L8: Perceptual Impairments and Apraxia Flashcards
What is perception?
Perception is the ability to process and interpret sensory information
What are 3 things that can be found in assessment in perception impairments and apraxia?
- Posture
- Movement quality
- Interaction with the environment
What are 3 essential skills for the physiotherapist for percetual impairments and apraxia?
- recognise perceptual and motor planning impairments
- apply simple tests to establish severity and monitor progress
- understand the implications of these impairments for movement retraining
- know how to modify physiotherapy management approach to optimise motor function
What are 6 features in perceptual impairments?
What are 4 definitions of unilateral neglect (UN) as a perceptual impairment?
- The failure to report, respond or orient (has the input but have the inability to respond sensory input)
- To novel or meaningful stimuli
- Presented to the side opposite a brain lesion
- When this failure cannot be attributed to either sensory or motor Impairments
Different to inattention
What is the incidence of unilateral neglect following a right CVA?
17 –80 % following right CVA
_____ neglect following _____CVA is most common
Left; right
For unilateral neglect, _____ hemisphere lesion – attention to both hemispheres
right
In a unilateral neglect, ____ hemisphere lesion- attention to right hemisphere
Left
What are 2 characteristics of right hemisphere lesion – attention to both hemispheres in unilateral neglect?
- attention is directed primarily to the right hemispace
- neglect of the left hemispace
What are 2 characteristics of left hemisphere lesion- attention to right hemisphere in unilateral neglect?
- does not usually result in UN
- intact right hemisphere can direct attention to both hemispaces
Is a right or left hemiplegia worse? Why?
Right hemi can be worse
- affected both hemispheres
What are 2 characteristics of unilateral neglect (right)?
- Normal variations in the side of cerebral dominance
- May also be non-lateralised impairments of attention
What are 2 things that neglect is associated with?
- longer length of stay in rehabilitation
- poorer functional outcome following stroke
What are 3 types of unilateral neglect?
- sensory neglect
- action-intentional disorders (motor neglect)
- memory and representational deficits
What are 2 characteristics of sensory neglect?
- decreased awareness of sensory stimulation in the contralesional hemispace
- despite intact primary sensory cortical area and sensory pathways (They can see and feel properly)
What are 3 characteristics of action-intentional (motor) neglect?
- Decreased ability to move in the contralesional hemispace
- Despite being aware of a stimulus in that space
- Not a deficit of the motor pathway (Have activation capacity)
Can see it, can reach to touch it but they don’t
What is a characteristic of memory and representational deficits (neglect)?
A disorder of memory of extrapersonal space
What are 3 characteristics that neglect is determined by (space)?
- Personal – affecting the contralesional body
- Peripersonal – contralesional near space within reaching distance
- Extrapersonal – space beyond reaching distance
What are 2 physiotherapy assessments that are incorporated for unilateral neglect?
- Observation during functional task analysis
- Standardised impairment assessments
- May not turn on muscles
What are 2 mismatches to note during functional assessment in unilateral neglect?
Note failure to use or attend to one side of body or environment
Note any mismatch between:
- quality of movement observed during on-bed assessment
- functional use of limbs
What are 3 common things seen during functional assessment in unilateral neglect?
- May run into objects and doorways
- May leave affected arm behind when rolling
- Difficulty crossing midline
What are 2 characteristics during impairments assessment in unilateral neglect?
- No consensus re optimum method of assessment
- Because there are several subtypes it is likely that a combination of tests will be required for a comprehensive diagnosis
What are 2 impairment measure examples for unilateral neglect?
What is the Star Cancellation task from Behavioural Inattention Test as a impairment measure for unilateral neglect?
What is inattention/extinction?
The failure to recognise or respond to a stimulus on the affected side only when the unaffected side is also being stimulated
- tactile, visual, auditory
Why should/ should not you touch the unaffected side in inattention/extinction?
Try not to touch the unaffected side as it will start stimulating this side (less awareness of affected side)
What are 2 characteristics in agnosia?
What is astereognosis agnosias?
Astereognosis (tactile agnosia)
- The inability to recognise objects by touch even though tactile, thermal and proprioceptive functions are intact
What is autotopagnosia agnosias? What are 3 characteristics of this?
Disturbed perception of the patient’s own body parts
- may be unaware of existence of one side of body
- may be unable to distinguish right from left (laterality)
- Assessment: draw a man test
What are the 3 processes for assessing agnosias?
What are 2 other impairments of visuospatial awareness when essential to rule out or be aware of impairment of primary visual skills for visual skills ?
Essential to rule out or be aware of impairment of primary visual skills:
- Eye movements
- visual scanning
- saccadic eye movements
- Visual fields
What are 4 other impairments of visuospatial awareness when disturbance of distance perception?
- Difficulty determining the relative distance between objects and oneself
- May present as difficulty with stairs or curbs or negotiating obstacles
- Point to two objects and ask which is closer or further away
- Pencil test
- Poor spatial alignment (deepth perception)
- Pick up the phone (at the back of the shelf)
- Knows what the phone is and where just not exact how far
- Shuffling around
What are 4 other impairments of visuospatial awareness when disturbance of size, colour or shape perception?
- Ask patient to compare size, colour or shape of objects
- Functionally the patient may show inappropriate fear
What are 3 other impairments of visuospatial awareness when disturbance of figure-ground perception?
- Inability to distinguish a specific stimulus from its background
- Visual
- Auditory
What are 6 things to test in other impairments of visuospatial awareness when disturbance of direction sense?
Test:
- up
- down
- left
- right
- forwards
- backwards
What are 2 characteristics of other impairments of visuospatial awareness?
