Perceptual Dysfunction Flashcards
what is perception?
-The integration of information that is psychologically meaningful
The ability to select stimuli that require attention and action
Integration with prior information
Facilitates interpretation
Why is discussing perception important?
Perceptual and cognitive deficits can lead to poor rehabilitation progress for patients, even despite motor skill return
Perception is important for learning
A Perceptual Screen is observed for
Often co-occurs with other system screens
Observe for:
-Inattention to therapist during subjective interview
-Inattention to half of body
-Decreased response to verbal cues
what is an Examination of Perceptual Deficits
Formal testing is indicated when there is a functional loss unexplained by motor or sensory impairments or deficits in comprehension
what is the purpose of the Perceptual Deficits
Determine which perceptual abilities are intact vs. which are impaired
Appropriately guide intervention
What are factors that influence perceptual deficits
-Psychological and emotional status
-A patient’s ability to detect relevant cues from the environment
-The presence of anxiety
-Receptive and expressive communication skills
-Depression
-Fatigue
How do I sequence this part of the exam? Perception, Sensation, or vision
(1)Perform sensory examination FIRST
-Visual screening
(2)Perform a cognitive screen
(3)Screen hearing
(4)Consult with family about usual vs. unusual behaviors
what is Perception?
-Cannot be viewed as independent of sensation
-More complex
-deficits do not lie with sensory ability itself, but rather the interpretation of sensation and the follow-up response
what is sensation
Awareness of stimuli through the organs of special sense, the peripheral cutaneous sensory system, or internal receptors
Perceptual Deficit/Visual Neglect consist of what
Inattention or neglect of visual stimuli presented on the involved side
what is visual field impairment?
Example: hemianopsia
The patient is aware of the deficit
The patient may compensate
spontaneously
what is One of the most common forms of sensory loss in those with hemiplegia
visual impairment
what are common visual impairments?
poor eyesight, diploplia, homonymous hemianopsia, and damage to the visual cortex or retina
what is a visual screening should include?
-Visual acuity
-Oculomotor control (smooth pursuits, “H-test”)
-Visual field testing
With Perceptual Deficits , what disorders you may see?
I: Body scheme: the relationship of the body parts to each other and the relationship of the body to the environment
I: Body image/body awareness: visual and mental image of one’s body that includes feelings about one’s body
II: Spatial relations: impairments that have in common a difficulty in perceiving the relationship between self and two or more objects in the environment
III: Agnosias: inability to recognize incoming information despite intact sensory capacities
what are the 5 body scheme and body impairments
Unilateral neglect
Anosognosia
Somatagnosia
Right-left discrimination
Finger agnosia
what is Unilateral Neglect/Unilateral Spatial Neglect
Lack of awareness of part of the body or the external environment which is not due to sensory loss
Observe for limited use of the more involved extremity
Limited reaction to sensory stimuli (visual, auditory, or somatosensory)
Be observant of spontaneous movements or specific responses to inquiries of movement on the involved side
Impairments may be an inability to attend to an object or the environment as a whole
what are examples of Neglected space
Neglect of personal space (pertains to the body)
Ex: failing to wash the left side of the body
Neglect of peripersonal space (area within arm distance from the body)
Ex: failing to use objects on the contralesional side of their plate
Neglect of extrapersonal space (the area of space beyond arm length)
Ex: failing to negotiate obstacles, doorways, etc.
What does neglect look like clinically?
Ignoring dressing the left half of the body
Ex: the patient may not put on the left sleeve or pant leg
Forgetting to shave the left half of the face
Neglecting to put on makeup on the left half of the face
Neglecting to eat from the left half of the plate
Bumping into objects on the left side
Propelling a wheelchair and veering to the right
Neglect summarized
Despite no sensory loss, individuals lack an ability to register and integrate stimuli from one side of the body and the environment or hemispace
Lesion area: inferior-posterior regions of the right parietal lobe
Testing: Behavioural Inattention Test (BIT) and observations of ADLs
Treatment strategies: remedial approach vs. compensatory approach
what are Interventions to Address Hemianopsia & Unilateral Neglect
-Strategies that encourage awareness and use of the environment on the hemiparetic side and use of the hemiparetic extremities
-Active visual scanning through turning the head and axial trunk rotation
-Visual, verbal or motor cues to direct the patient’s attention
-Encouraging active voluntary movements of the neglected limbs while encouraging the patient to look at his or her limbs
