Perceptual

stroke

1. Form Discrimination Definition. Impairment in form discrimination is the inability to perceive or attend to subtle differences in form and shape. he patient is likely toconfuseobjects of similar shape or not to recognize anobject placed in an unusual position. 2. Clinical Examples. The patient may confuse a pen with a toothbrush, a vase with a water pitcher, a cane with a crutch, and so forth.

2. Lesion Area. he lesion site is the parieto-temporooccipital region (posterior association areas) of the nondominant lobe. 4 . Testing. A number of items similar in shape and different in size are gathered. The patient is asked to identify them. One set of items might be a pencil, pen, straw, toothbrush, and watch, and the other might be a key, paper clip, coins, and ring. Each object is presented several times in different positions (e.g., upside down).

3. Treatment Suggestions. a. Remedial Approach. The patient should practice describing , identifying, and demonstrating the use of similarly shaped and sized objects.

4. The patient should sort like objects and should be assisted to focus on differentiating object cues. b . Compensatory Approach. The patient must be made aware of the specific deficit. If the patient can read, frequently used and confused objects can be labeled . The patient should be encouraged to use vision, touch, and self-verbalization in combination when objects are confused.

5. Spatial Relations 1. Definition. A spatial relations disorder, or spatial disorientation , is the inability to perceive the relationship of one object in space to another object o rto oneself. Thismay lead to, or compound,problems in constructional tasks and dressing. Crossing the midline may be a problem for patients with spatial relations deficits. Spatial relations skils are required to manage most ADL.

6. Clinical Examples. The patient might find it difficult to place the cutlery, plate, and spoon in the proper position when setting the table. The patient may be unable to tell the time from a clock because of difficulty in perceiving the relative positions of the hands . The patient may have difficulty learning to position his or her arms, legs, and trunk in relation to the wheelchair to prepare for transferring.

7. Lesion Area. The lesion site is predominantly the inferior parietal lobe or parieto -occipital-temporal junction , usually of the right side.

8. Testing. Recommended tests include the Perceptual Assessment Battery ( RPAB) Arnadottir OT-ADL Neurobehavioural Evaluation(A-ONE).

9. Treatment Suggestions. When using a remedial approach, patient ability to orient to other objects can be improved by giving the patient instructions to position himself or herself in relation to the therapist or another object. The therapist might say ,

10. “ Sitnext to me,” “Go behind the table,” or “Step Over the line.” In addition, the therapist can set up a Maze of furniture (obstacle course). Having the patient copy block or matchstick designs of increasing difficulty will increase awareness of the relationship

11. ship between one object (block or matchstick) and the next. If the patient avoids crossing the midline, activities that require crossing the midline both motorically and visually can be incorporated into other therapeutic activities (e.g., proprioceptive neuromuscularfacilitation [PNF] chop patterns). One specific

12. activity is to have the patient hold a dowel in front with both hands. The therapist guides it from

13. the less involved side to the more involved side. Later, the patient can progress to manipulating the dowel with only verbal or visual cues, and finally to guiding it independently.

14. Position in Space 1. Definition. Position in space impairment is the inability to perceive and to interpret spatial concepts such as up, down, under, over, in, out, in front of, and behind.

15. 2. Clinical Examples. If a patient is asked to raise the arm “above” the head during ROM activities or is asked to place the feet “on” the foot rests, the patient may behave as if he or she does not know what to do.

16. Lesion Area. The lesion is usually located in the non- dominant parietal lobe.

17. . Testing. To test function, two objects are used, such as a shoe and a shoebox. The patient is asked to place the shoe in different positions in relation to the shoebox; for example, in the box, on top of the box, or next to the box. Alternatively, the patient is presented with two objects and asked to describe their relationship

18. . For example, a toothbrush can be placed in a cup, under a cup, and so forth, and the patient is then asked to indicate the location of the toothbrush. Another mode of testing is to have the patient copy the therapist’s manipulations with an identical set of objects. For example, the therapist hands the patient a comb and a brush.

