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Stroke: Sensory / Perceptual Training (NEURO FINAL)
Terms in this set (23)
Sensation vs Perception:
What is sensation? (appreciation of stimuli through organs.... of .....)
What is perception? (integration of sensory impressions into info that is..... psych... ) It involves selection of what? (stim..., att.., and act..) There is integration of stimulation with each other and what else? (prior info and inter..)
Do you need to rule out sensory or motor impairments first?
•Sensation - The appreciation of stimuli through the organs of special senses, the peripheral cutaneous sensory system, or internal receptors
•Perception- "The integration of sensory impressions into information that is psychologically meaningful."
•Involves selection of stimuli, attention and action
•Integration of stimuli with each other and prior information and interpretation
•Must rule out sensory impairments first
Somatosensory deficits lead to impaired sensory or motor learning?
What superficial sensations are lost? (t.., p../temp)
What deep sensations could be lost? (prop..) IS this associated with poor recovery of functional LE or UE movement?
You may see a loss of what sensations? (combined... cort.. ) Impaired 2 pt discrimination is associated with poor LE or UE dexterity?
What abnormal sensations may be seen? (num..., and dyseth.., and hyperes... ) What pain may be seen? (central..., pos.....)
•Somatosensory deficits → impaired motor learning
Hemi sensory loss: face, UE, LE
•Loss of superficial sensations: touch, pain/temp
•Loss of deep sensations: proprioception
Associated with poor recovery of functional UE movement
•Loss of combined cortical sensations
Impaired 2 pt discrimination associated with poor UE dexterity
•Abnormal sensations: numbness, dysesthesias, hyperesthesia
Central post-stroke (thalamic) pain → non use of extremity
Sensory Discrimination Retraining:
Is supervised or unsupervised practice done?
Do you focus on restoring sensitivity to affected or unaffected hand/fingers/foot? Is this done via CNS or PNS stimulation? Does this promote cerebral or cortical reorganization?
Does this require residual sensory or motor function?
What is the goal? (stimulate what receptors, afferents, and GTO's? )
•Both supervised & unsupervised practice
•Focus on restoring sensitivity of affected hand / fingers / foot via CNS stimulation > promote cortical reorganization
•Requires some residual sensory function
•Goal: stimulate mechanoreceptors, muscle afferents, GTOs
•Sufficient intensity without adverse effects
Focus on what skills? (local..., graph..., sterog..., eyes open or closed?)
what attentional strategies are worked on? (focus pt on what? Requires what function? (cog)
Why should feedback be provided? (encou... and shap..)
What else should be provided? (safet... awa..., and education/care for what limbs?)
•Focus on skills of localization, graphesthesia, stereognosis, eyes closed (EC)
If fails, can repeat stimulus, make stimulus larger, or allow pt to look EO > EC
•Attentional strategies: focus pt on task, requires some cognitive function
•Provide feedback, for encouragement / shaping
•Provide safety awareness, education & care of anesthetic limbs!
Upper Extremity Stuff:
Patient can identify what? (various text..., temp..., objects pressed where? Identify shap..., lett..., numb.., drawn where?
Play with dom..., match blocks with ha...?
Match what? (pai...)
Discriminate what objects? (co..., bea..., but..)
Unilateral or Bilateral training tasks?
Lower Extremity Stuff:
Focus on loc... of touch
Early or late weight bearing/ approximation
What splints are used? (ai..)
Is constant or intermittent pressure therapy used?
what board is used? (BA__)
Where is a ball used?
•Identify various textures & temperatures
•Identify various objects pressed on skin
•Identify raised shapes: read Braille with one finger
•Identify shapes, letters, numbers drawn on skin
•Play Dominoes, match blocks with hands
•Match pairs of objects
•Discriminate objects: coins, beads, buttons
•Bilateral training tasks
•Focus on localization of touch
•Early weight bearing / approximation
•Use of air splints
•Intermittent pressure therapy
•Ball under foot
Sensory / Functional Retraining:
With functional task training, you should relate to simpler or more complex tasks
UE: do what with instruments? (hol... and pla...)
What fine motor tasks are done? (pick..., using a p..., tap..)
LE: Stepping doing what? (wei.. tran..)
