Cognitive and Perceptual RehabModule 1: Overview/General Considerations
for Intervention
Course Description:
This course is derived from the textbook by Glen Gillen “Cognitive and Perceptual
Rehabilitation: Optimizing Function” ©2009. The text reflects current practice with a
renewed focus on function-based assessments and evidence-based interventions. Cognitive
and Perceptual Rehabilitation: Optimizing Function includes all of the tools you need to
make a positive impact on your patients' lives. The text summarizes, highlights, and
constructively critiques the state of cognitive and perceptual rehabilitation. The goal is to
help you enhance your patients' quality of life by promoting improved performance of
necessary and meaningful activities, and decreasing participation restrictions.
Module 1: Overview/General Considerations for Intervention covers chapters 1 and 2.
Chapter 1: Overview of Cognitive and Perceptual Rehabilitation
Chapter 2: General Considerations: Evaluations and Interventions for Those Living with
Functional Limitations Secondary to Cognitive and Perceptual Impairments
Methods of Instruction:
Online course available via internet
Target Audience:
Physical Therapists, Physical Therapy Assistants, Occupational Therapists, and Occupational
Therapy Assistants
Educational Level:
Intermediate
Prerequisites:
None
Course Goals and Objectives:
At the completion of this course, participants should be able to:
1. Identify various classifications systems that can be used to guide the evaluation and
intervention process for those living with functional limitations secondary to cognitive
and perceptual impairments
2. Apply the principles of client-centered practice to this population
3. Identify outcome measures are appropriate for this population
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4.
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6.
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8.
9.
Recognize patterns of cognitive and perceptual impairments that interfere with
everyday function
List the differences between top-down and bottom-up approaches to assessment and
evaluation
List the pros and cons of the use of pen-and-paper (tabletop) assessment procedures
Differentiate between various forms of reliability and validity
Recognize the issue of generalization of clinical intervention strategies to everyday
functions
Understand the interplay of the environment context and task performance as it relates
to assessment and interventions
Criteria for Obtaining Continuing Education Credits:
A score of 70% or greater on the written post-test
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DIRECTIONS FOR COMPLETING
THE COURSE:
1.
2.
3.
4.
5.
6.
7.
8.
9.
This course is offered in conjunction with and with written permission
of Elsevier Science Publishing.
Review the goals and objectives for the module.
Review the course material.
We strongly suggest printing out a hard copy of the test. Mark your
answers as you go along and then transfer them to the actual test. A
printable test can be found when clicking on “View/Take Test” in your
“My Account”.
After reading the course material, when you are ready to take the
test, go back to your “My Account” and click on “View/Take Test”.
A grade of 70% or higher on the test is considered passing. If you
have not scored 70% or higher, this indicates that the material was
not fully comprehended. To obtain your completion certificate,
please re-read the material and take the test again.
After passing the test, you will be required to fill out a short survey.
After the survey, your certificate of completion will immediately
appear. We suggest that you save a copy of your certificate to your
computer and print a hard copy for your records.
You have up to one year to complete this course from the date of
purchase.
If you have a question about the material, please email it to:
[email protected] and we will forward it on to the author.
For all other questions, or if we can help in any way, please don’t
hesitate to contact us at [email protected] or
405-974-0164.
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CHAPTER 1
Overview of Cognitive and Perceptual Rehabilitation
KEY TERMS
Activity Demands
Activity Limitation
Areas of Occupation
Client-centered Practice
Client Factors
Context
Environmental Factors
Impairment
Participation Restriction
Performance Patterns
Performance Skills
Quality of Life
LEARNING OBJECTIVES
3. Understand which outcome measures are appropriate for this population.
4. Understand patterns of cognitive and perceptual
impairments that interfere with everyday function.
At the end of this chapter readers will be able to:
1. Understand various classification systems that can be
used to guide the evaluation and intervention process for those living with functional limitations secondary to cognitive and perceptual impairments.
2. Apply the principles of client-centered practice to
this population.
“Best practice is a way of thinking about problems in imaginative ways, applying knowledge
creatively to solve performance problems while also taking responsibility for evaluating the
effectiveness of the innovations to inform future practices.”38
functional activities. In general, this assumption
has not been supported by empirical research.
