JULY 1971

OCCUPATIONAL THERAPY

9

Assessment of parietal lobe functionin hemiplegia by M. E. GREGORY, M.A.O.T., S.R.O.T. Senior Occupational Therapist and J. A. AITKEN, M.B., Ch.B., M.R.C.P.E. Consultant Physician in Geriatrics Clatterbridge Hospital, Bebington, Wirral, Cheshire Introduction

The past decade has witnessed advances in our understanding of the hemiplegic patient. His problems extend beyond mere loss of motor function and thalamic sensory loss or impairment. Adams' and Hurwitz" have shown the importance of associated sensory deficits other than thalamic, especially when the infarcted area extends to the parietal lobes. Man is the only animal to show cerebral hemisphere inequality. Our nearest relatives, the apes, use each hand equally but in man one hemisphere is dominant and one hemisphere is subordinate. The majority of people are right-handed and their dominant hemisphere is the left, associated with the speech centre. Lesions of the left dominant hemisphere may produce right-sided weakness or paralysis with dysphasia. It is therefore not surprising that parietal lesions should produce in man different clinical pictures according to whether the right side or the left side is affected. Of greatest clinical interest and importance is the subordinate parietal lobe, i.e. the right parietal lobe in right-handed individuals. In Adams' and Merret's" series of 736 hemiplegics admitted to Belfast City Hospital the preponderance of dominant hemisphere lesions among patients who recovered was unexpected. The difference in the proportions of dominant and subordinate sided lesions was statistically significant only for men, but the same trend was evident in women. Eighty-two cases of hemiplegia reported by Anderson' from Hawaii reveal that the left hemiplegic with a subordinate hemisphere lesion is less likely to achieve independence in self-care than the right hemiplegic with a dominant hemisphere lesion, even though the right hemiplegic is often afflicted with dysphasia. There was also a disproportionately high incidence of subordinate sided lesions in patients failing to reach predicted goals or requiring prolonged periods to reach reduced attainments. The failure on the part of the patients with subordinate hemisphere infarction has been explained by mental barriers". Anderson's work indicates the importance of the subordinate parietal lobe in these results.

Syndromes of the parietal lobes The characteristic syndromes of parietal lobe involvement are shown in Table I. Apraxia as defined by Hurwitz" is the inability to carry out common previously learned purposive movements in the absence of marked motor and sensory impairment or incoordination. Apraxia tends to be bilateral in dominant parietal lobe syndromes and is often of the type known as ideomotor apraxia in which the patient does something entirely different from what he intends. Constructional apraxia is more often seen in lesions of the subordinate parietal lobe and is characterised by the inability of the patient to construct objects or things from their component parts. Disturbance of body image occurs when a patient lacks the mental awareness of the structure of his body enabling him to identify or orientate his body to understand the relationship of the parts of his body and to each other". It has been suggested that the subordinate parietal lobe has a dominant role in

JULY 1971

OCCUPATIONAL THERAPY

10

Table I PARIETAL LOBES DOMINANT

SUBORDINATE

Bilateral apraxia (Ideomotor)

Constructional apraxia

Gerstmann's syndrome Dyscalculia Dysgraphia Finger agnosia Right/Left disorientation

Disturbance of body image

Tactile astereognosis Postural disturbance

"I Anosognosia Autotopagnosia Visual agnosia Disturbance of spatial judgement Tactile astereognosis Postural disturbance

