is important in fulfilling the functions of the aging hand 1. Although the effects of aging on dysfunctions of the hand and wrist of healthy elderly individuals are still not well understood, the hands undergo many physiological and anatomical changes associated with aging 2. When the literature is examined, there are studies showing that the joint position sense 3,4, vibration 5, sensory threshold 6 and two-point discrimination 7 of the hand and the wrist are negatively affected as a result of the aging. However, no studies that show what an effect the senses of grip and pressure sensitivity, which are known to be a parameter of the proprioceptive sensation, healthy aging, have on the hand and the wrist have been encountered in the light of our current knowledge.
Disorder of the senses of hand and wrist, which have an important role in daily life activities, due to various reasons that arise with aging reduces the quality of life and independence of the geriatric population 8. It is generally accepted that there arises a decrease in sensory integrity with aging. However, despite so much emphasis on the lower extremity, studies have not focused sufficiently on age-related sensory changes in the upper extremity, even in hands and wrists, and the effects of these changes 2,8. No matter how important and different the characteristics of each part and all internal and external organs of the human body are, the hand and wrist have their own specific sensorial and motor characteristics 9. Sensorial and functional development of the wrist, hand and fingers allows the individual to easily gain experience in the social environment. Meanwhile, it is also important in terms of self-care skills and academic developments of the individuals 10. Just like the eyes, the hand is a very significant sensory organ allowing us to perceive our environment. Thanks to many sensory receptors found in the skin and deep tissues, the hand, which can be considered as an information organ, connects with the brain. These connection forms are extremely complex and detailed. The fact that more than 1/3 of the entire primary motor region of the brain belongs to the hand summarizes what a privileged organ the hand is 11. The very complicated and coordinated functions of the hand require a rich source of motor and sensory innervation of the regional muscles, skin and joints 12. There are big differences between different regions of the body in terms of density of the sensory receptors. However, the receptor density decreases with the advancing age 2,4.
Degenerations in the central and peripheral nervous system with aging influence the sensation of the hand and wrist 8. Understanding the somatosensorial system of the hand and wrist is important for clinicians working in the field of geriatric rehabilitation and hand and upper extremity rehabilitation. Even though there are studies in the literature that aging affects the sensation of the hand and the wrist 3,4,6,7, in the light of our current knowledge, no studies in which the joint position sense, grip sensitivity, pressure sensitivity, vibration, sensory threshold and two-point discrimination sensations of the hand and the wrist in young and old people were evaluated together have been encountered. Therefore the aim of our study is to evaluate the hand and wrist sensory parameters of young and geriatric people and to reveal the sensorial differences in young and geriatric hands and wrists.
MATERIALS AND METHODS
The residents of Kadikoy Yasam Nursing Home in Maltepe district of Istanbul city, the geriatric individuals living in Maltepe district, the young individuals continuing the university education and the individuals living in Uskudar district and accepted to participate in the study were included in our study. The study included 60 geriatric individuals and 60 young individuals. Ethical approval for the study was obtained from the Non-Interventional Clinical Research Ethics Committee of Istanbul Medipol University (10840098-604.01.01-E.13018). Geriatric individuals, the results of whose routine examinations in retirement homes and family practice clinics indicated no pathology in the upper extremities, and young individuals, whose upper extremity muscle strength and normal joint motions were considered to be gross were invited to the study. Individuals who accepted the invitation were re-evaluated according to exclusion and inclusion criteria before they were included in the study and those who were not considered appropriate were excluded from the study. The study inclusion criteria for the cases were to be between 20 and 25 years of age and between 70 and 75 years of age, to have verbal communication ability to answer questions, to volunteer to participate in the study. The study exclusion criteria for the cases were to have a skin injury, an open wound posing a risk of infection, a posture problem in the upper extremity, a rheumatic disease, a neurological disease, an orthopaedic problem in the hand and wrist and to have a severe mental and cognitive problem. Information was given about the study to the 120 individuals who were deemed appropriate and agreed to participate in the study and they were asked to sign the informed consent form required by Istanbul Medipol University Non-Interventional Clinical Ethics Committee.
All assessment were made by a same physiotherapist, in a well-ventilated the same physiotherapy and rehabilitation laboratory, at the same time interval (13:00-15:00), at the same room temperature and under the same lighting.
