COGNITIVE AND

PERCEPTUAL
IMPAIRMENTS
 OBJECTIVES
• UNDERSTANDING COGNITION AND
PERCEPTION
• PATHOPHYSIOLOGY
• REVIEW OF COGNITIVE AND PERCEPTUAL
IMPAIRMENTS
• CLINICAL INDICATORS
• ASSESSMENT
• TREATMENT MODIFICATION
BRAIN FUNCTION AND PARTS
 COGNITION PERCEPTION
• Method used by Central • Integration of sensory
Nervous System to impressions into
process information information that is
psychologically meaningful
• Ability to select those
stimuli that require
• Includes – attention and action, to
 Perception integrate those stimuli with
 Attention each other and with prior
 Thinking information and finally to
interpret them
 Memory
PERCEPTION
MEMORY TYPES
 COMMON CAUSE OF COGNITIVE
&PERCEPTUAL IMPAIRMENT

 Cerebrovascular accident

 Traumatic Brain Injury

STROKE/CVA
 CLINICAL INDICATORS
• Inability to do simple tasks independently or
safely
• Difficulty in initiating or completing a task
• Difficulty in switching from one task to the
next
• Diminished capacity to locate visually or to
identify objects that seem obviously necessary
for task completion
 CLINICAL INDICATORS
• They may be unable to follow simple one-
stage instructions, despite apparently good
comprehension
• They may make the same mistakes over and
over
• Activities may take an inordinately long time
to complete or they may be done impulsively
 COGNITIVE IMPAIRMENTS
• Attention disorder
• Memory disorder
 ATTENTION DISORDER
• Types:Sustained, Selective,Alternative,Divided

• Clinical symptom:
• Distractibility
• Pt stops dressing to talk to therapist
• ADLS like cooking and driving becomes
difficult
 REGION OF LESION
• Etiology:Due to affect in
• Multiple regions of brain
• Reticular formation-regulates arousal
• Various sensory systems that bring and code
• relevant sensory information
• Limbic and frontal regions that underlie the
drive and affective components of
concentration
 ATTENTION-ASSESSMENT
• COTNAB-Chessington Occupational Therapy
Neurological Assessment Battery -subtests
that examine attentional abilities
• PASAT- Paced Auditory Sensorial Attention Test
• Trail Making Test
 ATTENTION -THERAPY
• Remedial :
• Left hemiplegia- Should be trained to scan the
visual enviornment. A patient scanning too
quickly should be advised to slow down
• Right hemiplegia- Patient should be spoken to
more slowly to afford an opportunity to
process verbal information
 ATTENTION THERAPY
• Setting time or speed limits
• Amplification of critical stimuli
• Making crucial stimuli salient(noticeable)
• Environment grading(closed to distracting)
Adaptive approach for attention training

• Distractible patient should be assessed in a

noise-free, visually bland environment
• For patients who have difficulty reading due to
concentration issues can be given a card with
slit large enough for only one line to appear at
a time.
 Memory disorders
• Clinical symptoms:
• Patient may not be able to remember the
instructions given only seconds before by the
therapist.
• Therapist would have taught a new transfer
technique and the next day could see that
patient did not retain any of the steps involved
 REGION FOR MEMORY
• Cerebral Cortex
 Frontal
 Temporal
 Parietal
 Occipital
• Limbic system
 MEMORY-ASSESSMENT
• Rivermead Behavioural Memory Test (RBMT)
• Recall lists/objects that have just been
presented
• Teaching the patient a new verbal/visual task
and asking him to recall it a few hours/day
later
 MEMORY-THERAPY
• Remedial approach:Organising material to be
remembered
• Making logical association
• Compensatory approach:
• Using a diary/note book system to manage
ADL
 EXECUTIVE FUNCTIONS
• Those capacities that enable a person to
engage successfully in independent,
purposive,self-serving behavior
• Volition
• Planning
• Purposive action
• Effective performance
 CLINICAL SYMPTOMS
• Impulsiveness
• Poor judgement
• Poor planning ability
• Lack of foresight especially in left hemiplegia
 EXECUTIVE FUNCTION-REGIONS
• Frontal
• Prefrontal cortex
• Reciprocal connections with other cortical and
subcortical regions via the dorsolateral
prefrontal subcotical circuit
 EXECUTIVE FUNCTION-THERAPY
• REMEDIAL: By providing patient with structure,
feedback and routine
• ADAPTIVE:Therapist might ask patient to
perform a task in a room with minimal
distraction, or change the demands of the
patient’s work,home or community to diminish
the need to employ executive function. A
beeper/alarm can be used for poor initiation
 BODY SCHEME/BODY IMAGE DISORDERS