j

this function. Anosognosia, which literally translated means without knowledge of disease, has been defined by Babinski' as the failure of the hemiplegic to recognise the presence or the severity of his paralysis. It may range from unconcern (anosodiaphoria) to complete denial of his paralysis (autotopagnosia), or he may personify his paralysed limb, giving the limb a life of its own; for example, one patient called his limb a pig's foot. Others may believe the limb is another person. Visual agnosia may be defined as the inability to recognise objects, despite the fact that visual acuity is intact. Tactile astereognosis is the inability to recognise the nature of an object by touch in the presence of adequate sensory thalamic function. Postural loss occurs as a defect in the recognition of passive movements of the affected joints and unawareness of the direction in which such movement occurs. The patient may adopt unusual attitudes in the affected arm when confined to bed. He may lie with his arm in uncomfortable anti-gravity postures. Gerstmann's" syndrome is uncommon and is usually associated with some mental clouding and is often incomplete. Routine clinical and neurological examination and psychiatric examination will not reveal all the characteristic signs of parietal lobe involvement." The elucidation of these parietal lobe functions was attempted by the tests given below. Tests of parietal lobe function The tests are used with patients in the geriatric unit and general medical wards. Patients are tested as soon as possible after admission and re-tested at two-weekly intervals, if disorders are shown, to assess improvement. With very few exceptions we have found patients eager to co-operate and delighted rather than offended if they find the tests very easy. The world of the hemiplegic patient soon after the initial incident is so full of seeming difficulties and barriers to normal living that the majority of patients are only too glad if they find they can do something easily and well. The tests are recorded on a ten-page form. On the front page essential information regarding the patient is given, i.e. name, address, date of birth, diagnosis, ward, dominant hand, and hand used in test. A brief description of the patient's mental state is recorded by the occupational therapist ticking one or more of the following statements: Mentally clear Disorientated for time Disorientated for place Poor memory for recent events Demented patients and those with gross disorientation are excluded from the test but patients with mild disorientation and some cloudi~g of consciousness are able to co-operate in the assessment. The tests are listed below With a brief description of the equipment needed and the method of testing used: (1) Test Copying drawings to test for anosognosia, disorder of spatial judgement and apraxia.

JULY 1971

OCCUPATIONAL THERAPY

11

Equipment Test form, pencil for patient, felt pen for therapist. Method Occupational therapist draws (a) simple flower; (b) house; (c) triangle; (d) series of graduated points. Each drawing is done on a fresh sheet of paper and the patient copies each in turn before proceeding to the next. Therapist draws all diagrams in the presence of the patient, not beforehand, so that she can demonstrate exactly what is required.

Attempt by patient with anosognosia to copy therapist's drawing of flower

B:1

·m

Left: Attempt by patient with anosognosia to copy therapist's drawing of house Right: Patient with anosognosia attempts to draw a inan, showing presumed right arm stretching out into left extrapersonal space

12

OCCUPATlONAL THERAPY

JULY 1971

(2) Test Drawing from memory to test for body image disorder, anosognosia, autotopagnosia, disorder of spatial judgement and apraxia. Equipment Appropriate page of form and pencil for patient. . Method Instructions to "draw a man" and "draw a clock face" are printed on the form. Patient is asked by the therapist to read and carry out the instructions. (3) Test Assembling pieces of felt as in jigsaw puzzle to test for body image disorder, anosognosia and autotopagnosia. Equipment (a) Pieces of felt cut out to represent head, trunk, arms and legs; (b) pieces of felt cut out to represent face, eyes, nose, mouth, ears; (c) large piece of black felt as background on which to assemble body and face. Method (a) Patient is asked to assemble the pieces of felt representing the body on the background of black felt ; (b) patient is asked to assemble the pieces of felt representing the face on the background of black felt. In both cases the individual parts are first identified by the therapist but If the patient is unsure at any stage of the test of what a piece offelt represents, it is re-identified by the therapist.

Left: Felt body used for body image disorder assessment Right: Attempt of patient with body image disorder to construct felt body

