Week 6 : Retraining Sensory, Perceptual and Behavioural Deficits

Question 1

List the 2 types of somatosensory impairments

Answer 1

proprioception

tactile impairments

Question 2

Proprioception is made up of a range of sensations including

Answer 2

recognition of movement 
movement heaviness
awareness of movement direction 
position in space 
sense of force 
timing of muscular contraction

Question 3

Proprioception is critical to multisegmental movements

give a couple of examples

Answer 3

STS 
stand to sit
manipulation 
gait 
balance

Question 4

loss of proprioception is associated with what

Answer 4

poor motor function and reduced functional independence

Question 5

sensory loss in proprioception impairments can be very specific, give an example

Answer 5

patient may recognise limb movement and position, but not movement direction

Question 6

Tactile functions

Answer 6

sensory functions involve localisation and discrimination of stimuli

Question 7

Is tactile function more essential in UL or LL?

Answer 7

UL

Question 8

Difficulty in sustaining muscular contraction without tactile feedback results in what

Answer 8

slowness and clumsiness in many manual tasks

Question 9

sensory impairments are linked to poor spontaneous limb use, T or F?

Answer 9

T

Question 10

Functional impact of somatosensory impairments

Answer 10

relationship between motor and sensory function
impairments may be a major cause of functional disability
Individuals may recover the ability to activate muscle groups and control their limbs, however their activity and participation may still be very restricted in their natural environment
Tactile and proprioceptive sensation are critical to regaining effective motor function, especially upper limb
Somatosensation is required for the learning of new skills
Sensation functions in both regulatory and adaptive modes, guiding movements during their execution and correcting movements in order to improve the next attempt

Question 11

give an example of the functional impact of somatosensory impairment

Answer 11

a patient may be able to effectively perform all components required for drinking, however poor sensory feedback may result in them dropping their glass
a patient may effectively mobilise on stairs, however when stepping down a curb poor sensory feedback may result in fear and reduced confidence

Question 12

Assessment of somatosensory impairment

Answer 12

largely subjective
reliability and validity unconfirmed
common tests developed for peripheral lesions
cerebral lesions- emphasis needs to be on how stimulus is perceived and interpreted, not just nerve conduction
important to conduct thorough Ax of sensation
inc Hx of sensory loss and recovery, prognostic importance and treatment effectiveness
Determine how sensory impairments relate to performance of functional activities and participation

Question 13

Specific assessments of somatosensory impairments

Answer 13

light touch 
double simultaneous stimulation 
stereognosis 
pinprick 
temperature

Question 14

rehabilitation of somatosensory impairments

Answer 14

• founded on the assumption that sensory activation is specific to the task and the environment in which it is being performed
• system is selective in the inputs utilised for specific functional activities

meaningful task practice
- task oriented training is directed toward enabling the patient to perform critical everyday actions more effectively and efficiently in the relevant environment and involves practice of the actions themselves (+/- action/ environmental modification)

Question 15

During rehabilitation of somatosensory impairments, the pt must be an active participant because

Answer 15

non specific stimulation of a passive recipient is unlikely to affect the awareness of specific sensation

cognitively directed approach to motor training is required

Question 16

pt’s need challenging and meaningful functional based rehabilitation with pt attending to sensory inputs and their relationship to the task, give an example

Answer 16

STS practice provides the opportunity to be aware of inputs from tactile and pressure receptors in the soles of the feet and kinaesthetic input from muscle and joint receptors, and may assist in limb positioning and loading

Question 17

Visual impairments

- visual field loss

Answer 17

Vision is our major source of information about the environment and our place in it

Eye-head coordination is particularly critical for manipulating and negotiating the environment

Neurological lesions may result in oculomotor dysfunction (double vision, impaired saccadic movement), dry eyes or cognitive and perceptual manipulations of visual inputs (e.g. visual field loss, visuospatial agnosia)

Loss of visual information from half the visual field is not uncommon following stroke

Question 18

Review slide 16 on visual field defects

Answer 18

especially for end of term exam

Question 19

functional impact of visual field loss

Answer 19

Visual impairments have a negative impact upon a patient’s ability to engage actively in rehabilitation and participate in activities of daily living

The ability to locate and maintain stable gaze on a fixed target, and to move eyes while keeping the head still in order to locate objects in the peripheral field is critical to functional task performance

Movement is guided by visual information about the location of an object and the body, and about the relationship of different body limbs and segments

Visual impairments may result in a patient bumping into objects, missing utensils on a table, having difficulty reading etc

Question 20

Specific assessment for visual field loss

Answer 20

Subjective examination (pre-existing visual impairments and management strategies in place)
Visual acuity
Eye movements (CN III, IV, VI)
Visual fields

must be informed about the state of the patient’s visual system, given its critical role in movement control