The joint position sense (JPS) assessment was performed using the 3D Motion Sensor mOOver®. JPS assessment was performed all axes of movements of the wrist based on the principle of repeating the previously determined target angle with active movement. The target angles used for the assessment were determined to be 30° for flexion and extension, 10° for radial deviation and 15° for ulnar deviation. After positioning the wrist at the target angle prior to the measurement with the device’s own software, which gives visual feedback, individuals were asked to keep this position in mind and then to put the wrist into the same position. The angles of participant’s wrist position axes were noted and the absolute value of the difference between the target angle and position angle was recorded as the amount of “Joint Position Sense Error”. Measurements were repeated three times for each movement and the arithmetic mean of three error values was recorded as the amount of wrist JPS error 13-15.
Baseline Pneumatic Bulb Dynamometer® (BPBD) device was used to assess the grip sensitivity. The maximum grip strength was measured with the BPBD device, after then 50% of the maximum grip strength was determined as the target force and participant was told to apply the target force by showing the indicator of the device and was asked to keep this force in mind and apply again. This time, participant again applied the target force without showing the indicator and the difference between the target force and the force applied by participant was recorded as the absolute value. Measurements were repeated three times and participant’s “Grip Sensitivity Error” was noted by calculating the arithmetic mean of the error values 16-18.
Stabilizer Pressure Biofeedback® (SBP) device was used to assess the pressure sensitivities of the participants’ hands. The SBP device was first inflated up to 20 mmHg. The maximum pressure that could be applied on the pressure unit of the device by the palmar surface of the hand was measured. Half of the measured maximum pressure force was determined as the target pressure value and participant was asked to keep the target pressure value in mind by showing the manometer of the device. Participant, who kept this pressure in mind, was told that s/he would repeat the application. This time, participant was asked to apply the determined target pressure without showing the manometer and the absolute value of the difference between the target pressure and the pressure applied was noted. This application was done in the form of three repetitions and the arithmetic mean of the error values was calculated and recorded as “Hand Pressure Sensitivity Error” 19-21.
A 128 Hz diapason was used to assess the vibration on the head of ulna. Patient was asked to remain silent after feeling the vibration until finishing to feel it, and to tell when the sensation was over. The elapsed time was recorded in seconds 22,23. The Semmes-Weinstein Monofilament Test (SWMT) was used to assess the sensory threshold 24. The static two-point discrimination assessments were carried out from the distal ends of the all fingers by two point discriminator 25.
In the statistical analysis of data obtained in our study, Windows-based SPSS (IBM SPSS Statistics, Version 23.0, Armonk, NY, USA) package program was used. The sample size was calculated based on an observed effect size of d = 0.38 reported for the two point discrimination changes for age groups 7. To achieve 80% power to detect a difference with 95% confidence using two tailed test, a sample size of 53 participants was required for each group 7. “One-Sample Kolmogorov-Smirnov Test” was used to confirm the normal distribution compatibility of the data. Parametric tests were performed in the analysis since all data were normally distributed. Descriptive statistical information was demonstrated in the form of mean ± standard deviation (x̄ ± SD). Independent-Samples t Test was used in the comparisons of wrist joint position senses, grip and pressure sensitivities, sensory threshold and two-point discrimination and vibration durations according to age groups. The statistical significance level was accepted as p < 0.05.
60 young individuals (30 females, 30 males) whose ages ranged between 20 and 25 with a mean age of 21.61 ± 1.58 years and 60 geriatric individuals (30 females, 30 males) aged between 70 and 75 with a mean age of 71.68 ± 1.61 years, a total of 120 individuals participated in the study.
RESULTS AND COMPARISONS OF JOINT POSITION SENSE ASSESSMENT
A statistically significant difference was found between the young group and the geriatric group in terms of all directions of movement of the wrist (p = 0.000) (Tab. I).
RESULTS AND COMPARISONS OF GRIP SENSITIVITY AND PRESSURE SENSITIVITY ASSESSMENT
The error amounts of grip sensitivity and pressure sensitivity were found to be significantly lower in young individuals (p = 0.000) (Tab. II).
RESULTS AND COMPARISONS OF VIBRATION SENSATION ASSESSMENT
There was a statistically significant difference in both the dominant extremity and the nondominant extremity when the young group and the geriatric group were assessed in terms of vibration sensation durations (p = 0.000) (Tab. II).
RESULTS AND COMPARISONS OF SENSORY THRESHOLD ASSESSMENT AND TWO POINT DISCRIMINATION ASSESSMENT
There was a statistically significant difference between the young group and the geriatric group at the distal end of all fingers (p = 0.000) (Tab. III).