19. Treatment Suggestions. If using a retraining approach, three or four identical objects are placed in the same orientation (wrist weights, combs, mugs, and so forth). An additional object is placed in a different orientation. The patient is asked to identify the odd one, and then to place it in the same orientation as the other objects.

20. Topographical Disorientation 1. Definition. Topographical disorientation refers to difficulty in understanding and remembering the relationship of one location to another.As aresult , the patient is unable to get from one place to another , with or without a map. This disorder is frequently seen in conjunction with other difficulties in spatial relations.

21. Clinical Examples. The patient cannot find the way from his or her room to the physical therapy clinic, despite being shown repeatedly. he patient cannot describe the spatial characteristics of familiar sur- roundings , such as the layout of his or her bedroom at home . 3. Lesion Areas. he majority of cases involve damage to the right retrosplenial cortex, with Brodmann’s

22. area 30 compromised in most patients . Bilateral parietal lesions, and more rarely, left-side parietal lesions, can produce this problem .

23. . Testing. he patient is asked to describe or to draw a familiar route, such as the block on which he or she lives, the layout of his or her house, or a major neighborhood intersection. A patient with topographical disorientation will be unable to succeed In this task. However, the therapist must differentiate between memory problems and topographical orientation difficulties.

24. Treatment Suggestions. This deficit usually resolves 8 weeks after onset. However, several treatment techniques can be used to hasten recovery, or to assist long term if the condition persists. a. Remedial Approach. The patient practices going

25. from one place to another, following verbal instructions .Initially, simple routes should be used, and then more complicated ones. b. Compensatory Approach. Frequently travelled routes can be marked with colored dots. The spaces between the dots are gradually increased and eventually eliminated as improvement takes place. This is an example of taking a normally right-hemisphere task and (because there is

26. right-sided damage) converting it into a left hemisphere task. In this instance we take the spatial task of remembering routes ( right hemisphere task ) and substitute sequential Landmarks sequencing is typically a left hemisphere

27. strength) to accomplish the goal of getting from place to place. The patient should be reminded not to leave the clinic, room or home unattended, because he or She may get lost.

28. Depth and Distance Perception 1. Definition.T he patient with a disorder of depth and distance perception experiences inaccurate judgment of direction, distance, and depth. Spatial disorientation may be a contributing factor in faulty distance perception .

29. 2. Clinical Examples. he patient may have difficulty navigating stairs, may miss the chair when attempting to sit, or may continue pouring juice once a glass is filled. 150 3. Lesion Areas. his impairment may occur with a lesion in the posterior right hemisphere in the superior visual association cortices; it may be evident with right-sided or bilateral lesions. 4. Testing. 151

30. 4. Testing. a. For a functional test of distance perception, the patient is asked to take or to grasp an object that has been placed on a table. he object may also be held in front of the patient, in the air, and the patient is again asked to grasp it. he patient with impaired distance perception will overshoot

31. or undershoot. However, the movements look purposeful and smooth, which distinguishes this problem from a coordination deficit. 2 b. To determine depth perception functionally, the patient can be asked to fill a glass of water. A patient with a depth perception deficit may continue pouring once the glass is filled .

32. Treatment Suggestions. he patient should be assisted in becoming aware of the deficit (education to increase cognitive awareness). Emphasis should be placed on the importance of walking carefully on uneven surfaces, particularly the stairs. a. Remedial Approach. he patient is requested to place the feet on designated spots during gait training. Also, blocks can be arranged in piles 2 to 8 in (5 to 8 cm) high. he patient is asked to touch the top of the piles with the foot. his is done to reestablish a sense of depth and distance.

33. 55 154 b. Compensatory Approach. Practice in compensating for disturbances in depth and distance perception occurs intrinsically in many ADL skills, both those involving moving through space and those that involve manipulation. For example, the patient can hold the armrests of a chair to assist with sitting squarely. 2

34. Vertical Disorientation 1. Definition. Vertical disorientation refers to a distorted perception of what is vertical. Displacement of the vertical position can contribute to disturbance of motor performance, both in posture and in gait . Early in recovery, most patients post-CVA demonstrate

35. some impairment in the sense of verticality. This is not associated with or affected by the presence of homonymous hemianopia .