-Functional activities that encourage bilateral interaction
-Optimizing visual, tactile and proprioceptive stimuli on the more dominant side
What is anosognosia and
Defined as a lack of awareness, or denial, of a paretic extremity as belonging to the person
OR a lack of insight concerning, or denial of, paralysis or disability
This limits the patient’s ability to recognize the need for compensatory techniques
Clinical Examples:
-Maintains that ”nothing is wrong” or disowns their more involved limbs
-May refuse to accept responsibility for their more involved limbs
-May utilize words such as “my arm has a mind of its own”
summary of Anosognosia
Lack of awareness or denial of a paretic extremity
Lesion area: unclear, proposal of the supramarginal gyrus
Testing: subjective interviewing and asking questions such as: “what happened to your arm/leg”
Treatment strategies: prioritize safety
what is Somatagnosia
Impairment of body scheme
Lack of awareness of the body structure and the relationship of body parts to oneself or others
Also known as body agnosia
Patients often have difficulty following instructions
Extremities are often reported as ”heavy”
A lack of proprioception may compound this disorder
Clinical Examples:
Difficulty with transfers, dressing and with exercises requiring body parts moving in relation to others
Somatagnosia Summarized
Lack of awareness of the body structure and the relationship of body parts to oneself or to others
Lesion area: dominant parietal lobe; often seen with right hemiplegia
Testing: the patient is asked to point to body parts named by the therapist on themselves, the therapist, and on a picture or puzzle of a human figure; the patient is asked to imitate movements
Treatment strategies: remedial approach to facilitate body awareness
Ex: rubbing a body part or verbal identification of a body part
what is Right-Left Discrimination
-An inability to identify the right and left sides of one’s own body or that of the examiner
-A patient will have a difficult time verbally responding to commands that include the terms right and left
-A patient will have a difficult time imitating movements
Clinical Examples:
-The patient is unable to tell his or her left arm from right
-Incorrect shoe placement
-Difficulty with gait cues such as “turn right around the corner”
Right-Left Discrimination Summarized
Difficulty with identifying left vs. right
Lesion area: parietal lobe of either hemisphere
Testing: the patient is asked to point to body parts on command
6 responses should be elicited
To rule out: test first without the terms “left” and “right”
Treatment strategies: compensatory approach
Avoid left and right
Pointing or providing other distinguishing cues
Finger Agnosia Summarized
An inability to identify the fingers of one’s hand or that of the examiner’s
Lesion area: the parietal lobe at the region of the angular gyrus of the left hemisphere
Testing: a portion of Sauguet’s test that includes items such as the therapist’s touching the patient’s hand, vice versa, recognition on a picture, and with imitation
Treatment strategies: limited evidence, but a remedial approach can be attempted
what are Spatial Relations Syndrome Impairments
Figure-ground discrimination
Form discrimination
Spatial relations
Position in space
Topographical disorientation
Depth and distance perception
what is Figure-Ground Discrimination
An inability to distinguish a figure from the background in which it is embedded
Functional relevance: difficulty ignoring irrelevant visual stimuli, increased distractibility, shortened attention span, frustration, and reduced safety
Clinical Examples:
The patient cannot locate items within a drawer, locate buttons on a shirt, or have difficulty with stair negotiation (specifically descending)
Figure-Ground Discrimination is
Lesion area: parieto-occipital lesions of the right hemisphere
Testing: The Ayres Figure-Ground Test
Functional Based Test:
-Place a towel on a white sheet
-Locate the sleeve, buttons, and collar of a white shirt
Treatment strategies: remedial and compensatory
what is Spatial Relations Disorder/Spatial Disorientation
Inability to perceive the relation of one object in space to another object, or to oneself
-Spatial relation skills are required to manage most ADLs
Difficulties could result in impaired dressing, crossing midline, etc.
Clinical Examples:
-Difficulty with setting the table
-Difficulty reading a clock
-Difficulty with preparing for a transfer
Spatial Relations is also
*Lesion Area: inferior parietal lobe or parieto-occipital junction on the right
*Testing: Rivermead Perceptual Assessment Battery (RPAB) and the Arnadottir OT- ADL Neurobehavioural Evaluation (A-ONE)
Treatment strategies:
Remedial Approach: providing instructions to the patient to position himself or herself in relation to the therapist or another object; setup a maze; incorporation of midline crossing activities
what is position in space
An inability to perceive and to interpret spatial concepts such as up, down, over, under, etc.