Although studies 26-31 on sensory parameters in the literature have been commonly conducted in areas such as knee, ankle, shoulder and spine, it was found that the number of studies on the hand and wrist was limited. A study investigated the age-related changes occurring in the joint position sense of the human hand in 2012 revealed that aging affected the joint position sense negatively 4. It has been shown that JPS decreases with aging due to the changes in the muscle spindle function 32. Additionally, with the advancing age, a decrease is observed in JPS as a result of myelin abnormalities, axonal atrophy, and decrease in nerve conduction speed as well as the decrease in the sensory input processing and neuromuscular performance 33. When examined at a central level, there are studies showing that the somatosensory system is negatively affected by normal aging 34,35. Aging causes JPS to be affected negatively by leading to gradual reduction of the dendrites in motor cortex 32, losses in the number of neurons and receptors and neurochemical changes in the brain 32,36. As seen in the literature, it can be concluded that JPS, which is assumed to be one of the significant parameters of proprioceptive sensation 35, decreases as a result of age-dependent changes in the central and peripheral nervous system 29. Our results that negatively affects JPS supports the literature. It may be considered that age-related negatively affected joint position sense, which is one of the most important parameters of the proprioceptive sense, will lead to a reduction in the functionality of the hand and wrist, and will lead individuals to have difficulties in their daily living activities.
It was seen that there were not many studies in the literature on hand pressure sensitivity and grip sensitivity assessments 19,26. An article investigated the Parkinson’s disease-related pressure sensitivity sense, pressure sensitivities in different regions of the body were investigated and statistically negative differences were found in the pressure sensitivities of 11 different body points of 29 patients diagnosed with Parkinson’s disease 37. A study conducted by Ünver in 2017 investigated the changes in the sole pressure distribution of healthy elderly and young individuals, and emphasized that the sole pressure distributions in the elderly individuals were affected negatively, and that this resulted in falls 38. Despite the fact that the change in pressure sensitivities in different regions of the human body has been demonstrated to lead to negative results by these two studies, it is interesting that there was no study investigating the hand-related pressure sensitivity which is very important in terms of upper extremity functionality. The grip and hand pressure sensitivity is considered as a component of the proprioception 16,17. If we consider that pressure sensitivity is a parameter of proprioceptive sense, it can be used quickly and reliably by physiotherapists to evaluate proprioception in the hand and wrist.
Another technique that we investigated what kind of age-related change may occur in the hand and wrists is the assessment of vibration sensation. A study conducted by Özay et al. in 2012 argued that balance training provided to neuropathic patients due to type II diabetes has improved the vibration sensation and contributed to the gait 39. A study of Akseki et al. conducted on patients with patellofemoral pain syndrome indicated that as the perception of joint position sense worsened, the duration of vibration sensation shortened 27. These two studies have shown us that the vibration sensation had a very important role in measuring the proprioceptive sense and acquiring the functionality. The assessment of the vibration sensation can be used to determine the proprioceptive sensory loss and functional loss that may occur due to aging.
When we analysed the sensory threshold, the tactile sense threshold in all the fingers have increased in the negative direction with aging. It has been reported in the literature that SWMT, which is accepted as one of the most objective tests in the evaluation of tactile sensation, should detect 0.0677 grams monofilament as the normal sensory threshold value 24. In our current study, the mean weight felt in all fingers of the dominant extremity of the geriatric individuals was 3.48 ± 1.00 grams, and the mean weight felt in all fingers of the non-dominant extremity was 3.74 ± 0.85 grams. This results are interpreted as “decreased protective sensation” and “loss of protective sensation” in respect of tactile sensation in both extremities. A study conducted by Bowden et al. in 2013 investigating the age-related changes in the cutaneous sense of the healthy human hand obtained similar results with our study 6. The age-related negative affection of the sensory threshold may prove that the intensity of receptors required to perceive the tactile sense of the fingers, which is the distal region of the upper extremity, may reduce with aging, or that the perception power of tactile sensory receptors that will affect the daily life may naturally get weaker.
Another sensory parameter we have assessed in our study is the two-point discrimination. It was found in our study that the sense of static two-point discrimination was affected negatively in all fingers in both extremity depending on age. When the literature is reviewed, the most important classification used in the static two-point discrimination is the classification defined by the American Society of Hand Therapists 40. According to this classification, it is defined as “normal” between 0-5 mm, “decreased” between 6-10 mm, and “anesthesia” for inability of detection 40. According to the results, all the fingers had a “decreased” sense in our current study when the static two-point discrimination sensation values of dominant and nondominant extremities were examined. A study of Kaneko et al. included healthy participants aged between 20 and 79 years indicated that the static and moving two-point discrimination senses of participants above 60 years of age were affected negatively in the thumb and the little finger 7. It may be considered that receptors perceiving the two-point discrimination are stimulated by proprioceptive exercises since it is transmitted to the upper centers through proprioceptive pathways, and that the sense of two-point discrimination can also be improved in the geriatric hand.
