Embed Size (px)
Citation preview
142021
1
Perceptual Processes and AssessmentsAn Introduction
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
Learning Objectives
1 Identity the three basic types of neglect
2 Identify and describe 2 neglect treatments
3 Identify and describe the two types of apraxia
4 Describe two apraxia treatments
What is unilateral spatial neglect (USN)
Neglect is
bull ldquofailure to report respond or orient to sensory stimuli presented to the side contralateral to the stroke lesion siterdquo (Heilman et al 1985)
bull ldquoinability to integrate and use perceptual information from one side of the body or one side of the environmentrdquo (Guttman 2009 p73)
bull hellipalso called ldquounilateral neglectrdquo ldquohemi-inattentionrdquo ldquovisual neglectrdquo and ldquohemi-spatial neglectrdquo
bull hellipunder-detected under-evaluated and under-treated which is why rsquos vary
bull The tendency is to look for a ldquocommon signrdquo (eg right previous ldquoclockrdquo slide) or to assume its not present
1
2
3
142021
2
Why Does Neglect Usually Occur on the L Side
(A) Both parietal lobes work together ndash R controls BOTH sides
(B) R sided lesion rarr No bi-directional control L only ldquoseesrdquo R side
(C) L sided lesion rarr No Problem
Types of Neglect
Three Common Neglect Types
bull Extrapersonal neglect behaviors occurring in ldquolargerrdquo or ldquofarrdquo space
bull Large table Hallway shopping area
bullPt collides into surroundings or is reported to do so by care partner
bullBruising discoloring andor rippedfrayed clothing on the contralateral UE or LE
bullPt may think it is ldquonot a big dealrdquo or ldquojust part of the strokerdquo
4
5
6
142021
3
Three Common Types of Neglect (contrsquod)
Peripersonal neglectbehaviors occur in ldquonear personrdquo space
bull Ignores food on one side of the plate one side of the page one side of the clock
bullTHIS is the one that we tend to measure
Three Common Types of NeglectPersonal neglect
Attends to only one side of hisher body during ADLs (eg observe ptduring bathing ndash one side or both)
Shaving one side (above) but not the other
ldquoHanging glassesrdquo ndash you take them off pt puts back on hisher glasses
Misjudges body midline in severe cases
Other clues that neglect is present
Neglecting half of objects even when they are in full view of pt
bull ldquoAllocentric neglectrdquo or ldquoObject centered neglectrdquo eg pt ignores left side of a cup even when it is
placed on the right side of hisher body omits text that is on the contralesional side
Extinction
bull Pt can attend to a stimulus coming into visual field from either side
bull However when stimuli come from both sides simultaneously pt will only attend to ipsilesionalstimulus (thus ldquoextinguishingrdquo the contralesionalstimulus)
7
8
9
142021
4
Differential Diagnosis
Homonymous Hemianopsia vs USN
bull Homonymous (having the same name or designation) or standing in the same relation
bull hemi half
bull anopsia blindness
bull Homonymous Hemianopsia visual field loss on the same side of both eyes
Differential Diagnosis
Homonymous Hemianopsia
bull Have client turn head contralesionally they can see a stimulus on the wall or in front of them
bull Client demonstrates insight into visual loss
bull Can scan and perform clinical tests
bull Attempts to actively compensate
USN
bull Have client turn head contralesionally they cannot see stimulus
bull Client may not demonstrate insight into visual loss
bull Will not scan during clinical tests
10
11
12
142021
5
Assessment of NeglectThings to ConsiderSeveral neglect subtypes
Think about the domains you are testing and those that you are missing
Use multimodal assessment methods (at least 3-4 tests when possible
If other impairments exist supplement with real world activities in your assessment strategy
General Behavioral Assessments
Observe the ptrsquos behavior as a ldquofirst lookrdquo
GeneralbullPoor eye contact w people placed on contralesional
sidebull Fails to care for affected side leaves arm in
wheelchairhanging downbullDrops items from affected side and doesnrsquot appear to
notice (eg soap or eating utensil)bullDoes not noticerespond to people andor
conversations on contralesional side
Catherine Bergago Scale (CBS)
10-item checklist
Assesses performance of different daily activities rather than using test situations
Activities that can be associated to all range of spaces (eg shaving the face (personal) eating food from a plate (peripersonal) or colliding
13
14
15
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
2
Why Does Neglect Usually Occur on the L Side
(A) Both parietal lobes work together ndash R controls BOTH sides
(B) R sided lesion rarr No bi-directional control L only ldquoseesrdquo R side
(C) L sided lesion rarr No Problem
Types of Neglect
Three Common Neglect Types
bull Extrapersonal neglect behaviors occurring in ldquolargerrdquo or ldquofarrdquo space
