Transcript Altered Awareness Syndromes

Altered Awareness Syndromes
Theoretical Basis, Diagnosis,
Rehabilitation, Consequences
HENRY H. STONNINGTON
The five factors influencing an outcome of
Functional Autonomy
Perceptual Factor
Cognitive Factor
Motor Factor (upper extremity)
Motor Factor (balance)
Significant other(s)
Reason Perceptual (awareness)
factor is vital in rehab outcome
Impaired awareness significantly complicates
the rehab process. These patients
consistently underestimate their
impairments, when compared to family
members’, clinicians’ ratings, and their
performance in neuropsychological tests.
Disorders of self awareness
The perceptual Factors
Theoretical Basis
Theoretical Implications (1)
Mersulam 1985
Primary motor and Sensory Cortex respond
to one type of stimulus (idiotypic)
Rest of Cortex “association”
1. “unimodel” – modality specific –
association area
2. “heteromodel” – high order-association
area
Theoretical Implication (2)
Heteromodel Association area
Frontal lobe, pre-frontal, inferior parietal lobule,
superior marginal gyrus, angular gyrus
Interface Information
External World
Sensorimotor cortex
Interior World
Paralimbic areas
Theoretical Implications (3)
“Syndromes” of impaired awareness
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Pre-Frontal: Social judgment, anticipate change,
inappropriate social behavior and comments
Inferior Parietal Lobe: self-awareness of body, self
image, anosognosia
Superior marginal+angular gyrus+superior
temporal lobe: self perception of linguistic output,
visual, auditory, memory impairments,
misinterpretations leading to paranoid thinking
Theoretical Implications (4)
Involvement of Basal Ganglia
 Particularly the Putamen, Posterior limb of
Internal Capsule, Pulvinar of Thalamus, but
also Lentiform and Caudate nuclei.
 The frontostriato-pallido-thalamo-frontal
neuronal circuit involving the
heteromodel association areas
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ANOSOGNOSIA
The inability to be aware of the severity of
impairments, believing that everything is
intact.
This “Unawareness of Impairment” is a
Cognitive / Behavioral phenomenon, with a
variety of syndromes, related to damage of
various heteromodel brain areas, for example:
Inferior parietal lobule: Unawareness of
hemiplegia, Angular gyrus: aphasic syndromes:
unaware of impaired language output.
Complete and Incomplete
Anosognosia syndromes
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Bilateral Cerebral dysfunction in the
Heteromodel regions will result in complete
syndrome.
Unilateral Cerebral dysfunction will result in
partial syndromes.
After unilateral stroke, bilateral dysfunction
may be present for short time, and as the
bilateral phenomenon clears, the complete
anosognosia resolves into incomplete residual
unawareness syndromes.
NEGLECT
This is different from anosognosia, but
sometimes both can be present. If both are
present then patient is unaware of, for
example, hemineglect
 Neglect can be diagnosed particularly with
“double sensory stimulation”, touching both
arms at the same time, testing both visual
fields simultaneously.
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Particular Unawareness
Syndromes
Complete Anosognosia
In patient with hemiplegia (particularly left
hemiplegia, but can occur in right hemiplegia):
Denies that hemiplegic side belongs to him/her, says
“ Ah that’s Jimmy” or “ that belongs to the guy in
the next bed.”
That absolute unawareness usually improves as it
becomes a partial unawareness syndrome
Linguistic Unawareness
Syndromes
Aprosodia
 Unawareness of language error, inability to
self monitor.
 Jargon, Wernicke’s aphasia, a fluent aphasia
characterized by marked auditory
comprehension deficits, babbling with
incomprehensive words very fluently.
 Reality monitoring: confabulation.
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Anton’s syndrome
Unable to demonstrate sight: cannot count
fingers, discriminate shapes, objects,colors
 Pupils react to light
 Denies any visual difficulty, confabulates,
guesses, makes excuses for errors.
 Visual hallucinations
 Lesion involves bilateral calcerine cortex,
as well as other heteromodel areas.
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Diagnostics
Methods of measuring selfawareness and neglect at
the bedside.
Physical Examination
History: denials
 Observing behavior and denials
 Signs: Double sensory stimulation for
sensation and visual fields, differentiation
from homonymous hemianopia,
 testing denials,
 Other bed-side tests:
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Draw a clock with numbers and
hands
Cancel all E’s and I’s
(keep paper straight and quantify misses)
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COPY DIAGRAMS
THREE DIMENSIONAL
DESIGNS
Have photograph of blocks
And ask patient to copy that design with
actual blocks
One way of finding Constructional Apraxia
If present it will indicate possible difficulties
with dressing and other ADLs
Skilled Professional Tests
Visual discrimination, figure ground, visual
memory, visual synthesis & consistency,
 Bells test, a more refined cancellation test,
Benton test, Rey complex figure test,
 Occupational Therapy perceptual evaluation
battery
 Aphasia screening test-Halstead-Reitan
neuropsychological test battery
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Behavioral tests for visual
neglect
Picture scanning,
Telephone dialing,
Menu reading,
Article reading,
Time reading,
Coin sorting,
Sentence copying,
Map navigating,
Card sorting.
Levels of Awareness
Complete Anosognosia
 Intellectual Awareness: understanding
having difficulty in one specific activity
 Emergent Awareness: understanding
having difficulty in many circumstances
 Anticipatory Awareness: understanding
implication of deficit.
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Management
Rehabilitative Therapies
Strategies
Remediation Strategies
Strategies used to regain abilities
Compensatory Strategies
Strategies used to substitute for lost skills
Mobility&Neglect Remediation
Positioning of furniture,
 Early correct positioning, and handling,
 Controlled transfers, standing up, walking
without use of cane or any device.