An early example is the elegant work of Neistadt.47
The researcher had previously identified a relationship between construction tasks as measured by the
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Block Design Test and a standardized assessment of
meal preparation, the Rabideau Kitchen EvaluationRevised, concluding that constructional abilities may
contribute to meal preparation performance. Based
on these findings a randomized controlled trial was
PERSPECTIVES OF COGNITIVE AND
PERCEPTUAL REHABILITATION
The practice area of cognitive and perceptual
rehabilitation has and continues to shift in focus.
In the recent past, interventions were focused on
cognitive and perceptual stimulation activities
aimed at the remediation of a particular impairment. It was assumed that the remediation of an
identified impairment or impairments would
generalize into the ability to perform meaningful,
1
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
conducted to examine the effects of interventions
focused on retraining meal preparation skills versus the remediation of constructional deficits in
adult men with head injuries. Outcomes were meal
preparation competence and objective measures of
const ructional abilities. Forty-five subjects, ages 18
to 52, in long-term rehabilitation programs, were
randomly assigned to one of two treatment groups:
remediation of construction abilities (n = 22) via
training with parquetry block assembly, and a meal
preparation training group (n = 23). Both groups
received training for three 30-minute sessions per
week for 6 weeks, in addition to their regular rehabilitation programs. Results showed task-specific
learning in both groups and suggested that training in functional activities may be the better way to
improve performance in such activities in this population. In other words, those trained in construction
tasks performed better on novel tabletop construction tasks but did not improve on meal preparation
measures, whereas those trained in the meal preparation group demonstrated significantly improved
abilities related to the ability to make a meal at the
end of the intervention despite not improving on
measures of construction ability. Although the results
of this study are not unexpected based on a current
understanding of recovery, the study challenged the
typical interventions that were being taught in academic settings and those that were commonly used
in the clinic at the time it was published.
In general, interventions at that time were provided in controlled environments consisting of
tabletop activities that were novel and not focused
on function. Examples include engaging individuals
in block design activities, sequencing picture cards,
puzzle making, design copying, canceling a target stimulus on paper, pegboard designs, memory
drills, and so on. As technology became more readily available, specialized cognitive-retraining computerized programs were developed, marketed, and
quickly adopted into the clinical setting. In terms
of outcomes, interventions were deemed successful
when improvements were documented on specific
cognitive and perceptual impairment tests.
Similar to the interventions that were being used
at this time, measurement instruments attempted to
isolate a particular impairment via novel and nonfunctional test items such as copying words and
designs, picture matching, block building, sequencing pictures, free recall of words, memorizing and
attending to a number string, and so on. It has and
continues to become clear that interventions such as
these need to be reconsidered if we as clinicians expect
to influence function in the real world. In addition, it
is becoming clear that how we measure the success
of an intervention must be reconsidered. Significant
improvement in a letter cancellation test for a person
living with unilateral spatial neglect can no longer be
interpreted as a positive outcome if more meaningful functional changes (e.g., improved ability to read,
manage medications, play board games, manage
money, etc.) cannot be documented.
As rehabilitation professions began to understand the importance of evidence-based practice
and have refocused on “real-world” functional outcomes, the rehabilitation process has begun to shift
accordingly. Interventions that focus on strategies
for living independently, with a purpose, and
with improved quality of life despite the presence
perhaps of cognitive and perceptual impairments are
slowly becoming the clinical standard. Likewise, outcome measures that focus on documenting improved
functioning outside of a clinic environment and
those that include test items focused on performing
functional activities are being embraced.
These positive changes should be welcomed by
clinicians and the individuals to whom they provide
services because making a positive change in the life
of an individual living with cognitive and perceptual impairments has been notoriously difficult. It
is expected that as the research literature focused on
testing interventions continues to emerge, further
shifts in practice patterns will occur. Philosophically,
the clinical focus of what is called cognitive and perceptual rehabilitation may be better described as the
process of improving function and quality of life in
those individuals living with cognitive and perceptual
impairments.