bull Large table Hallway shopping area
bullPt collides into surroundings or is reported to do so by care partner
bullBruising discoloring andor rippedfrayed clothing on the contralateral UE or LE
bullPt may think it is ldquonot a big dealrdquo or ldquojust part of the strokerdquo
4
5
6
142021
3
Three Common Types of Neglect (contrsquod)
Peripersonal neglectbehaviors occur in ldquonear personrdquo space
bull Ignores food on one side of the plate one side of the page one side of the clock
bullTHIS is the one that we tend to measure
Three Common Types of NeglectPersonal neglect
Attends to only one side of hisher body during ADLs (eg observe ptduring bathing ndash one side or both)
Shaving one side (above) but not the other
ldquoHanging glassesrdquo ndash you take them off pt puts back on hisher glasses
Misjudges body midline in severe cases
Other clues that neglect is present
Neglecting half of objects even when they are in full view of pt
bull ldquoAllocentric neglectrdquo or ldquoObject centered neglectrdquo eg pt ignores left side of a cup even when it is
placed on the right side of hisher body omits text that is on the contralesional side
Extinction
bull Pt can attend to a stimulus coming into visual field from either side
bull However when stimuli come from both sides simultaneously pt will only attend to ipsilesionalstimulus (thus ldquoextinguishingrdquo the contralesionalstimulus)
7
8
9
142021
4
Differential Diagnosis
Homonymous Hemianopsia vs USN
bull Homonymous (having the same name or designation) or standing in the same relation
bull hemi half
bull anopsia blindness
bull Homonymous Hemianopsia visual field loss on the same side of both eyes
Differential Diagnosis
Homonymous Hemianopsia
bull Have client turn head contralesionally they can see a stimulus on the wall or in front of them
bull Client demonstrates insight into visual loss
bull Can scan and perform clinical tests
bull Attempts to actively compensate
USN
bull Have client turn head contralesionally they cannot see stimulus
bull Client may not demonstrate insight into visual loss
bull Will not scan during clinical tests
10
11
12
142021
5
Assessment of NeglectThings to ConsiderSeveral neglect subtypes
Think about the domains you are testing and those that you are missing
Use multimodal assessment methods (at least 3-4 tests when possible
If other impairments exist supplement with real world activities in your assessment strategy
General Behavioral Assessments
Observe the ptrsquos behavior as a ldquofirst lookrdquo
GeneralbullPoor eye contact w people placed on contralesional
sidebull Fails to care for affected side leaves arm in
wheelchairhanging downbullDrops items from affected side and doesnrsquot appear to
notice (eg soap or eating utensil)bullDoes not noticerespond to people andor
conversations on contralesional side
Catherine Bergago Scale (CBS)
10-item checklist
Assesses performance of different daily activities rather than using test situations
Activities that can be associated to all range of spaces (eg shaving the face (personal) eating food from a plate (peripersonal) or colliding
13
14
15
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
3
Three Common Types of Neglect (contrsquod)
Peripersonal neglectbehaviors occur in ldquonear personrdquo space
bull Ignores food on one side of the plate one side of the page one side of the clock
bullTHIS is the one that we tend to measure
Three Common Types of NeglectPersonal neglect
Attends to only one side of hisher body during ADLs (eg observe ptduring bathing ndash one side or both)
Shaving one side (above) but not the other
ldquoHanging glassesrdquo ndash you take them off pt puts back on hisher glasses
Misjudges body midline in severe cases
Other clues that neglect is present
Neglecting half of objects even when they are in full view of pt
bull ldquoAllocentric neglectrdquo or ldquoObject centered neglectrdquo eg pt ignores left side of a cup even when it is
placed on the right side of hisher body omits text that is on the contralesional side
Extinction
bull Pt can attend to a stimulus coming into visual field from either side
bull However when stimuli come from both sides simultaneously pt will only attend to ipsilesionalstimulus (thus ldquoextinguishingrdquo the contralesionalstimulus)
7
8
9
142021
4
Differential Diagnosis
Homonymous Hemianopsia vs USN
bull Homonymous (having the same name or designation) or standing in the same relation
bull hemi half
bull anopsia blindness
bull Homonymous Hemianopsia visual field loss on the same side of both eyes
Differential Diagnosis
Homonymous Hemianopsia
bull Have client turn head contralesionally they can see a stimulus on the wall or in front of them
bull Client demonstrates insight into visual loss
bull Can scan and perform clinical tests
bull Attempts to actively compensate
USN
bull Have client turn head contralesionally they cannot see stimulus
