Effectiveness of Cognitive
Skill Relllediation
in Acute Stroke Patients
(visual scanning, visual-spatial, time judgment, retraining)
Lynn Tondat Carter
Bertram E. Howard
William A. O'Neil
The purpose of this study was to
determine whether a cognitive
skills remediation program could
help acute stroke patients regain
important thinking skills. Patients
in a community hospital stroke
program were pre-tested in three
skill areas-visual scanning,
visual-spatial orientation, and
time judgment-and randomly
assigned to a treatment (n = 16) 01'
control ( n = 17) group. The
treatment group received cognitive
skill retraining on a one-to-one
basis for 30 minutes per day, 3 days
per week, f01' 3 weeks. The retraming involved the use of paper and
pencil tasks, simple cuing procedures, positive reinforcement, and
immediate feedback. A lthough the
control group did not receive thzs
treatment, conventzonal therapzes
continued for both groups.
Patients receiving treatment had
overall and separate skill
improvement scores that were significantly higher than those for
control patients. The implications
of this type of treatment program
are disc ussed.
erebra I vascular accident (CV A)
or stroke, is the third leading
cause of death in America today. Of
the more than 400,000 new victims
of stroke each year, approximately
180.000 die, leaving more than
220,000 survivors with varying degrees of disa bili ty (I ). In addi tion to
the more obvious motor and sensory impairments, cognitive skill
deficits are also a common conseq uence of stroke. Examples of these
deficits include decreased ability to
scan visually, orient visually and
spatially, remember, judge time,
learn, concentrate, and do simple
math computations (2-4). The
degree of disability can range from a
mild, annoying impairment to a
C
Lynn Tondat Carter, Ph.D., is
Associate Professor, Department of
Psychology, Southeastern Massachusetts University, N. Dartmouth, Massachusetts.
Bertram E. Howard, M.D., is a
Cardiologist; and
William A. O'Neil, M.D., is aNeurologist; both at St. Luke's Hospital, New Bedford, Massachusetts.
320
May 1983, Volume 37, Number 5
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severe and devastating inability to
perform even the simplest mental
functions necessary for carryi ng ou t
activities of daily living.
Historically, the emphasis of
cognitive skill research in braindamaged adults has been on the
identification and assessment of
deficits (4, 5). This is reflected by the
increase in the presence and depth
of questions about cognitive functioning on rehabilitation evaluation forms (6-8). While results of
recent research are helping rehabilitation staff to become more aware of
the importance and involvement of
cognitive and perceptual skill
deficits in the recovery process for
brain-damaged adults (9-12), formal
programs for the treatment of such
deficits are still uncommon.
One well-known treatment approach, based on years of research,
is used at the Institute of Rehabilitative Medicine, New York University. At the Institute, researchers
developed and tested numerous behavioraltreatment programs for the
remediation of a variety of cognitive
and perceptual skill deficits (2-5,1317, 23, 24). The programs emphasize the relearning and practice of
once-used cognitive sets and associated sensorimotor behaviors.
Some important steps of the treatment process are: identifying the
deficit area, giving informative
feed back to make the cl ien t a ware of
tht> deficit and subseq uent progress,
and retraining tasks relevant both
to the deficit skill area and to the
related daily activities of the client
(3,4, 13, 14). These techniques and
treatment programs, which can involve the use of scanning machines
and other training apparatus, are
made available to rehabilitation
staff at yearly workshops sponsored
by the Institute and through published monographs(e.g., 15-17).
Within the past several years, a
program of cognitive skill remediation that can be applied toa number
of rehabilitation settings was tested
and developed (18,19). The majority of the exercises in this program
involves the use of paper and pencil
tasks. This program incorporates
the same principles tested and used
effectively at the Institute of Rehabilitative Medicine: continuous reinforcement, immediate feedback,
cuing, gradually increasing the difficulty level, and stressing the importance of the skills being taught
to activities of daily living. In the
1980 study (18), rehabilitation patients (stroke and nonstroke elderly)
who received such training were
shown to improve significantly in
overall cognitive skill performance
in five skill areas compared to the
patients who did not receive this
training. This overall improvement
was primarily due to better performance in visual scanning, visualspatial orientation, and time judgment skills. The treated patients
received training for an average of
35 min utes, 3 times per week, for 4
weeks. All patients continued to
receive other traditional rehabilitation therapies.
One important issue yet to be
addressed is the optimal time for the
administration of cognitive skill
remediation following the occurrence of stroke. The value of early
rehabilitation using traditional
therapies for stroke patients (i.e.,
early mobilization, repositioning of
a patient, and initial physical therapy) is well known (20-22). Both the
mortality and the morbidity rate
decrease with early treatment.
