Perceptual Dysfunction Flashcards
What does Perception have the ability to do?
It has the ability to select stimuli that requires attention and action
What is Perception?
The integration of information that is psychologically meaningful
What does perception integration with?
Prior Information
What does perception facilitate?
Interpretation
Perceptual and Cognitive Deficits can lead to what?
They can lead to poor rehabilitation progress for patients, even despite motor skill return
Why is perception important?
For learning
What is a Perceptual Screen?
Often co-occurs with other system screens
What is observed during a Perceptual Screen?
-Inattention to therapist during subjective interview
- Inattention to half of body
- Decreased response to verbal cues
What is 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 are the purposes of examination of Perceptual Deficits?
- Determine which perceptual abilities are intact vs which are impaired
- Appropriately guide intervention
What are the factors that influence the exam?
- 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 should one sequence this part of the exam?
- Perform sensory examination BEST: visual screening
- Perform a cognitive screen
- Screen hearing
- Consult with family about usual vs unusual behaviors
What can perception NOT be viewed as?
Cannot be viewed as independent of sensation
Is perception more complex?
YES
Where do deficits not lie in perception?
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
What is Perceptual Deficit/Visual Neglect?
Inattention or neglect of visual stimuli presented on the involved side
What is visual field impairment?
- The patient is aware of the deficit
- The patient may compensate spontaneously
- Example: Hemianopsia
What is the most common forms of sensory loss in those with hemiplegia?
Visual Impairment
What are some common impairments that are included with visual impairments?
Poor eyesight, Diplopia, Homonymous Hemianopsia, and damage to the visual cortex or retina
What should a visual screening include?
- Visual acuity
- Oculomotor control (smooth pursuits, “H- test”)
- Visual field testing
What are some Body Scheme Perceptual Deficits?
The relationship of the body parts to each other and the relationship of the body to the environments
What are some Body Image/Body Awareness Perceptual Deficits?
Visual and mental image of one’s body that includes feelings about one’s body
What are some Spatial Relations Perceptual Deficits?
Impairments that have in common a difficulty in perceiving the relationship between self and two or more objects in the environment
What are some Agnosia’s Perceptual Deficits?
Inability to recognize incoming information despite intact sensory capacities
Which lobe do lesion happen that typically produce perceptual deficits?
Right Parietal Lobe
What are some impairments for Body scheme/Body image?
- Unilateral neglect
- Anosognoisa
- 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
What is Observed with Unilateral Neglect/Unilateral Spatial Neglect patients?
Limited use of the more involved extremity
What is Limited with Unilateral Neglect/Unilateral Spatial Neglect patients?
Limited reaction to sensory stimuli (visual, auditory or somatosensory)
What is should be observed with Unilateral Neglect/Unilateral Spatial Neglect patients?
Be observant of spontaneous movements or specific response to inquiries of movement on the involved side
What some impairments with Unilateral Neglect/Unilateral Spatial Neglect patients?
Impairments may be an inability to attend to an object or the environment as a whole
What is Neglect of personal space?
Pertains to the body (ex. failing to wash the left side of the body)
What is Neglect of Peripersonal Space?
Area within arm distance from the body (ex. failing to use objects on the contralateral side of their plate)
What is Neglect of Extrapersonal Space?
The area of space beyond arm length (ex. failing to negotiate obstacles, doorways)
What are some examples of how patient with neglect would clinically present?
- 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
Where the Lesions for patient that have Neglect?
Inferior-Posterior regions of the right parietal lobe
What kind of tests can be done with patient that have Neglect?
Behavioral Inattention Test (BIT) and Observations of ADLs
What are some treatment strategies that can be used with patients that have Neglect?
Remedial approach vs compensatory approach
What is Neglect?
Despite no sensory loss, individuals lack an ability to register and integrate stimuli from one side of the body and the environment or hemispace
What can promote turning the head and axial trunk rotation?
Active Visual Screening
What type of cues help direct a patient’s attention?
Visual, Verbal and Motor Cues
What can be encouraging with a Hemiparetic patient?
Encouraging active voluntary movement of the neglected limbs while encouraging the patient to look at his or her limbs
What type of encouragement should functional activities do?
Encourages bilateral interaction
What should be optimized on the dominant side?
Optimizing visual, tactile and proprioceptive stimuli
What is Anosognosia?
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
What are some limits with patients who suffer from Anosognosia?
This limits the patient’s ability to recognize the need for compensatory techniques
What are some clinical examples of Anosognosia?
- Maintains that “nothing is wrong” or disowns their involved side
- May refuse to accept responsibility for their more involved side
- May utilize words such as “my arm has a mind of its own”
Where are the Lesions with patients who suffer from Anosognosia?
Unclear, proposal of the supramarginal gyrus
What are some tests for patients who suffer from Anosognosia?
Subjective interviewing and asking questions such as “ what happened to your arm/leg”
What are some treatment strategies for patients who suffer from Anosognosia?
