WO2009047661A2

WO2009047661A2 - Sensory training tool

Info

Publication number: WO2009047661A2
Application number: PCT/IB2008/053753
Authority: WO
Inventors: Michal Grinberg-Avraham; Simona Gelav
Original assignee: Tel Hashomer Medical Research Infrastructure & Services Ltd.
Priority date: 2007-10-09
Filing date: 2008-09-16
Publication date: 2009-04-16
Also published as: WO2009047661A3; IL204974A0; US20100240510A1

Abstract

An apparatus and a method for sensory training of a subject with a limb sensory impairment, the apparatus comprising at least three stimulating tactile elements wherein each tactile element comprises at least two tactile features distinctively different from the textile features of the other two tactile elements; and a connecting member adapted to mechanically connect the at least three tactile elements.

Description

SENSORY TRAINING TOOL

FIELD

The invention relates to an apparatus and a method for sensory training.

BACKGROUND

Our nervous system includes many sensory nerves adapted to provide us with an awareness of our environment. The nervous system provides, for example, the sense of touch in the fingers, and the ability to feel cold or heat in different parts of our body. When the nervous system suffers damage, for example, as a result of a disease such as multiple sclerosis (MS), diabetes, polio, polyneuropathy, and the like, or as a result of a traumatic experience such as may be a cerebrovascular accident (CVA), a spinal cord injury, or an arm injury, one or more of our senses may be affected. For example, in some cases, the sense of touch may be replaced by feelings of numbness or tingling, or by a loss of feeling of vibration. In some extreme cases, the sense of touch may even be altogether lost.

MS is generally an unpredictable, potentially debilitating, chronic disease of the central nervous system which usually affects patients mildly, yet in some cases may render a person unable to walk, speak or write. It is estimated to affect approximately 250,000 - 300,000 people in the US and more than 1 million people worldwide, generally affecting twice as many women as men. Symptoms are typically first experienced in adults between the ages of 20 and 40 years old.

MS is suspected to be an autoimmune disease in which the immune system attacks proteins within the myelin sheath, a fatty covering that insulates and protects nerve fibers in the brain and the spinal cord analogous to how insulation protects an electrical wire. The attacks by antibodies and white blood cells in the immune system cause the myelin to swell, subsequently detaching from the nerve fibers and leaving hardened scarred (sclerosed) tissue in its place. When nerve impulses transmitted between the brain and/or the spinal cord and other parts of the body reach the scarred area in the nerve fiber, the transmission may be slowed down or wholly blocked, generally resulting in impaired or lost bodily functions. The name MS is generally attributed to multiple scarring ("sclerosis" in Greek means scarring) areas in the central nervous system. Signs and symptoms of MS are numerous, generally varying according to the location of the affected nerve fibers. These may include muscle weakness; fatigue; spasticity (characterized by spasms); impairment of pain, temperature, and touch senses; pain; ataxia (loss of ability to coordinate muscular movement); tremors; speech impairments; vision disturbances; vertigo (sensation of dizziness); bladder dysfunction; bowel dysfunction; sexual dysfunction; depression; euphoria; and cognitive abnormalities such as forgetfulness and difficulty in concentration.

More information on MS may be found in the following websites, http://en.wikipedia.org/wiki/Multiple_sclerosis, www.mayoclinic.com, www.ninds.nih.gov, all of which are incorporated herein by reference.

Cerebrovascular accident (CVA), one type of which is commonly known as "stroke", is estimated to be a third leading cause of death in the Western world and is further estimated to account for approximately 10% of deaths worldwide. CVA occurs as a result of an interruption of blood flow to a part or to a whole of the brain, generally the result of a thrombosis, embolism or cerebral hemorrhage. In a thrombosis, a clot builds up in an artery, partially or wholly blocking blood flow through the artery to the brain. In an embolism, the clot occurs in the artery as a result of a traveling particle lodging somewhere in the artery, wholly or partially blocking blood flow through the artery to the brain. In some cases, the traveling particle may be a piece of a clot forming in an artery due to a thrombotic condition. A cerebral hemorrhage occurs when a blood vessel in the brain ruptures or bleeds, such that the vessel cannot continue supplying blood to a part of the brain it normally supplies.

Symptoms of CVA generally vary according to the type of stroke and the area of the brain affected. Usually, a thrombosis or an embolism will result only in the part of the brain supplied by the blocked artery being affected. In the case of a hemorrhage, the affected area in the brain may be more widespread due to the bleeding and/or an increase in the intracranial pressure. Symptoms are widely varied and may include muscular weakness, numbness, memory loss, walking disability, loss of coordination, and many other forms of sensory impairments.

More information on CVA may be found in the following website, http://en.wikipedia.org/wiki/Cerebrovascular_accident, incorporated herein by reference. SUMMARY

An aspect of some embodiments of the invention relates to providing a method and an apparatus for improving sensation skills in subjects suffering from a loss or a reduction of sensation (sensory impairment) in a limb. More specifically, some embodiments of the invention relate to providing a method and an apparatus for improving sensation skills in subjects suffering from sensory impairment in one or both upper and/or lower limbs, in particular, in the fingers and/or the toes, due to a disease or a condition causing injury to a part of the nervous system. Optionally, a method and apparatus are provided for improving fine- motor skills in a subject. A method and an apparatus are described in Provisional Patent Application No. 60/978,451 , filed 09-Oct-2007, which is incorporated herein by reference in its entirety.

According to an aspect of some embodiments of the invention, there is provided a sensory training tool (STT) adapted to assist in ameliorating and/or help compensate for, impaired bodily functions such as sensory impairments, for example, associated with MS, polio, spinal cord injury or CVA. The STT may comprise a plurality of tactile stimulation elements (such as tubes covered with materials as described herein), and is adapted to be manipulated by a subject, such as, for example, an MS or CVA patient, for practicing fine- motor movements and for sensory texture and material recognition. For convenience hereinafter, a tactile stimulation element may also be referred to as an "element", "tactile element", or "stimulation element". At least three tactile stimulation elements, each comprising two tactile features (size, shape, material, and/or texture) distinctively different from that of the other elements, (for example, the three elements may have a same size and shape, but different material and texture; or may have a same size and material, but different shapes and textures), and a connecting member (such as a string or a chain) onto which the at least three tactile stimulation elements, are connected.