Stroke victims are more likely to
return to independent functioning
if placed on a rehabilitation stroke
program directly after the stroke
(20-22). Although physical, speech,
and occupational therapies are now
widely available for the acute stroke
patient, cognitive retraining may
not be routinely included as a part
of these programs. Moreover, to our
knowledge, there are no published
studies that have tested the effectiveness of a formal program of cognitive skills retraining in acute stroke
patients. The studies reporting on
cognitive skill techniques for stroke
patients have all been conducted
with patients at least 6 to 8 weeks
post-stroke or later (18,23,24).
The purpose of this study, therefore, was to determine the feasibility
of administering cognitive skill
training to acute patients within a
week post-stroke, and to test the
beneficial effects of such exposure.
Three cognitive skills were selected
for the study: visual scanning,
visual-spatial orientation, and time
judgment.
Method
Patients. Thirty-three acute stroke
patients from St. Luke's Hospital,
New Bedford, Massachusetts, were
pre-tested for scanning, visualspatial, and time judgment skills.
(Pre-testing was done after obtaining the signed approval of the medical coordinator and consent of the
patient.) The patients were randomly assigned to an experimental
or control group following pretesting. The following variables
were compared between experimental and control groups to check
for homogeneity: age, sex, pre-test
score, and medical condition. The
medical condition was assessed by
the type and amount of damage,
hemisphere damage, and the patient's functional abilities, and was
determined by l. medical coordinator's diagnosis; 2. neurological evaluation (Neurological Severity
Score), and 3. Barthel Score. CAT
scan reports and records of each
patient's medical history were used
to confirm the diagnosis and to rule
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321
Table 1
Means and Standard Deviations for Subject Variables of Experimental and Control
Patients
P Value
Variable
Experimental Group
Control Group
Age
X = 705 (±11.4)
X
Barthel Score
(of 100)
X = 25.2 (±8.6)
X = 22.9
Neurological Severity
Score (of 60)
X = 29.4
X =28.5 (±6.4)
>'20
Side of Damage,
No. cases
Right brain = 7
Left brai n = 9
Right brain = 8
Left brain = 9
>'50
Sex
M =7
F=9
M =9
F=8
>'50
Pre-test Score
(of 100)
54.2 (±24.3)
48.9 (±24.1)
>'10
No. Days-from
Admittance to Stroke
Program to Pre-test
481 (±1.6)
46 (±2.6)
>'20
No. Days from Pre-test
to Post-test
22.1 (±7.1)
22.2 (±6.3)
>'20
(±39)
= 73.4
(±9.2)
>'20
(±11.7)
>'20
Table 2
Mean Difference Improvement Scores' and Standard Deviations for Each Skill Area
Task
Control Group
n
Mean
SD
Experimental Group
Mean
n
SD
P Values
13.2
10
<.005
-3.3
18.0
15
<.005
7.8
30.3
13
<.05
Scanning
35.9
21.3
9
3.8
Visual-Spatial
31.0
22.8
14
Time-Judgment
24.8
18.3
12
• Based on a 100-pt scale.
out tumors and any extensive
bilateral damage or old brain damage. Table I displays the means and
standard deviations of these major
subject variables for the two groups.
The statistical comparisons between the experimental and control
groups (l-lests and chi-square tests)
reveal no significant differences for
age, Barthel Score (f unctiona I abil ities), Neurological Severity Score,
side of brain damage, sex, pre-test
scores, and duration between stroke
and pre-tes!.
Pre- and Post-tests. The pre-test
322
and post-test consisted of two similar forms of three tasks; leller cancellation (visual scanning), visualspatial matching to sample, and
time estimation. The testing procedures were thesameas those used by
Carter, et al. (18). For the letter cancellation task, the patient was visually and verbally instructed lO find
and cross out the target leller each
time it appeared among other letters on the page. The visual-spatial
task consisted of two parts of three
sets each. The first part required the
patient to match an object that was
identical lO the sample. For the
second part, the correct match was
the same as the sample but in a different spatial orientation. For these
tasks, if the patient was unable to
hold a writing instrument or point
to the correct response, the tester
pointed to each letter or figure lO
obtain a verbal or motor response.
For the time judgment task, each
patient was asked to estimate a 1minute time period. Verbal and
visual instructions were given and a
stopwatch was used to ensure that
the patient understood the task.
The score was the proportion of the
absolute value of the difference
between 60 seconds and the patient's
estimate of 60 seconds.