JULY 1971

OCCUPATIONAL THERAPY

13

(4) Test Copying shapes on a pegboard. Placing shapes in shapebox. Building three steps with six bricks. To test for three dimensional constructional apraxia, disorder of spatial judgement and anosognosia. Equipment (a) Pegboard and coloured pegs; (b) child's shapebox or posting box; (c) set of toy bricks or Koh's blocks. Method (a) Occupational therapist constructs two shapes in turn and asks the patient to copy the shape using some more of the pegs on another part of the board; (b) patient is asked to fit each shape into its appropriate hole in the box; (c) patient is asked to construct three steps from six bricks or blocks. (5) Test Identifying objects. Test for sensation and stereognosis. Equipment Piece of cotton wool, sandpaper, pen, coin, key. Duplicate set of these items. Method Patient is asked to close his eyes and feel and identify each item in turn with his affected hand. If he is unable to do this, the item is put in the unaffected hand. An aphasic patient is allowed to feel each item, with his eyes closed, in the normal way. The object is then removed and the patient opens his eyes and points to the appropriate object in the duplicate set. (6) Test Copying shapes using matchsticks to test for two dimensional constructional apraxia. Equipment Box of matches. Method Therapist makes simple shape on table using matchsticks and asks patient to copy it using some more matchsticks. (7) Test Striking match to test for apraxia. Equipment Box of matches. Method Patient is given box of matches and asked to strike a match. (8) Test Naming common objects to test for dementia!" Equipment Appropriate page of form and pencil to record result. Method Patient is asked to name: (a) ten towns; (b) ten colours; (c) ten animals; (d) ten fruits. This test is usually done first. If a patient scores less than 20 out of 40 he is excluded from the rest of the test. No time limit is imposed but the occupational therapist proceeds to the next part of the test if the patient says he cannot name any more objects in that section and he has had reasonable time to think. (9) Test Writing, number calculation, and naming fingers, distinguishing right from left, to test for Gerstmann's syndrome. Equipment Form and pencil for patient. Pencil to record results. Method (a) Dysgraphia - Patient is asked to write down a simple sentence dictated by the therapist, e.g., Today is Wednesday. (b) Dyscalculia - Patient is asked to do simple mental arithmetic calculations, and to add up three columns of figures written down by the therapist. (c) Finger agnosia - Patient is asked to identify fingers of his affected hand and non-

14

OCCUPATIONAL THERQPY

JULY 1971

affected hand and the fingers on the therapist's hand. (d) Right and left disorientation - Patient is asked to name his own right and left hands. Therapist then sits opposite patient and crossing her hands or feet, asks the patient to identify her left and right. At the end of the form there is space for the occupational therapist's comments. Observations on the patient's attitude towards the test and such things as lack of concentration, inattentiveness, difficulties due to one or more of the special senses, and any bizarre displays of behaviour not otherwise recorded by the tests, are noted. The test is dated and signed by the occupational therapist. Commonly identified disorders

The disorder most commonly found is that of body image disturbance. It must be emphasised that no patient is presumed to have a deficit on the basis of one test which looks disordered. This is the value of a series of tests. Only when the patient shows the same defect through a set of tests is he diagnosed as suffering from a parietal lobe disorder. Patients with body image disorder exhibit in their drawings of a man and a clock face their inability to relate correctly the component parts of each drawing. They cannot place together correctly the pieces of the felt body and face. Sometimes the pieces of felt are placed at random on the black felt background, occasionally the limbs are placed neatly on top of each other in piles. Anosognosia is the next most common disorder. In all cases the patients showing this disturbance drew the man, clock face, the house and flower omitting some or all of the left hand side of the drawing. In no case did a patient with a right hemiplegia exhibit this phenomenon. Thus in the "draw a man" and usually in the felt body test also, the left arm and leg (as seen in a mirror) were omitted. A few cases of right hemiplegia have shown mild body image disorder, that is, they have been unable to relate one specific part of the body to another, but there has not been total disorganisation, and it has not been particularly related to either the left or right side of the drawing. An interesting observation was that a number of patients with anosognosia drew a figure with a large right hand (as seen in a mirror) stretching across the midline of the body into left extrapersonal space. Patients with a left hemiplegia will sometimes exhibit autotopagnosia when performing the felt body test. The left arm and/or leg are placed at a distance from the body and the patient rationalises the position to the therapist, giving the limb a will and purpose of its own. Patients who cannot draw the triangle, put the shapes in the shapebox or correctly copy the pegboard patterns, are usually found to have spatial disorders. These tests, together with those for three dimensional constructional apraxia, have been found to be significant in the prognosis for eventual independence in the personal activities of daily living. Patients who cannot perform these tests are found to have great difficulty in dressing themselves, even if their body image is intact. Conversely, patients with a most disordered body image but no disturbance of spatial judgement or three dimensional constructional apraxia, have shown surprising ability to compensate for their poor body image and become independent. Disorders of perception are not uncommon. Many patients seem to lose the ability to see a shape as a whole. They are able to draw some or all of the component parts of the diagram, but they are disconnected and often at random. They are quite unable to copy a shape on the pegboard. A severe apraxia will be noted throughout the test as the patient will have difficulty in manipulating his pencil, although full comprehension of what is required and adequate motor power is present. However, a milder form of apraxia may not be evident until the patient is asked to strike a match. The apractic patient has great difficulty in performing this action. Apraxia in either two or three dimensions will be noted by the appropriate tests. Gerstmann's syndrome is related to the dominant parietal lobe and the most noticeable feature of the performance of a patient with this uncommon syndrome was her variability. On each occasion of testing there were some parts of the test which the patient was unable to do and these parts varied from day to day. There was a fairly consistent inability to name the middle, ring and index fingers. Two interesting signs unrelated to parietal lobe syndromes were observed. It was noticed that patients suffering from depression tended to draw a miserable looking man in the "draw a man" test, place the mouth curving downwards in the felt face test and choose

