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COGNITIVE&PERCEPTUAL DISORDERS
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L DISORDERS COGNITION
Cognition is a method used by CNS to processinformation.
It includes : Knowing Understanding
Awareness Judgement Decision making
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PERCEPTIONIntegration of sensory impressions into
information that is psychologically
meaningful.Thus perception is the ability to select those
stimuli which require attention & action,integrate them with each other & with prior
information and finally to interpret the results.
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Cognitive & perceptual capacities prerequisites for
learning and rehabilitation is largely a learning
process.
Thus, patients with cognitive and perceptual
disorders are limited in their abilities to learn self-care activities & ADL skills.
Therapists modification of assessment &intervention in light of these deficits will ensure that
patient receives the full benefits of these services.
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CLINICAL INDICATORSInability to do simple tasks independently or safely.
Difficulty in initiating or completing a task.
Difficulty in switching from 1 task to the next.Diminished capacity to locate visually or to identify objects
that seem obviously necessary for task completion.
Unable to follow simple one-stage instructions despiteapparently good comprehension.
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Make same mistakes over and over.
Activities may take an inordinately long time to
complete.
Activities may be done impulsively.
Appear distracted and frustrated and exhibit
poor planning.
May deny the presence or extent of disability.
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PERCEPTUAL DISORDERS1 . Body image/body scheme disorders
i. Somatognosia
ii. Unilateral neglect
iii. Right/left discrimination
iv. Finger agnosia
v. Anosognosia
2. Spatial relation syndromes
i. Figure ground discrimination
ii. Form constancy
iii. Position in space
iv. Topographic disorientation
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3 . Agnosias
i. Visual
ii. Auditory
iii.Tactile
4. Apraxias
i. Ideomotor
ii. Ideationaliii.Constructional
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Attention Memory Initiation
Judgment
Insight
Problem solving
Abstraction
Mental flexibility
Calculation
CATEGORIES OF COGNITIVEDEFICITS
SUNIL BHATT
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IMPAIRMENTS ASSESSMENT
AND
REHABILITATI
ON
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ATTENTIONAbility to select n attend to a specific stimulus while
simultaneously suppressing extraneous stimuli
Active process that helps to determine which
sensations n experiences are alerting n relevant to the
individual
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TYPES Sustained attention : capacity to attend to relevant information during
activity
Focused or selective attention : capacity to attend to a task despite
environmental visual or auditory stimuli
Alternating attention : capacity to move flexibly between task n
respond appropriately to the demands of each task
Divided attention : capacity to respond simultaneously to 2 or more
tasks or stimuli when all stimuli are relevant
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CLINICAL PRESENTATIONSustained attention: pt. just drifts off from an activity
Focused attention:
-stop dressing activity to talk
-easily disturbed by music or other noises
-distractibility
Divided attention: required when more than 1 response
is required or more than 1 stimuli need to be monitored
Alternating attention
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LESION SITE
Reticular activation system: arousal or
alertness
Frontal n temporal lobes: R>L
Sensory systems: bring n code relevantsensory information
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ASSESSMENTLoewenstein occupational therapy cognitive
assessment
Chessington occupational therapy neurological
assessment battery(COTNAB)
Stroop test
Paced auditory serial attention test(PASAT)
Trail making test
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STROOP TEST
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TESTSRandom letter test
Digit repetition test
Clinical observation n activity analysis
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BEDSIDE TESTING OF ATTENTION ANDCONCENTRATION
Digit span forwards and backwards*Recite months of the year, or days of the week, backwards
Serial subtraction of 7s (although note that calculation ability
needs to be intact)
*The normal range is forwards: 6 1; backwards: 5 1.
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REHABILITATIONPurpose:
To increase pt.s attention to appropriate stimuli and
disregard inappropriate stimuli.