The method of movement repetition, which was measured the joint position sense, grip and pressure sensitivity; it could be considered as one of the limitations of our study because it was influenced by many factors such as intellectual level, memory ability and learning.
Our results are of great importance in terms of demonstrating how healthy aging affects sensory changes in the hand and wrist. In our study, key evidence on many aspects of the hand and wrist sensory parameters has been provided for clinicians, working in the fields of geriatric rehabilitation and hand rehabilitation. This data will also help predict changes in sensory parameters that may occur in hand and wrist with aging and to design protective rehabilitation studies and treatment programs.
Figures and tables
|JPS||Young groupx̄ ± SD (°)||Geriatric groupx̄ ± SD (°)||pa|
|Dominant extremity||Flexion||3.95 ± 1.52||5.91 ± 0.97||.000|
|Extension||4.05 ± 1.64||6.05 ± 1.13||.000|
|Radial deviation||2.48 ± 1.03||4.19 ± 0.79||.000|
|Ulnar deviation||2.69 ± 1.05||4.49 ± 0.86||.000|
|Nondominant extremity||Flexion||4.88 ± 2.10||6.92 ± .095||.000|
|Extension||4.69 ± 1.75||6.90 ± 1.10||.000|
|Radial deviation||3.27 ± 1.22||5.13 ± .088||.000|
|Ulnar deviation||3.50 ± 1.13||5.42 ± 1.07||.000|
|Variables||Young group||Geriatric group||pa|
|Grip densitivity||x̄ ± SD (psi)||x̄ ± SD (psi)|
|Dominant extremity||1.98 ± 1.49||8.22 ± 3.21||.000|
|Nondominant extremity||2.80 ± 1.65||10.81 ± 4.72||.000|
|Pressure sensitivity||x̄ ± SD (mmHg)||x̄ ± SD (mmHg)|
|Dominant extremity||3.88 ± 3.08||11.46 ± 3.37||.000|
|Nondominant extremity||6.13 ± 3.13||14.76 ± 4.17||.000|
|Vibration sensation||x̄ ± SD (sec)||x̄ ± SD (sec)|
|Dominant extremity||11.96 ± 2.62||8.21 ± 1.27||.000|
|Nondominant extremity||8.51 ± 2.36||6.87 ± 1.52||.000|
|Fingers||Sensory threshold||Two point discrimination|
|Young groupx̄ ± SD (gr)||Geriatric groupx̄ ± SD (gr)||pa||Young groupx̄ ± SD (mm)||Geriatric groupx̄ ± SD (mm)||pa|
|Dominant extremity||1. Finger||0.23 ± 0.60||3.48 ± 1.00||.000||3.30 ± 0.53||6.35 ± 0.89||.000|
|2. Finger||0.09 ± 0.08||3.48 ± 1.00||.000||3.25 ± 0.47||6.35 ± 0.89||.000|
|3. Finger||0.10 ± 0.10||3.48 ± 1.00||.000||3.45 ± 0.59||6.35 ± 0.89||.000|
|4. Finger||0.11 ± 0.10||3.48 ± 1.00||.000||3.61 ± 0.71||6.36 ± 0.91||.000|
|5. Finger||0.11 ± 0.11||3.48 ± 1.00||.000||3.63 ± 0.71||6.36 ± 0.91||.000|
|Nondominant extremity||1. Finger||0.11 ± 0.11||3.74 ± 0.85||.000||3.61 ± 0.69||7.20 ± 0.83||.000|
|2. Finger||0.11 ± 0.11||3.74 ± 0.85||.000||3.60 ± 0.66||7.20 ± 0.83||.000|
|3. Finger||0.11 ± 0.12||3.74 ± 0.85||.000||3.78 ± 0.82||7.20 ± 0.83||.000|
|4. Finger||0.13 ± 0.13||3.74 ± 0.85||.000||3.85 ± 0.87||7.21 ± 0.82||.000|
|5. Finger||0.13 ± 0.13||3.74 ± 0.85||.000||3.85 ± 0.86||7.23 ± 0.83||.000|
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