Procedure. Following the pretesting and random assignment of
patients to groups, cognitive skill
remediation training was given to
the treatment group. This training
was administered on a one-lO-one
basis for 30 lo 40 minutes three
times per week and only for those
skill areas that needed improvement, which were defined as areas
with pre-test performances below
80 percent on any of the three skills
(visual scanning, visual-spatial,
and time judgment skills). Treatment continued for as long as the
patient was on the Stroke Program,
an average of 3 to 4 weeks. The
training exercises and procedures
were taken from the Thinking
Skzlls Workbook (19), which was
specifically designed to retrain visual scanning, visual-spatial, and
time judgment abilities in adult
patients. The training procedures
included the use of positive reinforcement, immediate feedback,
gradually increasing the difficulty
level of tasks, and showing the relevance of the training tasks to daily
skills. This training approach was
used in a previous study for rehabilitation patients (18).
May 1983, Volume 37, Number 5
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The nontreatment, or control
group, did not receive this training.
Other stroke program activities
continued routinely for both
groups. These included social
worker interviews, physical therapy, speech therapy, occupational
therapy, family visits, and constant
interaction with the rehabilitation
n ursi ng staf£.
The testing and training took
place between 9:00 and II :45 in the
morning before or after the other
stroke program therapies. The
stroke program staff was not informed of group assignment for the
patients in this project, or of the
experimental nature of the project.
Both treatment and nontreatment
patients were post-tested for performance on scanning, visual·
spatial, and time jud?;ment skills
before discharge from the stroke
program. Although several trainers
and testers were employed for the
duration of the study, in all cases
the sa me assista nt ga ve both the pretest and the post-test for anyone
patient. To help protect against
experimental bias, these pre-test
scores were not discl osed to the
tester or to the patient until after the
post-test was completed. At that
time, complete feedback was given
to all patients. For the major part of
the study, an experimental blind
testing procedure was used: that is.
group assignment-experimental
or control-was not known to the
tester. However, because of the
physical layout of the stroke unit, at
times it was possible for the tester to
see which patients were given training by the other assistant.
Results
Overall and separate skill area improvement scores, which represent
a difference from the pre-test to the
post-test score, were calculated for
all patients. The overall improve-
Figure 1
Pre-test (top) and post-test (bottom) performance on letter cancelation task by patient
in the experimental group
2S f •• o.~
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ment score for each patient represented a mean of the specific improvement scores for those skill
areas that were pre-tested at a performance level below 80 percent.
Therefore, scores for those patients
in the experimental and control
grou ps tha thad <l n 80 percen t pretest performance or better were not
included in the calculations for
those tasks (see procedure, no training was given for skill2=: 80%). This
0 P E V Z X W HUM",
was done to preven t possi bl e ceil ing
performance effects. The overall
me<ln improvement score was 32.2
(SD = 16.11) for the experimental
patients(n= 16)and4.9(SD= 13.98)
for the control patients (n = 17). A
statistical analysis with a Mann
Whitney-U test revealed that the
experimental group's overall improvement was significantly higher
than that of the control group (p <
.005).
The American Journal of Occupational Therapy
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323
Figure 2
Pre-test (top) and post-test ((bottom) performance on first part of visual-spatial task by
patient in the experimental group
FOR EACH SET. FI ND THE ONE OBJECT
THAT MATCHES TI1E OB,JECT AT THE TOP
FOR EACH SET, FIND THE ONE OBJECT
THAT MATCHES TI1E OBclECT AT THE TOP
o
o
CJ t:=:J
CJO~
V@O
Table 2 displays the separate skill
area improvement scores for both
experimental and control groups.
Mann Whitney- U tests were conducted between the groups for the
visual scanning, visual-spatial, and
time judgment tasks to determine
statistical differences. As Table 2
shows, the mean improvement
scores for each of these skills were
significantly better for those patients who received cognitive skill
remediation training. Notealso that
the n sizes vary for each task category. As men tioned a bove, those
patients that scored:::= 80 percent on
the pre-test were not included in the
calculations for those tasks. Since
this actually produced subgroups of
the original two groups, further
tests were conducted to ensure that
each of these subgroups was not differenton thesubject variables listed
in Table 1. These statistical tests
324
revealed no differences between the
experimental and control patients
in any of the skill area subgroups
for any of the variables (ps > .05)
Figures 1-3 are examples of patients' performances on visual scanning and visual-spatial tasks. The
pre-test and score is shown at the
top, and the post-test at the bottom,
for each case. Substantial improvement can be seen in the post-test for
patients who received training. In
the first figure, the patient found all
but one A on the post-test. When
finished, the patient was then asked
whether there were any more, the
tester said there was just one more,
and the patient quickly found it and
crossed it au t, the onl y one not
numbered. Numbering the letters
consecu t ive I y was a method this
patient used as a helpful aid. Note
the marked left-visual neglect on
the pre-test for this patient.
Discussion and Summary
This cognitive skill remediation
progra m ad min is tered to acu te
stroke patients resulted in significantly higher pre-test to post-test
performance scores compared to
those of patients who did not participate in the program. These higher
scores were found for each of the
three skills in the remediation training program: visual scanning,
visual-spatial orientation, and time
judgment.