Prioritize safety
What is Somatagnosia?
-Impairments of body Scheme
- Lack of awareness of the body structure and the relationship of body parts to oneself or others
What is Somatagnosia also known as?
Body Agnosia
What do patient have difficulty with when suffering from Somatagnosia?
Patients often have difficulty following instructions
What are extremities often reported as for Somatagnosia?
HEAVY
The lack of _____ may compound this disorder?
Proprioception
What is a clinical example of Somatagnosia?
Difficulty with transfer, dressing and with exercises requiring body parts moving in relation to others
Where is the lesion for patient who suffer from Somatagnosia?
Dominant parietal lobe; often seen with right hemiplegia
What are some tests for patient who suffer from Somatagnosia?
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
What are some treatment strategies for patient who suffer from Somatagnosia?
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 suffering from Right-Left Discrimination will have a difficult time with what?
A patient will have a difficult time verbally responding to commands that include the terms right and left
A patient suffering from Right-Left Discrimination will have a difficult time with what type of movements?
A patient will have a difficult time imitating movements
What are clinical examples of Right-Left Discrimination?
- The patient is unstable to tell his or her left arm from right
- Incorrect shoe placement
- Difficulty with gait cues such as “turn right around the corner”
Where is the lesion with patients suffering from Right-Left Discrimination?
Parietal Lobe of either hemisphere
What are some tests with patients suffering from Right-Left Discrimination?
The patient is asked to point to body parts on commands
- 6 responses should be elicited
- To rule out: test first without the terms “left” and “right”
What are some treatment strategies with patients suffering from Right-Left Discrimination?
Compensatory Approach
- Avoid left and right
- Pointing or providing other distinguishing cues
What is Finger Agnosia?
An inability to identify the fingers of one’s hand or that of the examiners
Where are lesions with patient suffering from Finger Agnosia?
The parietal lobe at the region of the angular gyrus of the left hemisphere
What some tests for a patient suffering from Finger Agnosia?
A portion of sauguets test that includes items such as the therapist’s touching the patients hand, vice versa, recognition on a picture, and with imitation
What are some treatment strategies for a patient suffering from Finger Agnosia?
Limited evidence, but a remedial approach can be attempted
What are some impairments for Spatial Relations Syndrome?
- 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
What is Functional Relevance for Figure Ground Discrimination?
Difficulty ignoring irrelevant visual stimuli, increased distractibility, shortened attention span, frustration and reduced safety
What are clinical examples of Figure Ground Discrimination?
The patient cannot locate items within a drawer, locate buttons on a shirt or have difficulty with stair negotiation (specifically descending)
Where are the lesions for patient suffering from Figure Ground Discrimination?
Parieto-Occipital lesion of the right hemisphere
What are some tests for patient suffering from Figure Ground Discrimination?
The Ayres Figure Ground Test
What are Functional Based Tests for patient suffering from Figure Ground Discrimination?
-Place a towel on a white sheet
- Locate the sleeve, buttons, and collar of a white shirt
What are some treatment strategies for patient suffering from Figure Ground Discrimination?
Remedial and Compensatory
What is Form Discrimination?
Impairment of discrimination in the inability to perceive or attend to subtle differences in form and shape
What are some clinical examples of Form Discrimination?
Confusing pen with a toothbrush, a vase with a water pitcher, and/ or a cane with a crutch
Where is the lesion for a patient suffering from Form Discrimination?
Parieto-temporooccipital region in the non-dominant lobe
What are some tests for a patient suffering from Form Discrimination?
The patient is asked to identify several items similar in shape and different in size
What are some treatment strategies for a patient suffering from Form Discrimination?
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
Why should Spatial Relation Skills be acquired?
Spatial relation skills are required to manage most ADL’s
If a patient doesn’t have Spatial Relation skills what difficulties can occur?
Difficulties could result in impaired dressing, crossing midline, etc
What are some clinical examples of Spatial Relations Disorder/Spatial Disorientation?
- Difficulty with setting the table
- Difficulty reading a clock
- Difficulty with preparing for a transfer
Where is the lesion located for patient who suffer from Spatial Relation Disorder?
Inferior Parietal Lobe or Parieto-Occipital Junction on the right
What are some tests for patient who suffer from Spatial Relation Disorder?
Rivermead Perceptual Assessment Battery (RPAB) and the Arnadottir OT-ADL Neurobehavioural Evaluation (A-ONE)
What are some treatment strategies for patient who suffer from Spatial relation Disorder?
Remedial approach: providing instruction 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
What are some clinical examples in Position in Space?
When asked “place your feet”on” the footrests” a patient may not know what to do
Where is the lesion located for patients who suffer from position in space?
Non-dominant Parietal Lobe
What are some tests for patients who suffer from Position in Space?
- 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 manipulations with an identical set of objects to the patient
What should be RULED OUT for patients how suffer from Position in Space?
Figure ground difficulty, apraxia and incoordination and a lack of comprehension should be ruled out
What are some treatment strategies for patients who suffer from Position in Space?