36. Clinical Example. A person with distorted verticality views the world differently and this may affect upright posture. 3. Lesion Area. The lesion site is in the nondominant parietal lobe

37. 4. Testing-The therapist holds a cane vertically and then turns it sideways to a horizontal plane. Researchers use a luminous rod with patients seated in a darkened room. T he patient is handed the cane and asked to turn it back to the original position. If the patient’s perception of the vertical position is distorted, the cane will most likely be placed. At an angle, representing the patient’s conception of t he world around himself or herself.

38. Treatment Suggestions-The patient must be made aware of the deficit. The patient should be instructed to compensate by using touch (tactile cues) for proper self-orientation, especially when going through doorways, in and out of elevators, and on the stairs.

39. Agnosias (Simple Perception) Agnosia is the inability to recognize or make sense of incoming information despite intact sensory capacities. Although this condition is relatively rare (as listed by the National Institutes of Health Office of Rare Diseases), I t can affect any sensory modality (e.g., vision, audition, touch, taste )

40. and anything (e.g., faces, sounds, colors , familiar or less familiar objects). Although there is an inability to recognize familiar objects using one or two of the sensory modalities, the ability to recognize the same object using other sensory modalities is usually Present.

41. Visual Agnosias 1. Definition. Visual object agnosia is the most common form of agnosia. It is defined as the inability to recognize familiar objects despite normal function of the eyes and optic tracts.

42. Clinical Examples. One remarkable aspect of this disor - der is the readiness with which the patient can identify an object once it is handled (i.e., information is received from another sensory modality). The patient may not recognize people, possessions, and common objects. Specific types of visual agnosia include simultanagnosia , prosopagnosia, and color agnosia.

43. a. Simultanagnosia also known as Balint’s syndrome, is the inability to perceive a visual stimulus as a whole. The patient perceives an entire array one part at a time. The lesion is usually in the dominant occipital lobe. b. Prosopagnosia was traditionally considered to be the inability to recognize familiar faces. Current thought suggests this phenomenon is related to

44. any visually ambiguous stimulus, the recognition of which depends on evoking a memory context, such as different species of birds or different makes of cars. Prosopagnosia is usually accompanied by visual field impairments. Bilaterally symmetrical occipital lesions are thought to be responsible for this impairment .

45. Color agnosia is the inability to recognize colors ; it is not color blindness. The patient is unable to identify or name colors on command, although color chips can be correctly paired. However, the meaning of color is lost so that the patient no longer associates a duckling as yellow or the sea as blue. Color agnosia is frequently associated with facial or other visual object agnosias .

46. It is usually the result of a dominant hemisphere lesion. The simultaneous occurrence of left-sided hemianopia , alexia (inability to read; word blindness), and color agnosia is a classic occipital lobe syndrome.

47. Lesion Area. The lesions associated with visual object agnosias are thought to occur in the occipito - temporo -parietal association areas of either hemisphere. These areas are responsible for the integration of visual stimuli with respect to memory. Recent evidence suggests visual object angnosias may result from damage in the medial structures of the ventral occipito -temporal cortex.

48. Testing-To test for this deficit, several common objects are placed in front of the patient. The patient is asked to name the objects, to point to an object named by the therapist, or to demonstrate its Use not.

49. Treatment Suggestions. a. Remedial Approach. Drills can be used to prac - tice discrimination between faces that are important to the patient (using photographs) and discrimination between colors and common objects. The therapist should assist the Patient in picking out salient visual cues for r elating names to faces

50. . Compensatory Approach. The patient is instructed to use intact sensory modalities, such as touch or audition, to distinguish people and objects

51. Auditory Agnosia 1. Definition. Auditory agnosia refers to the inability to recognize non-speech sounds or to discriminate between them. This rarely occurs in the absence of other communication disorders.

