test 2 - Right Hemisphere Syndrome - ch 8

Checklist of Everyday Neglect Behaviors

1. Does the patient show difficulties when: talking or communicating with others 2. Does the patient neglect the left/right side of personal space? 3. Does the patient show difficulties in eating? 4. Does the patient show difficulties in grooming (self-care skills, washing, bathing, etc) 5. Does the patient show difficulties in dressing? 6. Does the patient show difficulties in body movement transferring (from a bed to W/C,etc)? 7. Does the patient show difficulties in locomotion 1 (the patient collides against objects and wall on the affected side. The patient can not negotiate a W/C between doors, curbs, etc.)? 8. Does the patient show difficulties in locomotion 2 (the patient turns toward the direction of the affected side.) 9. Does the patient show difficulties during PT exercise? 10. Does the patient show difficulties during OT excercise?

Anosognosia

A condition in which a person with an illness seems unaware of the existence of his or her illness. Denial of illness 3 Levels of denial Acknowledge disability but unconcerned about them; failure to notice and use (mild) Acknowledge disability but underestimate deficits and minimize the effects (moderate) Reject the presence of major disabilities (paralysis, sensory loss, visual blindness, hemiplegia) or ownership of limbs (severe) IMPORTANT TO CLINICAL OUTCOMEE

RH prosodic Impairments

Aprosodia Auditory Affective Agnosia Dysprosody

Treatment of Attention

Arousal and Vigilance Sustained Attention Selective Attention Divided Attention Computerized Approaches APT Sustained Attention Yes/No questions Simple math problems Sorting Letter cancellation Solving mazes Selective Attention Response to auditory sequences Alternating Attention Shift responses during task Divided Attention Dual tasks

Attentional Deficits in RHD

Assumptions about attention The brains capacity to represent events is limited Attention protects the brains limited capacity through attentional selection and habituation Attention is a limited resource Various forms of processing require different degrees of attention Attention is unitary/attention is supervisory

____are the heart of communication problems associated with RHD

Discourse deficits

Dysprosody

Dysprosody - similar disorder caused by left hemisphere lesions - motor speech disorders

allocentric neglect

Ignoring all left sides of every object

Characteristics of Right Hemisphere Syndrome

Left visual neglect not a visual problem - most of them it's attentional issues no eye contact with someone on left - bad for pragmatics cant tell when they start or stop talking effectively Difficulty with facial recognition Poor awareness of deficits many times they still drive Poor self-monitoring inappropriate close proximity to you Impulsive behavior Poor initiation and motivation hard to tease out initiation and motivation Disorientation Impaired attention/memory Difficulty with organization and reasoning/problem - solving Difficulty with social aspects of language Difficulty understanding humor Difficulty with word retrieval Monotone and flat affect

Causes of Neglect

Lesions of the right hemisphere most common cause Damage involving the right inferior-parietal lobe or nearby temporo- parietal junction May be caused by lesions of inferior frontal lobe and lesions in the posterior cerebral artery

Predictors of Recovery RHD

Little is known about predictors of recovery Recovery data is more available for deficits such as neglect than cognitive communicative disorders ellis thinks recovery is poor

Treatment of Discourse Deficits

Management of narrative and conversational discourse Inference generation Informative content Alternative meanings and revision Management of social disconnection

Right Hemisphere Deficits

Pragmatic Deficits Discourse Deficits

tests for Assessing Pragmatics

Pragmatic Protocol Profile of Communicative Appropriateness Discourse Abilities Profile

Pragmatic Deficits in RHD

Turn-taking Topic maintenance Eye contact Interjection of irrelevant, tangential, or inappropriate comments Generally insensitive to rules of conversation

Sensorimotor Deficits

Visuosensory Deficits Hemianopia Hemisensory Deficits Hemiplegia Hypokinesia

you might see ___ in a patients chart who has right hemisphere disorder

anosognosia left neglect agnosia prosopagnosia initation problems social pragmatic issues Cognitive communication disorder

more severe H to have stroke in

left worse outcomes and more severe

does everyone with. RH stroke have Right Hemisphere Syndrome

no more than 50%

Agnosia

the inability to recognize familiar objects. inability to process sensory information Loss of ability to recognize objects, persons, sounds, shapes or smells while the specific sense is not defective nor is there any significant memory loss Auditory Visual Tactile

Right Hemisphere Syndrome

> 50% of individuals experiencing a right hemisphere stroke will exhibit characteristics of right hemisphere disorders resulting in communication issues that lead to inadequate or inappropriate social interactions

Indifference and Denial in RHD

Can be major obstacle in treatment Usually diminish with neurologic recovery Most clients are willing to participate but passively rather than actively Treatment should be delayed in patients who remain uncritical or unconcerned about poor performance

