L9: Physiotherapy management of perceptual and apraxic impairments

Question 1

What is the physiotherapy management for perceptual disorders?

Answer 1

Question 2

What are the 3 functional approaches in the physiotherapy management for perceptual disorders?

Answer 2

1. Training of functionally relevant and concrete tasks
2. Emphasis on the person paying attention to and orienting to the relevant objects and their position in space
3. Visual vertical intact – patient needs to overcome the perceived mismatch of sense of upright versus what they are seeing.

Question 3

What are the 3 characteristics of “Facilitate awareness of impairment making use of intact networks” in the management of perceptual disorders?

Answer 3

1. Vision – looking**** they see the world correctly so use this as key to align themselves to
   
   • Can also be used If they do not have tactile feedback
2. Tactile and proprioceptive sensation – touching, feeling, moving
   
   • If they have intact teactile sensation
3. Verbal and cognitive ability – say out load what happening, sensing, seeing, hearing
   1.

Question 4

What are the 5 characteristics “therapist driven verbal and cognitive ability” in the management of perceptual disorders?

Answer 4

1. Increase the person’s awareness and understanding of their impairments
   
   • e.g. if they have a disturbance of subjective postural vertical:
     
     • Point out that they are mistaken about the nature of vertical
     • Encourage them to align themselves with known vertically oriented objects (e.g. a door frame)
2. Advise patient to take their time and make frequent checks during activities that require spatial judgements
   
   • Don’t assume that they haven’t understood it (give them time to process)
3. Success of aligning to visual upright and not falling will provide confidence and adherence to your patient and therapy
4. Ask patient to express aloud in words
   
   • the sequence
   • spatial relations of a motor task
5. As a means of directing motor performance
   
   • Replicate the functional task (do not manipulate to make it impractical)
   • If a task is designed to be done close to the body (do it close to the body)

Question 5

What are the 3 characteristics “Facilitate attention: Visual Feedback” in the management of perceptual disorders?

Answer 5

1. Provide reminders to attend – verbal, tactile, task driven: auditory, visual, movement (Enhance or replace)
2. Gradually withdraw reminders so the patient becomes responsible for sustaining attention
   
   • Get them to slowly take over your role and become independent
3. Visual scanning training
   
   • Initially train scanning to side of neglect
   • Later train to scan to neglected side then back to other side
   • Use bright objects, cards, numbers on wall

Question 6

What is visual scanning training?

Answer 6

Obstacle courses – progressive difficulty

• Get add dual task (integrate skill while working on motor output)

Question 7

What are 3 things that visual scanning training improves?

Answer 7

1. scan the environment
2. look at what they are doing
3. talk about what can be seen

Question 8

What are 2 characteristics of mirros to facilitation attention (visual feedback) in perceptual disorders?

Answer 8

1. Often confuse patients with USN and agnosias
2. Vertical line of tape on a mirror is sometimes useful for providing orientation to the vertica

Question 9

What are 4 visual references to provide orientation to facilitation attention (visual feedback) in perceptual disorders?

Answer 9

1. Walls, plinths or tables
2. The therapist’s body
3. Taped lines (or coloured) on floor or steps
   
   • Bright tape on important items on left u e.g. left wheelchair brake

Inattentive to the left

• Interesting on left (physio –> find them)
• Boring wall on right (nothing happening on the right)

Question 10

What are 3 tacile/proprioception stimulation to facilitation attention (visual feedback) in perceptual disorders?

Answer 10

1. elasticised bandages
2. muscle tapping/sweeping
3. compression through joints and limbs

Question 11

What are 3 audiory reminders to facilitation attention in perceptual disorders?

Answer 11

1. Verbal cues
2. EMG biofeedback
3. weightbearing biofeedback

Question 12

What are 5 characteristics of training environment for physio management of perceptual disorders?

Answer 12

1. Use structured, simple environments
2. Keep space on unaffected side free of competing stimuli
3. Progress to open, complex environments
4. Start with attention focussed on task being practised
5. Progress to attention to environment while performing task

Question 13

What are 2 characteristics of Several treatment methods show promising results in improving neglect?

Answer 13

1. contralesional limb activation
2. prism adaptation therapy

Question 14

What are 7 recommended uses for the management of unilateral neglect?

Answer 14

1. Visual scanning training
2. Trunk rotation
3. Repeated neck muscle vibration
4. Mental imagery training
5. Video feedback training
6. Prism adaptation
7. Left limb activation

Question 15

What are 3 other techniques with potential usefulness in the physio management of unilateral neglect?