• BODY IMAGE:
• Visual and mental of one’s body that includes
feelings about one’s body, especially in relation
to health and disease
• BODY SHCEME:
• Postural model of body , including the
relationship of body parts to each other and the
relationship of the body to the environment
 DISTURBANCES IN BODY IMAGE/SCHEME

• Unilateral neglect
• Somatoagnosia
• Right-left discrimination
• Finger agnosia
• Anosognosia
 UNILATERAL NEGLECT
• Inability to register and integrate stimuli and
perceptions from one side of the body (body
neglect) and the environment or
hemispace(spatial neglect) which is not due to
a sensory loss
 SOMATOAGNOSIA
• Impairment in body
scheme/Autopagnosia/Body agnosia
• Lack of awareness of the body structure and
the reationship of body parts to oneself or to
others
• Lesion over dominant parietal lobe or
posterior temporal lobe .Primarily with right
hemiplegia.
RIGHT-LEFT DISCRIMINATION DISORDER

• Inability to identify the right and left sides of

one’s own body or of that of the examiner.
• Parietal lobe of either hemisphere
 FINGER AGNOSIA
• Inability to identify the fingers of one’s own
hands or of the hands of the examiner
• Parietal lobe - Angular gyrus/Supramarginal
gyrus
 ANOSOGNOSIA
• Sever condition including denial and lack of
awareness of the presence or severity of one’s
paralysis.
• Lesion in non dominant parietal lobe in the
region of the supramarginal gyrus
 GERSTMANN’S SYNDROME
• Bilateral finger agnosia
• Right-Left discrimination
• Agraphia
• Acalculia
 SPATIAL RELATIONS DISORDER
• Constellation of deficits that have in common
a difficulty in perceiving the relationship
between the self and two or more objects
• Figure ground discrimination
• Form discrimination
• Spatial relations
• Position in speace
• Topographical disorientation
 LOCATION OF LESION
• Lesion of Right parietal lobe plays a primary
role in space perception
• So more common in right sided lesions with
resulting left hemiparesis
FIGURE-GROUND DISCRIMINATION
• Inability to visually distinguish a figure from
the background in which it is embedded
• Patient has difficulty ignoring irrelevant stimuli
and cannot selec the appropriate cue to which
to respond
• Parieto occipital lesions of the right
hemisphere and less frequently of the left
hemisphere
 FORM DISCRIMINATION
• Inability to perceive or attend to subtle
differences in form and shape.
• Lesion site is parieto-temporo-occipital
region(posterior association area)of the non
dominant lobe
 SPATIAL RELATIONS DEFICIT
• Inability to perceive the relationship of one
object in space to another object or to oneself
• Lesion site is predominantly the inferior
parietal lobe or parieto-occipital-temporal
junction usually of the right side
 POSITION IN SPACE
• Inability to perceive and to interpret spatial
concepts such as up,down, under,over, in front
of.
• Lesion is usually located in the non dominant
parietal lobe
 TOPOGRAPHIC DISORIENTATION
• Difficulty in understanding and remembering
the relationship of one location to another
• Possible lesion sites are the inferior parietal
lobe or occipital association cotex and the
occipitotemporal cortex, particularly on the
right side
DEPTH AND DISTANCE PERCEPTION
• Experiences inaccurate judgement of
direction,distance and depth. Spatial
disorientation may be a contributing facgor in
faulty distance perception
• Lesion in the posterior right hemisphere in the
superior visual association cortices, bilateral
or right sided lesions
 VERTICAL DISORIENTATION
• Distorted perception of what is vertical
• The lesion site is in the nondominant parietal
lobe
 AGNOSIA(Simple Perception)
• Inability to recognize or make sense of
incoming information despite intact sensory
capacities
 AGNOSIA TYPES
• VISUAL OBJECT AGNOSIA
• AUDITORY AGNOSIA
• TACTILE AGNOSIA OR ASTEREOGNOSIS
 VISUAL OBJECT AGNOSIA
• Simultanagnosia
• Prosopagnosia
• Color agnosis
• SIMULTANAGNOSIA(BALINT’S SYNDROME)