52. Clinical Examples. The patient with auditory agnosia cannot tell, for example, the difference between the ring of a doorbell and that of a telephone, or between a dog barking and thunder . Lesion Area. The lesion is located in the dominant temporal lobe .

53. Testing. Testing is usually carried out by a speech language pathologist. The patient is asked to close

54. The eyes and to identify the source of various sounds. The therapist rings a bell, honks a horn, rings a telephone, and so forth, and asks the patient to identify The sound (verbally or by pointing to a picture). 5. Treatment Suggestions. Treatment generally consists of drilling the patient on sounds, but this has not been found to be particularly effective.

55. Tactile Agnosia or Astereognosis 1. Definition. Tactile agnosia, or astereognosis , is the inability to recognize forms by handling them, although tactile, proprioceptive, and thermal sensations may be intact. This impairment commonly causes

56. Difficulties in ADL skills, in as much as many self-care activities that are normally done in the a bsence of constant visual monitoring require the m anipulation of objects.

57. If tactile agnosia is present in combination with unilateral neglect or other sensory loss, performance in ADL skills may be severely hampered . 2 Clinical Examples. If a patient is handed a familiar object (key, comb, safety pin) with vision occluded, the patient will fail to recognize it.

58. 3. Lesion Area. The lesion is in the parieto-temporooccipital lobe (posterior association areas) of either hemisphere. 4. Testing. he patient is asked to identify objects placed in the hand by examining them manually without visual cues

59. Treatment Suggestions. a. Remedial ApproachThe patient practices feeling various common objects, shapes, and textures with vision occluded. The patient is instructed to

60. immediately look at the object for visual feedback and note special characteristics of the object. Compensatory Approach. To improve cognitive awareness, the patient is educated concerning the nature of the deficit and is instructed in visual compensation.

61. Apraxia Apraxia is an impairment of voluntary skilled learned movement. It is characterized by an inability to perform purposeful movements, which cannot be accounted for by inadequate strength, loss of coordination, impaired sensation, Attentional difficulties,abnormal tone,

62. Movement disorders , intellectual deterioration, poor comprehension, or uncooperativeness. Many patients with apraxia also present with aphasia, and the two deficits are sometimes difficult to distinguish .

63. The two main forms of apraxia discussed in the literature are ideomotor and ideational apraxia. Ideomotor and ideational apraxias are generally thought to be the result of dominant hemisphere lesions and may be particularly difficult to test in the patient with aphasia

64. Although aphasia and apraxia often occur together, there is not a strong correlation between the severity of the aphasia and the severity of the apraxia. A third form of apraxia, buccofacial apraxia, is actually a type of ideomotor apraxia and is characterized by difficulties with performing the purposeful movements that involve facial muscles related to the mouth. This may include responding to the command “pretend to blow out a candle,” or producing an orderly sequence of phonemes to produce speech

65. Hence, apraxia is a disorder of skilled movement and not a language disorder. Some rehabilitation texts also describe Constructional and dressing apraxias .

66. Ideomotor Apraxia 1 . Ideomotor apraxia refers to a breakdown between concept and performance. There is a disconnection between the idea of a movement and its Motor execution . It appears that the information Cannot be transferred from the areas of the brain That conceptualize to the centers for motor execution. thus ,

67. the patient with ideomotor apraxia is Able to carry out habitual tasks automatically and Describe how they are done but is unable to imitate Gestures or perform on command.

68. Clinical Examples. Several examples of ideomotor apraxia follow. The patient is unable to “blow” on command. However, if presented with a bubble wand, the patient will spontaneously blow bubbles. he patient may fail to walk if requested to in a traditional manner.

69. . However, if a cup of coffee is Placed on a table at the other end of the room and The patient is told, “Please have coffee,” the patient is likely to traverse the room to get it . A male patient is asked to comb

70. He may be able to identify the comb and even tell you what it is used for; however, he will not actually use the comb appropriately when it is handed to him. Despite this observation in the clinic, his wife reports that he combs his hair spontaneously every morning. A female patient is asked to squeeze a dynamometer. She appears not to know what to do with it, although her comprehension is adequate, the task has just been demonstrated, and it is clear that she has adequate strength.