OCCUPATIONAL THERAPY

JULY 1971

15

dark colours for the pegboard. Secondly, mirror image disorder was not infrequently encountered especially with the pegboard test. Patients reversed all shapes done by the therapist and were unable to correct them even when the difference was pointed out. Throughout the test the patient's comprehension of verbal and written instructions is being tested and his concentration and attention span. Lack of concentration can in itself be a most effective barrier to independence, even in the absence of other disorders. Any exaggerated response, for example catastrophic reaction, is also noted. Results (Table II and graph) A total of 151 patients was tested; of the dominant parietal lobe lesions 13 (30 per cent) gave an abnormal test; of the subordinate parietal lobe lesions 31 (61 per cent) gave an abnormal test; and of the controls 5 (10 per cent) were abnormal. Thus, in this series the Table II Dominant hemisphere

-.

----

TOTAL (151) NORMAL TEST

-

ABNORMAL TEST

Subordinate hemisphere

Control

100%

51

100%

55

100%

31

70%

20

39%

50

90%

13

30%

31

61%

5

10%

lOll

50

10

rmmm Ullllllll TEST

1II0RMAL

,. , CA.SES

Z

~ABNOR~L

~o

§TEST 4C

30

20

DOMINANT SUBORDINATE CONTROL

16

OCCUPATIONAL THERAPY

JULY 1971

subordinate parietal lobe was twice as commonly involved as the dominant parietal lobe in each group of hemiplegic patients. In the dominant hemisphere lesions the extent of the disorder was rarely as severe as the commonly found gross disorder in the subordinate hemisphere patients. Approach to treatment

Treatment is, at the moment, in an experimental stage. Recognition of any disorders in the early stage of treatment is of value to both the patient and all members of the treatment team. In particular, the knowledge of a patient's difficulties will prevent the occupational therapist from planning an unrealistic treatment programme. Patients with gross body image disorder, spatial difficulties, and/or contructional apraxia will stand a better chance of learning the techniques of feeding and dressing one-handed as well as the more complicated domestic activities of daily living, if some time has first been spent in trying to correct these disorders. As soon as the patient is fit to co-operate, the occupational therapist can start re-inforcing the patient's body image by all possible means. It may only be possible for the patient to take a passive role at first, but following the same movement patterns as the physiotherapist will already be using, the occupational therapist can take the patient's affected hand to his face and let the face and hair feel the fingers. Later, a wet flannel mitten can be put on the affected hand and the patient can try washing his face with the therapist's help. These activities should be done frequently but until there is some spontaneous movement in the affected arm, each session should last for only a matter of a few minutes. It is essential to re-inforce constantly in the patient's mind the fact that he has two sides to his body and that his affected limbs belong to him. In the later stages, tracing round one's own reflection in a full length mirror and tracing with a pencil round drawings of people have been found useful. Knowledge gained from the results of the tests has proved to be of value in enabling the occupational therapist to understand why a patient with an adequate return of motor and sensory power does not make the expected progress in activities of daily living. This knowledge shared with the other members of the treatment team should mean that the overall approach to the patient is one of greater understanding and that time is not wasted in expecting the patient to perform activities which require a degree of parietal lobe functioning that he does not possess. Summary (1) In a series of 151 elderly patients rational but some with slight mental clouding, 44