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REMEDIAL APPROACH
Train to scan visual environment in slow n systematic manner
Setting time n speed limit
Amplification of critical stimuli
Environmental gradation(non distractible)
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ADAPTIVE APPROACH
Removing the distraction
Interventions :
Computerized training programmes using reaction times
Pattern recognition (cognitrone)
Paper n pencil tasks
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ORIENTATION
time
place
person
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Characteristics common to orientation loss:
Reflected verbally or behaviorally
May be temporary or long lasting
All or none phenomenon
Dimension of time most vulnerable
Most common sequence of recovery of orientation: person
place time
Associated with memory impairment
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EVALUATION OFORIENTATIONTEST OF ORIENATION FOR REHABILITATION
PATIENTS (TORP)
Contains 46 items n measures orientation to person n
personal situation, place, time, schedule n temporal
continuity
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LOWENSTEIN OCCUPATIONAL
THERAPY COGNITIVE ASSESSMANT
(LOTCA) ORIENTATION SUBTEST
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REHABILITATION FOR ORIENTATION
REMEDIAL APPROAC H:
Pt. participate in daily orientation gp.
Provide daily individual reality orientationADAPTIVE APPROACH
Labeled pics of family members etc
Personal items from homeOrganize daily routine
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MEMORYA mental process that allows the individual to
store experiences n perceptions for recall at a
later time
Not localized in one particular place in nervous
systemImportant for rehab.
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Comprises:
Acquisition or learning
Storage or retention
Retrieval or recall
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Levels of memory:
Immediate recall : retention of information that has been stored for a
few seconds
Short term memory : retention of events or learning that has taken
place within few min, hours or days
Long term memory:
Consists of early experiences n information acquired over a period of
years
Not commonly seen foll. stroke
Common foll. brain injury n in Alzheimer dis.
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MEMORY
Rivermed Behavioral MemoryTest (RBMT)
Test of everyday memory functioning
Contextual memory test(CMT)
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BEDSIDE TESTING OF MEMORY .
First check that patient is attentive and that language function is adequate
Anterograde verbal memory
Ask the patient to name three distinct objects (e.g. Ball,Flag, Tree)
Ensure that the patient has registered the information(repeat up to three times
if necessary)
If the patient can immediately name the objects, ask the patient to repeat the
three objects three minutes later
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Anterograde visual memory
Show the patient faces in a magazine
Ensure they have recognized them
Retest after 5 min
Retrograde memory
Ask the patient to describe recent events on the ward, or visits
from relatives
Ask about important historical events and major events in the
patients life, e.g. date of marriage
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MEMORY RETRAINING
Purpose:to enable the pt to effectively encode n recall information so that learning can occur.
Remedial approach :
Organizing material to be remembered
Build strategies
Computer games
Memory tests
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COMPENSATORY APPROACH
Use of diary or notebook(memorylog)
Beeper or wallcalender
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Training:
Date books, post-it notes, timers, calendars
External self talk, routines n habits, organization n planning in ways that will reduce number of memory
slips
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ABILITIES
Result of complex n dynamic interactions between a no.
of brain structures united in functional systems
Depend on intact primary cognitive capabilitiesProblem solving
Reasoning
Concept formation
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EXECUTIVE FUNCTIONS
Consists of those capacities that enable a person
to engage successfully in independent, purposive,
self serving behavior
4 overlapping components
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Assessment:
Executive Functions Assessment
Good Samaritan Hospital For Cognitive
Rehabilitations Executive Functions
Behavioral Rating Scale
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REMEDIAL APPROACH
Provide structure, feedback n routine
PT initially acting as pts frontal lo be
COMPENSATORY APPROACH
Assist pt for poor abilities by utilizing other intact cognitivefunctions
Environment modification
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3. About what time is it? 1 _____ x 3 =______
(within one hour)
4. Count backwards 20 to 1 2 _____ x 2 =______
5. Say the months in reverse order 2 _____ x 2 =______
6. Repeat the phrase just given 5 _____ x 5 =______
Total error score = _____/28
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PERCEPTUAL
DISORDERS AND
REHABILITATION
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UNILATERAL NEGLECT
Inability to register and integrate stimuli and
perceptions from one side of the body, and the
environment which is not due to sensory loss.