Answer 15

1. Sustained attention training
2. Sensory stimulation e.g. vestibular
3. Half-field patching

Question 16

What are the 7 general principles of the pushing behaviour in the physio management of perceptual disorders?

Answer 16

1. Avoid activities that make the patient fearful as fear will increase the tendency to push
2. Be cautious with handling to affected side during functional training
3. Minimise over-activity of unaffected - stronger side
4. Promote selective trunk activity
5. Retrain weight transfer in sitting and standing to accept weight to the unaffected side.
6. Use objects as targets for patient to ‘ACTIVELY’ (No assistance) move to unaffected side …. Acceptance of weight
7. Throughout task training encourage the patient to understand the mismatch between the true visual vertical and their own incorrect sense of the body’s relation to gravity

Question 17

What are 4 characteristics of “Use external/environmental cues as a frame of reference for correct alignment” in pushing behaviour?

Answer 17

1. table, box or rail on unaffected side
2. another object may be used in front to ‘box’ in
3. if pushing off table – block and putty
4. Up against the wall (shoulder against –> tactile feedback as support)

Question 18

What are 4 characteristics of retraining weight transfer in the pushing behaviour?

Answer 18

1. Facilitate weight transfer in relaxed, supported positions initially
   
   • eg reclined sitting
2. Progress to facilitated weight transfer with smaller base of support
3. Use automatic activities / facilitation techniques to promote weight transfer
   
   • Reaching to pick up objects
     
     • centrally at first
     • then towards unaffected side
4. Use automatic activities / facilitation techniques to promote weight transfer
   
   • Early walking with appropriate facilitation
   • Stepping on/off block with affected leg… promotes loading of unaffected leg… Acceptance of weigth
   • Stair training

Start this day 1 –> training brain that perception is wrong and train doing normal ways (gait)

Question 19

What are 9 characteristics of gait training and pushing behaviour?

Answer 19

1. Early mobilisation
   
   • Beside single rail attached to a wall
   • Excellent cues for weight transfer and orientation
   • Reduces fear
   • Easy access to assist affected lower limb
2. Caution with handling on affected side
3. Caution re weight shift by pulling on bar
4. Encourage hand to slide along rail (rail should be used as a cue only)
5. Extra person behind if necessary to assist manually with balance and weight transfer
6. Do not allow dependence on the rail to develop
   
   • Get patient to weight shift independently –> do not go weight shift for them
7. ASAP progress to mobilising without a rail
8. Single Canadian crutch on unaffected side often more useful than a single stick or 4 point stick
9. Often useful to “warm up” with a walk beside the rail

Question 20

What are the 2 functional approach in the general principles for all types of apraxia?

Answer 20

1. Goal oriented training of functional activities
2. Preferably within the patient’s usual environment

Question 21

What are the 2 visual cues in the general principles for all types of apraxia?

Answer 21

1. gesture
2. demonstration

Question 22

What are the 2 instructions in the general principles for all types of apraxia?

Answer 22

1. Keep commands simple (even monosyllabic)
2. Make use of intonation and inflection of voice

Question 23

What are 7 general prinicples for all types of apraxia?

Answer 23

1. Use intact networks to compensate for lost functions
2. Use visual cues
3. Instructions
4. Allow sufficient time for patients to attempt movement
5. Use manual guidance / facilitation (Enhance or replace) to give idea of movement required
6. Request sequenced motor actions within the patient’s capabilities (Do something that is common sense and simple)
7. Gradually demand increasingly complex sequenced motor tasks

Question 24

What are 2 characteristics of ideomotor apraxia?

Answer 24

1. Train tasks as a whole (not component parts)= Keep it big
2. Respond best to commands for automatic movement rather than step by step instructions
   
   • “stand up” vs
   • “lean forward, bring the knees forward and put weight on both legs”
   • Demonstrated
3. Use facilitation and handling to give idea of movement required
4. Use objects to give idea of the motor task required
5. Allow sufficient time for the patient to attempt movement

Question 25

What are 2 characteristics of ideational apraxia?

Answer 25

1. Breakdown tasks into components initially
2. Use cues
   
   1. Gesture
   2. Demonstration
   3. Simple verbal cues with intonation

Question 26

What are 3 characteristics of constructional apraxia?

Answer 26

1. Establish visual, perceptual or planning disorder
2. Train with 2 and 3 D objects / tasks
3. Add
   
   • Verbal, visual, contextual cues for success
   • Slowly increase complexity of task and movement integrations