WORLD HEALTH ORGANIZATION’S
INTERNATIONAL CLASSIFICATION OF
FUNCTION AS A FRAMEWORK FOR
CHOOSING ASSESSMENTS, INTERVENTIONS,
AND DOCUMENTING OUTCOMES
The World Health Organization’s (WHO) International Classification of Functioning, Disability,
and Health (ICF)68 is a classification system that
describes body functions and structures, activities,
and participation. The various domains are inclusive and consider the body itself as well as the individual and societal perspectives. The ICF embraces
the relationship between the person and the context
in which daily living occurs and therefore includes
environmental factors as part of the classification
system. The ICF is a useful guide to rehabilitation,
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
particularly when considering assessments, interventions, and outcomes for people living with cognitive
and perceptual impairments.6,49 Elements of the classification system (Table 1-1) include the following68:
• Body structures: Anatomic parts of the body
(organs, limbs, and their components)
• Body functions: Physiologic functions of the body
systems inclusive of psychological functions
• Impairments: A negative aspect related to problems in body function or structure such as significant deviation or loss
• Activities: Execution of a task or action by an
individual
• Activity limitation: A negative aspect manifested as an individual’s difficulty in executing
activities
Table 1-1
• Participation: Involvement in life situations
• Participation restrictions: A negative aspect manifested as an individual experiencing problems
in life situations
• Environmental factors: Physical, social, and attitudinal environment in which people live and
conduct their lives; includes environmental as
well as personal factors
From an evaluation, intervention, and rehabilitation outcomes perspective, it is important to
consider the relationships between the classification categories of the ICF rather than focusing on
one category at a time (Figure 1-1). For example,
“Mark” may survive a right frontoparietal stroke
resulting in visuospatial impairments and unilateral spatial neglect of the left side (impairment of
Summary of the International Classification of Functioning, Disability, and Health
(ICF) Related to Cognitive and Perceptual Rehabilitation
ELEMENT
BODY STRUCTURES
Structures of the nervous system
BODY FUNCTIONS
Mental functions
Seeing functions
ACTIVITIES/PARTICIPATION
Learning and applying knowledge
General tasks and demands
Self-care
Mobility
Communication
Domestic life
Interpersonal relationships
Major life areas
Community, social, civic life
ENVIRONMENTAL FACTORS
Products and technology
Support and relationships
Attitudes
Service, systems, and policies
3
DESCRIPTION/EXAMPLES
Cortical lobes (frontal, temporal, parietal, occipital), midbrain, basal ganglia and
related structures, diencephalon, cerebellum, brainstem, cranial nerves
Global mental functions: consciousness, energy and drive, orientation, intellectual
functions, psychosocial functions, temperament and personality, etc. Specific
mental functions: attention, memory, psychomotor functions, emotional
functions, language, perceptual functions (e.g., visuospatial, tactile perception),
thought, abstraction, organization/planning, sequencing of complex
movements, judgment, problem solving, body image, insight, calculations, etc.
Visual acuity, visual field, quality of vision, function of the muscles of the eye
Reading, writing
Carrying out a daily routine, undertaking a single task, undertaking multiple
tasks
Washing, dressing, toileting
Changing body positions, handling objects, walking, driving, using
transportation
Communication with spoken or nonverbal messages, speaking
Household tasks, shopping, assisting others
Social and family relationships
Education, work and employment, volunteer work, economic life
Recreation, leisure, religion
Aids for use in daily living, mobility, communication, employment, recreation,
education, design, and construction of buildings for private or public use
Family, friends, animals, health care professionals
Personal, societal
Housing, legal, civil protection
Data from World Health Organization: International Classification of Functioning, Disability and Health, Geneva, 2001, World Health Organization.
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Health condition
(disorder or disease)
Body Functions
& Structure
Participation
Activity
Environmental
Factors
Personal
Factors
Contextual factors
Figure 1-1 Interaction between components of the International Classification of Functioning, Disability, and Health. (From World Health
Organization: International Classification of Functioning, Disability and Health, p. 18, Geneva, 2001, World Health Organization.)
body functions). These impairments may in turn
result in Mark’s inability to perform tasks such as
word processing, driving a car, balancing a checkbook, or preparing a meal (activity limitations). The
resultant activity limitations may adversely affect
Mark’s ability to continue gainful employment or
live on his own (participation restrictions).
AMERICAN OCCUPATIONAL THERAPY
ASSOCIATION’S PRACTICE FRAMEWORK
AS A FRAMEWORK FOR CHOOSING
ASSESSMENTS AND INTERVENTIONS,
AND DOCUMENTING OUTCOMES
The American Occupational Therapy Association
(AOTA) has published a framework for guiding
practice (Table 1-2).2 Components of the framework include the following:
• Performance in areas of occupation: Occupations
and daily life activities
• Client factors: Factors such as body structures
and body functions that affect performance in
areas of occupation
• Performance skills: Observable elements of action
that have implicit functional purposes
• Performance patterns: Patterns of behavior
related to daily life activities
• Context: Conditions within or surrounding the
client that affect and influence performance
• Activity demands: Aspects of an activity required
to carry out the activity
The AOTA Practice Framework and the WHO’s
ICF are interrelated despite the use of different terminology (Figure 1-2).
