PT 606 - Rehab for Common Perceptual and Cognitive Deficits

What is visual perceptual hierarchy?

an organized hierarchy of processes that interact with and sub serve each other

What is homonymous hemianopia? What is it confused with?

* blindness in the nasal field of one eye (ipsilateral) and temporal field of the other eye (contralateral)
* may be confused with USN

What is unilateral spatial neglect?

* hemi-inattention, visual-spatial neglect, and visual neglect
* deficit of attention
* failure to report, respond, orient to meaningful stimuli presented to the side opposite the brain lesion, when this failure cannot be attributed to sensory or motor defects

What can USN result from?

an infarct to inferior parietal lobe of either hemisphere

What kind of neglect is more common and more severe?

left neglect = R hemisphere damage

What are the hypotheses between the R and L hemispheres?

* R is dominant for attention
* R knowledge of and attends to both R/L body schema and extra personal space
* L knowledge of and attends to R body schema and extra personal space

Long-standing USN results in…?

* longer rehab stays
* lower levels of independence on D/C
* greater difficulty with ADL
* more frequent falls
* higher risk for deterioration 1 year post-CVA
* greater burden on caregivers

What are the types of USN?

* personal or body neglect
* extra personal neglect
* motor neglect

What are manifestations of personal-body neglect?

* does not wash L side of body
* does not comb L side of hair
* does not shave L side of face
* Does not dress L side of body
* does not use/incorporate L side into bed mobility
* difficulty finding vertical position
* severe cases do not recognize the L side of their body

What are manifestations of near extra personal neglect?

* not eating food on L side of plate
* unable to find items on L (fork, toothbrush)
* unable to read

What are manifestations of far extra personal neglect?

* locating clock on wall
* propelling a w/c - hitting obstacles on L
* watching TV

What are manifestations of motor neglect?

* relatively intact movement when encouraged to use contralateral limb
* no or little involvement of the contralateral limb in bimanual task
* dropping, forgetting about items in L hand

What should be provided when performing remediation treatment?

graded sensory stimulation from the neglected hemisphere to the neglected side of the body

* approach from L (auditory, visual)
* tactile - touch pt on L
* proprioceptive - wt bear on affected side
* move into neglected space
* move neglected side of body into neglected space \*

What are specific evidence-based interventions for neglect?

* visual scanning training into the left environment
* visual smooth pursuits from right to left
* trunk rotation and scanning
* limb activation and spatio-motor cueing
* mental imagery
* mirror therapy - mirror visual feedback
* video feedback
* FES, TENS
* virtual reality
* prism adaptation
* partial visual obstruction (glasses)

What are adaptations for someone with USN?

* L side w/c brake extension
* phone on R
* nurse call button on R
* anchoring
* keeping L side of body safe

Visual spatial perception disorders are a result from what?

damage to parietal lobe of R hemisphere

Presence of visual-spatial deficits are associated with what?

* increase in falls
* decreased performance in basic ADL and mobility

What are typical deficits that come from problems with high-order visual processing?

* Perceiving depth - stereopsis
* figure-ground discrimination
* interpreting spatial relations or position in space

What is a spatial relations deficit?

* difficulty perceiving/understanding the relative orientation of an object in relation to the self


* difficulty understanding the position of objects in relation to each other

What are manifestations of visual spatial perception disorders?

* difficulty orienting clothing to body to get dressed
* orienting dentures/glasses to apply
* maneuvering self around obstacles
* position w/c and self for safe transfer

What are remediation treatments for visual spatial perception disorders?

* identify the spatial requirements of a task
* decrease spatial requirement of tasks, then gradually increase spatial requirements
* use cognition and backward chaining to re-teach spatial relationships
* minimal visual cues, maximize verbal cues

What are adaptation treatments for visual spatial perception disorders?

* decrease the spatial requirement of the task, adapt the task, adapt the environment
* repetitive task practice - do same task over and over in same manner
* use cognitive strategy training - self talk, external cues

What is apraxia or limb apraxia?

deficit in execution of learned movement that cannot be accounted for by either weakness, incoordination, or sensory loss, or by incomprehension or inattention to commands

Apraxia occurs due to the result of whatever?

damage to left inferior parietal lobe, prefrontal and premotor cortex

What is praxis?

idea-plan-execution

What are the types of apraxia?

* conceptual or ideational
* motor or ideomotor apraxia

What is ideational or conceptual apraxia?

* pt no longer understands the concept of the task
* breakdown in the knowledge of what is to be done to complete the task
* loss of the metal representation of what needs to be done
* disturbance in the conceptual organization of the task

What are manifestations for ideational apraxia?

* inappropriate use of tools (toothbrush)
* does not use objects (eats with fingers)
* sequences task steps inaccurately (shoes/socks)
* decreased initiation, perseveration

What is motor or ideomotor apraxia?

* idea and purpose of the task is understood
* difficulty is in the execution phase, carrying out the required movements
* loss of access to kinesthetic memory patterns

What are manifestations for ideomotor apraxia?

* clumsy or awkward movements
* difficulty crossing midline to complete a task (adjusting hair brush, tooth brush)
* difficulty orientating UE to pick up an object

What are general considerations with apraxia?

* increased complexity of task - increases errors
* learning new tasks is extremely difficult (transfers, ambulation aids, hemi-dressing)

What are remediation treatment for apraxia?

* decrease complexity of task (gradually increase)
* use hand over hand assistance, minimal verbal instruction
* practice at level of task, not component parts

What are adaptation treatments for apraxia?

* decrease complexity of task and environment
* use cognitive strategy training (CST)
* internal rehearsal
* verbalization during task (self talking-questioning)
* external cues