The patient was a 33-year-old female with no significant medical history. She lived with her husband and daughter. She previously worked as an aesthetician and was currently on maternity leave. The activities of daily living training (ADL) and IADL were independent, and she was right-hand dominant. She initially presented with generalized seizures, was diagnosed with a right parietal lobe lesion, and had visited our hospital for surgery.
T2-weighted magnetic resonance imaging (MRI) of the head (
Figure 1) revealed a space-occupying lesion with a mass measuring 5.7 × 4.6 × 5.6 cm in her right parietal lobe. T2-weighted image acquisition is used in radio imaging diagnosis [
8]. The patient underwent awake lumpectomy under local anesthesia and was pathologically diagnosed with glioblastoma. Postoperatively, oral treatment with temozolomide was initiated in combination with radiotherapy.
2.1. Initial Evaluation
The cranial nervous system revealed visual field defects in the lower left quadrant. Her kinesthetic and balance functions were normal. During left gaze, there was a delay in eye movement onset. In reaching movements of the upper extremities, the left upper extremity failed to reach the target in a single movement, with a delay of approximately 2 s compared to the right extremity; a similar result was observed when looking at the left side. The line bisection test was normal, but a trisection of straight lines and circles was unsuccessful. The line-crossing test yielded a score of 23/40, and the flower reproduction test score was 0/1. The course cube test score was 0/131 [
8] (
Figure 2). The Mini-Mental State Examination (MMSE) score was 29/30 [
9], and although there was a reduction in figure copying, there was no obvious decrease in delayed recall. Although the basic movements in the hospital ward were generally independent, the patient often encountered obstacles, including people, without noticing them on her left side while walking. The ADL showed that she had leftover food because of poor recognition of the left side when eating. When changing her jacket, she sometimes did not notice that the buttons were incorrectly fastened or that the collar was folded in. The Functional Independence Measure score was 97, and it consisted of 62 motor and 35 cognitive items. In terms of time recognition, there was a difference between actual time perception and self-recognition. The number of seconds for folding the clothes was measured, and the degree of shaping was defined on a five-point scale (5 out of 5 indicates correctly folded clothing; 1 point was deducted for the following items: wrapping is different, the sleeves are not folded, the hem is not folded, or the shape is distorted). The action of folding clothes took more than 5 min, and the finished form was in a state where the left sleeve and hem were not properly folded and could not be shaped. In particular, errors increased when attention was focused on patterns and pockets, and many procedural errors could not be corrected by verbal guidance alone (
Figure 3). In summary, the patient had visuospatial cognitive impairment (construction disorder, visual attention disorder, visual ataxia, sensory hemispatial neglect, etc.) and left visual field impairment [
9].
2.2. Intervention
Occupational therapy was performed five times a week for 40 min a day (
Figure 3). With reference to a previous report [
7], cognitive rehabilitation was performed while being conscious of the difficulty level so as not to cause an erroneous reaction. The intervention occurred as follows: (1) direct therapeutic intervention was repeated while confirming procedures and precautions based on memory, and providing feedback; (2) compensatory therapeutic intervention using tactile and kinesthetic senses as visual compensation was performed; and (3) the intervention was conducted in a step-by-step manner. Therefore, specific IADL training was incorporated and the degree of difficulty was adjusted.
Direct therapeutic intervention is a treatment that stimulates and activates impaired function by repetitive practice of the impaired function or ability, and it has been reported that the functional improvement effect of repetitive motion is related to the regeneration and sprouting of neuronal axons. Direct therapeutic intervention is one of the most common types of rehabilitation for constructive impairment.
Compensatory interventions also utilize other functions or factors to achieve the impaired function or ability. Compensatory interventions are reported to reorganize the internal structure of nerve tissue by substituting other remaining healthy functions and combining impaired function with residual function. In addition, compensatory treatments are used to compensate for impaired functions and abilities using external assistance. Furthermore, we aim to promote spatial analysis and integration with various sensory inputs [
7].