Question 21

Rehabilitation of visual field loss

Answer 21

Ensure pre-existing visual impairments are corrected (e.g. glasses in situ)

Understand specific visual impairments to give consideration to environmental factors such as glare and lighting during motor training

Compensation training is usually necessary
– Encourage eye and head movements to bring objects into view
– Encourage patient to pay attention in detection tasks

Question 22

List the three perceptual-cognitive impairments

Answer 22

apraxia
visual perceptual impairments
unilateral neglect

Question 23

What is apraxia

Answer 23

difficulty performing everyday activities not accounted for by weakness, sensory loss, incoordination, inattention or lack of comprehension

Question 24

list two types of apraxia

Answer 24

ideational apraxia

ideomotor apraxia

Question 25

What is ideational apraxia

Answer 25

characterised by absentmindedness and lack of purpose in performing various actions

Question 26

what is ideomotor apraxia

Answer 26

hinders the individual’s ability to select, sequence and use object

Question 27

Patient presentation with apraxia

Answer 27

Patients with apraxia often appear to be absent minded, act impulsively and may be thought to have intellectual deteorioration as opposed to a lack of awareness of the appropriate movement at a specific time

Question 28

apraxia is often assessed and described in terms of functional terms, give a couple examples

Answer 28

walking, dressing

Question 29

What are visual perceptual impairments

Answer 29

may include distortion of the perception of verticality; difficulty appreciating the three-dimensional nature of objects; difficulty navigating from place to place; inability to discriminate numerical symbols; incapability of telling the time; difficulty visualising familiar people and objects; poor understanding of up-down, in-out, front-back; difficulty with figure-ground perception

Question 30

patient presentation with visual perceptual impairments

Answer 30

often appear to be deaf or lacking in concentration

Question 31

What is unilateral neglect

Answer 31

a complex disorder of spatial representation, spatio-motor programming and spatial attention which results in the failure to attend or respond to, identify or orientate toward meaningful stimuli presented to the side contralateral to the lesioned hemisphere

Question 32

unilateral neglect is multimodal, involving what systems

Answer 32

visual, auditory, olfactory and proprioceptive systems

Question 33

Which side is usually affected with unilateral neglect

Answer 33

left side due to right side lesion

Question 34

unilateral neglect is also referred as what

Answer 34

hemi-agnosia, hemi-neglect, unilateral visual inattention, hemi-inattention, neglect syndrome, spatial neglect, hemi-spatial neglect

Question 35

Unilateral neglect is typically associated with what
may be present in what
or associated with what

Answer 35

stroke

post TBI

cerebral tumours

Question 36

reported incidence of unilateral neglect

Answer 36

29-85%

Question 37

what sort of prognosis is unilateral neglect associated with

Answer 37

poorer

Question 38

unilateral neglect is multidimensional in terms of distribution and modality, list the 4 modalities

Answer 38

Personal: failure to acknowledge stimuli on contralateral side of body
– Spatial: failure to acknowledge stimuli in contralateral side of space
– Sensory: deficit in awareness of contralateral sensory stimuli (visual, auditory, somatosensory)
– Motor: failure to respond to stimulus when person is aware of it – not due to weakness or spasticity

Question 39

Functional impact of perceptual-cognitive impairments

Answer 39

Significant functional consequences as patient’s have reduced ability to carry out many everyday tasks which restricts their independence

Serious effects of outcome of rehabilitation, discharge destination, length of stay and independence

Question 40

Assessment for perceptual cognitive impairments

Answer 40

Must be informed about the state of a patient’s perceptual-cognitive impairments to guide appropriate rehabilitation interventions and determine capacity to participate in rehabilitation
Perceptual-cognitive impairments most commonly assed by neuropsychologists and occupational therapists, however many become evident through functional task performance and thus must be recognised and referred
No single test identifies all perceptual-cognitive impairments, nor will impairments manifest themselves in all tasks
No clear consensus on evaluation

Question 41

rehabilitation of perceptual cognitive impairments

Answer 41

More research required to identify optimal interventions

Recovery and trainability of everyday actions likely to be affected by presence of perceptual-cognitive impairments

Compensation may be required (rehabilitation goals… prognosis… safety)

Difficult to plan treatments due to lack of clear understanding of underlying mechanisms of perceptual and cognitive deficits and poor evidence, with many promising techniques lacking generalisability

Question 42

Remediation of perceptual cognitive impairments

Answer 42

Overall aim is to address specific deficits by increasing the patient’s awareness of the nature of their impairments and training them to reorient their attention to particular situations while practicing functional tasks