According to an aspect of some embodiments of the invention, there is provided a method of sensory training comprising stimulating tactile sensation using a plurality of tactile stimulation elements, wherein each tactile stimulation element comprises two tactile features distinctively different from the other two elements and wherein a connecting member connects the at least three elements. The method provides for practicing of fine-motor movements and for sensory texture and material recognition by having the subject manipulate the plurality of tactile stimulation elements and by connecting the elements to the connecting member to form the STT. Optionally, the method provides for sensory training by having the subject manipulate the elements and sense temperature differences associated with the elements.

According to an aspect of some embodiment of the invention, the SST may be adapted to be used as an occupational therapy tool for training a subject, increasing dexterity by improving fine-motor skills (connecting the elements together by means of the connecting member); improving visual acuity through an ability to discern shapes, sizes, and materials, and by stringing the elements onto the connecting member; and improving decision-making skills, abstract-reasoning skills, problem-solving skills, memory skills, sequencing skills, coordination, and perceptual skills, through assembly of an article of wear such as, for example, a necklace or a belt. Optionally, the subject may assemble an article of use such as, for example, a decorative item.

In an embodiment of the invention, the STT comprises a plurality of tactile stimulation elements, which may range in number from 3 elements to 300 elements, for example 12 elements, each element comprising a relatively short, hollow tube. The elements may be strung together (mechanically connected) to form a necklace by inserting a connecting member, for example, a string or a wire, through each hollow tube. Additionally or alternatively, the elements may be strung together to form a belt, or optionally a decorative item, which may be hung from a permanent or temporary fixture adapted to hang the STT. The elements are of dimensions, which may require the patient to use fine-motor skills (movement) for their manipulation, yet sufficiently large so that they may be comfortably handled by the patient. For example, each element may be of a size range from 10 mm to 50 mm in length, for example, 20 mm; and of a width or diameter ranging from 5 mm to 30 mm, for example, 10 mm. Additionally or alternatively, each element may be of a larger dimensional scale, and may be relatively long, ranging in length from 50 mm to 120 mm, for example 80 mm, and of a diameter or width ranging from 10 mm to 100 mm, for example 50 mm.

Each tube is fabricated from aluminum metal, which may optionally be another type of metal or metal alloy such as, for example, copper, brass, gold, silver, titanium, stainless steel, or another material capable of being formed into a hollow tube such as, for example, wood, plastic, paper, carton, ceramic, and the like. Each tube may be covered, wholly or partially, with its own particular material and/or may comprise its own particular texture, such that each tactile stimulation element may be differentiated one from the other according to the material and/or the texture. Optionally, the elements may be differentiated from one another by temperature. Examples of materials may be plastic, rubber, paper, aluminum foil, metal fabric, wood, combined fabric, metal, beads, Velcro™, and the like. Examples of textures may be smooth rubber, soft rubber, thick rubber, wires with beads, smooth surface-finished metal, rough surface-finished metal, sharp edges, textured metal, flexible metal, Velcro™, felt, aluminum foil paper, Perspex, and the like. In some embodiments of the invention, one or more elements may comprise other types of geometrical shapes such as, for example, spherical, cylindrical, or other polyhedral shapes, and preferably with a hole for stringing together.

According to an aspect of an embodiment of the invention, there is provided a method for sensory education of an MS patient with upper limb sensory impairments. Comprising the use of an STT, the patient undergoes an adaptive training program in which, by practicing fine- motor movements and sensory texture recognition, sensory education is performed. Patient sensory impairments are evaluated, for initial assessment and to determine progress, using sensory tests such as, for example, the Threshold Semmes-Weinstein Monofilament Test (MFT) and the Constant Two-point Discrimination Test (2-PDT). The Threshold Semmes- Weinstein Monofilament Test tests light touch sensibility using 5 MF grading forces from 2.83g - 6.65g forces. Touch sensibility requiring forces greater than or equal to 3.61g is considered abnormal; 2.83g is normal, 3.61g is diminished light touch, 4.3 Ig is diminished protective sensation, and 4.56 to 6.65g is loss of protective sensation. The Constant Two-point Discrimination Test determines the minimum distance at which a subject can discriminate between being touched at one or two points. A distance greater than or equal to 5mm distance is considered abnormal; 5mm is a mild impairment, 6 to 10mm is a moderate impairment, 11 to 15mm is a severe impairment, and greater than 15mm is a very severe impairment. Optionally, the patient may undergo sensory tests such as a 9-Hole Peg Test (9-HPT). The 9 Hole Peg Test is a relatively simple, timed test of fine motor coordination. The test comprises the subject placing 9 dowels in 9 holes. Subjects are then scored on the amount of time it takes to place and remove all 9 pegs. Additionally or alternatively, the patient may undergo a Functional Dexterity Test (FDT).

In an embodiment of the invention, the method provides for sensory education by exposing a patient to an adaptive, essentially self-training, program comprising daily exposure to a plurality of materials, textures, shapes and dimensional scales through the use of the STT during a four-week period. Optionally, the training program may be shorter than four weeks or alternatively, longer than four weeks, and may include daily instruction by trained personnel. Optionally, a plurality of large tactile stimulation elements comprising a relatively large tubular element, a flat rectangular element, a ball shaped element, and/or other polyhedral shaped elements, which optionally may or may not be strung together, may be used. The large tactile stimulation elements may each be covered, wholly or partially, with different materials and/or each may comprise a different texture, such that each element may be differentiated from the other according to material and/or texture. Optionally, the elements may be of different dimension.

Prior to the start of training, the patient is subject to the MFT and the 2-PDT for assessment of degree of impairment. The patient then undergoes a familiarization process with the STT, based on receiving feedback on performance. Optionally, the large tactile stimulation elements may be used. Following completion of the training program, the patient is again subject to the MFT and the 2-PDT to assess progress. Optionally, the patient may undergo the 9-HPT prior to the start of testing and/or finish of testing. Additionally or alternatively, the patient may undergo the FDT prior to the start of testing and/or finish of testing.