IADL training consists of setting-based therapeutic interventions. IADL training is aimed at enhancing adaptive behavior in daily life and preventing and reducing problem behaviors. Previous reports have demonstrated that improvement can be observed through a systematic step-by-step approach based on the patient’s specific functionality and abilities [
4].
2.3. Occupational Therapy Course
- (1)
Phase 0
Occupational therapy was started after the operation, and bradykinesia, reaching movement, and oculomotor disorder showed immediate improvement. However, there was a decline in time recognition, such as being unable to prepare for the scheduled start time, even if the start time and examination time were verbally communicated on the same morning. In addition, many errors were observed regarding the folding of clothes. A follow-up MRI confirmed a marked improvement in postoperative edema, but no improvement was observed when the clothes were folded.
- (2)
Phase 1
To address the challenges encountered during daily activities, we began with the patient sitting on their knees and attempting to put on patterned shirts and long-sleeved front-opening shirts with pockets, which is a frequent activity in daily life. However, the presence of visual distractions in the training room hindered her ability to continue working effectively. Considering the effects of visual attention impairment, we adjusted the environment by minimizing visual stimuli on the walls and organizing working material on desks. The patient preferred patterned shirts but changed to a solid color shirt because she thought that the pattern may have distracted her. Due to their difficulty, the patient began occupational therapy with short-sleeved shirts instead of long sleeves. Owing to the difficulty in focusing on her lower left hand, the treatment was performed in a standing position to increase her field of vision while grasping the entire garment. Instructions for the procedures were given orally to her as her auditory comprehension and memory were preserved. She was instructed to manually perform a series of actions, such as checking the front and back, checking the order from the right side when aligning the front body to the center, and checking that the shirt was in the correct position. Regarding awareness of time, the patient was instructed to keep note of the clock, along with staff and family. We provided an opportunity to check the elapsed and remaining time during rehabilitation.
- (3)
Phase 2
Five weeks after the operation, she increased the speed with which she folded her clothes and was able to complete the task in about 3 min. However, there were many operational errors such as the left half of the clothes being twisted, the sleeves sticking out, and the shoulder width being different between the left and right sides. We questioned the lack of visual insight for predicting the finished form and thought it would be difficult to make judgments based solely on sight. Therefore, we introduced a compensatory intervention that recognizes the discrepancy between tactile and visual sensations to call attention to the correction area. By repeating this training, the patient experienced a reduction in attentional distractions and an improvement in attention distribution. Eight weeks after surgery, she exhibited a noticeable improvement in her ability to independently identify and rectify twisted or protruding sleeves in her clothing. In addition, the patient became aware of the corrections that were required on her left side without prompting and was able to put on long-sleeved and buttoned shirts. Twelve weeks after surgery, her lower left cognitive deficit was correctable with verbal commands.
Time awareness plays a crucial role in enhancing our ability to be punctual and prepared. We emphasized the importance of allocating specific time for rehabilitation treatment and practiced task-switching techniques. Additionally, due to difficulties in perceiving the left side as a whole, the patient was unable to cut food into equal sizes during cooking.
To address this, in the equipartition task, we introduced a compensatory therapeutic intervention in which tactile input was performed in the same manner as the action of folding clothes.
- (4)
Phase 3
Rehabilitation training was performed while the patient sat on a sofa to create an environment similar to that at home. We aimed to improve the patient’s ability to handle multiple tasks simultaneously by simulating real-life scenarios and implementing them using dialogue. As a result, there was an improvement in the recognition and distribution of attention toward clothing as a whole.
At 10 weeks postoperatively, the patient demonstrated independent time management skills, with a decrease in the frequency at which she checked her watch. Moreover, errors in everyday life decreased, and left-sided cognitive deficits were only observed in certain situations [
10].
The patient was discharged after ensuring her competence in daily activities and providing her with appropriate guidance.