 Lateral transfers over affected hand, looking
to affected side, lateral transfer kneeling,
always controlled by therapists and nurses,
and involving families in techniques.
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Rehab of neglect, mobility, loss
of awareness
Restraining normal side techniques
 Full “old fashioned” ProprioceptiveNeuromuscular-Facilitation technique of
Kabat/Knott/Voss, ie using a lot of oral and
sensory (touching) stimulation
 Use of pressure (air splints), taping
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Motor Memory
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The reason Proprioceptive Neuromuscular
Facilitation technique is important is:
Memory and Learning involves two systems:
Explicit and Implicit.
Explicit means facts, while Implicit (abstract?)
involves Perceptual-motor processes. PNF
provides Explicit information, attenuating
Implicit learning deficits.
Kinetic Chain
“Closed Kinetic Chain” exercises have
become popular in Sport and
Musculoskeletal rehabilitation methodology
particularly using external loads. Studies
have shown this to work.
It also can be applied to stroke rehabilitation
as it follows the same principles as PNF.
BEWARE
Although loss of awareness and neglect are
most obvious (if looked for) in patients with
Left Hemiplegia, it must also be always
looked for in Patients with Right
Hemiplegia, where it is not uncommon.
It always needs to be looked for in all patients
who have Brain Injuries or diseases such as
brain tumors.
Visual Cognition
Visual Memory
Pattern Recognition
Scanning
Attention
Oculomotor Control Visual Fields Visual Acuity
Neuro-Rehabilitative Optometry
Neuro-optometric rehabilitation is an
individualized treatment regimen for
visual deficits resulting from physical
disabilities, traumatic brain injuries and
other neurological insults.
Identifying neurological, binocular, motor,
perceptual problems, and followed with
Orthoptics /Vision Therapies.
Neuro-Optometric Therapy
The Rehabilitation of
Visual / Perceptual / Motor Disorders:
Acquired strabismus, diplopia, binocular
dysfunction, convergence and/or
accommodative paresis/paralysis,
oculomotor, visual-spatial dysfunction,
visual perceptual, cognitive deficits,
Visual field loss, Visual neglect, denial
Neuro-Rehabilitative Optometry 2
Visual Motor Therapy
 Visual Perceptual therapy to allow
relearning eye-hand coordination
providing perceptual information of
object size, texture, location, visual
discrimination
 Neglect/Homonymous hemianopia differ
 LATER: Prism, Lenses, Occlusion
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Remediation of Spatial deficits
Searching for increasingly complex arrays
of visual details (figure ground),
 Assemble three dimensional figures
working through progressive levels of
complexity (constructional apraxia),
 To improve perception of body schema:
name, identify and move neglected body
part.
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Remediation of Visual Spatial Deficits.
Interactive 3-D software (action games,
navigation simulators),
 In a LEFT hemiplegia, stimulation with
TENS, vibration on the LEFT side of neck,
and hand as well as pressure and movement
appears to activate the contra lateral right
hemisphere.
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Educating family in Visual-Spatial impairments
Caretakers are often torn between whether to believe
the treatment team or the patient regarding
contradictory appraisal of abilities
Patient asserts the treatment team is “making a big
deal out of nothing”, rallying support of family.
Lack of concern of deficits and unawareness of
deficits will have profound impact on driving,
recreational and vocational pursuits and giving
responsibilities to patient.
Caretakers
It must always be remembered that the counseling
and proper management of the caretakers is as
much the task of the rehabilitation team, as is the
patient/client.
There must be early involvement of the caretakers as
well as those involved in the community
reintegration, such as vocational therapists, and
the use of Supportive Employment.
CONSEQUENCES
LONG TERM OUTCOME
Eventual Outcome
“Impaired self-awareness reflects a clear
disruption of the integration of thinking and
feeling” (Prigatano)
 Blame others, become paranoid, and
therapists can precipitate a clinical crisis.
 There is a positive association between
accurate self-awareness and favorable
employment outcome ( Sherer ).
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Further Vocational Facts
30% of patients after a Traumatic Brain Injury
resume reasonably productive lifestyles 2 to 4
years after injury.
Only 10% remain productive in a 10 – 15 year
follow-up.
It may well be that this is due to loss of self
awareness syndromes, as suggested in the Sherer
research studies, but more research is necessary
Do we know?
Prigatano hypothesized that there may be a
possibility that the neural substrate for selfawareness may be the same as the neural
substrate for other complex integrative
functions that are needed for successful
employment outcome.
As always in Rehabilitation more research is
needed.
REFERNCES (1)
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Prigatano GP, Disturbances of self-awareness of
deficit after traumatic brain injury. IN: Prigatano
GP., Schacter DT, eds: Awareness of deficits after
brain injury: Clinical and Theoretical Issues, New
York N.Y., Oxford University Press,1991
Prigatano GP: Disorders of self awareness after
brain injury, IN: Principles of Neuropsychological
Rehabilitation: New York, Oxford, Oxford
University Press, 1999
Mersulam MM: Principles of Behavioral
Psychology. F.A. Davis, Philadelphia, 1985
REFERNCES (2)
Shaw J. The assessment of Rehabilitation of
Visual-Spatial Disorders. IN: Johnstone B.,
Stonnington HH, eds: Rehabilitation of
Neuropsychological Disorders: Psychology
Press, Philadelphia, PA, 2001
 Sherer M. et al: Impaired awareness and
Employment Outcome after TBI: J. Head
Trauma Rehabilitation, 1998: 13(5) 52-61
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