Somatosensory impairment is common after stroke having been reported in 65% [1], 60–74% [2], and 100% [3], of all stroke patients. Totals of 7–53% of patients reported impaired tactile sensation, 31–89% impaired stereognosis, and 34–64% impaired proprioception [4]. Somatosensory function may be defined as the ability to interpret bodily sensations. Loss of this function negatively affects the ability to explore the environment [5], to discriminate sensory information, to recovery, to engage in activities of daily living [6], to participate successfully in rehabilitative and functional outcomes [6] [7], and to remain safety [8].

Today, a disability is regarded as resulting from the interaction between an impaired subject and barriers in the physical, attitudinal, communication, and social environments [9]. The environment has a major impact on the experience and extent of disability. Inaccessible environments create disabilities by virtue of the existence of barriers to participation and inclusion [10]. Categorization of environmental factors as either facilitators or barriers is necessary to reduce the creation of disability and facilitate rehabilitation [11]. The aim of the present study was to identify environmental facilitators and barriers encountered by geriatric stroke geriatrics stroke patients with or without somatosensory injuries.

Participants
We studied 78 geriatric stroke patients. The inclusion criteria were medical stability [1], the ability to adequately comprehend the assessment instructions [2], age over 65 years [3], and either no or mild limitation of voluntary motor control and cognitive functioning as defined based on the International classification of functioning, disability and health(ICF qualifier) [12].

Data collection
All patients answered semi-structured questions based on International classification of functioning, disability and health (ICD) categories of environmental factor. We used the extended version of the ICF core set of stroke questions exploring stroke outcomes. The study ran from June to October 2015. The core set of questions explores 166 ICF categories, of which 37 are environmental categories. Eight categories belong to the chapter 'products and technology', 3 categories to 'natural environment and human-made changes to environment', 7 categories to 'support and relationships', 9 categories to 'attitudes' and 10 categories to 'services, systems and policies' [10]. The scale was proposed by the World Health Organization (WHO) [9].

Assessment of environmental factors
The proposed ICF qualifier has nine response categories ranging from 4 to +4. A specific environmental factor can be a mild/moderate/severe/complete barrier (1 to 4), a mild/moderate/substantial/complete facilitator (+1 to +4), or can have no influence (0), not specified (8), not applicable (9) [9].

Data analysisThe aim of this study was to identify the presence of absence of facilitators and barriers. The degrees of the qualifier scale were reduced to categorical data as follows: ICF qualifiers 1 to 4 were recoded to 1 (facilitator), qualifiers 1 to 4 were recoded to 1 (barrier), the response option '8 - not specified' was handled as a missing, and qualifiers 0 (neither/nor) and 9 (not applicable) were maintained. Univariate statistics were used to describe the sample characteristics and examine the frequency of facilitators and barriers. To describe the subjects, frequency analysis and to investigate differences between groups, Chi-square test was used. All tests were carried out two sided at local alpha levels of 5%. Statistical analyses were made with SPSS (version 18.0).

Description of the participants
Of all patients, 37 were somatosensorily impaired. They were unable to detect stimuli applied to the affected side in any of six trials. Rivermead Assessment of Somatosensory Performance (RASP) were defective in all of six primary somatosensory sensations(sharp/dull discrimination, surface pressure touch, detection of a surface touch, temperature discrimination, the ability to detect movement, and capacity to define the direction of proprioception). A total of 41 patients experienced normal sensation as revealed by RASP. The characteristics of all participants are given in Table 1.

Experienced environmental factors by stroke with somatosensory injuries
More than half or all participants with somatosensory injuries identified two ICF categories as a facilitators and at least one category as a barriers. Participants lacking somatosensory injuries identified six ICF categories as a facilitator and none as a barrier. Geriatric stroke patients with somatosensory injuries identified the immediate family (e310), friends (e320), and acquaintances, peers, colleagues, neighbors and community members (e325) as facilitators in the ICF chapters of supports and relationship, transportation services, systems and policies (e540), health services, systems and policies (e580) as barriers in the ICF category of servicese, systems and policies. Geriatric stroke patients with somatosensory injuries identified these facilitators and barriers significantly more often than did geriatric stroke patients with normal somatosensory function (all p values were <0.05).

The same environmental factors may exert different effects in patients varying int nature and severity of impairment [11]. This is the first study to identify facilitators and barriers perceived by geriatric stroke with somatosensory injuries.

These patients identified the immediate family (e310), friends (e320), and acquaintances, peers, colleagues, neighbors and community members (e325) as facilitators in the ICF category of support and relationships, and they identified transportation services, systems and policies (e540), and health services, systems and policies (e580) as barrier in the ICF categories of services, systems and policies. Geriatric stroke patients with somatosensory impairments identified these facilitators and barriers significantly more often than did geriatric stroke patients with normal somatosensory function.

Immediate family, friends, acquaintances, peers, colleagues, neighbors and community members are in chapters of supports and relationship. Somatosensory loss compromises communication and interaction with the surroundings [5]. Limitations in motor functioning may contribute the learned non-use of a limb, triggering further deterioration in motor function, and it can have a negative impact on re-acquisition of skilled upper limb movement [13]. Activity limitation also has impacts on life roles, social communication, safety, participation in activities, sexual functioning, and leisure. Such limitations negatively affect social interactions with family, friends, and community members. It is important for community members to improve their understanding of psychosocial coping mechanisms and modes of adaptation to somatosensory loss.