Emphasis on attending to visual stimuli is critical

Training should include cues found in everyday life

Apraxia: cueing (proprioceptive, tactile and kinaesthetic) – verbal or physical prompts at each stage of a task

Neglect: draw attention to affected side (adapt environment to present visual, auditory and tactile stimuli); train affected side with active intentional movements in neglected part of extrapersonal space

Question 43

Remediation during physiotherapy for perceptual cognitive impairments

Answer 43

Emphasise visual scanning to search for targets
Encourage head and eye movements to locate apparently ‘missing’ objects
Use marks to assist in anchoring vision
Reorient during physiotherapy to ensure attention is focused
Avoid using criticism or words with negative connotations
– Do not use the term ‘neglect’ – Don’t nag

Question 44

what is dysphasia

Answer 44

disturbances of language caused by an insult to

specific brain regions

Question 45

list two types of dysphasia

Answer 45

receptive

expressive

Question 46

what is expressive dysphasia

Answer 46

problem producing the correct word or sequence of words

us

Question 47

what is receptive dysphasia

Answer 47

problem of understanding language

Question 48

Dysphasia usually occurs with lesions of what

Answer 48

left cerebral cortex

Question 49

what is dysarthria

Answer 49

disturbance of articulation

Question 50

what is dysphonia

Answer 50

disturbance in vocalisation

Question 51

what is dyspraxia

Answer 51

impaired planning and sequencing of muscles required for speech

Question 52

What is wernickes dysphasia

Answer 52

Lesions usually dominant temporal lobe Deficit in comprehension
Severe difficulty reading and writing Repetition of spoken language impaired Naming impairedFluency preserved or increased

Question 53

What is Broca’s dysphasia

Answer 53

Frontal lobe lesion
“Expressive dysphasia” Comprehension usually preserved Language expression affected Repetition of spoken language impaired Naming impaired
Fluency decreased
May result in almost complete loss of language expression to a slowed, deliberate speech utilising only key words and simple grammatical structure

Question 54

functional impact of language impairments

Answer 54

Language is distinguished from other kinds of human communication by its creativity, form, content and use
In written and spoken forms, language represents social and interactive activities
Loss or impairment of language has a profound effect
Patients often very isolated and easily frustrated as attempts to communicate fail

Question 55

assessment of language impairments

Answer 55

Early diagnosis of language impairment by a speech pathologist is essential to identify the patient’s specific problems so that the family and rehabilitation team can understand the nature and extent of the communication deficits and the best ways of communicating

Question 56

rehabilitation of language impairments

communication strategies for phyios

Answer 56

Don’t exclude the patient from conversation or answer on their behalf
Keep sentences short and simple
Provide time for the patient to respond and to switch from one topic to another
Phrase questions so that they can be answered with yes/no or some other form of short response where there is expressive dysphasia
Use gestures, situational cues, visual prompts, facial expressions to enhance communication and comprehension
Engage in eye contact as eye contact facilities communication and more positive attitudes
Be honest in establishing communication and a relationship with your patient
– Communicate misunderstanding
– Utilise prompts
– Divert behaviour if the patient becomes frustrated
Discourage perseveration on words and phrases as iit interferes with real communication

Question 57

Rehabilitation strategies for wernickes dysphasia

Answer 57

Picture cards
One stage commands
Break down questions into key words Use demonstration
Use gestures and facial expression Short and simple questions

Question 58

Rehabilitation strategies for broca’s dysphasia

Answer 58

Ask yes/no questions
Use visuals scales eg. VAS
Give patient time to get words out Use probing questions, e.g. What is it used for? What does it start with?

Question 59

summary #1

Answer 59

Significant relationship between motor and sensory function
Tactile and proprioceptive sensation are critical to regaining effective motor function, especially upper limb
Eye-head coordination is particularly critical for manipulating and negotiating the environment
Loss or impairment of perceptual-cognitive and language functions has a profound effect on indepedendence
Somatosensation is required for the learning of new skills

Question 60

summary #2

Answer 60

Given their critical role in movement control, physiotherapists must be informed about the state of a patient’s somatosensory and perceptual-cognitive functions, to guide appropriate rehabilitation interventions and determine capacity to participate in rehabilitation
Assessment is multi-disciplinary (physiotherapist, neuropsychologist, occupational therapists, speech pathologist)
Challenging and meaningful functional based rehabilitation with patient attending to sensory inputs and their relationship to the task

Question 61

Summary #3

Answer 61

Overall aim of rehabilitating somatosensory and perceptual-cognitive impairments is to address specific deficits by increasing the patient’s awareness of the nature of their impairments and training them to reorient their attention to particular situations while practicing functional tasks
Compensation training is usually necessary for visual, perceptual-cognitive and language impairments