• Inability to perceive a visual stimulus as a whole

• PROSOPAGNOSIA

• Inability to recognise familiar faces, different species

of birds or different makes of cars

• COLOR AGNOSIA

• Inability to recognize colours ; it is not colour

blindness.
 LESIONS CAUSING VISUAL AGNOSIA

• Lesion is over the occipito temporo pareital

association areas of either hemisphere. These
areas are responsible for the integration of
visual stimuli with respect to memory
 AUDITORY AGNOSIA
• Inability to recognise nonspeech sounds or to
discriminate between them
• Lesion is over dominant temporal lobe
 TACTILE AGNOSIA/STEREOGNOSIS
• Inability to recognize forms by handling them,
although tactile, proprioceptive and thermal
sensations are intact
• Lesion is in the parieto-temporo-occipital
lobe(posterior association areas) of either
hemisphere
 APRAXIA
• Disorder of voluntary skilled learned
movement.
• Inability to perform purposeful movements
 TYPES OF APRAXIA
• IDEOMOTOR
• IDEATIONAL
• CONSTRUCTIONAL
 IDEOMOTOR APRAXIA
• Breakdown between concept and
performance
• Disconnection between idea of a movement
and its motor execution
• Lesions over the left dominant
hemisphere.There is evidence that both
frontal lesions and posterior parietal lesions
can result in apraxia
 IDEATIONAL APRAXIA
• Failure in the conceptualization of the task
• Inability to perform a purposeful motor act,
either automatically or on command
• Lesion is over the dominant parietal lobe.
• Will also be seen in diffuse brain damage, such
as cerebral arteriosclerosis
 CONSTRUCTIONAL APRAXIA
• Faulty spatial analysis and conceptualization of
the task
• Inability to produce two - three dimensional
forms by drawing, constructins, or arranging
blocks or objects spontaneously on command
• Lesions are on the posterior parietal lobe of
either hemisphere
ASSESSMENT
 PURPOSE OF ASSESSMENT
• Perceptual performance is positively correlated
with ability to perform ADLs
• Functional loss unexplained by motor deficit,
sensory deficit or deficient comprehension
• Higher level tasks such as driving, banking,or
planning a meal may only emerge as areas of
difficulty once the patient is discharged home
• To determine which cognitive and perceptual
abilities are intact and which are limited
 PURPOSE OF ASSESSMENT
• Understanding the manner in which a
particular deficit influences task performance
will foster the application of a therapeutic
strategy in which intact capabilities may be
used to compensate for or to overcome
deficits
 INFLUENCE ON BALANCE
• Attention, cognition, judgement and memory are critical for optimal
balance skills
• Attention deficits reduce awareness of environmental hazards and
opportunities interfering with anticipatory postural control
• Memory loss may preclude recall of safety measures
• Distractibility, poor judgement and slowed processing also increase risk
of falls
• Fear of falling may lead to self imposed participation restrictions that
precipitate a downward or spiral of more sedentary behaviours and
social isolation which negatively affect balance and raise the risk of falls
• Also impedes motor learning processes which is crucial for relearning
of balance skills
LEVEL OF COGNITIVE FUNCTIONING
 THEORETICAL FRAMEWORK OF
MANAGEMENT
• TRANSFER OF TRAINING APPROACH
• SENSORY INTEGRATION APPROACH
• NEURODEVELOPMENTAL APPROACH
• FUNCTIONAL APPROACH
• COGNITIVE REHABILITATION
 TRANSFER OF TRAINING APPROACH

• Practice in one task with particular perceptual

requirements will enhance performance on
other tasks with similar perceptual demands
SENSORY INTEGRATIVE APPROACH
• Offering opportunities for controlled sensory
input, the therapist can effect normal CNS
processing of sensory information and thus
elicit specific desired motor responses.
• The performance of these adaptive responses,
inturn, influences the way in which the brain
organizes and processes sensation, thus
enhancing the ability to learn
 NEURODEVELOPMENTAL APPROACH