Transportation services, systems and policies, health services, systems and policies are in ICF chapters of services, systems and policies. The important role played by sensations in motor function is particularly evident under conditions of sensory conflict, such as that experienced when walking on a rough surface [14]. Impairment of bodily sensation can have negative impacts on personal safety, motor function [1] postural control and ambulation [15]. Somatosensory injured stroke patient's special needs about services, systems and policies should be assessed and reflected in planning of public services, systems and policies.

More than half of patients with somatosensory injuries identified two or more ICF categories as facilitators and one more as a barrier. However, patients without such injuries identified six ICF categories as a facilitators and no category as a barrier. The somatosensory system allows us to explore the environment, alerting us to danger and affording a means of communication with others [16]. It is thus important that the environments in which care is delivered are accessible, safe and appropriate to the needs of patients with somatosensory loss. It is necessary to create adaptive technologies that facilitate continuation of valued activities in barrier-free environment [17].

Our small sample size is limitations of this may hamper their generalization of the results.

In conclusion, geriatric stroke patients with somatosensory injuries perceived more several barriers terms of supports and relationship, services, systems and policies than did patients without such injuries.

1. Carey LM, Matyas TA, Oke LE. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Arch Phys Med Rehabil 1993 Jun;74(6):602–11.   [CrossRef]   [Pubmed]    
2. Hunter SM, Crome P. Hand function and stroke. Reviews in Clinical Gerontology 2002;12(1):66–81.   [CrossRef]    
3. Sandra CL. Elder care in occupational therapy. 2ed. Slack Incorporated; 2003.    
4. Connell LA, Lincoln NB, Radford KA. Somatosensory impairment after stroke: frequency of different deficits and their recovery. Clin Rehabil 2008 Aug;22(8):758–67.   [CrossRef]   [Pubmed]    
5. Gaubert CS, Mockett SP. Inter-rater reliability of the Nottingham method of stereognosis assessment. Clin Rehabil 2000 Apr;14(2):153–9.   [CrossRef]   [Pubmed]    
6. Tyson SF, Hanley M, Chillala J, Selley AB, Tallis RC. Sensory loss in hospital-admitted people with stroke: characteristics, associated factors, and relationship with function. Neurorehabil Neural Repair 2008 Mar-Apr;22(2):166–72.   [CrossRef]   [Pubmed]    
7. Yekutiel M. Sensory re-education of the hand after stroke. London, Philadelphia: Whurr; 2000.    
8. Jang SH. Recovery mechanisms of somatosensory function in stroke patients: implications of brain imaging studies. Neurosci Bull 2013 Jun;29(3):366–72.   [CrossRef]   [Pubmed]    
9. World report on disability. Geneva, Switzerland: World Health Organization; 2011. [Available at: http://www.who.int/disabilities/world_report/2011/report.pdf]    
10. Preventing disease through healthy environments. Geneva, Switzerland: World Health Organization; 2006. [Available at: http://www.who.int/quantifying_ehimpacts/publications/preventingdisease.pdf]    
11. Algurén B, Lundgren-Nilsson A, Sunnerhagen KS. Facilitators and barriers of stroke survivors in the early post-stroke phase. Disabil Rehabil 2009;31(19):1584–91.   [CrossRef]   [Pubmed]    
12. Okochi J, Utsunomiya S, Takahashi T. Health measurement using the ICF: test-retest reliability study of ICF codes and qualifiers in geriatric care. Health Qual Life Outcomes 2005 Jul 29;3:46.   [CrossRef]   [Pubmed]    
13. Jeannerod M, Michel F, Prablanc C. The control of hand movements in a case of hemianaesthesia following a parietal lesion. Brain 1984 Sep;107 (Pt 3):899–920.   [CrossRef]   [Pubmed]    
14. Wing AM, Flanagan JR, Richardson J. Anticipatory postural adjustments in stance and grip. Exp Brain Res 1997 Aug;116(1):122–30.   [CrossRef]   [Pubmed]    
15. Reding MJ, Potes E. Rehabilitation outcome following initial unilateral hemispheric stroke. Life table analysis approach. Stroke 1988 Nov;19(11):1354–8.   [CrossRef]   [Pubmed]    
16. Connell LA, Lincoln NB, Radford KA. Somatosensory impairment after stroke: frequency of different deficits and their recovery. Clin Rehabil 2008 Aug;22(8):758–67.   [CrossRef]   [Pubmed]    
17. Andrade PM, Ferreira FO, Mendonça AP, Haase VG. Content identification of the interdisciplinary assessment of cerebral palsy using the International Classification of Functioning, Disability and Health as reference. Disabil Rehabil 2012;34(21):1790–801.   [CrossRef]   [Pubmed]    

• Beatrix A, Asa L, Katharina SS. Facilitators and barriers of stroke survivors in the early post stroke phase. Disability and Rehabilitation, 2009;31(19):1584-1591.
• Connell, LA, Lincoln NB, Radford KA. Somatosensory impairment after stroke: frequency of different deficit and their recovery. Clinical Rehabilitation. 2008;22(8):758–767.
• Carey M, Matyas T, Oke L. Sensory loss in stroke patients: effective training of tactile and proprioceptive discrimination. Archives of Physical Medicine and Rehabilitation 1993;74(6):602–611.