The document discusses various types of visual perception deficits including form discrimination, spatial relations, position in space, topographical disorientation, depth and distance perception, and vertical disorientation. It defines each deficit, provides clinical examples, identifies common lesion areas, and gives suggestions for testing and treatment approaches including remedial and compensatory methods.

2. • Form Discrimination
Definition. Impairment in form discrimination is the inability to
perceive or attend to subtle differences in form and shape. he
patient is likely toconfuseobjects of similar shape or not to recognize
anobject placed in an unusual position.
2. Clinical Examples. The patient may confuse a pen with a
toothbrush, a vase with a water pitcher, a cane with a crutch, and so
forth.

3. Lesion Area. he lesion site is the parieto-temporooccipital
region (posterior association areas) of the nondominant
lobe.
4. Testing. A number of items similar in shape and
different in size are gathered. The patient is asked to
identify them. One set of items might be a pencil,
pen, straw, toothbrush, and watch, and the other
might be a key, paper clip, coins, and ring. Each
object is presented several times in different positions
(e.g., upside down).

4. Treatment Suggestions.
a. Remedial Approach. The patient should practice describing,
identifying, and demonstrating the use of similarly shaped and sized
objects.

5. The patient should sort like objects and should be assisted to focus on
differentiating object cues.
b. Compensatory Approach. The patient must be made aware of the
specific deficit. If the patient can read, frequently used and confused
objects can be labeled. The patient should be encouraged to use vision,
touch, and self-verbalization in combination when objects are
confused.

6. • Spatial Relations
1. Definition. A spatial relations disorder, or spatial disorientation, is
the inability to perceive the relationship of one object in space to
another object o rto oneself. Thismay lead to, or compound,problems
in constructional tasks and dressing. Crossing the midline may be a
problem for patients with spatial relations deficits. Spatial relations
skils are required to manage most ADL.

7. Clinical Examples. The patient might find it difficult to place the
cutlery, plate, and spoon in the proper position when setting the table.
The patient may be unable to tell the time from a clock because of
difficulty in perceiving the relative positions of the hands.
The patient may have difficulty learning to position his or her arms,
legs, and trunk in relation to the wheelchair to prepare for transferring.

8. • Lesion Area. The lesion site is predominantly the inferior parietal lobe
or parieto-occipital-temporal junction, usually of the right side.

9. • Testing. Recommended tests include the Perceptual Assessment
Battery (RPAB) Arnadottir OT-ADL Neurobehavioural Evaluation(A-
ONE).

10. Treatment Suggestions. When using a remedial
approach, patient ability to orient to other objects
can be improved by giving the patient instructions
to position himself or herself in relation to the therapist
or another object. The therapist might say,

11. • “Sitnext to me,” “Go behind the table,” or “Step
Over the line.” In addition, the therapist can set up a
Maze of furniture (obstacle course). Having the patient
copy block or matchstick designs of increasing difficulty will increase
awareness of the relationship

12. ship between one object (block or matchstick) and
the next.
If the patient avoids crossing the midline, activities that require
crossing the midline both motorically and visually can be incorporated
into other therapeutic activities (e.g., proprioceptive
neuromuscularfacilitation [PNF] chop patterns). One specific

13. • activity is to have the patient hold a dowel in front with both hands.
The therapist guides it from

14. • the less involved side to the more involved side. Later, the patient can
progress to manipulating the dowel with only verbal or visual cues,
and finally to guiding it independently.

15. • Position in Space
• 1. Definition. Position in space impairment is the inability to perceive
and to interpret spatial concepts such as up, down, under, over, in,
out, in front of, and behind.

16. • 2. Clinical Examples. If a patient is asked to raise the arm “above”
the head during ROM activities or is asked to place the feet “on” the
foot rests, the patient may behave as if he or she does not know what
to do.

17. Lesion Area. The lesion is usually located in the non-
dominant parietal lobe.

18. • . Testing. To test function, 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; for example, in the box, on top of the
box, or next to the box. Alternatively, the patient is
presented with two objects and asked to describe
their relationship

19. . For example, a toothbrush can be placed in a cup, under a cup, and so
forth, and the patient is then asked to indicate the location of
the toothbrush. Another mode of testing is to have the patient
copy the therapist’s manipulations with an identical set of objects. For
example, the therapist hands the patient a comb and a brush.