According to some embodiments, the STT can be modified according to the needs of a patient. For example:

STT 1 - a relatively, difficult level that includes tubes from various textures such as plastic, paper and rubber.

STT 2 - a relatively, difficult level that includes tubes from various textures such as metal, fabric, plastic, paper, foil paper, and rubber.

STT 3- a relatively, easy level that includes tubes from three textures such as metal, fabric, and beads.

Following a 3-week self-training program conducted by the inventors on a group of 14 MS patients, sensory improvement was measured in each finger of a hand. Average sensory improvement for the group ranged from 16.5% to 27.1%, depending on the tested finger, using the 2-PDT and ranged from 4.3% to 12.5% using the MFT.

Further Testing was conducted on a larger group of 35 MS patients. Average sensory improvement for the group ranged from 13% to 30%, depending on the tested finger, using the

2-PDT (N = 340 fingers, p < 0.001) and ranged from 2% to 10% using the MFT (N = 340 fingers, p = 0.013). In sixteen of the patients, the 9-HPT and FDT were additionally assessed. Fine-motor coordination improved in speed of performance, with the left hand decreasing from 38.07 seconds to 34.27 seconds and the right hand decreasing from 44.23 seconds to 36.8 seconds (30 hands, p=0.012).

There is provided, in accordance with an embodiment of the invention, an apparatus for sensory training of a subject with a limb sensory impairment, the apparatus comprising at least three stimulating tactile elements, wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and a connecting member adapted to mechanically connect the at least three tactile elements. Optionally, the apparatus comprises at least four stimulating tactile elements. Optionally, the apparatus comprises at least five stimulating tactile elements. Optionally, the apparatus comprises at least six stimulating tactile elements. Additionally or alternatively, the apparatus is adapted to allow fine-motor movements. Optionally, the apparatus is adapted to allow texture recognition. Optionally, the apparatus comprises a necklace, a bracelet, a belt, and/or a hanging artifact. Optionally, the connecting member comprises a string, a wire, a leather strand, and/or a chain. Optionally, the tactile element comprises a hollow tube.

There is provided, in accordance with an embodiment of the invention, a method for sensory training of a subject with an upper limb sensory impairment, the method comprising stimulating tactile sensation using at least three stimulating tactile elements wherein each tactile element comprises at least two tactile feature distinctively different from the tactile features of the other two tactile elements; and mechanically connecting the at least three tactile elements. Optionally, the method comprises using at least four stimulating tactile elements. Optionally, the method comprises using at least five stimulating tactile elements. Optionally, the method comprises using at least six stimulating tactile elements. Additionally or alternatively, the method further comprises fine-motor movements. Optionally, the method further comprises texture recognition. Optionally, the method further comprises connecting the at least two stimulating tactile elements in a necklace, a bracelet, a belt, and/or a hanging artifact. Optionally, the method further comprises connecting the at least two stimulating tactile elements with a string, chain, leather strand, and/or a wire.

There is provided, in accordance with an embodiment of the invention, an occupational therapy apparatus for training a subject with a limb sensory impairment, the apparatus comprising at least three stimulating tactile elements wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and a connecting member adapted to mechanically connect the at least three tactile elements. Optionally, the apparatus comprises at least four stimulating tactile elements. Optionally, the apparatus comprises at least five stimulating tactile elements. Optionally, the apparatus comprises at least six stimulating tactile elements. Additionally or alternatively, the apparatus is adapted to allow fine-motor movements. Optionally, the apparatus is adapted to allow texture recognition. Optionally, the apparatus comprises a necklace, a bracelet, a belt, and/or a hanging artifact. Optionally, the connecting member comprises a string, a wire, a leather strand, and/or a chain. Optionally, the tactile element comprises a hollow tube. Additionally or alternatively, the method further comprises fine-motor movements. Optionally, the method further comprises texture recognition. Optionally, the method further comprises connecting the at least two stimulating tactile elements in a necklace, a bracelet, a belt, and/or a hanging artifact. Optionally, the method further comprises connecting the at least two stimulating tactile elements with a string, chain, leather strand, and/or a wire. Optionally, the tactile feature is a weight.

There is provided, in accordance with an embodiment of the invention, a method for occupational therapy training for a subject with an upper limb sensory impairment, the method comprising stimulating tactile sensation using at least three stimulating tactile elements wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and mechanically connecting the at least three tactile elements. Optionally, the method comprises using at least four stimulating tactile elements. Optionally, the method comprises using at least five stimulating tactile elements.

Optionally, the method comprises using at least six stimulating tactile elements. Optionally, the tactile feature is a weight.

In some embodiments of the invention, the tactile feature is a material. Optionally, the material comprises a rubber, a plastic, a paper, a metal, a fabric, a textile, a wood, a glass, a fur, or any combination thereof.

In some embodiments of the invention, the tactile feature is a texture. Optionally, the texture comprises a compressible surface, an elastic surface, an irregular surface, a surface with sharp edges, a smooth surface, a flexible surface, a rough surface, a textured surface, or any combination thereof. In some embodiments of the invention, the tactile feature is a shape. Optionally, the shape is spherical, cylindrical, irregular, or polyhedral. Additionally or alternatively, the tactile feature is a scale of size.

BRIEF DESCRIPTION OF FIGURES

Examples illustrative of embodiments of the invention are described below with reference to figures attached hereto. In the figures, identical structures, elements or parts that appear in more than one figure are generally labeled with a same numeral in all the figures in which they appear. Dimensions of components and features shown in the figures are generally chosen for convenience and clarity of presentation and are not necessarily shown to scale. The figures are listed below.