Combine tasks with what imagery? (men..)
What therapy is used? (mir..)
Combine with what? (E-s..)
•Functional task training: relate to simple motor tasks
•UE: hold and play instruments
•Fine motor tasks: pick up objects, use pen, tap fingers
•LE: stepping & weight transfers
•Combine with mental imagery
•Combine with E-Stim
What is it? (defective vision/blind on 1/2 or.1/4 of visual field?)
What % of CVA pts have this? ( 17 or 40?) What % of pts recover?( 17 or 40?)
What anatomical problem is this? (sensory or motor loss within pts visual field?)
Sensory Retraining for Hemianopsia:
Increase or decrease awareness of deficit?
Teach patient to do what? (scan vis.. env.., and turn head to affected or unaffected side?)
What compensatory things are done? (remind.... , external or internal cues? )
Should you start on affected or unaffected side?
Should exercises be done unilaterally or bilaterally?
•Defective vision (or blindness) in one-half of visual field
•Occurs in 17% of CVA, < 40 % recover
•Anatomical problem is one of sensory loss within the patient's visual field
Sensory Retraining for Hemianopsia:
Increase awareness of deficit
Teach patient to scan visual environment, turn head to affected side
Compensatory: constant reminders, external cues, e.g. red anchor line (tape) on floor or mat
Initially on unaffected side > move to affected side
Exercises: bilateral UE activities
crossing midline activities, e.g. PNF Chop or Lift
Strategies for Visual Function:
What type of training uses visual orientation discrimination and search? (feed...)
Is videotaped performance used?
What other training is done? (virtu... )
Mental imagery of movements of left limbs is done on left or right hemispace
Is mirror therapy a good option?
•Feedback-based training of visual orientation discrimination & search (verbal cueing)
•Computer training/ virtual reality
•Mental imagery of movements of left limbs in left hemispace
What is Body Scheme? (postural model of body including relationship of its par...., and real... to env..) Is it essential for motor or sensory behavior?
What is Body Image? (What sort of image?) What else besides image does it include? (feelings..)
Body scheme/body image disorders:
What are some disorders? (unila... neg.., anos..., somat..., autopagn..., R-L disc..)
•Postural model of the body including relationship of its parts, and relationship to the environment
•Essential for motor behavior
•Visual and mental image of body that includes person's feelings regarding health and disease
Body scheme/body image disorders:
•Autopagnosia, body agnosia
•R - L discrimination
Occurs in what % of pts with CVA? (20, 21, 22, 23?)
Visual Spatial Neglect? (inability to reg.. and integrate visual stimuli and perceptions situated same or opposite side of there stroke? They have inability to perform motor acts on unaffected or affected hemispace?)
What is body neglect? (inability to register and integrate stimuli and perceptions from one or both sides of the body? Do pts have frequent hemi sensory loss?
Symptoms? (Pt is aware or unaware of problem? Is it a deliberate failure to look left, is it caused by hemianopia?
What does it affect? (exploration of what? Internal or external images?)
Occurs in ~ 23% of patients with stroke
Visual Spatial Neglect (USN) :
inability to register & integrate visual stimuli & perceptions situated on the opposite side of their stroke or perform motor acts in the neglected hemispace
Body Neglect (UBN):
inability to register & integrate stimuli & perceptions from one side of body (personal neglect)
Frequent hemi sensory loss: 2/3s have abnormal proprioception
•Pt is unaware of problem, corrections
•Not a deliberate failure to look left & not caused by hemianopia
•Affects exploration of outside world
•Affects internal / mental images
What % of patients have a R hemisphere lesion?( 17 or 85%) L hemisphere lesion? ( 17 or 85%)
Common with lesions to right or left inferior parietal lobe? ACA or MCA? Inferior or Superior division? Also seen after lesions where? (right or left frontal lobe, post or pre-central gyrus thalamus, and BG?)
What % recover after 12 weeks? IS it common to have UN for more than a year?
Occurs with or without hemianopsia?
