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What cognitive impairements can people get post stroke?
- - language
- - perception
- - spatial attention
- - memory
- - executive functions
- - apraxia
Implications of rehabilitation?
- - needs to be assessed to be recognised
- - needs to be addresed to maximized potential for outcome
- - need to adjust rehabilitation according to nature of the deficit
If you are left hemisphere dominant what would you expect?
- - controls (R) sided voluntary movements
- - responsible for verbal- analytical activities
- - (R) handed
If you have have a right hemisphere lesion?
- - non dominant
- - controls L sided voluntary movements
- - responsible for viso- spatial functions
Note cognition is represented differntly
Perceptual deficits in CNS dysfunction
What is unilateral spatial neglect?
- the faliure to respond, report, or orient to stimuli presented to contralesional side of the body or space and this failure can not be attributed to either sensory or motor defects
- - it is often accompaine by sensory and motor problems eg hemianopia, decreased sensation and paresis
- -varies in degree of severity- neglect worse end
- Non dom integrate spatial info symptoms above are from severe stroke
WHat are the types of unilateral neglect?
- - Sensory (inatention, attentional neglect)
- - Motor (output neglect, intentional neglect)
- - Representational neglect
- - Extinction (inattention)- sensory or visual
What is sensory unilateral neglect?
- unaware of sensory stimuli on the contralesion side. Can be visual, auditory, somatosensory
What is motor unilateral neglect?
- failure to generate movement responses to a stimulus even though the person is aware of the stimulus and can not be exaplined by weakness
What is representational neglect?
- where the person ignors the contralesional half of internally generated images- visualisation of a task, envt or an action- neglect in memory as well
What is extinction (inattention) neglect
- - sensory or visual
- - this is the failure to respond to or recognise a stimulus on the affected side when simultaneous simultaneous stimuli are present on both sides ofthe body in the same area
- - double stim
Where in space do you get neglect?
- - personal space- dressing outside of body
- - peri-personal space: within reaching distance (most common)- eat food from one side of plate, read from middle of page
- - extra-personal space: beyond arm's reach- attend to things outside of arms reach- bump into things on the left side
What is Extinction?
- - attention deficits
- - pts can report single item at any location
- - only report ipsilesional item when two targets are presented simultaneouly
What are some visual imagery/ representational deficits?
- - pt can neglect information in imagined space- life describe bedroom and will on describe things on one side eg left
- - even unexperienced mental imagery: "imagery you are in the north of france looking south what cities do you see.
- See lecture for image
What is agnosia?
- - perceptual deficit that deals witha persons lack of recognition of familiar objects as percieved through the senses
- For example:
- - visual agnosia
- - tactile agnosia
- - auditory agnosia
What is autotopagnosia?
- - literally: unawareness of own parts
- - disturbances in perception of the pts own body or body parts
- - worst instance, denial of owning lim
- - can be described as body image problems
- - neglect of one side of body eg in dressing, moving about in bed, using hand for task
- Usually occurs with dense hemisensory loss
What is anosognosia?
- - lack of insight
- - unawareness of conditions/ denial that stroke has occurred
- - unconcern for the paralysis
- - minimize responsibility for resulting problems
- - unrealistic about outcome
- - pt lying but they think it is unreal
what is motor impersistence?
- - failure to persist in/sustain a motor activity or contraction due to inability to sustain directed attention
- - start an activity but fail to complete
How do you assess visuospatial neglect?
- - observation of function and how pt moves within envt is best
- - pointing to objects in the room
- - drawing tests: man, house, clock, line bisection, line cancellation
- - test for double stim
- - watch for apparent unawareness of bilateral stimuli eg handling, proprioception
What is egocentric neglect?
- ignoring items on the left side of a display
What is allocentric neglect?
- ignoring the left side of items regardless of there position or display
what is autotopagnosia?
- neglect of body parts
how do you assess for autotopagnosia?
- - observe function for neglect of body parts eg leave arm behind when rolling, foot poorly positioned on footplate or floor
- - unaware of body position in space/ verticality
How do you assess for anosognosia?
- - no standard assessment
- - observe pt and listen for explanation of condition for denial, confabulation etc
what is constructional apraxia?
- - the impairment in producing designs in 2 or 3 dimensions by copying, drawing or constructing, whether upon command or spontaneoulsy
- - cant put spacial info into tasks
what is topographical disorentation?
- - an inability to find ones way in familiar surroundings or to learn in a new situation
- - difficulty in understanding and remembering relationships of places to one another
- - pt can recognise faces but not places
What is poor spatial judgement?
- - inability to judge distance, depth, size or shape
- - vertically- position self, position objects in external envt
- - cant tell which ball is bigger
- - cant judge dpth of step
How can you assess contructional apraxia?
- - 2D tests: drawing, copying matchstick patterns
- - 3D tests: copying block designs, puzzles, build tower (benton's 3D constructional praxis tests), make a sandwich
How can u test dressing apraxia?
- observe pt attempting to dress and note problems
How do u test for topographical disorentation?