Figure IA schematically illustrates a perspective view of exemplary tactile stimulation elements included in an exemplary STT, in accordance with an embodiment of the invention;

Figure IB schematically illustrates a perspective view of the STT of Figure IA with the tactile stimulation elements arranged in a necklace, in accordance with an embodiment of the invention;

Figures 1C, ID and IE schematically illustrate perspective views of the exemplary tactile stimulation elements of the STT of Figure IA and IB used for practicing fine-motor movements, in accordance with an embodiment of the invention;

Figure 2 schematically illustrates a perspective view of the STT shown in Figures IA and IB worn as a necklace, in accordance with another embodiment of the invention;

Figure 3 schematically illustrates exemplary tactile stimulation elements and tactile features associated with the elements, in accordance with an embodiment of the invention;

Figures 4A and 4B schematically illustrate perspective views of exemplary large tactile stimulation elements used for sensory texture and/or material recognition, in accordance with an embodiment of the invention; Figure 5 schematically illustrates a flow diagram of a method for sensory education of MS patients with upper limb sensory impairments, in accordance with an embodiment of the invention;

Figures 6 A, 6B and 6C schematically illustrate an exemplary representation of an MFT, a bar graph illustrating results of an MFT conducted on 14 MS patients, and a pictorial diagram illustrating results of an MFT conducted on 35 MS patients, respectively, in accordance with an embodiment of the invention;

Figures 7A, 7B and 7C schematically illustrate an exemplary representation of an MFT, a bar graph illustrating results of a 2-PDT conducted on 14 MS patients, and a pictorial diagram illustrating results of a 2-PDT conducted on 35 MS patients, respectively, in accordance with an embodiment of the invention; and

Figure 8 schematically illustrates a bar graph with the results of an FDT conducted on 16 MS patients in a training program based on the method for sensory education shown in Figure 6, in accordance with an embodiment of the invention.

DETAILED DESCRIPTION

Reference is made to Figure IA, which schematically illustrates a perspective view of a plurality of exemplary tactile stimulation elements included in an exemplary STT 100; to Figure IB which schematically illustrates a perspective view of STT 100 with the tactile stimulation elements arranged in a necklace 150; and to Figures 1C, ID and IE which schematically illustrate perspective views of the exemplary tactile stimulation elements of STT 100 while being used for practicing texture and material recognition, and for practicing fine- motor movements; all in accordance with an embodiment of the invention.

STT 100 includes a first element tactile stimulation element 102, a second element 104, a third element 106, a fourth element 108, a fifth element 110, a sixth element 112, a seventh element 114, an eight element 116, a ninth element 118, a tenth element 120, an eleventh element 122, a twelfth element 124, a connecting member 103, and an exercise board

101. STT 100 may comprise not less than three elements and not more than 5 elements.

Optionally, STT 100 may comprise not less than 5 elements and not more than 10 elements. Optionally, STT 100 may comprise not less than 10 elements and not more than 20 elements. For example, STT 100 may additionally comprise a thirteenth element 105, a fourteenth element 107, a fifteenth element 107, a sixteenth element 109, a seventeenth element 111, and an eighteen element 113. Optionally, STT 100 may comprise not less than 20 elements and not more than 40 elements. Optionally, STT 100 may comprise not less than 40 elements and not more than 100 elements. Optionally, STT 100 may comprise not less than 100 elements and not more than 200 elements. Optionally, STT 100 may comprise not less than 200 elements and not more than 300 elements. Optionally, STT 100 may comprise more than 300 elements.

In accordance with an embodiment of the invention, elements 102 - 124 each include a distinctive tactile feature, which allows a subject to handle the elements with his/her fingers and to distinguish one element from another. For example, tactile features may include sizes and/or shapes of elements 102 -124, the features adapted to enable a subject with an upper limb sensory impairment, such as, for example, an MS patient or a CVA patient, to practice fine- motor movements with his/her fingers. Furthermore, the tactile features may include textures of surfaces, and/or materials partially, or wholly, covering elements 102 — 124, the features adapted to teach the patient sensory texture and/or material recognition by feeling the elements in his/her fingers. Elements 102 -124 are relatively short, ranging in length from 10 mm to 50 mm long, for example 20 mm, and of a diameter or width ranging from 5 mm to 30 mm, for example 10 mm. Elements 102 -124 are generally adapted to be strung together (mechanically connected) by connecting member 103, which may optionally be a rope, a cord, a string, one or more leather strands, a wire or cable, a chain or any other element which may serve to string together the elements. Elements 102 -124 are further adapted to be fitted by the patient onto tubular extensions protruding from exercise board 101, for example tubular extension 131, and are additionally adapted to be removed by the patient from the tubular extensions. The tubular extensions, for example tubular extension 131, may be cylindrical in shape with a circular cross-section. Optionally, the tubular extensions, for example tubular extension 131, may comprise a triangular cross-section, or a rectangular cross-section, or any other type of cross- sectional shape suitable to accommodate fitting of elements 102 -124. Elements 102 -124 may be adapted to be fitted onto any one of the tubular extension, for example tubular extension 131. Optionally, each element of elements 102 - 124 may be adapted to be fitted onto only one corresponding tubular extension. Optionally, each element 102 - 124 may be adapted to fit onto a plurality of corresponding tubular extensions less than the total number of tubular extensions protruding from exercise board 101. Exercise board 101, including the tubular protrusion, for example tubular protrusion 103, may be made from a metal, plastic, wood, glass, composite board, or any other material or combination of materials, suitable for allowing a patient to practice fitting element 102 - 124 onto, and removing from, the tubular extension. Exercise board 101 may be adapted to be used by a patient while placed in a horizontal position and/or while placed in a vertical position. Optionally, exercise board 101 may be used while placed in an inclined position. Although exercise board 101 is shown with twelve tubular extensions such as, for example, tubular extension 131, it may be appreciated by a person skilled in the art that the number of tubular extensions may be less than twelve, or optionally greater than twelve.