CLIENT-CENTERED PRACTICE
Client-centered practice is an approach to providing
rehabilitation services,“which embraces a philosophy
of respect for, and partnership with, people receiving services. Client-centered practice recognizes the
autonomy of individuals, the need for client choice
in making decisions about occupational needs,
the strengths clients bring to a therapy encounter,
the benefits of client-therapist partnership, and the
need to ensure that services are accessible and fit the
context in which a client lives.”36
Law and colleagues37 as well as Pollock,50 suggest
that the therapist implementing this approach to
evaluation include the following concepts:
1. Recognizing that the recipients of therapy are
uniquely qualified to make decisions about their
functioning
2. Offering the individual receiving services a
more active role in defining goals and desired
outcomes
3. Making the client-therapist relationship an
interdependent one to enable the solution of
performance dysfunction
4. Shifting to a model in which therapists work
with individuals to enable them to meet their
own goals
5. Evaluation (and intervention) focusing on the
contexts in which individuals live, their roles and
interests, and their culture
6. Allowing the individual who is receiving services
to be the “problem definer,” so that in turn the
individual will become the “problem solver”
7. Allowing the client to evaluate his or her own
performance and set personal goals
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Table 1-2
5
Summary of the American Occupational Therapy Association (AOTA) Practice
Framework Related to Cognitive and Perceptual Rehabilitation
DOMAIN
EXAMPLES
Performance in areas of occupation
Client factors
Performance skills
Performance patterns
Context
Activity demands
Basic/personal activities of daily living, instrumental activities of daily living,
education, work, play, leisure, social participation
Mental Functions: consciousness, energy and drive, orientation, intellectual
functions, psychosocial functions, personality, attention, memory,
psychomotor, language, perceptual functions (e.g., visuospatial), thought,
abstraction, organization, planning, judgment, problem solving, insight,
calculations, motor planning, etc.
Process skills: energy, knowledge, temporal organization, organizing space and
objects, adaptation
Motor skills: posture, mobility, coordination, strength and effort, energy
Communication/interaction skills: physicality, information exchange, relations
Habits, routines, roles
Cultural, physical, social, personal, spiritual, temporal, virtual
Objects and their properties, space demands, social demands, sequence and
timing, required actions, required body functions and structures
Data from American Occupational Therapy Association: Occupational therapy practice framework: domain and process, Am J Occup Ther 56:609-639, 2002.
Practice Framework
ICF
Client Factors
Body Structures & Body Functions
Performance in Areas of Occupation
Activities
Participation
Context
Environmental Factors
Figure 1-2 Relationships between the American Occupational Therapy Association (AOTA) Practice Framework and the World Health
Organization’s International Classification of Functioning, Disability, and Health (ICF).
Through the use of these strategies the evaluation
process becomes more focused and defined, clients
become immediately empowered, the goals of therapy are understood and agreed on, and an individually tailored intervention plan may be established.
The Canadian Occupational Performance Measure36
is a standardized tool that embraces a client-centered
approach and is discussed later.
van den Broek56 specifically recommends using
a client-centered approach as a way to enhance
neurorehabilitation outcomes and states that
treatment failure may be secondary to clinicians
focusing interventions on what they believe the
client needs rather than what the client actually
wants. van den Broek56 affirms that client-centered
goal setting is a key to successful rehabilitation
outcomes, stating:
cannot be judged to be effective or ineffective. Moreover,
the quality and type of goal setting sets the tone of the
interaction between the clinician or treating team and
the patient. Goals that are proposed, suggested, or identified by the clinician tend to be those based on what
the clinician believes the patient needs. Of equal, if not
more importance, however, is what the patient wants to
achieve. Patients tend to be motivated toward achieving
or satisfying their wants, and may not be so motivated
or quite unmotivated toward achieving other goals. The
process of goal setting therefore involves arriving at an
overlap between needs and wants, or where this is not
possible agreeing to work toward wants that represent
a reasonable compromise. Goal setting that ends with
treatment goals that consist of needs that the patient does
not want or is indifferent toward is not client centered
but prescriptive, and runs the risk of concluding in an
ineffective outcome.”