Treatment of Neglect

Compensation Verbal Cues Visual and Tactile Cues Anchors Restructuring the environment Facilitation Pharmocological Vestibular Stimulation Behavioral Treatments Left Limb Stimulation

Treatment of Pragmatics

Discuss language pragmatics with client Jointly view talk shows, movies, videotapes Videotape client Community Practice Eye Contact Conversation turn taking Conversational topic maintenance

expression deficits in RHD

Expression Poor macrostructure Reduced informative content Reduced flexibility Reduced specificity Reduced ability to generate alternatives Reduced conversation structure Excessive speech output Unelaborated speech output

Left Hemispatial Neglect

Failure to respond to information presented on the side opposite (contralateral) to their brain lesion Estimates 31%-66% RHD 2%-15% in LHD Neglect is not a visouspatial problem but an attentional problem

Aprosodia

Impairment of speech prosody Inability to either produce or comprehend the affective components of speech (emotional tone) Caused by lesions of the right perisylvian region Expressive aprosodia characterized by "flat speech" right anterior lesions Receptive aprosodia right posterior lesions

Burns Inventory of Communication and Cognition

Individuals ages 18-80 who have communication or cognitive deficits as a result of a neurological injury. Administered in 30 minutes Three sections - scanning and tracking, visuospatial skills, prosody and abstract language

Subtypes of left hemispatial neglect

Left "allocentric" neglect (errors on the left sides of individual stimuli, regardless of location with respect to the viewer was most strongly associated with right superior temporal gyrus Left "egocentric" neglect (errors on the left of the viewer) was most strongly associated with right angular gyrus

Test of Everyday Attention

Map search - Subjects have to search for symbols on a coloured map. The score is the number out of 80 found in 2 minutes. This subtest is age-sensitive and usable with almost all brain-damaged patients, including those with Alzheimer's disease. It measures selective attention and loads on the same factor as the Stroop Test and the d2 cancellation test. Elevator counting - Subjects are asked to pretend they are in an elevator whose door-indicator is not functioning. They therefore have to establish which 'door' they have arrived at by counting a series of tape-presented tones. This is an established measure of sustained attention sensitive to right frontal lesions. listening to sounds to determine what floor theyre on - up sounds vs down sounds Elevator counting with distraction - Subjects have to count the low tones in the pretend elevator while ignoring the high tones. This was designed as a subtest of auditory selective attention. Visual elevator - Here, subjects have to count up and down as they follow a series of visually presented 'doors' in the elevator. This reversal task is a measure of attentional switching, and hence of cognitive flexibility. It is self-paced and loads on the same factor as the number of categories on the Wisconsin Card Sorting Test. Auditory elevator with reversal - The same as the visual elevator subtest except that it is presented at fixed speed on tape. Telephone search - Subjects must look for key symbols while searching entries in a simulated classified telephone directory. Telephone search dual task - Subject must again search in the directory while simultaneously counting strings of tones presented by a tape recorder. The combined performance on sub-tests 6 and 7 gives a measure of divided attention - a 'dual task decrement'.

3 Formal Tests of RHD

Mini Inventory of Right Brain Injury (MIRBI) The Rehabilitation Institute of Chicago Clinical Management of Right Hemisphere Dysfunction (RICE) Burns Inventory of Communication and Cognition

left hemisphere strokes are:

More common than RHSs More severe More often have a poorer outcome, principally due to the higher incidence of large-vessel ischemic strokes in the territory of the left middle cerebral artery.

Treatment Outcome Factors

Nature and severity of deficits Time post onset Personality Patient goals Premorbid cognitive strengths and weaknesses Indifference and Denial

Theories of Neglect - attentional theories

Neglect is the result of abnormalities in the distribution of attention When attention is cued to the contralesional side, neglect is almost reduced individuals have difficulty directing attention to the neglected space

Bookness

Patient opens a book and traces its perimeter Reading tasks printed in the book are administered Match stimuli on right and left side of book Perimeter of the book should be traced before each trial

Treatment of Problem Solving and Reasoning

Patients tend to get lost in the details Structure Approach I.D. the problem Think of several possible solutions Evaluate the feasibility and potential consequences of each solution Choose the best solution Apply it Evaluate the results

Mini-Inventory of Right Brain Injury (MIRBI-2)

Provides severity index and deficit profile for clients ages 20 through 80. Designed for SLP, OT, PT Provides a deficit profile based on underlying disorders of processing. Tests clients: attention ability to explain incongruities absurdities figurative language and similarities affective language, emotions and affect processing understanding humor praxis expressive ability

Assessing Attention

Published Measures Test of Everyday Attention The Stroop Test Trail Making Test Informal Measures Arousal Vigilance and Sustained Attention Selective Attention Alternating Attention

Priming attention in left hemispace

Purposeful movements such as tracing the border of the workspace treatment for left neglect

is visual neglect more prevalent in RHD or LHD

RHD Neglect is most often observed after stroke and affects approximately two thirds of right hemisphere stroke patients. Patients with neglect fail to be aware of or acknowledge items on their contralesional side and attend instead to items towards the same side as their brain damage—their ipsilesional side. Their neglect may be so profound that they are unaware of large objects, or even people, in extrapersonal space. Some patients fail to use their contralesional limbs even if they have little or no weakness. many have anosognosia Persisting neglect is a poor prognostic indication for independence after stroke.