Elements 102 - 124 may be cylindrically shaped and generally comprise a metal tube with a circular cross-section, such as, for example, tube or element 118. Optionally, the metal tube, for example tube 118, may comprise a triangular cross-section, or a rectangular cross- section, or any other type of cross-sectional shape suitable for stringing together elements 102 - 124 by means of connecting member 103. The metal tubes, for example tube 118, are generally fabricated from aluminum, although they may optionally be fabricated from another metal or metal alloy. Examples of such metals and/or metal alloys may include copper, brass, gold, silver, titanium, or stainless steel. Optionally, each element 102 - 124 may comprise a tube fabricated from a different metal, or any number of elements may comprise tubes fabricated from a same metal. Optionally, one or more metal tubes, for example tube 118, may be replaced with tubes fabricated from wood, plastic, paper, carton, ceramic, or any other material which may be formed into a tube and may be adapted to be strung together by means of connecting member 103.

Each tube, for example, tube 118, may be of one or more uniform materials, or may be covered, wholly or partially, with its own particular material, or combination of materials, and/or may comprise its own particular texture, such that each element 102 -124 may be differentiated one from the other, when handled by the patient, according to the material and/or the texture. Examples of materials may be plastic, rubber, paper and aluminum foil, metal fabric, wood, combined fabric, metal, beads, Velcro™, and the like. Optionally, the materials may comprise deformable (and/or deflection) characteristics which may include elastic properties, wherein they return to their original shape when stretched or compressed, such as, for example with soft rubber or thick rubber; or may include plastic properties wherein they do not return to their original shape when stretched or compressed (or bent), such as for example, with wires or aluminum foil. Optionally, some materials may be rigid, and may not be substantially compressed nor stretched nor bent, such as for example, thick metal. Optionally, the materials may comprise characteristics associated with weight, whereby they may be differentiated as being of a heavy weight (for example, thick metal), a medium weight (rubber), and/or a light weight (for example, felt or paper). Examples of textures may be smooth rubber, wires with beads, smooth surface-finished metal, rough surface-finished metal, sharp edges, textured metal, flexible metal, Velcro™, felt, aluminum foil paper, Perspex, and the like. In some embodiments of the invention, one or more elements 102 - 124 may comprise other types of geometrical shapes such as, for example, spherical, prismal, irregular, or other polyhedral shape, adapted to be strung by means of connecting member 103.

For example, in the embodiments shown in Figures IA and IB, elements 102 - 124, comprise materials or textures as described herein. Element 102 comprises a felt material covering over the metal tube. Element 104 comprises a string wound around the tube. Element 106 comprises a fabric material covering the tube. Element 108 is a smooth surface metal tube comprising three soft rubber rings, and may optionally have more or less rubber rings. Element 110 is a metal tube comprising 5 thick rubber rings, and may optionally have more or less rubber rings, for example, two rings as shown in Element 122. Element 112 comprises a metal tube with a relatively thick paper covering. Element 114 is a metal tube comprising a geometrically shaped cross-section with relatively sharp edges such as, for example, a dodecagon. Element 116 comprises a metal tube with an aluminum foil paper covering. Element 118 comprises a smooth metal tube. Element 120 comprises a metal tube with a covering of bristles. Element 124 comprises a metal tube with a covering of rubber bands wrapped around the tube. Element 105 comprises a metal tube with an indentation spiraling along the length of the tube. Element 107 comprises a plastic tube. Element 109 comprises a metal spring. Element 111 comprises a metal tube with wires extending the length of the tube and beads placed on the wires. Element 113 comprises a metal tube with a plastic material covering. It may be appreciated by a person skilled in the art that the shapes, dimensional scales, materials and/or textures described for elements 102 - 124 in STT 100 are for illustrative purposes, and are in no way intended to be limiting in any manner or form.

In an embodiment of the invention, STT 100 may be used to form necklace 150 by stringing connecting member 103 through 13 elements from elements 102 - 124. These include element 113, element 108, element 110, element 118, element 114, element 116, element 102, element 105, element 112, element 107, element 109, element 120, and element

111. Optionally, necklace 150 may comprise more or less elements 102 - 124, for example 9 elements or 25 elements. Optionally, necklace 150 may comprise one or more elements 102 - 124 different to those shown in the figure, or may be connected together by connecting member 103 in a different arrangement to that shown in the figure. Alternatively, STT 100 may be assembled to form a belt, which may be worn by the patient, or optionally a decorative item, which may be hung from a permanent or temporary fixture adapted for hanging the STT.

Reference is also made to Figure 2, which schematically illustrates a perspective view of STT 100 worn as a necklace 151, in accordance with another embodiment of the invention. Necklace 151 comprises fewer elements 102 - 124 compared to necklace 150 in Figure IB, for example 12 elements. Additionally, the elements 102 - 124 are connected together by connecting member 103 in a different arrangement compared to that in necklace 150. Furthermore, one or more of the elements 102 - 124 used in necklace 151 may be different to those used in necklace 150. For example, necklace 151 comprises element 122, element 114, element 116, element 102, element 112, element 120, element 105, element 110, element 118, element 108, element 109, and element 111.

Reference is also made to Figure 3, which schematically illustrates some exemplary tactile stimulation elements, which may be comprised in STT 100 and the tactile features associated with the elements, in accordance with an embodiment of the invention. The tactile features may be essentially divided into five groups: materials, textures, shapes, sizes (including scales of size), and temperature. Block A schematically shows exemplary large tactile stimulation elements covered with some materials which may be used to stimulate material recognition such as, for example, plastic, rubber, paper, metal, fabric, wood, and the like, including any combination thereof. Block B schematically shows exemplary elements comprising some textures which may be used to stimulate texture recognition such as, for example, a smooth texture, a rough texture, a soft texture, a striped texture, and the like, including any combination thereof. Block C schematically shows exemplary elements comprising some shapes which may be used to stimulate fine-motor skills, such as, for example, a ball-shaped element, a square shaped element, a hollow tube, a cylindrical element, or other regular or irregular geometrically shaped element. Block D schematically shows exemplary elements comprising sizes, and scale of sizes, which may be used to stimulate fme- motor skills, such as, for example, both large elements and small elements. Block E lists elements which may be used to stimulate temperature sensing. Optionally, the elements shown in Blocks A, B, C and D may be used for stimulating texture and material recognition, and for stimulating fine-motor skills. Optionally, some of the elements shown in Blocks A, B, C and D may be used to stimulate temperature sensing.