Clinically, pt. may ignore one half of the body while
performing ADLs.
Lesions involving infero-posterior regions of right
parietal lobe are significant determinants of neglect.
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ASSESSMENT
Behavioural inattention test (BIT)
Which includes making simple drawings.
Patient is asked to perform tasks such as baking
cookies & changes in pts performance in response to
cueing are observed.
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INTERVENTION
1. Remedial approachStimuli specialised for rt. And lt. side of the brain should be
used.
Eg. Rt. Brain activation shapes & blocks
Lt. brain activation letters , numbers etc.
Simple verbal instructions to encourage turning of head to
neglected side and anchor the attention towards the same.
2
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2. Cognitive compensation
Patient taught to be aware of the deficit through visual scanning
starting from the neglected side.
Training for ADL & other required tasks by repeated practice.3. Adapting the environment
Patient should be addressed & demos should be given from the
unaffected side.
Mirror placed in front of the patient when he is dressing to draw
attention towards the neglected side.
In transfer of training, pt. participates in tasks which require him
to look from the affected side such as watching TV.
ANOSOGNOSIA
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ANOSOGNOSIA
Denial & lack of awareness of the presence of severity of
ones paralysis.
Pt. maintains there is nothing wrong & may disown the
paralysed limbs & refuse to accept the responsibility for
them.
Pts. Have tendency to cover the paretic limb.
Lesion usually in the non-dominant parietal lobe in the
region of supramarginal gyrus.
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ASSESSMENT
Assessed by talking to the pt. & asking him questions
like :
What happened to the arm/leg
Whether he/she is paralysed
Why the limb cannot be moved
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INTERVENTION
Extremely difficult to compensate for this
deficit.
Safety is of paramount importance as the
typically do not acknowledge that they have
a disability & will therefore refuse to be
careful.
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SOMATOAGNOSIA
Lack of awareness of the body structure & the relationship of
body parts to oneself or others.
Lesion in dominant parietal or posterior temporal lobe , thus,
disorder is primarily seen with right hemiplegia.
Clinically, pt. may have difficulty in performing transfer
activities.
Difficulty in dressing.
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ASSESSMENT
Pt. is asked to point the body parts being
named by the therapist.
Imitate movements of the therapist.
Answer questions about relationship of body
parts.
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RIGHT LEFT DISCRIMINATION
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RIGHT LEFT DISCRIMINATION
Inability to identify the right & left side of the body.
Patients are often unable to imitate movements.
Clinically, pt. is unable to follow instructions using the
concept of right & left.
Lesion site parietal lobe of either hemisphere.
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ASSESSMENT
Patient is asked to point body parts on
command
Eg. Right ear, left arm, right leg so on & so
forth.
Six responses should be elicited.
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INTERVENTION
In giving instructions to the pt. avoid using
directional words such as right or left,
instead use arm with the watch.
Adaptive environment
Right side of all common objects like wall,
shoes & clothing to be marked with red tape.
FINGER AGNOSIA
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FINGER AGNOSIA
Inability to identify the fingers of ones own hand orthe hands of the examiner.
Usually occurs bilaterally & most common in the
middle 3 fingers.Correlates with poor dexterity in tasks such as tying
shoe laces, typing, buttoning etc.
Lesion in either parietal lobe in the region of angular
or supramarginal gyrus.
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Gerstmanns syndrome- bilateral finger agnosia +
right-left discrimination + agraphia + acalculia
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ASSESSMENT
A portion of Sauguets test :
Name the fingers touched by the therapist with eyes open (5
times) if successful, with eyes closed (5 times).Point to fingers named by the therapist on pts own hands (10
times), therapists hand (10times),
on a schematic model.
Point to equivalent finger on a life-sized picture.
Imitate finger movements.
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INTERVENTIONS
Pts discriminative tactile systems are
stimulated.
Transfer of training pt. quizzed on finger
identification.