“Goal setting is of central concern as without goals,
rehabilitation has no direction and the intervention
Another argument for using a client-centered
approach to guide the intervention focus with this
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
population is that interventions typically used for
those living with cognitive-perceptual dysfunction
are notoriously difficult to generalize to other realworld settings and situations. For example, visual
scanning training via tabletop activities for those living with unilateral spatial neglect most often will not
automatically generalize to the client’s being able to
use the scanning strategy to find items in the refrigerator unless the strategy is specifically taught in the
context of the activity. In addition, strategies that are
taught to accomplish a specific task (e.g., using an
alarm watch to maintain a medication schedule for
those living with memory loss) will not necessarily generalize or “carry over” to another task such as
remembering therapy appointments. Finally, there
are a large number of clients whose level of brain
damage preclude them from generalizing learned
tasks.48 This issue of task-specificity related to treatment interventions must always be considered by
clinicians working with this population. A clientcentered approach will help ensure that outcomes,
goals, and tasks used as the focus of therapy are at
least relevant, meaningful, and specific to each client
as well as the caretaker or significant others despite the
potential lack of being generalizable for a segment
of the population living with various cognitive and
perceptual impairments.
WHAT ARE APPROPRIATE OUTCOMES
WHEN DESIGNING INTERVENTIONS
FOR PEOPLE LIVING WITH COGNITIVE
AND PERCEPTUAL IMPAIRMENTS?
Although not as a problematic as the recent past, the
practice area of cognitive and perceptual rehabilitation has been plagued by a lack of well-designed
clinical trials demonstrating positive outcomes.
A starting point is to decide what is considered
an appropriate, meaningful, and ideal outcome to
measure. This decision will help guide interventions
as well. The preceding paragraphs have already discussed the importance of keeping a client-centered
focus during the rehabilitation process. A clientcentered focus is paramount when considering outcomes as well. The following case illustrates various
possible outcomes:
Mary is a 32-year-old woman who survived an
anoxic event that has resulted in moderate/severe
short term memory impairments. Mary is a single mother of a 5-year-old boy. She works from
home (desktop publishing). Mary’s days were quite
structured before her brain injury. Mornings were
characterized by basic self-care followed by tasks
related to getting her son to school (choosing his
clothing, making lunch, etc.). As the sole financial
provider, Mary spent the greater part of the rest of
the day in her home office working on the computer, fielding phone calls, and organizing present or upcoming jobs. Lunch was usually a quick
cold sandwich. Mary stopped working at 3:30 when
her son arrived home from school. Depending on
the day she would drive her son to Little League or
drum lessons. Mary always cooked a full dinner and
spent the rest of the evening helping with homework and watching television. Mary’s memory
impairments are preventing her from continuing
to work. For safety reasons, her mother has moved
in to help with childcare, household organization,
and financial matters. Mary has recently expressed
feelings of low self-esteem, saying that “she can’t
do anything by herself anymore.” Mary has stated
that she is most concerned about starting to work
(finances are limited) and she would like to take a
more active parenting role again. Prior to initiating
interventions, Mary participated in three assessments including standardized measures of memory
impairment, instrumental activities of daily living
(IADL) (e.g., homemaking and child care), and
quality of life (QOL).
Possible (noninclusive) outcomes for Mary
based on the ICF68 may include the following:
• OUTCOME 1: Following cognitive rehabilitation, Mary has improved her scores
on a standardized memory scale (decreased
impairment) but changes are not detected on
measures of IADL and QOL (stable activity
limitations/participation restrictions).
• OUTCOME 2: Following cognitive rehabilitation, Mary has no detectable changes on the
standardized memory scale (stable impairment) but changes are detected on measures of IADL and QOL (decreased activity
limitations/participation restrictions).
• OUTCOME 3: Following cognitive rehabilitation, Mary has detectable changes on
the standardized memory scale (decreased
impairment) as well as changes that are
detected on measures of IADL and QOL
(decreased activity limitations/participation
restrictions).