20. Treatment Suggestions. If using a retraining approach,
three or four 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.

21. • Topographical Disorientation
• 1. Definition. Topographical disorientation refers to difficulty in
understanding and remembering the relationship of one location to
another.As aresult, the patient is unable to get from one place to
another, with or without a map. This disorder is
frequently seen in conjunction with other difficulties
in spatial relations.

22. Clinical Examples. The patient cannot find the way
from his or her room to the physical therapy clinic,
despite being shown repeatedly. he patient cannot
describe the spatial characteristics of familiar sur-
roundings, such as the layout of his or her bedroom
at home.
3. Lesion Areas. he majority of cases involve damage
to the right retrosplenial cortex, with Brodmann’s

23. area 30 compromised in most patients.
Bilateral parietal lesions, and more rarely, left-side parietal
lesions, can produce this problem.

24. • . Testing. he patient is asked 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.
A patient with topographical disorientation will be unable to succeed
In this task. However, the therapist must differentiate between memory
problems and topographical orientation difficulties.

25. Treatment Suggestions. This deficit usually resolves
8 weeks after onset.
However, several treatment techniques can be used to hasten recovery,
or to assist long term if the condition persists.
a. Remedial Approach. The patient practices going

26. from one place to another, following verbal
instructions .Initially, simple routes should be
used, and then more complicated ones.
b. Compensatory Approach. Frequently travelled routes can be marked
with colored dots. The spaces between the dots are gradually increased
and eventually eliminated as improvement takes place. This is an
example of taking a normally right-hemisphere task and (because there
is

27. right-sided damage) converting it into a left hemisphere
task. In this instance we take the spatial task of remembering routes
(right hemisphere task) and substitute sequential
Landmarks sequencing is typically a left hemisphere

28. • strength) to accomplish the goal of getting from place to place. The
patient should be reminded not to leave the clinic, room or home
unattended, because he or She may get lost.

29. • Depth and Distance Perception
• 1. Definition.T he patient with a disorder of depth and
• distance perception experiences inaccurate judgment
• of direction, distance, and depth. Spatial disorientation
• may be a contributing factor in faulty distance
• perception.

30. • 2. Clinical Examples. he patient may have difficulty
• navigating stairs, may miss the chair when attempting
• to sit, or may continue pouring juice once a
• glass
• is filled.
• 150
• 3. Lesion Areas. his impairment may occur with a
• lesion in the posterior right hemisphere in the
• superior visual association cortices; it may be
• evident with right-sided or bilateral lesions.
• 4. Testing.
• 151

31. • 4. Testing.
• a. For a functional test of distance perception,
• the patient is asked to take or to grasp an object
• that has been placed on a table. he object may
• also be held in front of the patient, in the air, and
• the patient is again asked to grasp it. he patient
• with impaired distance perception will overshoot

32. • or undershoot.
• However, the movements look
• purposeful and smooth, which distinguishes this
• problem from a coordination deficit.
• 2
• b. To determine depth perception functionally, the
• patient can be asked to fill a glass of water.
• A
• patient with a depth perception deficit may continue
• pouring once the glass is filled.

33. • Treatment Suggestions. he patient should be assisted
• in becoming aware of the deficit (education to
• increase cognitive awareness). Emphasis should be
• placed on the importance of walking carefully on
• uneven surfaces, particularly the stairs.
• a. Remedial Approach. he patient is requested to
• place the feet on designated spots during gait training.
• Also, blocks can be arranged in piles 2 to 8 in
• (5 to 8 cm) high. he patient is asked to touch the
• top of the piles with the foot. his is done to
• reestablish a sense of depth and distance.

34. • 55
• 154
• b. Compensatory Approach. Practice in compensating
• for disturbances in depth and distance perception
• occurs intrinsically in many ADL skills, both
• those involving moving through space and those
• that involve manipulation. For example, the
• patient can hold the armrests of a chair to assist
• with sitting squarely.
• 2

35. • Vertical Disorientation
1. Definition. Vertical disorientation refers to a distorted
perception of what is vertical. Displacement of
the vertical position can contribute to disturbance of motor
performance, both in posture and in gait. Early in recovery, most
patients post-CVA demonstrate

36. some impairment in the sense of verticality.
This is not associated with or affected by the presence of homonymous
hemianopia.