71. Lesion Area. Apraxia results most frequently from lesions in the left, dominant hemisphere. There is evidence that both frontal lesions and posterior parietal lesions can result in apraxia . 4. Testing. The Goodglass and Kaplan test for apraxia is composed of universally known movements, such as blowing, brushing teeth, hammering, shaving, and so forth. It is based on what the authors consider a hierarchy of difficulty for patients with apraxia.

72. First the patient is asked, “Show me how you would bang a nail with a hammer.” If the patient fails to do this or uses his or her fist as if it were a hammer, the patient is told, “Pretend to hold the hammer.” If the patient fails following this instruction, the therapist demonstrates the act and asks the patient to imitate it. The patient with apraxia typically will not improve after demonstration but will improve with use of the actual implements .

73. Treatment Suggestions. a. Remedial Approach. In the remediation of apraxias , it is advised that the therapist speak slowly and use the shortest possible sentences. One commandshould be given at a time, and the second command should not be given until the first task is completed. When teaching a new task, it should be brokendown into its component parts. One component

74. is taught at a time, physically guiding the Patient through the task if necessary. It should be Completed in precisely the same manner each time . When all the individual units are mastered, an attempt to combine them should be made. A great deal of repetition may be necessary.

75. Compensatory Approach. Strategy training involves teaching The patient compensatory techniques to overcome The apraxia such as use of pictures in the correct Sequence to support ADL skills

76. Ideational Apraxia 1. Definition. Ideational apraxia is a failure in the conceptualization of the task. It is an inability to perform a Purposeful motor act, either automatically or on command, because the patient no longer understands the Overall concept of the act, cannot retain the idea of the task ,

77. or cannot formulate the motor patterns required. Often the patient can perform isolated components of A task but cannot combine them into a complete act. Furthermore, the patient cannot verbally describe the Process of performing an activity, describe the function of objects, or use them appropriately.

78. . Clinical Examples. When presented in the clinic with a toothbrush and toothpaste and told to brush the teeth, the patient may put the tube of toothpaste in the mouth, or try to put toothpaste on the

79. toothbrush without removing the cap. Further, the patient may be unable to describe verbally how tooth brushing is done. Similar phenomena may be evident in all aspects of ADL (washing, meal preparation, and so forth) and so may limit the safety and potential independence of the patient.

80. Lesion Area. The lesion causing ideational apraxia is thought to be in the dominant parietal lobe. This deficit also may be seen in conjunction with diffuse brain damage, such as cerebral arterioscleros

81. Testing. The tests for ideational apraxia are similar to those for ideomotor apraxia. The major expected response difference is that the patient with ideomotor apraxia can perform a motor act spontaneously and

82. automatically at the appropriate time, but the Patient with ideational apraxia is unable to do so. 5 . Treatment Suggestions. The treatment techniques are the same as those for ideomotor apraxia.

83. Buccofacial Apraxia 1. Definition. Buccofacial or oral apraxia involves difficulties with performing purposeful movements with The lips , tongue, cheeks, larynx, and pharynx on command .

84. Clinical Examples. A patient may have difficulty responding to the command “pretend to blow out a candle” or “blow a kiss.” However, in a normal context where the patient may perform these actions automatically, performance is not impaired.

85. In addition, while patients may be able to produce the individual phonemes required for speech, the patient may have difficulty in producing an orderly sequence of phonemes. Formulaic Speech (common , routine phrases) or automatic.

86. Lesion Area. Difficulties with buccofacial apraxia seem associated with lesions in the frontal and central opercula, anterior insula, and a small area of the first temporal gyrus (adjacent to the frontal and central opercula). Although buccofacial apraxia often Coexists with Broca’s aphasia, the two may be seen independently .

87. Testing . The patient should be examined by a speech-language pathologist. 5. Treatment Suggestions. The speech-language pathologist can advise the health care team on strategies to c ommunicate with patients who have buccofacial apraxia.