Reference is made to Figures 4A and 4B which schematically illustrate perspective views of large tactile stimulation elements 402 - 418 optionally comprised in STT 100, and adapted for use by the patient for sensory texture and/or material recognition, in accordance with some embodiments of the invention. Optionally, elements 402 - 418 may also be used for stimulating fine-motor skills in the patient. Optionally, elements 402 - 418 may be a large- scale version of elements 102 - 124 in Figures IA and IB. For example, Elements 402 - 418 may be relatively long, ranging in length from 50 mm to 120 mm, for example 80 mm, and of a diameter or width ranging from 10 mm to 100 mm, for example 50 mm.

Elements 402 - 418 may be cylindrically shaped and generally comprise a metal tube with a circular cross-section, such as, for example, a large-scale version of tube or element 118. Optionally, the tube may comprise a triangular cross-section, or a rectangular cross-section, or any other type of geometrically shaped cross-section. The tubes are generally fabricated from aluminum, although they may optionally be fabricated from another metal or metal alloy. Examples of such metals and/or metal alloys may include copper, brass, gold, silver, titanium, or stainless steel. Optionally, each element 402 - 418 may comprise a tube fabricated from a different metal, or any number of elements may comprise tubes fabricated from a same metal. Optionally, one or more tubes may be fabricated from wood, plastic, paper, carton, ceramic, or any other material which may be formed into a tube.

Each tube may be covered, wholly or partially, with its own particular material, or combination of materials, and/or may comprise its own particular texture, such that each element 402 - 418 may be differentiated, one from the other, when handled by the patient, according to the material and/or the texture. Examples of materials may be plastic, rubber, paper, aluminum foil, metal fabric, wood, combined fabric, metal, beads, Velcro™, and the like. Examples of textures may be smooth rubber, soft rubber, thick rubber, and wires with beads, smooth surface-finished metal, rough surface-finished metal, sharp edges, textured metal, flexible metal, Velcro™, felt, aluminum foil paper, Perspex, and the like. In some embodiments of the invention, one or more elements 402 - 418 may comprise other types of geometrical shapes such as, for example, spherical, prismal, or other polyhedral shape. For example, in the embodiments shown in Figures 4A and 4B, elements 402 - 418, comprise materials or textures as described herein. Element 401 comprises circular patches of rubber material covering the tube. Element 402 comprises a gauze material covering the tube. Element 403 comprises a cord wrapped around the tube. Element 404 comprises a cardboard wrapped around the tube. Element 405 comprises adhesive strips covering the tube. Element 406 comprises rubber bands stretched along the length of the tube and the circumference of the tube. Element 407 comprises a tube with wires extending the length of the tube and optional beads placed on the wires. Element 408 comprises a natural, or optionally synthetic fur, covering the tube. Element 409 comprises patches of a felt material distributed along the length and circumference of the tube. Element 410 comprises a textured paper covering the tube. Element 412 comprises a tube with a covering of rubber bands wrapped around the length of the tube. Element 414 comprises a Velcro™ type material covering the tube. Element 416 comprises a tube with an aluminum foil paper covering. Element 418 comprises a fabric material covering the tube. It may be appreciated by a person skilled in the art that the shapes, dimensional scales, materials and/or textures described for elements 402 - 418 in STT 100 are for illustrative purposes, and are in no way intended to be limiting in any manner or form.

Reference is made to Figure 5, which schematically shows a flow diagram of a method for sensory education, for example, of patients with upper limb sensory impairments using STT 100 of Figures IA, IB, 2, 3 and 4A and 4B, in accordance with an embodiment of the invention. In accordance with an embodiment of the invention, the method provides for sensory education by exposing an MS patient to an adaptive, self-training program comprising 15 minutes of daily exposure to a plurality of materials, textures, shapes and dimensional scales through the use of the STT during a four- week period. Optionally, the training program may be shorter than four weeks or alternatively, longer than four weeks. Additionally, in some embodiments of the invention, the daily exposure time may be less than or greater than 15 minutes. Sensory education comprises improving fine-motor skills and sensory texture and material recognition. Additionally or alternatively, the training program may include daily instruction. Optionally, SST 100 may be adapted to be used as an occupational therapy tool for training the patient, increasing dexterity by improving fine-motor skills, for example by connecting elements 102 - 124 together by means of connecting member 103, including handling the elements to distinguish their weight; improving visual acuity through an ability to discern shapes, sizes, and materials, in the elements, and by stringing the elements onto the connecting member; and improving decision-making skills, abstract-reasoning skills, problem- solving skills, memory skills, sequencing skills, coordination, and perceptual skills, through assembly of elements 102 - 124 into necklace 150.

a. [Step 501] At the start of the training program, the patient is subject to an MFT and a 2-PDT so as to establish a degree of sensory impairment. Optionally, other types of sensory tests, which may serve to determine the degree of impairment, may be performed instead of either one or both tests, or in addition to both tests. For example, an FDT and/or a 9-HPT may be conducted. The tests are generally conducted by appropriate medical personnel who may comprise one or more occupational therapists and/or physical therapists.

b. [Step 502] Based on the results of the tests, the medical personnel determine whether the patient may undergo the training program. If it has been determined that the patient may undergo the training program, Step 503 follows. If not, Step 505 follows.

c. [Step 503] A patient accepted into the training program undergoes a first training session, mediated and instructed by the therapist. The session includes familiarization with STT 100 as a whole and with each one of elements 102 - 124. Familiarization comprises touching and feeling elements 102 - 124 with the fingers of one and/or two hands, visual contact, and verbal contact by verbally describing each of the elements. The patients also identify/recognize elements 102 - 124 with their eyes closed. During the familiarization process, the patient is generally provided with feedback by the therapist related to performance. In Figures 1C and ID it is possible to view an example of the sensory texture recognition part of the familiarization process, where the patient holds and feels elements 102 - 124 of STT 100 using a right hand. The patient may additionally or alternatively hold elements 102 - 124 with a left hand. In Figure IE it is possible to view an example of the fine-motor movement part of the familiarization process, where a patient attempts to insert connecting member 103 through element 105 using both hands.