37. Clinical Example. A person with distorted verticality
views the world differently and this may affect
upright posture.
3. Lesion Area. The lesion site is in the nondominant
parietal lobe

38. 4. Testing-The therapist holds a cane vertically and
then turns it sideways to a horizontal plane.
Researchers use a luminous rod with patients seated
in a darkened room. The patient is handed the
cane and asked to turn it back to the original position.
If the patient’s perception of the vertical position
is distorted, the cane will most likely be placed.
At an angle, representing the patient’s conception of
the world around himself or herself.

39. Treatment Suggestions-The patient must be made
aware of the deficit. 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.

40. Agnosias (Simple Perception)
Agnosia is the inability to recognize or make sense of
incoming information despite intact sensory capacities.
Although this condition is relatively rare (as listed by the
National Institutes of Health Office of Rare Diseases),
It can affect any sensory modality (e.g., vision, audition,
touch, taste)

41. and anything (e.g., faces, sounds, colors,
familiar or less familiar objects). Although there is an
inability to recognize familiar objects using one or two
of the sensory modalities, the ability to recognize the
same object using other sensory modalities is usually
Present.

42. Visual Agnosias
1. Definition. Visual object agnosia is the most common
form of agnosia.
It is defined as the inability
to recognize familiar objects despite normal function
of the eyes and optic tracts.

43. Clinical Examples. One remarkable aspect of this disor-
der is the readiness with which the patient can identify
an object once it is handled (i.e., information is received
from another sensory modality).
The patient may not recognize people, possessions, and common
objects. Specific types of visual agnosia include simultanagnosia,
prosopagnosia,
and color agnosia.

44. a. Simultanagnosia also known as Balint’s syndrome,
is the inability to perceive a visual stimulus as a
whole. The patient perceives an entire array one
part at a time. The lesion is usually in the dominant
occipital lobe.
b. Prosopagnosia was traditionally considered to be
the inability to recognize familiar faces. Current
thought suggests this phenomenon is related to

45. any visually ambiguous stimulus, the recognition
of which depends on evoking a memory context,
such as different species of birds or different
makes of cars. Prosopagnosia is usually accompanied
by visual field impairments. Bilaterally symmetrical
occipital lesions are thought to be responsible for this impairment.

46. Color agnosia is the inability to recognize colors; it is not color
blindness. The patient is unable to identify or name colors on
command, although color chips can be correctly paired.
However, the meaning of color is lost so that the patient no
longer associates a duckling as yellow or the sea as
blue.
Color agnosia is frequently associated
with facial or other visual object agnosias.

47. It is usually the result of a dominant hemisphere
lesion.
The simultaneous occurrence of left-sided
hemianopia, alexia (inability to read; word blindness),
and color agnosia is a classic occipital lobe
syndrome.

48. Lesion Area. The lesions associated with visual
object agnosias are thought to occur in the
occipito-temporo-parietal association areas of either
hemisphere. These areas are responsible for the integration
of visual stimuli with respect to memory.
Recent evidence suggests visual object angnosias
may result from damage in the medial structures
of the ventral occipito-temporal cortex.

49. Testing-To test for this deficit, several common
objects are placed in front of the patient. The
patient is asked to name the objects, to point to an
object named by the therapist, or to demonstrate its
Use not.

50. Treatment Suggestions.
a. Remedial Approach. Drills can be used to prac-
tice discrimination between faces that are
important to the patient (using photographs)
and discrimination between colors and common
objects. The therapist should assist the
Patient in picking out salient visual cues for
relating names to faces

51. . Compensatory Approach. The patient is instructed
to use intact sensory modalities, such as touch or
audition, to distinguish people and objects

52. Auditory Agnosia
1. Definition. Auditory agnosia refers to the inability
to recognize non-speech sounds or to discriminate
between them. This rarely occurs in the absence of
other communication disorders.