• Perception is considered integral to the

handling techniques that provide the patient
with sensory input and to the subsequent
feedback accompanying correct movement
during movement retraining
• Ex: Weight bearing activities enhance
proprioception and bilateral activities enhance
total body awareness and diminish unilateral
neglect.
 FUNCTIONAL APPROACH

• Widely used approach

• Adults with brain damage will have difficulty
generalising and learning from dissimilar tasks
• Direct repetitive practice of specific functional
skills that are impaired – enhances patient
independence in those tasks
 FUNCTIONAL APPROACH
 Compensation: Changes that need to be made
in the patient’s approach to tasks
 Adaptation: Alterations that need to be made
in the human and physical environment in
order to facilitate relearning of skills
 Cognitive awareness: Aware of deficiencies
 COMPENSATORY TECHNIQUES
• Use simple directions
• Establish and carry out a routine
• Do each activity in a consistent manner
• Employ repetition as much as necessary
 COGNITIVE REHABILITATION
• Focuses on training individuals with brain
injury to structure and organize information
• Addresses memory, high language disorders
and perceptual dysfunction under one
umbrella
 COGNITIVE REHABILITATION..
 Therapist is concerned on
 Patient’s perceptual style
Perceptual strategy
Response to different types of cues
Rate and consistency of task performance
 COGNITIVE REHABILITATION..
• DYNAMIC
INTERACTIONAL
MODEL OF COGNITION
• Dynamic interplay
between
1. Characteristics of the
patient
2. Characteristics of the
task
3. Characteristic of the
environment in which it is
performed
 Characterisitcs of Patient
• Information processing strategy
• Metacognition(including awareness of one’s
own performance)
• Prior experiences, attitudes and emotions
 Task Variables
• Nature of the task
• Familiarity of the task
• Spatial arrangements
• Instruction set
• Movement and postural requirements
 Environmental Variables
• Social and cultural environment in which
treatment occurs
• Physical context
 Cognitive Approach-Tx Strategy
• Use of multiple environments in which to carry out
the training activity to enhance transfer of learning
• Analysing the characteristics of the task to establish
criteria to determine if transfore of learning in fact
took place
• Providing training to make the patient aware of
abilities, the level of difficulty of the task, and
promote self-assessment of performance
• Relating new information or skills to previously
learned ones
 Neistadt
• REMEDIAL- Sensory Integrative approach,
Neurodevelopmental approach,Transfer of
training approach,Cognitive Retraining Model
• ADAPTIVE-Functional approach is both
adaptive and remedial
 EDUCATION
• Education of patient, family and friends is
essential to let them know as to why it is
inadvisable or impossible for the patient to do
some things safely or independently and why
other things must be done in a specific way
• Feedback is essential in patient’s own
education as his own feedback may be
inaccurate owing to perceptual and cognitive
dysfunctions
 FEEDBACK
• KNOWLEDGE OF RESULTS(KR)
• Information regarding whether or not the
patient attained the correct outcome.
• KNOWLEDGE OF PERFORMANCE
• Information regarding the manner in which
the task was accomplished
 STAGES OF HEALING FOR
CAREGIVERS/FAMILY
• Stage1:Acceptance-Stupid and helpless
• Stage2: Bargaining-see for alternate to gain power over
sense of helplessness
• Stage 3: Struck in perspective(Withdrawal,overeating,anger)
• Stage 4: Reclaiming power- Understanding that these
emotions are not workable or desirable.
• Stage 5: Merging with the illusion-Relate to facts in a
powerful way
• Stage 6: Active steps to prepare for the resolution of
emotions connected with the process
 STAGES OF HEALING FOR CAREGIVERS/FAMILY

• Stage 7: Physical or emotional discharge

• Stage 8: Family and caregivers begin to look for ways to
make things work more easily
• Stage 9: Caregivers relate to the energy of the universe
and begin to see the connections to all life around
them
• Stage 10: Time to connect with the creative force of
the universe
• Stage 11: People live day to day without being attached
to the situation
 ROLE OF PT
• In hospital setting, PT is often the first member of
the rehabilitation team to see a patient with brain
injury
• An understanding of cognitive and perceptual
dysfunction may go a long way toward alleviating
much of the potential frustration that often
accompanies treatment of a patient with brain
damage, most of which is the result of inappropriate
expectations on the part of the therapist,the patient,
and the family.