Each of these skills is relevant to
lhe performance of other tasks that
are normally performed on a dail y
basis. Visual scanning is needed for
reading and looking at objects in
the entire visual field. Retraining of
visual scanning skills has been
shown to improve reading and other
related tasks in right brain-damaged
patients (14). Deficits in visual
scanning were found to be related to
May 1983, Volume 37, Number 5
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Figure 3
Pre-test (top) and post-test (bo//om) performance on second part of visual-spatial task
by patient in the experimental group
FOR EACH SET FIND THE ONE OBJECT
THAT MATCHES THE OBJECT AT THE TOP
:3 Eryoors
&
~
~
<8>
1> <f/
t:l W
@0
FOR EACH SET FIND THE OOE OBJECT
o
<B>
THAT MAltHES THE OBJECT AT TI-£ TOP
e,,"yoO yo S
(Q)
CQ)
@®
@
CD
CiJ
~
&
0>
Q
\QJ
~
@
W
@J
~
an increase in accident-prone behavior of both right and left braindamaged rehabilitation patients
(24). According to Diller and Weinberg, this relationship is understandable since scanning is necessary for many activities in a rehabilitation setting, such as accurately
perceiving and locating objects in
space, operating a wheelchair, and
for transferring to and from a wheelchair (24).
Visual-spatial orientation is a
skill needed for identifying and perceiving objects with different forms
and in various positions (object
constancy). In a recent study by
Kaplan and Hier (II), visual-spatial
orientation was found to be an
important predictor of functional
ability, as measured by self-care
scores and disposition status, in
patients with right brain damage.
<;;p <9
They suggest that occupational
therapists should reconsider the
importance of visuospatial skills in
successfully rehabilitating patients
with right brain damage. In our
st udy, as can be noted in the resu Its,
not only were visual-spatial deficits
the most frequent skill deficit, but
they were found in patients with
both right and left brain damage.
Time judgment, or estimating a
I-minute time interval, is a skill
that requires attention, orientation,
and an immediate awareness of
events. An awareness of the length
of the training session was incorporated into the training for this task.
This presumably helped to orient
the patient to better attend to the
actual training process.
Traditionally, when cognitive
skill remediation programs have
been employed, they are started later
~
~
9
in the rehabilitation process, that is,
not in the acute phase or week following brain damage. The argument given has been that before this
phase the stroke or head tra u ma
patient is not emotionally or mentally prepared to engage in this type
of active rehabilitation (16). Yet,
this study demonstrated that it is
feasi ble to s uccessf ull y implement a
cognitive skills remediation program for stroke patients during the
acute phase of rehabilitation. Such
a program may ideally be intergrated into a patient's ongoing occupational therapy treatment program during the acute phase. This
of course does not pree! ude a more
extensive program later in the rehabilitation process.
Moreover, since the trend of recent research indicates that mental
or cognitive abilities play an impor-
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325
tant role in the effective rehabilitation of brain-damaged patien ts (II,
12, 22), early intervention and
treatment of such deficits would be
desirable in order to maximize the
rehabilitative efforts. Future research is needed to ascertain the
exact nature of this relationship
between the return of functional
abilities and the degree of cognitive
skill impairment, as well as the
effect of cognitive skill remediation
on the recovery of activities of daily
living.
Another consideration is the impact that thinking skill deficits
would have on the patient's emotional and general mental attitude.
Such deficits can lead to frustration
and, if left unattended, even to depression. In our study, many of the
patients seemed relieved that their
thinking skills were also being
helped after the stroke. In general,
during this acute phase, these patients worked steadily and eagerly
on the retraining tasks. They were
shown the relevance of these tasks to
their daily living routine, and the
trainers constantly incorporated
items in the patients' hospital room
(family pictures, greeting cards,
reading material) into the training
for each skill area.
In conclusion, this study demonstrated that a cognitive skills remediation program was effective in
improving thinking skills for acute
stroke patients. Since the assessment and treatment of cognitive
skill deficits are becoming increasingly viewed as important to occupational therapy (II), future research focusing on the integration
of these remediation procedures
with existing occupational therapy
programs would be beneficial.
Acknowledgments
This research was supported by a
grant awarded to the first author by
326
Southeastern New England Long
Term Care Gerontology Center,
Brown University, through the
Administration on Aging, Older
Americans Act Title IV E, 90 AT2161. The authors thank the Administration, Nursing, and Rehabilitation Staff at St. Luke's
Hospital for their encouragement
and support of this project; Lori
Levesque, Pamela Grumney, and
Jo Ellen Guerreiro for their assistance as testers and trainers; and
finally, David S Greer, M.D,
Andrea Lukoff, OTR, and Johanna
Duponte, OTR, for their helpful
suggestions on earlier drafts of this
manuscript.
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