- 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
What are some clinical examples of Topographical Disorientation?
- Difficulty with describing home layout
- Difficulty getting to and from the therapy gym despite exposure
Where is the lesion located for patient who suffer from Topographical Disorientation?
Right Retrosplenial Cortex, Bilateral pareital lesions. L parietal lesion
What is the remedial approach for topographical disorientation?
practice going from one place to another
- simple to more complex
- verbal instructions should be used
What is the compensatory approach for topographical disorientation?
- frequent routes can be marked with colored dots
- safety considerations such as not leaving home independently
What will a patient with depth and distance perception experience?
inaccurate judgement of direction, distance and depth
What are clinical examples of depth and distance perception?
- a patient may miss a chair when returning to sit
- pt may continue pouring water despite a full glass
Where is the lesion with depth and distance perception?
posterior right hemisphere in the superior visual association cortices
How do we test for depth and distance perception?
- object grasp on a table o rin the air
- fill a glass of water
How can we treat depth and distance perception?
- assist the patient in becoming aware of the deficit
- provide education on uneven terrain and stair negotionation
What is a remedial treatment approach for depth and distance perception?
- place feet on designated spot during gait training
- touch foot to a pile to re-establish sense of depth and distance
What is a compensatory approach for depth and distance treatment strategies?
utilize UE support to sit squarely within a chair
What is vertical disorientation?
distorted perception of what is vertical
Where is the lesion with vertical disorientation?
nondominant parietal lobe
How do we test for vertical disorientation?
therapist holds a cane and then turns it sideways to a horizontal positon and the patient is asked to return the cane back to the original positon
What are treatment strategies with vertical disorientation?
enhance awareness and cue tactile input to assist
What is pushers syndrome also known as?
ipsilateral pushing or contraversive pushing
What is pusher’s syndrome?
motor behavior characterized by active pushing with the stronger extremities toward the hemiparetic side with a lateral postural imbalance
What does pushers syndrome result in?
a loss of balance towards the hemiparetic side
What area is affected with pusher’s syndrome?
posterolateral thalamus
What is the result with pusher’s syndrome?
altered perception of the bodys orientation in relation to gravity
What is there a misconception about with pusher’s syndrome?
subjective postural vertical
What often happens with sitting in a wheelchair with pusher’s?
a thrust push over the wheelchair arm
What kind of transfers are often less successful with pusher’s?
to the less involved side
What happens with standing with pusher’s
results in instability on the hemiparetic limb resulting in increased fall risk
What are some common impairments with walking with pushers?
difficulty with weight transfer toward the less involved LE, postural scissoring of the more involved LE, and difficulty with unilateral AD training
What is the examination critera for pusher’s?
- spontaneous body posture with tilting towards 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 will pusher’s syndrome invdividuals resist?
- any attempy at passive correction to midline
with pusher’s syndrome, the brain will compensate with….
therapeutic training
- reorienting patients to true vertical
- managing the environment to optimize these visual cues
What is agnosia?
the inability to recognize or make sense of incoming information despite intact sensory capacities
What kind of agnosias are there?
- 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
What are clincial examples of visual object agnosia?
- difficulty recognizing people, possessions, and common objects
- ex: dimultanagnosia, prosopagnosia, color agnosia
What is the lesion area of visual object agnosia?
occipito-temporo-parietal association areas of either hemisphere
How do we test for visual object agnosia?
place several common objects in front of a patient with instruction to name, point or demonstrate use of each object
What can make visual object agnosia difficult to recognize?
aphasia and apraxia
What is a remedial approach for visual object agnosia treatment?
practice drills to discriminate between faces of importance to the patient, discriminate between colors and common objects
What is a compensatory approach for visual object agnosia?
encourage use of intact sensory modalities to distinguish people and objects
What is auditory agnosia?
an ability to recognize non-speech sounds or to discriminate between them
What are clinical examples of auditory agnosia?
- inability to distinguish the ring of a doorbell and that of a telephone
- inability to distinguish between the bark of a dog and thunder
Where is the lesion with auditory agnosia?
dominant temporal lobe
How is audority agnosia tested for?
performed by a SLP
what are treatment strategies for auditory agnosia?
- 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
What are clinical examples of tactile agnosia?
inability to recognize a familiar object when it is handed to the patient
Where is the lesion with tactile agnosia?
parieto-temporoocipital lobe (posterior association areas) of either hemisphere
How do we test for tactile agnosia?
object identification in the hand without visual cues
What is the remedial approach for tactile agnosia?
instruct feeling objects placed within the hand followed by immediate visual feedback
What is the compensatory approach for tactile agnosia?
visual compensation
How do we mitigate impairments for agnosia?
- 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
____________ is key
collaboration
Who should we communicate and collaborate with an _____ ______ to enhance assessment and intervention strategies utilized
occupational therapist
Who is specifically trained to treat perceptual deficits?
OTs