bull Client may not demonstrate insight into visual loss
bull Will not scan during clinical tests
10
11
12
142021
5
Assessment of NeglectThings to ConsiderSeveral neglect subtypes
Think about the domains you are testing and those that you are missing
Use multimodal assessment methods (at least 3-4 tests when possible
If other impairments exist supplement with real world activities in your assessment strategy
General Behavioral Assessments
Observe the ptrsquos behavior as a ldquofirst lookrdquo
GeneralbullPoor eye contact w people placed on contralesional
sidebull Fails to care for affected side leaves arm in
wheelchairhanging downbullDrops items from affected side and doesnrsquot appear to
notice (eg soap or eating utensil)bullDoes not noticerespond to people andor
conversations on contralesional side
Catherine Bergago Scale (CBS)
10-item checklist
Assesses performance of different daily activities rather than using test situations
Activities that can be associated to all range of spaces (eg shaving the face (personal) eating food from a plate (peripersonal) or colliding
13
14
15
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
4
Differential Diagnosis
Homonymous Hemianopsia vs USN
bull Homonymous (having the same name or designation) or standing in the same relation
bull hemi half
bull anopsia blindness
bull Homonymous Hemianopsia visual field loss on the same side of both eyes
Differential Diagnosis
Homonymous Hemianopsia
bull Have client turn head contralesionally they can see a stimulus on the wall or in front of them
bull Client demonstrates insight into visual loss
bull Can scan and perform clinical tests
bull Attempts to actively compensate
USN
bull Have client turn head contralesionally they cannot see stimulus
bull Client may not demonstrate insight into visual loss
bull Will not scan during clinical tests
10
11
12
142021
5
Assessment of NeglectThings to ConsiderSeveral neglect subtypes
Think about the domains you are testing and those that you are missing
Use multimodal assessment methods (at least 3-4 tests when possible
If other impairments exist supplement with real world activities in your assessment strategy
General Behavioral Assessments
Observe the ptrsquos behavior as a ldquofirst lookrdquo
GeneralbullPoor eye contact w people placed on contralesional
sidebull Fails to care for affected side leaves arm in
wheelchairhanging downbullDrops items from affected side and doesnrsquot appear to
notice (eg soap or eating utensil)bullDoes not noticerespond to people andor
conversations on contralesional side
Catherine Bergago Scale (CBS)
10-item checklist
Assesses performance of different daily activities rather than using test situations
Activities that can be associated to all range of spaces (eg shaving the face (personal) eating food from a plate (peripersonal) or colliding
13
14
15
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
5
Assessment of NeglectThings to ConsiderSeveral neglect subtypes
Think about the domains you are testing and those that you are missing
Use multimodal assessment methods (at least 3-4 tests when possible
If other impairments exist supplement with real world activities in your assessment strategy
General Behavioral Assessments
Observe the ptrsquos behavior as a ldquofirst lookrdquo
GeneralbullPoor eye contact w people placed on contralesional
sidebull Fails to care for affected side leaves arm in
wheelchairhanging downbullDrops items from affected side and doesnrsquot appear to
notice (eg soap or eating utensil)bullDoes not noticerespond to people andor
conversations on contralesional side
Catherine Bergago Scale (CBS)
10-item checklist
Assesses performance of different daily activities rather than using test situations
Activities that can be associated to all range of spaces (eg shaving the face (personal) eating food from a plate (peripersonal) or colliding
13
14
15
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
6
Personal Neglect Tests
Comb and Razor TestbullComb right and left side for 30s compact or
razor for 30s bull left = (left strokes) (left + ambiguous +
right strokes) bull (razorcompact case left) + (comb left))
2bullA score lt 035 indicates the presence of left
personal neglect A score gt 035 indicates the absence of left personal neglect
Face washing ndash left versus right side
Peri personal Tests Indented Paragraph Test (Caplan B 1987)
bullPt reads therapist circles omitted phrases as test continues
bullMild neglect-1-9 omissions
bullMod-severe 10+ omissions
bullRandom indentation makes looking left less predictable
Line bisection testbullPlace a mark with a pencil through the center of a
series of horizontal lines Usually a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect
bull The test is scored by measuring the deviation of the bisection from the true center of the line A deviation of more than 6 mm from the midpoint indicates USN
16
17
18
