Introduction
Body awareness is considered an interactive process that includes awareness of the body's physiological
states, processes (including pain and emotion) and actions (including
movement), and is shaped by an individual's attitudes, perceptions,
beliefs and social/cultural context experiences (1)
(p.2). The nature of impairments post-stroke would suggest that body
awareness may likely be impacted in stroke survivors how this has
received little attention in the literature.
Awareness has been proposed to develop from a body schema (unconscious representation of the position of the body in space plus the position of sensation on the body surface) (2–31), and body image (a conscious representation of one's self) (2, 3, 7–10, 13, 17, 19, 32–34).
Considering recent literature, the triadic model has
been proposed to further explain the nature and properties of body
representations. The triadic model retains the dyadic (schema and image)
notion however subdivides body image into two further representations:
body structural descriptions and body semantics. Body structure
describes a topological map primarily derived from visual input but also
somatic perception. It provides a structural description of the
relationships between body parts boundaries, proximity and relative
position (2, 9, 12, 15, 25–28, 35–38).
Body semantics describes the relationship between words and meaning and
represents semantic and lexical information about the body (including
functions of body parts, associations between body parts and objects,
and body part names) (9, 12, 15, 25–28, 35–40).
The importance of body awareness lies in its' role in
constantly monitoring, updating and providing feedback about the
position and movement of one's body through space. It is also the main
process used in integrating information for perception, decision making
and action, making accurate body information essential for the precise
control of movements (10, 41).
The neuroanatomical basis influencing body awareness is understood to
include an integrated system of brain regions and functional networks.
The main regions within the somatosensory network (and important for
body schema) are found primarily in the parietal cortex (SI and SII) as
well as the thalamus, insula and cerebellum (50, 75, 94). A more
distributed network, including attention and visual networks, is
involved in the conscious processing of somatosensory information (50,
75, 95). Information processing of sensation for perception, and
sensation for action, is described to involve both parallel and serial
processing (75). It is important to note that all senses (exteroception
and interoception) feed into the representation/s. Furthermore, body
image involves affective and memory input from the limbic system and the
semantic and lexical aspects require input from the language and
spatial areas of the parietal lobes in their respective hemispheres.
Intact body awareness is thought to be a major factor
that supports motor function and recovery of individuals following
stroke (10, 41).
One in two people experience impairments in sensation and perception
after a stroke which interrupts the representation of the body that is
held in the brain (42) and has a profound impact on an individual's body awareness (43–46).
Altered motor and sensory cortical processing leads to inaccurate body
information which can manifest in many different ways such as altered
perception of limb size, position, shape or weight. This impairs the
precision and control of one's movements (including postural control,
dynamic balance, coordination) and the individual's ability to explore
the immediate environment safely (41, 43–45). Subsequently it affects one's functional abilities, execution of daily activities and quality of life (35, 41, 47–49), making simple actions such as preparing breakfast, taking a shower or going for a walk challenging (10, 40). Further, reduced body awareness often interferes with the duration of rehabilitation and discharge destination (43, 45, 50).
Emphasising further the important role of body awareness
in stroke recovery, body awareness training has been linked to positive
rehabilitation outcomes, particularly with balance and mobility (51–53).
However, we currently have little understanding of body awareness
during stroke recovery or whether it is important for enabling
behavioural restitution. While much work has been focussed on initial
motor impairment, structural damage and the neurobiological course of
the recovery process (54), little attention has been directed to body awareness (43).
Indeed, from sensory and motor impairment studies, research suggests
recovery is most marked within the first 3 months after stroke, although
ongoing recovery can be observed at 6 months and later (54–56).
In particular, evidence from sensory rehabilitation studies have
indicated the potential for marked recovery from months to years after
stroke (43), and body awareness similarly may continue to evolve over the first 2 years (7, 49).
There is some suggestion that individuals within the first 2–6 months
direct their attention toward the way their body functions and try to
find new ways to manage daily activities and actions. Subsequently from 6
to 12 months the focus shifts to forming an understanding and
acceptance of their bodily changes (7).
The purpose of this study was to first investigate if
body awareness is impaired after a stroke and if it recovers over time,
and second, identify if body awareness is associated with sensation,
motor impairment, self-efficacy and quality of life. It was hypothesised
that body awareness will initially be impaired after stroke, improve
within the first few months and will be associated with improvements in
motor, sensory and quality of life measures.
Davide Cardile
Viviana Lo Buono
*
Francesco Corallo
Simona Cammaroto
Caterina Formica
Ines Serrada
Brenton Hordacre
Susan Hillier