53. Clinical Examples. The patient with auditory agnosia
cannot tell, for example, the difference between the
ring of a doorbell and that of a telephone, or
between a dog barking and thunder.
Lesion Area. The lesion is located in the dominant
temporal lobe.

54. Testing. Testing is usually carried out by a speech language
pathologist. The patient is asked to close

55. The eyes and to identify the source of various sounds.
The therapist rings a bell, honks a horn, rings a telephone,
and so forth, and asks the patient to identify
The sound (verbally or by pointing to a picture).
5. Treatment Suggestions. Treatment generally consists
of drilling the patient on sounds, but this has not
been found to be particularly effective.

56. Tactile Agnosia or Astereognosis
1. Definition. Tactile agnosia, or astereognosis, is the
inability to recognize forms by handling them,
although tactile, proprioceptive, and thermal sensations
may be intact. This impairment commonly causes

57. Difficulties in ADL skills, in as much as many
self-care activities that are normally done in the
absence of constant visual monitoring require the
manipulation of objects.

58. If tactile agnosia is present in combination with unilateral neglect or
other sensory loss, performance in ADL skills may be
severely hampered.
2 Clinical Examples. If a patient is handed a familiar
object (key, comb, safety pin) with vision occluded,
the patient will fail to recognize it.

59. 3. Lesion Area. The lesion is in the parieto-temporooccipital
lobe (posterior association areas) of either
hemisphere.
4. Testing. he patient is asked to identify objects
placed in the hand by examining them manually
without visual cues

60. Treatment Suggestions.
a. Remedial ApproachThe patient practices feeling
various common objects, shapes, and textures
with vision occluded. The patient is instructed to

61. immediately look at the object for visual feedback
and note special characteristics of the object.
Compensatory Approach. To improve cognitive
awareness, the patient is educated concerning the
nature of the deficit and is instructed in visual
compensation.

62. Apraxia
Apraxia is an impairment of voluntary skilled learned
movement. It is characterized by an inability to perform
purposeful movements, which cannot be accounted for by
inadequate strength, loss of coordination, impaired sensation,
Attentional difficulties,abnormal tone,

63. Movement disorders, intellectual deterioration, poor comprehension,
or uncooperativeness.
Many patients with apraxia also present with aphasia, and the two
deficits are sometimes difficult to distinguish.

64. The two main forms of apraxia discussed in the literature are
ideomotor and ideational apraxia. Ideomotor and ideational
apraxias are generally thought to be the result of dominant
hemisphere lesions and may be particularly difficult to test
in the patient with aphasia

65. Although aphasia and apraxia
often occur together, there is not a strong correlation
between the severity of the aphasia and the severity of the
apraxia. A third form of apraxia, buccofacial apraxia, is
actually a type of ideomotor apraxia and is characterized
by difficulties with performing the purposeful movements
that involve facial muscles related to the mouth. This may
include responding to the command “pretend to blow out
a candle,” or producing an orderly sequence of phonemes
to produce speech

66. Hence, apraxia is a disorder of skilled
movement and not a language disorder.
Some rehabilitation texts also describe
Constructional and dressing apraxias.

67. Ideomotor Apraxia
1. Ideomotor apraxia refers to a breakdown
between concept and performance. There is a disconnection
between the idea of a movement and its
Motor execution. It appears that the information
Cannot be transferred from the areas of the brain
That conceptualize to the centers for motor execution.
thus,

68. the patient with ideomotor apraxia is
Able to carry out habitual tasks automatically and
Describe how they are done but is unable to imitate
Gestures or perform on command.

69. Clinical Examples. Several examples of ideomotor
apraxia follow. The patient is unable to “blow” on
command. However, if presented with a bubble
wand, the patient will spontaneously blow bubbles.
he patient may fail to walk if requested to in a traditional
manner.

70. . However, if a cup of coffee is
Placed on a table at the other end of the room and
The patient is told, “Please have coffee,”
the patient is likely to traverse the room to get it.
A male patient is asked to comb

71. He may be able to identify the comb and even tell you what it is used
for; however, he will not actually use the comb
appropriately when it is handed to him. Despite
this observation in the clinic, his wife reports that
he combs his hair spontaneously every morning. A
female patient is asked to squeeze a dynamometer.
She appears not to know what to do with it,
although her comprehension is adequate, the task
has just been demonstrated, and it is clear that she
has adequate strength.

