2 The five factors influencing an outcome of Functional Autonomy Perceptual FactorCognitive FactorMotor Factor (upper extremity)Motor Factor (balance)Significant other(s)
3 Reason Perceptual (awareness) factor is vital in rehab outcome Impaired awareness significantly complicates the rehab process. These patients consistently underestimate their impairments, when compared to family members’, clinicians’ ratings, and their performance in neuropsychological tests.
4 Disorders of self awareness The perceptual FactorsTheoretical Basis
5 Theoretical Implications (1) Mersulam 1985Primary motor and Sensory Cortex respond to one type of stimulus (idiotypic)Rest of Cortex “association”1. “unimodel” – modality specific – association area2. “heteromodel” – high order-association area
6 Theoretical Implication (2) Heteromodel Association areaFrontal lobe, pre-frontal, inferior parietal lobule, superior marginal gyrus, angular gyrusInterface InformationExternal World Interior WorldSensorimotor cortex Paralimbic areas
7 Theoretical Implications (3) “Syndromes” of impaired awareness Pre-Frontal: Social judgment, anticipate change, inappropriate social behavior and commentsInferior Parietal Lobe: self-awareness of body, self image, anosognosiaSuperior marginal+angular gyrus+superior temporal lobe: self perception of linguistic output, visual, auditory, memory impairments, misinterpretations leading to paranoid thinking
8 Theoretical Implications (4) Involvement of Basal GangliaParticularly the Putamen, Posterior limb of Internal Capsule, Pulvinar of Thalamus, but also Lentiform and Caudate nuclei.The frontostriato-pallido-thalamo-frontal neuronal circuit involving the heteromodel association areas
9 ANOSOGNOSIAThe inability to be aware of the severity of impairments, believing that everything is intact.This “Unawareness of Impairment” is aCognitive / Behavioral phenomenon, with a variety of syndromes, related to damage of various heteromodel brain areas, for example:Inferior parietal lobule: Unawareness of hemiplegia, Angular gyrus: aphasic syndromes: unaware of impaired language output.
10 Complete and Incomplete Anosognosia syndromes Bilateral Cerebral dysfunction in the Heteromodel regions will result in complete syndrome.Unilateral Cerebral dysfunction will result in partial syndromes.After unilateral stroke, bilateral dysfunction may be present for short time, and as the bilateral phenomenon clears, the complete anosognosia resolves into incomplete residual unawareness syndromes.
11 NEGLECTThis is different from anosognosia, but sometimes both can be present. If both are present then patient is unaware of, for example, hemineglectNeglect can be diagnosed particularly with “double sensory stimulation”, touching both arms at the same time, testing both visual fields simultaneously.
13 Complete AnosognosiaIn patient with hemiplegia (particularly left hemiplegia, but can occur in right hemiplegia):Denies that hemiplegic side belongs to him/her, says “ Ah that’s Jimmy” or “ that belongs to the guy in the next bed.”That absolute unawareness usually improves as it becomes a partial unawareness syndrome
14 Linguistic Unawareness Syndromes AprosodiaUnawareness of language error, inability to self monitor.Jargon, Wernicke’s aphasia, a fluent aphasia characterized by marked auditory comprehension deficits, babbling with incomprehensive words very fluently.Reality monitoring: confabulation.
15 Anton’s syndromeUnable to demonstrate sight: cannot count fingers, discriminate shapes, objects,colorsPupils react to lightDenies any visual difficulty, confabulates, guesses, makes excuses for errors.Visual hallucinationsLesion involves bilateral calcerine cortex, as well as other heteromodel areas.
16 Methods of measuring self-awareness and neglect at the bedside. DiagnosticsMethods of measuring self-awareness and neglect at the bedside.
17 Physical Examination History: denials Observing behavior and denials Signs: Double sensory stimulation for sensation and visual fields, differentiation from homonymous hemianopia,testing denials,Other bed-side tests:
19 Cancel all E’s and I’s (keep paper straight and quantify misses) HERSIKEzUMINOPENFIKGHEIVZQOPIWMBEZIDVQILMEJYTITSEKIXCEIRYMEKJCINPDE THRINMKEQWRETHIZLFEWIZIHPWIZNPEKVCDEJMIZXYENPEITRFKIQPESTIKLMEDOPUEAMNIQWTEHTIESXINPESTAKUNOVFKENPIROAEZQPECIT
21 THREE DIMENSIONAL DESIGNS Have photograph of blocksAnd ask patient to copy that design with actual blocksOne way of finding Constructional ApraxiaIf present it will indicate possible difficulties with dressing and other ADLs
22 Skilled Professional Tests Visual discrimination, figure ground, visual memory, visual synthesis & consistency,Bells test, a more refined cancellation test, Benton test, Rey complex figure test,Occupational Therapy perceptual evaluation batteryAphasia screening test-Halstead-Reitan neuropsychological test battery
24 Levels of Awareness Complete Anosognosia Intellectual Awareness: understanding having difficulty in one specific activityEmergent Awareness: understanding having difficulty in many circumstancesAnticipatory Awareness: understanding implication of deficit.