d. [Step 504] Once the patient completes the first training session, he or she continues the training program at home in a self-training mode for a period of four weeks, approximately 15 minutes per day. In the self-training mode, the patient practices with STT 100 every day to both separate elements 102 - 124 and to string them together. Referring again to Figures 1C and ID, it is possible to view an example of the sensory texture recognition part of the self- training mode where the patient holds and feels elements 102 - 124 of STT 100 using the right hand. The patient may additionally or alternatively hold elements 102 - 124 with a left hand. Referring again to Figure IE, it is possible to view an example of the fine-motor movement part of the familiarization process, where a patient attempts to insert connecting member 103 through element 105 using both hands.

e. [Return to Step 501] Once the patient has completed the four weeks of training the sensory tests are repeated to evaluate progress. Based on the results, the medical personnel make a decision as to whether to repeat the training program, modify, or stop the training program.

Reference is made to Figures 6A, 6B and 6C, which schematically illustrate a representation of an MFT, a bar graph illustrating results of the MFT conducted on 14 patients subject to the training program based on the method for sensory education shown in Figure 5, and a pictorial diagram illustrating results of the MFT conducted on an additional 35 MS patients also subject to the training program, respectively; and to Figures 7 A, 7B and 7C which schematically illustrate an exemplary representation of a 2-PDT, a bar graph illustrating results of the 2-PDT conducted on the 14 MS patient, and a pictorial diagram illustrating results of the 2-PDT conducted on the 35 MS patients, respectively; all in accordance with an embodiment of the invention.

In a first round of training, fourteen patients underwent the training program which comprised the first training session and 3 weeks of self-training. The patients underwent - preliminary MFT and 2-PDT in order to determine the degree of sensory impairment in each patient. The average value of the touch sensibility, and the average value of the minimum distance at which the patient can discriminate between being touched at one or two points, for the group, as measured for each finger in both hands, is shown in Figures 6B and 7B respectively, and is as follows:

MFT (g) 2-PDT (mm)

Thumb - 4.16 7.74

Index finger - 4.07 7.20

Middle finger - 3.9 7.06

Ring finger - 3.86 7.53 Little finger - 3.9 6.67

Upon completion of the 3 -week self-training period, the patients underwent a second round of MFT and 2-PDT in order to determine the degree of sensory impairment in each patient. The average value of the touch sensibility, and the average value of the minimum distance at which the patient can discriminate between being touched at one or two points, for the group, as measured for each finger in both hands, is shown in Figures 6B and 7B respectively, and is as follows:

MFT(g) 2-PDT (mm)

Thumb - 3.98 6.26

Index finger - 3.56 5.87

Middle finger - 3.6 5.89

Ring finger - 3.69 5.76

Little finger - 3.73 4.86

A comparison of the above tables and/or the two graphs shows that there was an overall sensory improvement in the group of 14 patients, as follows (in percentages for each type of test), when tested according to the MFT and the 2-PDT:

MFT (%) 2-PDT (%)

Thumb - 4.33 19.12

Index finger- 12.53 18.47

Middle finger - 7.7 16.57

Ring finger - 4.4 23.51

Little finger - 4.36 27.14

Further testing was conducted on a larger group of the 35 MS patients subject to the training program. Average sensory improvement for the group ranged from 13% to 30%, depending on the tested finger, using the 2-PDT (N = 340 fingers, p < 0.001) and ranged from 2% to 10% using the MFT (N = 340 fingers, p = 0.013). The percentage changes in sensory improvement are shown in Figures 6C and 7C for the MFT and 2-PDT respectively, and are as follows:

MFT (%) 2-PDT (%)

Left Hand Right Hand Left Hand Right Hand

Thumb - 2 2.04 17 23.4

Index finger - 9 8.32 26.5 13

Middle finger - 9.9 10 33 15

Ring finger - 3 2 23 21

Little finger - 6 6 30 21

Reference is made to Figure 8, which schematically illustrates a bar graph with the results of an FDT conducted on 16 of the 35 MS patients subject to the training program based on the method for sensory education shown in Figure 5, in accordance with an embodiment of the invention. A 9-HPT was also conducted on the patients. Fine-motor coordination improved in speed of performance, with the left hand decreasing from 38.07 seconds to 34.27 seconds and the right hand decreasing from 44.23 seconds to 36.8 seconds (30 hands, p=0.012).

In the description and claims of embodiments of the present invention, each of the words, "comprise" "include" and "have", and forms thereof, are not necessarily limited to members in a list with which the words may be associated.

The invention has been described using various detailed descriptions of embodiments thereof that are provided by way of example and are not intended to limit the scope of the invention. The described embodiments may comprise different features, not all of which are required in all embodiments of the invention. Some embodiments of the invention utilize only some of the features or possible combinations of the features. Variations of embodiments of the invention that are described and embodiments of the invention comprising different combinations of features noted in the described embodiments will occur to persons with skill in the art.

Claims

1. An apparatus for sensory training of a subject with a limb sensory impairment, the apparatus comprising:

at least three stimulating tactile elements, wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and

a connecting member adapted to mechanically connect the at least three tactile elements.

2. The apparatus of claim 1 wherein the apparatus comprises at least four stimulating tactile elements.

3. The apparatus of claim 1 wherein the apparatus comprises at least five stimulating tactile elements.

4. The apparatus of claim 1 wherein the apparatus comprises at least six stimulating tactile elements.

5. The apparatus of claim 1 wherein the apparatus is adapted to allow fine-motor movements.

6. The apparatus of claim 1 wherein the apparatus is adapted to allow texture recognition.

7. The apparatus of claim 1 wherein the apparatus comprises a necklace, a bracelet, a belt, and/or a hanging artifact.

8. The apparatus of claim 1 wherein the tactile feature is a material.

9. The apparatus of claim 8 wherein the material comprises a rubber, a plastic, a paper, a metal, a fabric, a textile, a wood, a glass, a fur, or any combination thereof.