DISCRIMINATION
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DISCRIMINATION
Inability to visually distinguish a figure from thebackground in which it is embedded.
Pt. has difficulty in ignoring irrelevant visual stimuli and
cannot select the appropriate stimuli to which to respondto.
Clinically, pt. is unable to locate objects in a pocketbook or
drawer, buttons on a shirt, may not be able to tell when
one step ends & another begins esply. While descending.
Lesion mostly in the parieto-occipital region of right
hemisphere.
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ASSESSMENT
Ayres figure ground test.
Functional tests :
White towel on a white sheet
Pick out a spoon from an unsorted array of utensils.
INTERVENTIONS
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INTERVENTIONS
Compensation through cognitive awareness:
Pt. is taught to examine group of objects slowly &
systematically & sort them carefully using other intact
senses like touch.
Adaptation & simplification of the environment:
Brightly colored tapes to mark edges of stairs.
Transfer of training:Start with 3 totally dissimilar objects & progress to more
similar ones.
FORM DISCRIMINATION
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FORM DISCRIMINATION
Inability to perceive or attend to subtle differences inform & shape.
Clinically, pt. may confuse a pen with a toothbrush or
a cane with a crutch.
Lesion site is parieto-temporo-occipital region of the
non-dominant lobe.
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ASSESSMENT
Items similar in shape & different in size are
kept together , pt. is asked to identify each
one.
Eg. One set pencil, straw, toothbrush etc.
second set coin, ring, paper clip etc.
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INTERVENTION
Frequently used objects with similar shapes
can be labeled.
Encourage the pt. to use other intact senses
to identify & distinguish objects from each
other.
SPATIAL RELATION DEFICITS
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SPATIAL RELATION DEFICITS
Inability to perceive the relationship of one object in spaceto another object or to oneself.
Crossing the midline may be a problem for such patients.
Clinically, pt. may find it difficult to place the cutlery,spoon & plate in proper position when setting the table.
Pt. may be unable to tell the time from a clock due to
difficulty in perceiving the relative position of hands.Lesion site is predominantly inferior parietal lobe or
parieto-occipital-temporal junction usually on the right
side.
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ASSESSMENT
Therapist draws picture of a clock , pt. is asked to fill
the numbers and draw the hands corresponding to a
particular time as instructed by the therapist.
2-3 objects placed on a paper in a particular pattern ,
pt. is asked to duplicate the pattern.
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INTERVENTION
Patient can be given instructions on
positioning himself in relation to the therapist
or any other object :
Eg. sit next to me
stand behind the table
step over the line
POSITION IN SPACE
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POSITION IN SPACE
Inability to perceive & interpret spatial concepts such
as up down , above under.
Clinically, if the patient is asked to raise the arm
above his head during ROM assessment pt. would not
know what to do.
Lesion usually in the non dominant parietal lobe.
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ASSESSMENT
Place the objects , one on top of another or
one below the other.
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INTERVENTION
3-4 objects are placed in a specific
orientation an additional object is placed in
different orientation & pt. is asked to pick the
odd one & place it in similar way as the
others.
TOPOGRAPHIC DISORIENTATION
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TOPOGRAPHIC DISORIENTATIONDifficulty in understanding & remembering relationship of one location to another.
Pt. is unable to get from one place to another with orwithout a map.
Clinically, pt. is unable to find his room in a physiotherapyclinic despite being shown repeatedly.
Possible lesion sites :
Inferior parietal lobeOccipital association cortex
Occipitotemporal cortexBilateral parietal lesions
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ASSESSMENT
Patients is asked to draw a familiar route
either to his house or the neighbourhood.
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INTERVENTION
Frequently travelled routes to be marked with
dotted lines , gradually space between the dots is
reduced & eventually the line are removed.
Practice going from one place to another with the
help of verbal instructions.
Simple routes should be used.
DEPTH & DISTANCE PERCEPTION
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DEPTH & DISTANCE PERCEPTION
Inaccurate judgement of direction, distance & depth.