Generalization in RHD

RHD tend not to spontaneously generalize from one context to another Gains in the clinic may be limited by the patients failure to apply learned behaviors to daily life interactions Important to create treatment hierarchy with small steps Train responses across a variety of tasks and contexts Incorporate aspects of the target environment into treatment Involve RHD adults family members, friends, and caregivers

Discourse Deficits in RHD

Reduced ability to generate inferences Reduced ability to comprehend and produce main concepts and central themes Reduced level of informative content Reduced ability to manage alternative meanings Reduced sensitivity to communicative content

comprehensive deficits in RHD

Reduced sensitivity to: Gist of narratives (spoken & written) Intended/implied meaning New info. or revision of old info Emotional content Paralinguistic information Conversation rule and conventions Communicative setting; purpose, and role of the participants

Edgeness

Requires the use of a work space with a raised border Patient becomes familiar with spatial boundaries by tracing the perimeter (edge) with one finger Colored cubes are placed on the work space Patient is told how many cubes are present Patient is instructed to find and remove cubes Patient is not told where to look but is encouraged to keep looking until all cubes are found Technique should be applied to other tasks as skills improve

Treatment Approaches: task vs process oriented

Task Oriented Approaches Improve performance on specific activity Balancing a checkbook reading a menu using the phone preparing a document for work Using a calculator or copy machine (harder to generalize) Process Oriented Approaches Address impairment vs disabilities and focus on underlying cause vs symptoms

Theories of Neglect - Representational Theories

The representation of space and spatial relations is mapped topographically across hemispheres Contralateral half of these mental representations is under-represented in patients with neglect NEGLECT CAUSE BY DISTURBED INTERNAL REPRESENTATION OF SPACE

why might someone with RHD have problems with comprehension

They exhibit impairments in the ability to integrate and interpret incoming information may also be impaired, leading to difficulties with some aspects of comprehension" attention

Nonstandardized Assessment Procedures

Visual scanning and visual inattention Activities of daily living skills Visual integration (.face recognition, visual assembly, figure-ground discrimination, copying geometric shapes) Higher cognitive and perceptual functions (inferencing, problem solving/reasoning) Linguistic and cognitive flexibility (analogies, generative naming or word fluency) reading writing line cancellation line bisection

patients with RHD appear

disinterested and insensitive communication partners, who may take little account of social communication conventions, perhaps interrupting and failing to make eye contact, or alternatively as a verbose, rambling communicator whose discourse shows tangential associations They exhibit impairments in the ability to integrate and interpret incoming information may also be impaired, leading to difficulties with some aspects of comprehension" Prosodic, affective and cognitive impairments, including denial, attention deficit and neglect, may accompany and contribute to the communication disorder

what tasks can you use to tell if someone has neglect

draw a clock copy this image tell me about this picture make an X in the middle of these lines

are right stroke people homogenous or heterogenous

heterogenous based on Location and extent of lesions Presence and severity of difficulties Other factors that influence communication performance: Age Cognitive ability Educational level Time of lesion Individual response Handedness

Prosopagnosia

inability to recognize faces No loss of knowledge of the person

most common stroke

ischemic

why is the left hemispace more prone to neglect?

it is only supported by the RH the right hemispace is supported by LH and RH right hemisphere attends to both sides left hemisphere only attends to right

egocentric neglect

lack of perception of stimuli to the left of the patient's own body whole left side

are most strokes in the left H or right H

left

Active left limb movements in left hemispace

treatment for left neglect Increased activation of the right hemisphere Visual cueing to left hemispace Motor cuing to left hemispace

t/f Every year, more than 795,000 people in the United States have a stroke. About 610,000 of these are first or new strokes. About 185,00 strokes—nearly one of four—are in people who have had a previous stroke. About 87% of all strokes are ischemic strokes, when blood flow to the brain is blocked.

true

t/f Few data for any given therapy approach with RHD

true We know less about RHD than LHD LHD=focal specific deficits....tend to result in specific linguistic behaviors......predictable results....normal performance better defined .RHD...diffuse effects from focal deficit (CVA)......performance on tests are difficult to predict.....normal performance is difficult to predict LHD...typically targets specific deficits RHD...targets a variety of deficits

do people with RHD have problems with word retieval

yes

Stroop test example

• Stroop Effect: the color naming/word experiment • Automatic processes vs. conscious processes Name the COLOR (not what the word says).