10. The apparatus of claim 1 wherein the tactile feature is a texture.

11. The apparatus of claim 10 wherein the texture comprises a compressible surface, an elastic surface, an irregular surface, a surface with sharp edges, a smooth surface, a flexible surface, a rough surface, a textured surface, or any combination thereof.

12. The apparatus of claim 1 wherein the tactile feature is a shape.

13. The apparatus of claim 12 wherein the shape is spherical, cylindrical, prismal, irregular or polyhedral.

14. The apparatus of claim 1 wherein the tactile feature is a scale of size.

15. The apparatus of claim 1 wherein the tactile element comprises a hollow tube.

16. The apparatus of claim 1 wherein the connecting member comprises a string, a wire, a leather strand, and/or a chain.

17. A method for sensory training of a subject with an upper limb sensory impairment, the method comprising:

stimulating tactile sensation using at least three stimulating tactile elements wherein each tactile element comprises at least two tactile feature distinctively different from the tactile features of the other two tactile elements; and

mechanically connecting the at least three tactile elements.

18. The method of claim 17 comprising using at least 4 stimulating tactile elements.

19. The method of claim 17 comprising using at least 5 stimulating tactile elements.

20. The method of claim 17 comprising using at least 6 stimulating tactile elements.

21. The method of claim 17 further comprising fine-motor movements.

22. The method of claim 17 further comprising texture recognition.

23. The method of claim 17 further comprising connecting the at least two stimulating tactile elements in a necklace, a bracelet, a belt, and/or a hanging artifact.

24. The method of claim 17 wherein the tactile feature is a material.

25. The method of claim 24 wherein the material comprises a rubber, a plastic, a paper, a metal, a fabric, a textile, a wood, a glass, a fur, or any combination thereof.

26. The method of claim 17 wherein the tactile feature is a texture.

27. The method of claim 26 wherein the texture comprises a compressible surface, an elastic surface, an irregular surface, a surface with sharp edges, a smooth surface, a flexible surface, a rough surface, a textured surface, or any combination thereof.

28. The method of claim 17 wherein the tactile feature is a shape.

29. The method of claim 28 wherein the shape is spherical, cylindrical, prismal, irregular, or polyhedral.

30. The method of claim 17 wherein the tactile feature is a scale of size.

31. The method of claim 17 wherein the tactile element comprises a hollow tube.

32. The method of claim 17 further comprising connecting the at least two stimulating tactile elements with a string, chain, leather strand, and/or a wire.

33. An occupational therapy apparatus for training a subject with a limb sensory impairment, the apparatus comprising:

at least three stimulating tactile elements wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and

34. The apparatus of claim 33 wherein the apparatus comprises at least four stimulating tactile elements.

35. The apparatus of claim 33 wherein the apparatus comprises at least five stimulating tactile elements.

36. The apparatus of claim 33 wherein the apparatus comprises at least six stimulating tactile elements.

37. The apparatus of claim 33 wherein the apparatus is adapted to allow fine-motor movements.

38. The apparatus of claim 33 wherein the apparatus is adapted to allow texture recognition.

39. The apparatus of claim 33 wherein the apparatus comprises a necklace, a bracelet, a belt, and/or a hanging artifact.

40. The apparatus of claim 33 wherein the tactile feature is a material.

41. The apparatus of claim 40 wherein the material comprises a rubber, a plastic, a paper, a metal, a fabric, a textile, a wood, a glass, a fur, or any combination thereof.

42. The apparatus of claim 33 wherein the tactile feature is a texture.

43. The apparatus of claim 42 wherein the texture comprises a compressible surface, an elastic surface, an irregular surface, a surface with sharp edges, a smooth surface, a flexible surface, a rough surface, a textured surface, or any combination thereof.

44. The apparatus of claim 33 wherein the tactile feature is a shape.

45. The apparatus of claim 44 wherein the shape is spherical, cylindrical, prismal, irregular, or polyhedral.

46. The apparatus of claim 33 wherein the tactile feature is a scale of size.

47. The apparatus of claim 33 wherein the tactile feature is a weight.

48. The apparatus of claim 33 wherein the tactile element comprises a hollow tube.

49. The apparatus of claim 33 wherein the connecting member comprises a string, a wire, a leather strand, and/or a chain.

50. A method for occupational therapy training for a subject with an upper limb sensory impairment, the method comprising:

stimulating tactile sensation using at least three stimulating tactile elements wherein each tactile element comprises at least two tactile features distinctively different from the tactile features of the other two tactile elements; and

mechanically connecting the at least three tactile elements.

51. The method of claim 50 comprising using at least 4 stimulating tactile elements.

52. The method of claim 50 comprising using at least 5 stimulating tactile elements.

53. The method of claim 50 comprising using at least 6 stimulating tactile elements.

54. The method of claim 50 further comprising fine-motor movements.

55. The method of claim 50 further comprising texture recognition.

56. The method of claim 50 further comprising connecting the at least two stimulating tactile elements in a necklace, a bracelet, a belt, and/or a hanging artifact.

57. The method of claim 50 wherein the tactile feature is a material.

58. The method of claim 57 wherein the material comprises a rubber, a plastic, a paper, a metal, a fabric, a textile, a wood, a glass, a fur, or any combination thereof.

59. The method of claim 50 wherein the tactile feature is a texture.

60. The method of claim 59 wherein the texture comprises a compressible surface, an elastic surface, an irregular surface, a surface with sharp edges, a smooth surface, a flexible surface, a rough surface, a textured surface, or any combination thereof.

61. The method of claim 50 wherein the tactile feature is a shape.

62. The method of claim 61 wherein the shape is spherical, cylindrical, prismal, irregular, or polyhedral.

63. The method of claim 50 wherein the tactile feature is a scale of size.

64. The method of claim 50 wherein the tactile feature is a weight.

65. The method of claim 50 wherein the tactile element comprises a hollow tube.

66. The method of claim 50 further comprising connecting the at least two stimulating tactile elements with a string, chain, leather strand, and/or a wire.