Clinically, pt. may have difficulty in navigating stairs,
may miss the chair when attempting to sit, continuepouring juice when glass is filled.
Lesion in posterior right hemisphere in the superior
visual association cortices, bilateral or right sided
lesions.
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ASSESSMENT
Grasp an object that has been placed on the
table. Impaired pt. will undershoot or
overshoot the target. (distance perception)
Fill water in a glass (depth perception)
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INTERVENTION
Cognitive awareness (walking carefully on
uneven surfaces particularly stairs).
Place feet on designated spots during gait
training.
Blocks arranged in piles 2-8 inches high, pt.
is asked to touch the feet on top of each pile.
VERTICAL DISORIENTATION
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VERTICAL DISORIENTATION
Distorted perception of what is vertical.
Causes disturbances in motor performance, posture
& gait.
Lesion site non dominant parietal lobe.
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ASSESSMENT
Therapist holds a cane vertically, then
displaces it to horizontal position. Pt. is asked
to take the cane & return it to original
position.
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INTERVENTION
Patient is asked to use the sense of touch for
proper self orientation esply. When going
through doorways, in & out of elevators or on
the stairs.
VISUAL OBJECT AGNOSIA
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VISUAL OBJECT AGNOSIA
Inability to recognise familiar objects despite normal function of eyes &
optic tracts.
Simultanagnosia (Balints syndrome)- inability to perceive a visual
stimulus as a whole . Lesion is dominant parietal lobe.
Prosopagnosia related to any visually ambiguous stimuli, the
recognition of which depends on evoking memory context such as
different species of birds or different makes of cars. Bilaterally
symmetrical occipital lesions.
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Color agnosia inability to identify colors , ability
to name the objects is retained. Classic occipital
syndrome.
AUDITORY AGNOSIA
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AUDITORY AGNOSIA
Inability to recognise nonspeech sounds or to
discriminate between them.
Pt. is unable to tell the difference between sound of
a doorbell & that of a telephone or between dog
barking & thunder.
Lesion in dominant temporal lobe.
ASTEREOGNOSIS
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ASTEREOGNOSIS
Inability to recognize forms by handling them
although, tactile, proprioceptive & thermal
sensations may be intact.
Difficulty in ADLs.
Lesion in parieto-temporo-occipital lobe of either
hemisphere.
IDEOMOTOR APRAXIA
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IDEOMOTOR APRAXIA
Pt. is able to carry out habitual tasks automatically &
describe how they are done but is unable to imitate
gestures or perform on command.
Lesion in the left, dominant hemisphere.
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ASSESSMENT
Goodglass & Kaplan test for apraxia
Consists of universally known movements like
brushing teeth, blowing, hammering etc.
based on hierarchy of difficulty for pts. With
apraxia.
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INTERVENTION
Simplified commands
Short & precise set of instructions
Sensorimotor approach
IDEATIONAL APRAXIA
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IDEATIONAL APRAXIA
Inability to perform a purposeful motor act eitherautomatically or on command because the pt. no
longer understands the overall concept of the act,
cannot retain the idea of the task or cannot
formulate the motor patterns required.
Lesion in dominant parietal lobe.
CONSTRUCTIONAL APRAXIA
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CONSTRUCTIONAL APRAXIA
Faulty spatial analysis & conceptualisation of the task.
Pt. for eg. Understands everything about a sandwhich & what it is
for but, is unable to assemble one.
Lesion in the posterior parietal lobe of either hemisphere.
REFERENCES
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REFERENCES Textbook of medical physiology Guyton &Hall (9 th edition)Physical rehabilitation OSullivan (4 th edition)Impact of Motor, Cognitive, and PerceptualDisorders on Ability to Perform Activities of Daily Living After Stroke Louisette Mercier,
Thrse Audet, Rjean Hbert, AnnieRochette and Marie-France Dubois Stroke
2001;32;2602-2608www.acnr.co.uk/pdfs/volume4issue5/v4i5cognitive.pdf
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THANK YOU !!!!!