•R hemisphere lesion: 85% , L hemispheric lesion 17%
Common with lesions to right inferior parietal lobe - MCA, inf. Division
Also seen after lesions to right frontal lobe, post-central gyrus thalamus, and basal ganglia
•54% recover after 12 weeks but common to have UN > 1 year post CVA
•Can occur with & without hemianopsia
Symptoms of Unilateral Neglect:
What is Allocentric or Extra-personal neglect? (inattention to space beyond what? )
What is peri-personal neglect? (Deficits within what distance?)
Egocentric or Personal neglect? (deficits doing what activites? )
Motor neglect? (deficit in attention and action into and toward the right or left side?)
Is there an increasing or decreasing attention? Is there over or under arousal?
•Allocentric or Extra-personal neglect: inattention to space beyond arm's reach (doorways)
•Peri-personal neglect: Deficits within reaching distance (Plate, armrest)
•Egocentric or Personal neglect: deficits in grooming or dressing (Shaving, make-up)
•Motor neglect: deficit in attention and action into and toward left side
•Decreased attention & Under arousal
What tests are used? (lin b.., star..., figure cop.., visu.. trac..., )
Star Cancellation Test: How many stars? Letters? Short words? Small stars? What does the pt have to do? (cross out the small or large stars?) What score indicates unilateral neglect? (<41, 42, 43, 44? )
Patients tend to read/write only on right or left side?
Identifies objects on right or left side?
Visual tracking test? (tracks from affected to unaffected orrr unaffected to affected? They maintain this for how many seconds?
•Line Bisection Test
•Star Cancellation Test
52 large stars, 13 letters,10 short words, 56 smaller stars
Pt must cross out all "small stars"
< 44 indicates unilateral neglect
•Figure Copying Test
•Reads / writes words only on right side of page
•Identifies objects only on the right side
•Visual Tracking Test: tracks from unaffected > affected side and maintains for 5 sec.
Strategies to improve L sided Attention:
How to increase awareness of affected side? (vis sca..., head... turn..., trun.. rot..., vis... trac..)
Provide what sort of stimuli to neglected side? (vis... ,tac.., prop..) Examples of this include what? (tapp..., rubb..., vibr...)
Do you want maximize stimuli to right or left brain? ( sha...and bloc..)
Do you want to minimize stimuli to right or left brain? (lett... and numb..)
What should you do if inattention occurs? (reori...)
•Increase awareness of affected side: visual scanning, head turning, axial trunk rotation, visual pursuit / tracking
•Provide visual, tactile, proprioceptive stimuli to neglected side: tapping, rubbing (rough cloth), vibrator
•Maximize stimuli to R brain: shapes & blocks
•Minimize stimuli to L brain: letters, numbers
•Reorient if inattention occurs
Will a Right or left hemifield patch be more effective than a monocular eye patch? What does it stimulate? (right or left superior colliculus? ↑or↓ in eye movements to right or left field? )
What do prism glasses do? (redirects image on retina to R or L hemiside, leading to recalibration of visuo-motor coordination, stimulating R or L hemisphere functions?
Combine with what sort of cuing to redirect attention? (vis)
•R hemifield patch may be more effective than R monocular eye patch.
stimulates right superior colliculus, ↑ eye movements to the left field
•Prism glasses: redirects image on retina to R hemiside > recalibration of visuo-motor coordination, stimulates R hemisphere functions
•Combine with visual cuing to redirect attention
UN Assessment: Motor Effects:
With the hemi-side what symptoms? (hypo or hyperkinesia ,hyper or hypometria?)
Persistent deviation toward good or bad side?
What Asymmetries are seen in performance? (↑or↓ use on good side for functional tasks? Do they bump into objects on the left or right? Fail to comb and wash left or right half of body?
Problems dressing on left or right?
Repetitive trauma on left or right side when doing transfers/w/c use?
•Hemi-side: hypokinesia, hypometria
•Persistent deviation toward sound side
•Asymmetries in performance:
↑ use of sound side for functional tasks
Bumps into objects on left
Fails to comb, wash left half of body
Eats only from right half of plate
Problems dressing on left
•Repetitive trauma left side: transfers, w/c use
Strategies for Improved Motor Function:
Maximize right or left hemisphere activation?
Minimize stimuli to left or right or left hemisphere
Should you do axial trunk rotation to right or left side?
Incorporate what movements? (scann....with lim...)