- - ask pt to draw a floor plan of home
- - show way back to ward or how to move from room to dinning room
- - take pt to area with which they were previously familiar- shopping centre
How can you test poor spatial judgement?
- - ask pt to indicate which object is- nearer, bigger, rounder etc
- - vertically- hold up stick against plain background and pt indicates if upright
What occurs if a pt has a left hemisphere stroke?
- - idomotor apraxia
- - identional apraxia
- both occur with dom hemisphere stroke
what is ideomotor apraxia?
- - inability to imitate gestures or perform purposeful movement on command even though the concept of the task is fully understood
- - often demonstration preseveration- can still understand the meaning of it eg toothbruch but can clean there teeth
What is ideational apraxia?
- - inability to carry out activities automatically or on command because no longer understands concept or idea behind the act
- - cant tell u tooth brush is for cleaning teeth- might try to brush hair
- -f u give the pt components of movt they will do it better
How do you assess ideomotor and identional apraxia?
- - pt is given a command to do a movt, or motor task eg roll over, drink from a cup, bursh your teeth
- - observe response; automatic task is easier with ideomotor apraxia
What is the goodglass assessment for apraxia?
- scale, in decreasing order of difficulty
- 1. Pantomine (show me how to comb ur hair)
- 2. Imitation (watch how i comb and then you do it)
- 3. Use of actual object
- 4. Imitation of examiner using actual object
What are the treatment strategies for perceptual problems?
- - no real answer or recipe
- - functional approach used
- - basic principles follow feature of motor learning: repetition practice, reinforcement, small step progression, transfer of skills into functional activities
- - use visual cues/ spatial ability with planning problems
- - use verbal strategy with spatial problems
- - use verbal and cognitive ability with (L) hemiplegics
- - use gestures, automatic cues and only simple verbal cues with (R) hemiplegics
What are the treatment strategies for perceptual problems. Promote awareness of/ attention to body and space?
- - scanning/visual attention
- - tactile/ proprioceptive stimulation
- - attention to task being practice
- - use structured, simple envts
- - self commentary techniques
- - use mental imagery before attempting the task
- - provide suuport for when the pt becomes frusterated
Spatial mapping reference frame
How would you treat constructional dyspraxia?
- trouble with spatial information, therefore use verbal strategy
What is a strategy for treating dressing apraxia?
- - use cues
- - use colour codes
- - labels
- - set procedures
How can you treat ideomotor apraxia?
- - do not break moveemtn or task up into separate parts
- - respond best to automatic, simple cues
- - more facilitation and handling to give idea of movement
- - use of objects to give idea of the motor task required
- - train tasks as a whole (not component parts)
How can you treat identational apraxia?
- - cueing
- - breakdown of tasks into components
What is pusher syndrome?
- - client pushes excessively to affected side in sitting and standing-decreased ability to transfer weight to unaffected side in sitting, standing, walking, transfer
- - overactivity of unaffected side - abduction and extension of non- paretic- extremities; trunk shortened and laterally- flexed
- - rotation/lateral flexion of head away from affected side
- - resists attempts to passively correct position of head or trunk alignment in sitting or standing
- - lack of awareness of falling to affected side and fear falling when corrected
What is the degree of severity of pusher syndrome?
- - pusher- most severe form. Client is unable to transfer weight to unaffected side, accompained by overactivity and inability to relax that side
- - faller/leaner- less severe form, still decreased ability to weight shift to unaffected side but no overactivity of side
- - difficulty with weight shift causing asymmetry during gait. This may be worse in a complex envt
What are some other characteristics of pusher syndrome?
- - altered spatial knowledge (perception of upright/ vertically)
- - Mismatch between visual and percieve body vertically
- - there is a characteristic forceful resistance by the pt against interventions aimed at correcting their tilted posutre
- - occurs in lesions of (R) and (L) postero-lateral thalamus
- - (R) sided lesions were highly associated with spatial neglect, often in presence of hemianpoia or inattention and (L) sided lesions with aphasia and ideomoto dyspraxia
- - pts can identify visual verrtical of external objects
What are the treatment strategies to manage a pusher pt?
- - let the pt see they are not upright i.e realise that they have disturbed perception of body position
- - visually explore surroundings and use visual aids in envt to show vertical orientation to compare to (use mirror is esp beneficial)
- - learn movts necessary to reach vertical body position
- - maintain vertical position while doing other activities
What are treatment strategies you can do to manage push pts in sitting and standing?
- - reaching forwards before and during standing
- - gain alignment and awareness of it
- - weight shift, internal displacement (automatic)
- - structure envt eg table, plinth, bars, wall
- - visual, verbal and tactile cues
- - gain relaxation of unaffected side and maintian flexibility of both sides
- - hndling
- -use fedback eg mirro, limb load monitor
what are the main issues of a pusher?
- - perception of midline
- - disordered spatial representation
- - disordrs of attention
- - impact of cognitive load of tasks
- - level of processing in neglected hemisphere