Out of the three outcome scenarios, outcome 1 is
the least desirable. In the past this type of outcome
may have been considered successful (i.e., “Mary’s
memory has improved”). This outcome may be
indicative of an intervention plan that is overfocused on attempts to remediate memory skills
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
(e.g., memory drills, computerized memory programs) without consideration of generalization
to real-life scenarios. If a change at the impairment level of function does translate or generalize to improved ability to engage in meaningful
activities, participate successfully in life roles, or
enhance quality of life, the importance of the
intervention needs to be reconsidered. Outcomes
2 and 3 are more clinically relevant, arguably more
meaningful to Mary and her family, and represent more optimal results of structured rehabilitation services. Outcome 2 may have been achieved
by focusing interventions on Mary’s chosen tasks.
Interventions such as teaching compensatory strategies including the use of assistive technology may
have been responsible for this outcome. Mary is
able to engage in chosen tasks despite the presence
of stable memory impairments.
Finally, outcome 3 represents improvement
(decreased impairment, improved activity performance, and improved quality of life) across multiple health domains. Although this outcome may
be considered the most optimal, the relationships
among the three measures are not clear. Clinicians
may assume that the improved status detected by
the standardized measure of memory was also
responsible for Mary’s improved ability to perform household chores and childcare. This reasoning is not necessarily accurate. The changes within
the health domains may in fact be independent of
each other. In other words, Mary’s improved ability to manage her household after participating in
treatment may be related to the fact that interventions included specifically teaching Mary strategies to manage her household. Similar to outcome
2, this positive change may have occurred with or
without a documented improvement in memory
skills.
Traditionally clinicians and researchers involved
in working with those living with cognitive and perceptual impairments use standardized measures of
cognitive-perceptual impairment (i.e., standardized
tests of attention, memory, apraxia, neglect) as the
primary outcome measure to document effectiveness of interventions. Although this is one important level of measurement and following chapters
will review specific cognitive-perceptual measures
in detail, it is not sufficient to use these measures
as the sole or important indicator of successful
interventions. It is critical that clinical programs
and research protocols not only include but also
focus on measures of activity, participation, and
quality of life as a key outcome. As stated, positive
7
changes in these measures are more relevant than
an isolated change on an impairment measure—
the impairment change must be associated with a
change in other health domains. Individuals receiving services, family members, and third-party payers alike are likely to be more satisfied with changes
at these arguably more meaningful levels of function. The following standardized, valid, and reliable measurement instruments are suggested to
document successful clinical and research outcomes related to improving function in those with
functional limitations secondary to the presence of
cognitive and perceptual impairments.
For a thorough review of performance-based
measures, refer to Law and associates.39 Unless otherwise indicated, they are not impairment-specific
evaluations; therefore, they have high use when
working with this population.
Quality of Life Measures
The construct of quality of life is broad and complicated. In her paper “What Is Quality of Life?”
Donald17 summarizes several issues related to quality of life:
• “Quality of life is a descriptive term that refers
to people’s emotional, social and physical wellbeing, and their ability to function in the ordinary tasks of living.
• Health-related quality of life analyses measure
the impact of treatments and disease processes
on these holistic aspects of a person’s life.
• Quality of life is measured using specially
designed and tested instruments, which measure
people’s ability to function in the ordinary tasks
of living.
• Quality of life analyses are particularly helpful
for investigating the social, emotional, and physical effects of treatments and disease processes on
people’s daily lives; analyzing the effects of treatment or disease from the client’s perspective;
and determining the need for social, emotional,
and physical support during illness.
• Quality of life measures can therefore help to
decide between different treatments, to inform
clients about the likely effects of treatments, to
monitor the success of treatments from the client’s perspective, and to plan and coordinate
care packages.”
Clinicians and researchers should consider
improving quality of life as an overarching theme
related to rehabilitation in general. Specific assessments are reviewed below.
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Medical Outcomes Study Short Form-36
The Medical Outcomes Study Short Form-36 (SF36)59 is a widely used survey instrument for assessing a client’s health-related quality of life. The SF-36
measures eight domains: physical functioning, role
physical, bodily pain, general health, vitality, social
functioning, role emotional, and mental health,
and has two summary scores (physical and mental). The SF-36 has demonstrated its reliability and
validity in multiple populations and can be administered in various ways. The SF-1258 and SF-2060 are
abbreviated versions of the SF-36 health profile.