•Maximize right hemisphere activation:
left UE/LE unilateral active movements in neglected left hemispace; crossing midline, E-Stim
•Minimize stimuli to left hemisphere: CIM
•Axial trunk rotation to left side
Elongates posterior neck muscles on left side
•Task training: activities & mobility skills
•Integrate scanning movements with limb movements
UN Recovery / Disability:
When will patients recover some function? (how many months?
PAtients with severe, prolonged neglect show slower or faster recovery along with poor or great functional outcomes?
Significant predictor or UT or LT disability?
•Many patients recover some function within 1st 3 months, 60% recover 26-52 weeks post CVA
•Patients with severe, prolonged neglect: slower recovery, poor functional outcomes
•Significant predictor of LT disability
What is it? (denial, unawa... of def.../pres.. or seve... of ones paralysis?)
Includes denial of what extremities? (paret)
Is prognosis usually better or worse than UN?
Incidence is >20-__% of pts with neglect?
Strategies for Anosognosia:
Focus on awareness of impairments during what activities?
When should patient compare performance? (before and after what?)
What should you have patient describe? (diff...)
We should highlight new ways what can be done? (ta..)
Focus on what? (prob.. sol..)
Place all items for functional independence outside or within pts field of vision? This may lead to what? (learned non....)
Adapt environment to focus on right or left side?
Is compensation usually adequate with anosognosia? Requires a low or high level of awareness?
Is safety critical?
•Denial, neglect, unawareness of deficit / presence or severity of one's paralysis
•Includes denial of the paretic extremities as part of self
•Prognosis is significantly worse than UN, often incapacitating
•Incidence > 20 - 58% of patients with neglect
•Focus on awareness of impairments during ADLs, functional task training
•Have patient compare performance before and after stroke
•Have patient describe difficulties
•Highlight new ways task is now done
•Focus on problem solving: to organize task, find or locate items in environment
•Place all items for functional independence within pt's field of vision > learned non-use
•Adapt environment to focus on left side,
e.g. red anchor line (tape)
•Compensation usually inadequate with anosognosia: requires high level of awareness
•Safety is critical; placement issues
Are significant improvements seen with training task specific?
Successful outcomes are related to what? (severity, intensity, focus..)
What situation would bring only short lived outcomees limited to the period of the intervention? (mild, mod, or severe neglect?)
Its difficult to evaluate what? (carryov..)
•Significant improvements seen with training: may be task specific
•Successful outcomes: related to severity of deficits, intensity /consistency of training, functional focus
•With severe neglect, can be short-lived, limited to period of intervention
•Difficult to evaluate carryover for daily use
What is it? (inability to make sense of what?)
What are the different forms of agnosia? (vis.., aud.., fing.., tact..)
What are examples of visual agnosia? (simult..., prospag.., and col..)
What is and example of tactile agnosia? (aster...)
Somatoagnosia / Autopagnosia:
Primarily occurs with R or L hemispheric lesions?
What do pts have trouble identifying on themself and others?(bod... par..)
Are patients able to imitate us for learning purposes?
•Inability to make sense of incoming sensory info
•Visual object agnosia
Simultanagnosia, Prosopagnosia and Color agnosia
Somatoagnosia / Autopagnosia:
•Primarily occurs with L hemispheric lesions (R hemi) but can occur in R sided lesions
•May not be able to identify body parts of others as well as self
•Unable to imitate and use demonstration for learning
Spatial Relation Disorders:
Examples? (fig.. gr..., for.. disc.., spat.. rel..., pos.. in spa.., topog.. dis..., depth and dis...., vert.. dis..)
Relationship of objects
•Position in space
Up, down, under, on
Locations, gets lost
•Depth and distance deficits
•Vertical disorientation (SVV)
•"Pusher Syndrome" or Contraversive pushing, Posterior pushing
What is it? (loss of what sort of movement?)
Breakdown between what? (conc.. and perf..)
Inability to do what? (perform tasks..... )
Can they perform it automatically?
inability to do what? (perform tasks ....)
Lost what of the task? (conc)
•Loss of skilled voluntary movement
Breakdown between concept and performance
Inability to perform a task on command or by imitation
Can perform it automatically
Inability to perform a task on command or by imitation
Inability to retain the idea of the task
Lost concept of the task
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