Perception Dysfunction

Spatial Relations Disorders

(Complex Perception)
Spatial Relations Disorders
(Complex Perception)
Impairments that have in common a
difficulty in perceiving the relationship
between the self and two or more objects.
Right parietal lobe plays a primary role in
space perception
Occurs in patients with right-sided lesions
with resulting left hemiparesis
Spatial Relations Disorders

Figure–ground discrimination
Form discrimination
Spatial relations
Position in space
Topographical disorientation
Depth and distance perception
Vertical disorientation
Figure–Ground Discrimination
 Inability
to visually distinguish a figure from the
background in which it is embedded

 Clinical Examples- The patient cannot locate items in

a pocketbook or drawer, locate buttons on a shirt,
distinguish the armhole from the remainder of a solid-
colored shirt. The patient may not be able to tell when
one step ends and another begins on a flight of stairs,
especially when descending

 Lesion Areas- Parieto-occipital lesions of the right

hemisphere and less frequently the left hemisphere
Figure–Ground Discrimination
Figure–Ground Discrimination
 Testing-

a. The Ayres Figure–Ground Test (subtest of the Southern

California Sensory Integration Tests) requires the subject to
distinguish the three objects in an embedded test picture, from a
possible selection of six items.

Other similar tests- show the patient overlapping line drawings of

everyday objects and ask to name these

b. Function-based Tests.- Place a white towel on a white sheet and

ask to find the towel, ask to point out the sleeve, buttons, and collar
of a white shirt, or to pick out a spoon from an unsorted array of
eating utensils.
(rule out poor eyesight, hemianopia, visual agnosia, and poor
comprehension)
Figure–Ground Discrimination
Treatment-

a) Remedial Approach- practice in visually

locating objects in a simple array (such as
three very different objects), and progress
to more difficult ones (four or five
dissimilar objects and three similar ones).

b) Compensatory Approach- to use other,

intact senses (e.g., touch) when searching
for items
Form Discrimination
Inabilityto perceive or attend to subtle
differences in form and shape

Clinical Examples- may confuse a pen with a

toothbrush, a vase with a water pitcher, a cane
with a crutch

Lesion Area- parieto- temporo occipital

region (posterior association areas) of the non
dominant lobe
Form Discrimination
Testing-
Ask to identify a number of items similar
in shape and different in size presented in
different positions (upside down) e. g.
pencil, pen, straw, toothbrush (rule out
visual agnosia)
Form Discrimination
Treatment-
Remedial Approach- The patient should
practice describing, identifying, and
demonstrating the use of similarly shaped and
sized objects, should sort like objects

Compensatory Approach- If the patient can

read, frequently used and confused objects
can be labeled, encourage to use vision,
touch, and self-verbalization in combination
Spatial Relations
 Inabilityto perceive the relationship of one object in space
to another object, or to oneself
 May lead to, or compound, problems in constructional
tasks and dressing

 Clinical Examples- difficulty placing the cutlery, plate,

and spoon in the proper position when setting the table;
unable to tell the time from a clock; difficulty learning to
position his or her arms, legs, and trunk in relation to the
wheelchair to prepare for transferring

 Lesion Area- inferior parietal lobe or parieto-occipital-

temporal junction
Spatial Relations
Testing-
Rivermead Perceptual Assessment Battery
(RPAB)79 and the Arnadottir OT-ADL
Neurobehavioural Evaluation (A-ONE)
(Rule out unilateral neglect and
hemianopia)
Spatial Relations
 Treatment-

a) Remedial Approach- instruct to position himself/herself

in relation to the therapist or another object (“Sit next to
me,” “Go behind the table,” or “Step over the line.”)

b) Set up a maze of furniture (obstacle course), ask to

copy block or matchstick designs

c) If the patient avoids crossing the midline- PNF chop

patterns e.g. have the patient hold a dowel in front with
both hands (Progression: therapist guidance- verbal and
visual cues- doing it independently)
Position in Space
Inability to perceive and to interpret spatial
concepts such as up, down, under, over, in, out,
in front of, and behind

Clinical Examples- ask to raise the arm “above”

the head during ROM activities or is ask to
place the feet “on” the footrests, the patient may
behave as if he or she does not know what to do

Lesion Area- non dominant parietal lobe

Position in Space
 Testing-

a) Two objects are used, such as a shoe and a shoebox.

