OPTA 204( Body Scheme Disorders and Neglect)
What is body Scheme?
“An unconscious automated system that is required for environmental exploration through movements and static posture.”
- Relates to someone’s idea of their own body
- Someone’s idea of bodies in general
- Looks at the idea of one’s own body image
Body Scheme Includes
- Knowledge of body parts and function
- Information about body position and changes that occur in movement relative to other positions
- Motor representation
Intact body scheme is the foundation that allows for understanding of the body in space
- Allows for appropriate movements
- Interaction with environment
- Assists with perception of environment
Areas of the brain responsible for Body Scheme
Parietal cortex
Cerebellum
Note: impairment of body scheme can occur in a variety of forms. So someone might only have difficulty with their own personal body scheme but not with individual body schemes in general or not with other people’s body parts
Autotpagnosia
- Failure to recognize one’s body parts and their relationship to each other
- Might confuse sides of the body
- Might not be able to tell if body part is their own or the examiner’s
- Might have difficulty using both sides of body
Testing for Autopagnosia
Ask client to identify a body part on themself or on a doll or drawing or ask the person spatial questions
-“Touch your left leg”
-“Show me your _____ arm”
-“Are your feet above or below your knees?”
-“Is your shoulder between your neck and your elbow?”
Have client draw a person with all main body parts
-Did they draw two arms and two legs?
-Are the body parts somewhat proportional?
Treatment for Autopagnosia
Restorative approach:
- Tactile stimulus: Rub part of body with different textures
- Practice identifying body parts as named by TA
- Use both sides of body for an activity
Adaptive approach:
- Educate client and family on deficits
-Educate client and family on how to assist with ADLs etc.
- Be specific with directions: “use your right hand to pick up your cup”
Neglect
- AKA left neglect or Unilateral Spatial Neglect
- “The inability to integrate and use perceptions from one side of the body.” Most commonly occurs on left side of body.
- unaware that they are not attending to the affected side where as visual feild cut aware they aren't seeing one side and would compensate by moving head
Unilateral Neglect
Neglect can occur in various forms and severities
- Personal neglect
- Near extra personal neglect
- Far extra personal neglect
Note: It can be termed unilateral body neglect- this would be a body scheme disorder. If it only affects extra personal space, it would not fall within the category of a body scheme disorder.
testing for neglect
- Clock drawing
- House drawing
- H-cancellation
- Bedside Screen: Extinction
neglect treatment
Adaptive approach:
- Verbal cueing
- Client and family education and assistance with ADLs
- Teach self monitoring: have I shaved both sides of my face?
Neglect Etiology and Epidemiology
- Brain injury, stroke , neoplasia, aneurysms.
- left hemisperic stroke 54% right hemisperic 43%
- 65 years of age
Spatial neglect can affect the following aspects of spatial processing:
- Perception-attention neglect: People with neglect having no disorder of sensation may still fail to perceive events on the neglected side.
- Motor intentional aiming deficits: Patients may exhibit difficulty in initiating or performing movements on the contralesional side even when the motor system of the neglected side is intact.
- Representational neglect: Also known as imagery neglect, first reported in an experiment by Bisiach and Luzzatti in 1978. In this scenario, the patient will have a defective left-sided internal mapping of scenes or objects.
Behavioral changes in Neglect
- The patient may have anosognosia, which is the unawareness of the deficit.
- Self-neglect: The patient will perform all tasks from the non-neglected right side due to unawareness of his left side of the body, e.g., asymmetric shaving, grooming, etc.
- Anosodiaphoria: this is an unconcerned behavior about the deficit due to emotional dysfunction secondarily to the involvement of the limbic system in the right cerebral hemisphere stroke. Hyperarousal is also observable in neglect disorder.
Signs of neglect
- After the stroke, the bed-ridden patients look away from the right side. The patient in a wheelchair will have difficulty in navigating towards the left side.
- Allochiria: This is an illusory visual phenomenon in which patients with neglect will only respond to stimuli presented to the right side of their body as if it had been to the other side while neglecting the left sided-stimuli. When one approaches such patients from the left side, they respond looking at the right side; a phenomenon also labeled as allesthesia.[12]
- Somatoparaphrenia: The patient develops a delusional belief that the neglected side of the body belongs to someone else.[5] At times, it can cause grave consequences when such patients deny life-threatening conditions, e.g., left-sided chest pain due to myocardial infarction.
- The patient may have peripersonal or extrapersonal neglect, depending on the inability to reach out in the space within the reaching distance or outside that distance.
Treatment for neglect
- Prism Adaptation Treatment: moves healthy side of body wearing binocular optical prisms. role of prisms is to shift the visual image around 11 degrees towards the lesional field.
- limb activation and optokinetic stimulation. patient moves affected limb towards the neglected side after receiving sensory or verbal stimuli. This strategy will analyze spatial motor systems directly and, perception-attention function indirectly.
- medication such as cholinesterase inhibitors such as rivastigmine or donepezil are used as the primary treatment strategy in post-stroke class IIb patients. benzodiazepines, anticholinergic, antidopaminergic, and sedatives/hypnotics because of the reappearance of resolved symptoms in neglect patients or the development of delirium.
Agnosognosia
-Severe form of neglect where a patient does not recognize the severity of their paralysis
Usually transient
How will this affect treatment outcome?
- Ignorance make people not understand why they are doing treatment
- People usually describe paralyzed limb (as in after a stroke) as lazy or tired but do not recognize the severity of injury
- Often this incorporates sensory and cognitive issues with function: Person does not have awareness of deficits