26 Strategies Remediation Strategies Strategies used to regain abilities Compensatory StrategiesStrategies used to substitute for lost skills
27 Mobility&Neglect Remediation Positioning of furniture,Early correct positioning, and handling,Controlled transfers, standing up, walking without use of cane or any device.Lateral transfers over affected hand, looking to affected side, lateral transfer kneeling, always controlled by therapists and nurses, and involving families in techniques.
28 Rehab of neglect, mobility, loss of awareness Restraining normal side techniquesFull “old fashioned” Proprioceptive- Neuromuscular-Facilitation technique of Kabat/Knott/Voss, ie using a lot of oral and sensory (touching) stimulationUse of pressure (air splints), taping
29 Motor MemoryThe reason Proprioceptive Neuromuscular Facilitation technique is important is:Memory and Learning involves two systems: Explicit and Implicit.Explicit means facts, while Implicit (abstract?) involves Perceptual-motor processes. PNF provides Explicit information, attenuating Implicit learning deficits.
30 Kinetic Chain“Closed Kinetic Chain” exercises have become popular in Sport and Musculoskeletal rehabilitation methodology particularly using external loads. Studies have shown this to work.It also can be applied to stroke rehabilitation as it follows the same principles as PNF.
31 BEWAREAlthough loss of awareness and neglect are most obvious (if looked for) in patients with Left Hemiplegia, it must also be always looked for in Patients with Right Hemiplegia, where it is not uncommon.It always needs to be looked for in all patients who have Brain Injuries or diseases such as brain tumors.
32 Oculomotor Control Visual Fields Visual Acuity Visual CognitionVisual MemoryPattern RecognitionScanningAttentionOculomotor Control Visual Fields Visual Acuity
33 Neuro-Rehabilitative Optometry Neuro-optometric rehabilitation is an individualized treatment regimen for visual deficits resulting from physical disabilities, traumatic brain injuries and other neurological insults.Identifying neurological, binocular, motor, perceptual problems, and followed withOrthoptics /Vision Therapies.
34 Neuro-Optometric Therapy The Rehabilitation ofVisual / Perceptual / Motor Disorders:Acquired strabismus, diplopia, binocular dysfunction, convergence and/or accommodative paresis/paralysis,oculomotor, visual-spatial dysfunction, visual perceptual, cognitive deficits,Visual field loss, Visual neglect, denial
35 Neuro-Rehabilitative Optometry 2 Visual Motor TherapyVisual Perceptual therapy to allow relearning eye-hand coordination providing perceptual information of object size, texture, location, visual discriminationNeglect/Homonymous hemianopia differLATER: Prism, Lenses, Occlusion
36 Remediation of Spatial deficits Searching for increasingly complex arrays of visual details (figure ground),Assemble three dimensional figures working through progressive levels of complexity (constructional apraxia),To improve perception of body schema: name, identify and move neglected body part.
37 Remediation of Visual Spatial Deficits. Interactive 3-D software (action games, navigation simulators),In a LEFT hemiplegia, stimulation with TENS, vibration on the LEFT side of neck, and hand as well as pressure and movement appears to activate the contra lateral right hemisphere.
38 Educating family in Visual-Spatial impairments Caretakers are often torn between whether to believe the treatment team or the patient regarding contradictory appraisal of abilitiesPatient asserts the treatment team is “making a big deal out of nothing”, rallying support of family.Lack of concern of deficits and unawareness of deficits will have profound impact on driving, recreational and vocational pursuits and giving responsibilities to patient.
39 CaretakersIt must always be remembered that the counseling and proper management of the caretakers is as much the task of the rehabilitation team, as is the patient/client.There must be early involvement of the caretakers as well as those involved in the community reintegration, such as vocational therapists, and the use of Supportive Employment.
41 Eventual Outcome“Impaired self-awareness reflects a clear disruption of the integration of thinking and feeling” (Prigatano)Blame others, become paranoid, and therapists can precipitate a clinical crisis.There is a positive association between accurate self-awareness and favorable employment outcome ( Sherer ).
42 Further Vocational Facts 30% of patients after a Traumatic Brain Injury resume reasonably productive lifestyles 2 to 4 years after injury.Only 10% remain productive in a 10 – 15 year follow-up.It may well be that this is due to loss of self awareness syndromes, as suggested in the Sherer research studies, but more research is necessary
43 Do we know?Prigatano hypothesized that there may be a possibility that the neural substrate for self-awareness may be the same as the neural substrate for other complex integrative functions that are needed for successful employment outcome.As always in Rehabilitation more research is needed.
44 REFERNCES (1)Prigatano GP, Disturbances of self-awareness of deficit after traumatic brain injury. IN: Prigatano GP., Schacter DT, eds: Awareness of deficits after brain injury: Clinical and Theoretical Issues, New York N.Y., Oxford University Press,1991Prigatano GP: Disorders of self awareness after brain injury, IN: Principles of Neuropsychological Rehabilitation: New York, Oxford, Oxford University Press, 1999Mersulam MM: Principles of Behavioral Psychology. F.A. Davis, Philadelphia, 1985
45 REFERNCES (2)Shaw J. The assessment of Rehabilitation of Visual-Spatial Disorders. IN: Johnstone B., Stonnington HH, eds: Rehabilitation of Neuropsychological Disorders: Psychology Press, Philadelphia, PA, 2001Sherer M. et al: Impaired awareness and Employment Outcome after TBI: J. Head Trauma Rehabilitation, 1998: 13(5) 52-61