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
7
Line crossing subtest (Albertrsquos test)bullMax score is 36 lines crossed (18 left 18 right ndash the
four central lines are not scored)
bullPt scored 16 ndash the acceptable range is 34-36
Star cancellationbull Pt scored 18 and crossed 2 letters (K and N)
bull Acceptable range ndash 52-54
bull Recommended in post-stroke guidelines reliable valid
bull Best predictor of USN is point of origin when pt starts task
bull bestrdquo is upper left corner
Extrapersonal tests of neglect
Point to Objects Test (Stone amp Greenwood 1991)
Describe everything in the room
Name or point to objects in room
- Identify number of pictures on wall chairs tables closets shelves within the room
- From patientrsquos reference point determine degree of visual scanning of room
- Score based on number identifiedtotal number of objects
19
20
21
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
8
Interventions for USN
bull Modifying the Environment or Task
bull Feedback
bull Mental Imagery
bull Providing Therapy (behavioral therapy computer therapy)
bull Providing Meds
bull Providing Something ldquoSpecialrdquo (eg glasses brain stimulation)
Sim
ple
Str
aigh
tfo
rwar
d
Resou
rces Co
st
Aw
aren
ess
of
or
atte
nti
on
to b
od
y sp
ace
Rem
ediatio
n o
f deficits in
po
sition
space o
r orien
tation
Modifying the Environment
bull Bright red duct tape on walls table edges corners on left
bull Left sided cueing devices (eg LED motion sensor lights right)
Behavioral Modification
bull Behavioral cues that remind the pt to remember the left side (right-wwwhabitchangercom)
22
23
24
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
9
Awareness Training (Tham et al 2002)
Shaping of increased awareness through progressively increased challenges
Begin in activities that are familiar and comfortable
Can be used to look for items in a room while seated pre-ambulation etc
Can be used to remember aspects of a familiar environment
Can be used to ldquostretchrdquo into new unfamiliar environments
1 Agree on a scanning strategy (eg lighthouse)
2 Show pt where item is
3 Have pt perform the scanning task as normal to try and find _________ (eg clock on wall red line on piece of paper)
4 Stop and check flash cards
1 What did I see What did I not see2 Am I remaining focused
3 Did I use the ldquolighthouse beamrdquo or other strategy
5 Try again Cue as needed
6 When pt finds it have pt create a map or write down where it is in ptrsquos environment
7 Use mental imagery to imagine where it is before next attempt
8 Use laptop cameras to tape and play back environment
9 Repeat
Strategies to augment scanning approaches
bull Place an anchor or marker near the targeted item make it smaller or less colorful as training progresses
bull How would pt like to self monitor Cards Journal Self evaluation checklist
bull Scan the entire space
bull Have pt mentally imagine scene
25
26
27
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
10
TENSParameters
bull Frequency 100 Hz
bull Pulse Duration 100 micros
bull Intensity sensory threshold (pleasant tingling)
bull Applied via two 2x2 in electrodes on posterolateral aspect of neck (lateral to spine) and upper trapezius on neglected side
bull Administered for 15 minutes
bull Evidence Ebrsrcom ldquoThere is moderate evidence that TENS treatments used in conjunction with explorationscanning training results in improvements on tests of neglect reading and writing post strokerdquo
What is apraxia
ldquoDifficulties in executing learned movement sequences beyond limitations that could be explained be weakness lack of coordination sensory deficits sensory loss comprehension of deficits memory or motivationrdquo
(Sabari 2008)
bull Itrsquos not because theyrsquore hemiparetic or weak (ldquohelliponce you get stronger your apraxia will resolvehelliprdquo) Thatrsquos a motor deficit
bull Itrsquos not because they donrsquot know what or where the object is (although it looks like that sometimes)
bull Itrsquos not because they donrsquot remember what the object is (although it looks like that sometimes)
bull Itrsquos not because they canrsquot sense the object (ldquooh he canrsquot feel ithelliprdquo)
It is because there is damage to the praxis system
28
29
30
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
11
Clinical Associations
31
32
33
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
12
Using familiar objects incorrectly
bull Dressing apraxia ndash no such thing
bull Tool apraxia ndash one in the same
34
35
36
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
13
How Do I Measure It ndash p 10
37
38
39
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
14
40
41
42
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
15
43
44
45
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
142021
16
Thank you
Steve Page OTRL PhD MS MOT
SPageneurorecoverynet
wwwStevePRehabcom
StevePRehab
StevePRehab
46