Clinical examples:
When asked “place your feet “on” the footrests” a patient may not know what to do
Lesion area: nondominant parietal lobe
Testing:
Utilize a shoe and shoebox and ask the patient to place the shoe in different positions in relation to the shoebox OR you can present a relationship and ask the patient to describe
Have the patient copy the therapist’s manipulations with an identical set of objects to the patient
position in space is also
-Figure-ground difficulty, apraxia and incoordination, and a lack of comprehension should be ruled out
Treatment strategies:
-Retraining approach: 3 or 4 identical objects are placed in the same orientation with an additional object placed in a different orientation
–The patient is asked to identify the odd one and place it in the same orientation
what is Topographical Disorientation
Difficulty in understanding and remembering the relationship of one location to another
Clinical Examples:
Difficulty with describing home layout
Difficulty getting to and from the therapy gym despite exposure
Lesion area: right retrosplenial cortex, bilateral parietal lesions, L parietal lesions
Testing: the patient is asked to draw or describe a familiar route
Rule out memory problems
how do you treat Topographical Disorientation
Remedial Approach: practice going from one place to another
-Simple to more complex
-Verbal instructions should be used
Compensatory Approach:
-Frequent routes can be marked with colored dots (progression can occur with greater distance placed between dots)
-Safety considerations such as not leaving home independently
what is Depth and Distance Perception
A patient with this disorder will experience inaccurate judgement of direction, distance, and depth
Clinical Examples:
-A patient may miss a chair when returning to sit
-A patient may continue pouring water despite a full glass
Lesion areas: posterior right hemisphere in the superior visual association cortices
Testing:
-Object grasp on a table or in the air
-Fill a glass of water
what are treatment strategies for Depth and Distance Perception
Assist the patient in becoming aware of the deficit
Provide education on uneven terrain and stair negotiation
Remedial Approach:
-Place feet on designated spot during gait training
-Touch foot to a pile to re-establish sense of depth and distance
Compensatory Approach:
-Utilize UE support to sit squarely within a chair
what is Vertical Disorientation
-Distorted perception of what is vertical
-Clinical Example: a person has a distorted view of the world
-Lesion area: nondominant parietal lobe
-Testing:
*The therapist holds a cane and then turns it sideways to a horizontal position and the patient is asked to return the cane back to the original position
Treatment strategies:
-Enhance awareness and cue tactile input to assist
What is pushers syndrome
-Also known as ipsilateral pushing or contraversive pushing
-Defined as “motor behavior characterized by active pushing with the stronger extremities toward the hemiparetic side with a lateral postural imbalance”
-Results in a loss of balance towards the hemiparetic side
-Area affected: posterolateral thalamus
-Results in altered perception of the body’s orientation in relation to gravity
There is a misperception of subjective postural vertical
what are functional implications of pushers syndrome
-Sitting within a wheelchair often results in a thrust push over the wheelchair arm
-Transfers are often less successful to the less involved side
-Standing often results in instability on the hemiparetic limb resulting in increased fall risk
-During walking, common impairments include difficulty with weight transfer towards the less involved LE, potential scissoring of the more involved LE, and difficulty with unilateral AD training
examination criteria for pushers syndrome
-Spontaneous body posture with tilting toward the more paretic side
-An increase in pushing force by the less involved extremities as evidenced by increased abduction and extension
-Resistance to passive correction of the posture
what are some things you should know about pushers syndrome
Individuals with pusher’s syndrome will actively and strongly resist any attempt at passive correction to midline
The brain can compensate with therapeutic training
Therapeutic management goals include:
-Re-orienting patients to true vertical
-Managing the environment to optimize these visual cues
what is Agnosia impariments?
Agnosia: the inability to recognize or make sense of incoming information despite intact sensory capacities
Visual object agnosia
Auditory agnosia
Tactile agnosia
what is visual object agnosia
-An inability to recognize familiar objects despite normal function of the eyes and optic tracts
Clinical Examples:
-Difficulty recognizing people, possessions, and common objects
-Examples include: simultanagnosia, prosopagnosia, color agnosia
-Lesion area: occipito-temporo-parietal association areas of either hemisphere
-Testing: place several common objects in front of a patient with instruction to name, point or demonstrate use of each object
-Aphasia and apraxia can make this deficit difficult to recognize
what are strategies and treatment for visual object agnosia
Remedial Approach:
-Practice drills to discriminate between faces of importance to the patient, discriminate between colors and common objects
Compensatory Approach:
-Encourage use of intact sensory modalities to distinguish people and objects
what is auditory agnosia
-An inability to recognize non-speech sounds or to discriminate between them
Clinical Examples:
-Inability to distinguish the ring of a doorbell and that of a telephone
-Inability to distinguish between the bark of a dog and thunder
-Lesion area: dominant temporal lobe
-Testing: often performed by a SLP
- Treatment strategies:
-Drill the patient on sounds, but reduced effectiveness overall
what is tactile agnosia
-The inability to recognize forms by handling them although tactile, proprioceptive, and thermal sensations may be intact
Clinical Examples:
-Inability to recognize a familiar object when it is handed to the patient
-Lesion area: parieto-temporooccipital lobe (posterior association areas) of either hemisphere
-Testing: object identification in the hand without visual cues
Treatment strategies:
-Remedial Approach: instruct feeling objects placed within the hand followed by immediate visual feedback
-Compensatory Approach: visual compensation
How do we mitigate these impairments?
-Use verbal cues to enhance success
-Minimize clutter and activity within the treatment environment
-Practice in a closed environment with limited distractions
-Provide adequate lighting
-Provide clear boundaries and reference points
Collaboration is Key
Communicate and collaborate with an Occupational Therapist to enhance assessment and intervention strategies utilized.
Occupational Therapists are specially trained to treat perceptual deficits.