72. Lesion Area. Apraxia results most frequently from
lesions in the left, dominant hemisphere. There is
evidence that both frontal lesions and posterior
parietal lesions can result in apraxia.
4. Testing. The Goodglass and Kaplan
test for apraxia
is composed of universally known movements, such
as blowing, brushing teeth, hammering, shaving,
and so forth. It is based on what the authors consider
a hierarchy of difficulty
for patients with
apraxia.

73. First the patient is asked, “Show me how
you would bang a nail with a hammer.” If the patient fails to do this or
uses his or her fist as if it were a hammer, the patient is told, “Pretend
to hold
the hammer.” If the patient fails following this
instruction, the therapist demonstrates the act and
asks the patient to imitate it. The patient with
apraxia typically will not improve after demonstration
but will improve with use of the actual implements.

74. Treatment Suggestions.
a. Remedial Approach. In the remediation of apraxias,
it is advised that the therapist speak slowly and use
the shortest possible sentences.
One commandshould be given at a time, and the second command
should not be given until the first task is
completed.
When teaching a new task, it should be
brokendown into its component parts. One component

75. is taught at a time, physically guiding the
Patient through the task if necessary. It should be
Completed in precisely the same manner each
time.
When all the individual units are mastered,
an attempt to combine them should be
made.
A great deal of repetition may be necessary.

76. Compensatory Approach. Strategy training involves teaching
The patient compensatory techniques to overcome
The apraxia such as use of pictures in the correct
Sequence to support ADL skills

77. Ideational Apraxia
1.Definition. Ideational apraxia is a failure in the conceptualization
of the task. It is an inability to perform a
Purposeful motor act, either automatically or on command,
because the patient no longer understands the
Overall concept of the act, cannot retain the idea of the
task,

78. or cannot formulate the motor patterns required.
Often the patient can perform isolated components of
A task but cannot combine them into a complete act.
Furthermore, the patient cannot verbally describe the
Process of performing an activity, describe the function
of objects, or use them appropriately.

79. . Clinical Examples. When presented in the clinic
with a toothbrush and toothpaste and told to brush
the teeth, the patient may put the tube of toothpaste
in the mouth, or try to put toothpaste on the

80. toothbrush without removing the cap. Further, the
patient may be unable to describe verbally how
tooth brushing is done. Similar phenomena may
be evident in all aspects of ADL (washing, meal
preparation, and so forth) and so may limit the
safety and potential independence of the patient.

81. Lesion Area. The lesion causing ideational apraxia is
thought to be in the dominant parietal lobe. This
deficit also may be seen in conjunction with diffuse
brain damage, such as cerebral arterioscleros

82. Testing. The tests for ideational apraxia are similar to
those for ideomotor apraxia. The major expected
response difference is that the patient with ideomotor
apraxia can perform a motor act spontaneously
and

83. automatically at the appropriate time, but the
Patient with ideational apraxia is unable to do so.
5. Treatment Suggestions. The treatment techniques are
the same as those for ideomotor apraxia.

84. Buccofacial Apraxia
1. Definition. Buccofacial or oral apraxia involves difficulties
with performing purposeful movements with
The lips, tongue, cheeks, larynx, and pharynx on
command.

85. Clinical Examples. A patient may have difficulty
responding to the command “pretend to blow
out a candle” or “blow a kiss.” However, in a
normal context where the patient may perform
these actions automatically, performance is not
impaired.

86. In addition, while patients may be able
to produce the individual phonemes required for
speech, the patient may have difficulty in producing
an orderly sequence of phonemes. Formulaic
Speech (common, routine phrases) or automatic.

87. Lesion Area. Difficulties with buccofacial apraxia
seem associated with lesions in the frontal and central
opercula, anterior insula, and a small area of the
first temporal gyrus (adjacent to the frontal and central
opercula). Although buccofacial apraxia often
Coexists with Broca’s aphasia, the two may be seen
independently.

88. Testing. The patient should be examined by a
speech-language pathologist.
5. Treatment Suggestions. The speech-language pathologist
can advise the health care team on strategies to
communicate with patients who have buccofacial
apraxia.