of whom suffered a right hemiplegia, 13 had involvement of parietal lobes. In 51 patients with left hemiplegia, 31 had involvement of the parietal lobes. (2) Involvement of the subordinate parietal lobe constitutes a handicap to the patient becoming independent in the activities of everyday living. (3) The value of a series of specific tests to determine the nature of the handicap is discussed. (4) Patients with impairment of spatial judgement and constructional apraxia have a poorer prognosis, with regard to a return to independence than those with body image disorder or anosognosia alone. (5) Early treatment of these disorders is indicated. Experience suggests that if not treated early the features of parietal lobe involvement persist and may prevent independence being attained. For the future, techniques of treatment must be further developed. References 1. Adams, G. F. (1966) "Treatment of Hemiplegia Complicated by Sensory Defects", Physiotherapy, 52, 345-349. 2. Hurwitz, L. J. (1966) "Sensory Defects in Hemiplegia", Physiotherapy, 52, 338-342. 3. Adams, G. F., Merret, J. D. (1961) "Prognosis and survival in the Aftermath of Hemiplegia", British Medical Journal, i, 309. 4. Anderson, E. K. (1970) "Parietal Lobe Syndromes in Hemiplegia", American Journal ofOccupational Therapy, XXIV: 13. . 5. Adams, G. F. and Hurwitz, L. J.(l963) "Mental Barriers to Recovery from Strokes", Lancet, 2, 533. 6. Macdonald, J. c., "Body Scheme in Adults with Cerebral Vascular Accidents",

JULY 1971

OCCUPATIONAL THERAPY

17

American Journal of Occupational Therapy, XIV (1960) :75. 7. Babinski, J. (1914) "Contribution it. l'etude des troubles mentaux dans l'hemiplegie organique cerebrate", Rev. Neurol., I, 845-848. 8. Gerstmann, J. (1924) "Fingeragnosie: Eine umschriebene Storing der Orientierung am eigenen Korper", Wien Klin. Wschr., 37, 1010-1012. 9. Critchley, M., The Parietal Lobes. Arnold & Co., 1953. 10. Isaacs, B. and Ahktar, A. J. To be published. Acknowledgments The authors would like to thank Miss M. Fraser, Head Occupational Therapist, and the other members of the Occupational Therapy Department for their work and interest in the project. Dr. J. A. Aitken thanks his colleagues, Dr. F. J. Zacharias, Dr. M. W. W. Wood, Dr. P. L. Robinson and Dr. J. Meecham, for allowing him access to patients under their care and for their helpful comments.

Letters to the Editor Correspondents are urged to write on one side of the paper only. Typewritten letters should be in double spacing.

Professionally educated or technically trained? Sir-I was very interested in the quotation from Professor Michael Swann in the Comment headed "Examinations" in the May issue of Occupational Therapy. While I obviously agree with Professor Swann that we do not want occupational therapists who have not been "trained" and "examined" I do query whether the methods of examination presently in use are the best which could be developed to ensure that graduates leaving our schools are professionally educated, not just technically trained. Robert M. Hutchins in "The Learning Society" says "The means of education do more than effect the ends of education, they become the ends. If, for example, the student is selected, placed, promoted and graduated by examinations, the system, from his point of view, must be to pass examinations. And the content of his course must be such that he can be examined on it. Consciously or unconsciously, those who determine the course of study must ask themselves not what the student should learn but on what he can be examined". This quotation seems to me to be relevant to the present system of training occupational therapists. While I believe that we should retain a system of examination similar to that at present in use I do feel strongly that the

marks awarded in these should not be the only criterion for passing or failing a student. Without imposing a great deal of extra work on anyone would it not be relatively simple to devise a system by which a proportion of marks was awaraded to written and viva voce examinations, a proportion to the overall progress of the student as assessed by the training school, and a proportion to progress as assessed by clinical training staff? Such an approach would seem to me to be not only fairer to the students but would enable the training schools to lay the necessary emphasis on the 'non-examination' subjects which seem to me to be so important if we are, as a profession, to develop a really educational programme. At the present time it appears that "the tail is wagging the dog", with the whole emphasis during training on ensuring that the students are capable of passing examinations which are geared only to those subjects which can be examined easily by means of written or viva voce examinations. It has been said that the aim of education is to help the individual to develop his highest powers and this cannot be done by emphasis on merely gaining technical skills and trying to fit each individual into a rigid pattern. We all, as therapists,