- Difficulty with route finding / poor topographical memory
- Inability to find one’s way in familiar surroundings or to learn the way in a new situation
What are 5 other impairments of visuospatial awareness when disturbance of verticality perception?
- Subjective postural vertical
- Perception of own body orientation
- Observe posture and ask if client feels
straight' orfalling/leaning to one side’ - Move client into various positions
- Is there fear of falling?
What are 4 other impairments of visuospatial awareness for Subjective Visual Vertical – vestibular cortex (part of the thalmus)?
- Perception of position of objects in environment
- Hold a stick against a background (Blank wall) with no cues
- Slowly rotate stick
- Ask client to tell you when it is vertical or horizontal
What is pushing behaviour (3 characteristics)?
- an asymmetrical trunk posture towards the hemiplegic side
- active pushing towards the hemiplegic side
- Can be associated with left or right hemi’s – postero-lateral thalmus
What are 4 other terms for pushing behaviour?
- Pusher syndrome
- Contraversive pushing
- Ipsilateral pushing
- Lateropulsion
What are 3 clinical features of pushing behaviour?
- Overactivity of the nonparetic ipsilesional arm and leg
- extend the unaffected arm and leg and actively push away from the nonparetic side
- Active pushing not collapsing on weak side
- Loss of midline orientation of head and trunk
What are 2 clinical features for resistance to attempts at passive correction of posture towards the ipsilesional side in the pushing behaviour?
- Falling towards hemiplegic side
- Fear of falling towards the ipsilesional side
What are 3 features of the severity of PB?
- Vary between individuals
- Vary within individuals over time
- Become more obvious when the base of support is reduced and or when task become more complex
What are 2 clinical features for the most severe pushing behaviour (PB)?
- inability to transfer weight to unaffected side
- in any position (lying / sitting / standing)
What are 2 clinical features for the least severe pushing behaviour (PB)?
- Typical post-stroke asymmetry in less challenging situations
- PB only evident during walking or in more challenging environments
What is the incidences of pushing behaviour?
What is the prognosis for pushing behaviour?
What is the mechanism for the pushing behaviour?
Mechanism: Theories:
Disturbed perception of verticality:
- ? SVV
- ? SPV
- ? BOTH
- Not supported with recent evidence
Graviceptive Neglect
- Disrupted processing of graviceptive information
Right hemisphere syndrome
- PB is frequently associated with unilateral neglect but not always
- Left hemisphere syndrome
- PB is frequently associated with aphasia nut not always
What is the physiotherapy assessment for pushing behaviour?
- Scale for Contraversive Pushing
- Quantifies the presence and severity of PB
- Assessment of verticality perception
- Neglect assessment
What is apraxia?
What is the incidences of apraxia?
- Pure cases without other physical or cognitive impairment are rare
- Usually the person’s voluntary movement is less skilled than would be predicted by their other physical and cognitive impairments
- Incidence: approximately 1/3 of left brain damaged patients
What are 4 types of apraxia? What are the important ones for physio?
What are 4 characteristics of ideomotor apraxia?
- The inability to perform purposeful movement on external command even though the concept of the task is fully understood
- Habitual tasks may be able to be carried out automatically
- While not able to perform on command
- Exactly the same activity may be executed perfectly in a natural setting
What are 3 characteristics of ideomotor apraxia when learning to walk?
- May attempt to lift one foot without shifting weight onto the other
- Take several small steps with one foot without moving the other
- When assisted on both sides may take small steps forward with the feet and leave the rest of the body behind
Right hemiplegic –> already have language deficits
When are 2 situations when ideomotor apraxia performs motor tasks best?
- When they are requested and done automatically – ‘stand up’ – ‘pick up cup’
- Give a functional task to drive movement (eg. stand up, reach to the cup)
- When an object is provided that will give meaning to the motor command
What are 3 characteristics of ideational apraxia?
- Inability to perform an activity consisting of a complex series of actions either automatically or on command
- There is a failure to comprehend, develop or retain the concept of what is desired
- Can perform individual movements but cannot develop sequence of action
- e.g. light a match; clean teeth; roll over
- Use simple cues (unable to put bigger pictures together (functional tasks)
What are 2 tyhings that ideational apraxia can’t do?
- Cannot pretend to perform an act or describe the function of an object
- Eg. show me how you clean your teeth
- Unable to perform tasks automatically
- Performance doesn’t improve with presentation of an object
What are the 3 most frequent errors in ideational apraxia?
- omissions
- Mis-location or misuse of objects
- sequence errors
What are 2 assessments of apraxia?
- Series of tasks
- e.g. brush teeth, use hammer, wave goodbye
- Asked to perform movements on command
- e.g. “show me how to use a toothbrush
What are the 3 characteristics of Goodglass and Kaplan Test for Apraxia?
- If patient fails on command
- Therapist asks the patient to imitate
- Use motor imagery
- If the patient still fails - use real objects
What is the impairment in constructional apraxia?
producing designs in 2 or 3 dimensions by copying, drawing or constructing on command or spontaneously
What is contructional apraxia?
Functionally difficult to perform purposeful acts while using objects in environment
- e.g. making bed or setting the table
- Poor conceptualisation of the spatial requirements of activities
- Either right or left hemisphere damage
What is right hemisphere damage constructional apraxia?
Felt to be due to visual or spatial disorders
What is left hemishere damage constructional apraxia?
Felt to be due to conceptual planning disorders
What are 2 2D constructional apraxia tests?
- draw a man, house or clock
- copy matchstick patterns
What are 2 3D constructional apraxia tests?
- build a tower
- copy block designs
- puzzles
Whatis dressing like in apraxia?
- Unable to relate spatial forms of clothes to that of the body
- Due to disorder of recognition of body parts or visuospatial neglect