The patient is asked to place the shoe in different
positions in relation to the shoebox; e. g. in the box, on
top of the box, or next to the box

b) Copy the therapist’s manipulations- The therapist then

takes an identical set and places them in a particular
relationship to each other, such as the comb on top of
the brush. The patient is requested to arrange his or her
comb and brush in the same way (Figure–ground
difficulty, apraxia, incoordination, and lack of
comprehension)
Position in Space
Treatment-
Retraining approach- 3 or 4 identical
objects are placed in the same orientation
(wrist weights, combs, mugs, and so
forth). An additional object is placed in a
different orientation. The patient is asked
to identify the odd one, and then to place
it in the same orientation as the other
objects
Topographical Disorientation
 Difficulty in understanding and remembering the
relationship of one location to another

 Clinical examples- cannot find the way from his/her

room to the physical therapy clinic, cannot describe
the spatial characteristics of familiar surroundings,
(the layout of his or her bedroom at home)

 Lesion areas- right retrosplenial cortex, with

Brodmann’s area 30 compromised in most patients,
bilateral parietal lesions, and more rarely, left-side
parietal lesions
Topographical Disorientation
Testing-
ask to describe or to draw a familiar route,
such as the block on which he or she
lives, the layout of his or her house, or a
major neighborhood intersection (Rule
out memory problems)
Topographical Disorientation
 Treatment- usually resolves 8 weeks after onset
a) Remedial Approach. The patient practices going from
one place to another, following verbal instructions
(progression- simple route to complex one)

b) Compensatory Approach- Frequently traveled routes can

be marked with colored dots. The spaces between the
dots are gradually increased and eventually eliminated as
improvement takes place. In this instance we take the
spatial task of remembering routes (right hemisphere
task) and substitute sequential landmarks (sequencing is
typically a left hemisphere strength) to accomplish the
goal of getting from place to place.
Depth and Distance Perception
Inaccurate judgment of direction, distance, and
depth

Clinical Examples-
a) Difficulty navigating stairs
b) may miss the chair when attempting to sit
c) may continue pouring juice once a glass is filled

Lesion area- posterior right hemisphere in the

superior visual association cortices, may be evident
with right-sided or bilateral lesions
Depth and Distance Perception
Testing-

a) Functional test for distance perception-

ask to take or to grasp an object that has been
placed on a table or in front of the patient or
in the air, patient will overshoot or
undershoot. (Rule out coordination deficit)

b) Functional test for depth- can be asked to fill

a glass of water, patient may continue to
pour once it is filled
Depth and Distance Perception
 Treatment-

Emphasis- walking carefully on uneven surfaces

(e.g. stairs)

a) Remedial Approach- place the feet on designated

spots during gait training; blocks can be arranged
in piles 2 to 8 in (5 to 8 cm) high, ask to touch the
top of the piles with the foot

b) Compensatory Approach- the patient can hold the

armrests of a chair to assist with sitting squarely
Vertical Disorientation
Distorted perception of what is vertical.
It can contribute to disturbance of motor
performance (Gait or posture)
Not associated with or affected by the presence of
homonymous hemianopia

Clinical Example.- A person with distorted

verticality views the world differently and this may
affect upright posture

Lesion Area- Non dominant parietal lobe

Vertical Disorientation
Vertical Disorientation
Testing-
a) The therapist holds a cane vertically and
then turns it sideways to a horizontal
plane.
b) The patient is asked to turn it back to the
original position.
c) Positive test- the cane will most likely be
placed at an angle
Vertical Disorientation
Treatment-
The patient should be instructed to
compensate by using touch (tactile cues)
for proper self-orientation, especially
when going through doorways, in and out
of elevators, and on the stairs.
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