Sickness Impact Profile
The Sickness Impact Profile (SIP)11 is used to evaluate the effect of disease on physical and emotional
functioning. The measure includes two overall
domains: physical and psychosocial. The measure
has 12 categories including sleep and rest, eating,
work, home management, recreation and pastimes,
ambulation, mobility, body care and movement,
social interaction, alertness behavior, emotional
behavior, and communication. The instrument
yields an overall score, 2 domain scores, and 12
category scores; items are weighted according to a
standardized weighting scheme. A stroke-specific
version (Stroke Adapted Sickness Impact Profile) is
available.57
Nottingham Health Profile
The Nottingham Health Profile (NHP)27,28 was
developed to be used in epidemiologic studies of
health and disease and consists of two parts. Part
1 contains 38 yes/no items in six dimensions: pain,
physical mobility, emotional reactions, energy,
social isolation, and sleep. Part 2 contains 7 general yes/no questions concerning daily living problems including paid employment, jobs around the
house, personal relationships, social life, sex life,
hobbies, and holidays. The two parts may be used
independently.
Stroke Impact Scale
The Stroke Impact Scale (SIS)19,33 is a stroke-specific
measure that provides information on function and
quality of life. This self report measure including 59
items that form eight subgroups including strength,
hand function, basic and instrumental activities of
daily living, mobility, communication, emotion,
memory and thinking, and participation. The SIS
is valid, reliable, and sensitive to change in stroke
populations and is reliable when responses are
provided by proxy.
Reintegration to Normal Living
The Reintegration to Normal Living (RNL)66,67
assessment is used to document reentry into everyday life following a sudden illness or event. This
functional status measure quantitatively assesses the
degree of reintegration to normal living achieved
by clients after illness or trauma and is useful. This
tool assesses global function and the individual’s
satisfaction with basic self-care, in-home mobility,
leisure activities, travel, and productive pursuits.
Clients are provided with 11 statements to which
they respond. The test can be completed using a
pen-and-paper format or an interview format.
Satisfaction with Life Scale
The Satisfaction with Life Scale (SWLS)16 is a 5item scale that uses a 7-point Likert scale response
format. Individual scores are added to create a total
score ranging from 5 to 35. A score of 20 represents
a neutral point at which the respondent is equally
satisfied and dissatisfied. The items in the SWLS are
limited to general life satisfaction.
Activity and Participation Measures
Outcomes related to cognitive perceptual rehabilitation must be detectable and evidenced by decreasing
activity limitations and participation restrictions. Outcomes are individualized and based on the activities
(basic activities of daily living [ADL], IADL, paid
and unpaid work, and play and leisure) that clients
want to be able to do or need to do to live a safe and
productive life. Measurement instruments that focus
on the activity and participation levels are critical to
document the effectiveness of cognitive-perceptual
rehabilitation interventions. Examples follow.
Community Integration Questionnaire
The Community Integration Questionnaire (CIQ)62-64
consists of 15 items relevant to home integration, social
integration, and productive activities. It is scored to
provide subtotals for each of these, as well as for community integration overall. Scoring is primarily based
on frequency of performing activities or roles, with
secondary weight given to whether activities are done
jointly with others, and the nature of these other persons. The CIQ can be completed, by either the client or
a proxy, in about 15 minutes.
Craig Handicap Assessment and
Reporting Technique
The Craig Handicap Assessment and Reporting
Technique (CHART)61 measures the degree to
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
which impairments and activity limitations result in
decreased participation. The original CHART had
27 questions and included the following domains:
(1) physical independence: ability to sustain a
customarily effective independent existence; (2)
mobility: ability to move about effectively in one’s
surroundings; (3) occupation: ability to occupy
time in the manner customary to that person’s sex,
age, and culture; (4) social integration: ability to
participate in and maintain customary social relationships; and (5) economic self-sufficiency: ability
to sustain customary socioeconomic activity and
independence.
The revised CHART46 (32 questions) contains a
sixth domain designed to assess orientation: cognitive independence. Each of the domains or subscales of the CHART has a maximum score of 100
points. High subscale scores indicate less handicap,
or higher social and community participation. The
CHART can be administered by interview, either in
person or by telephone, and takes approximately
15 minutes to administer. Participant-proxy agreement across disability groups on the CHART has
provided evidence in support of the use of proxy
data for people with various types of disabilities.
A shorter version of the instrument, the CHART
Short Form, has 19 items that yield the same
subscales as the original CHART.
Activity Card Sort
The Activity Card Sort (ACS)9,30 uses a Q-sort
methodology to assess participation in 80 instrumental, social, and high and low physical demand
leisure activities. Clients sort the cards into different
piles to identify activities that were done prior to
insult or injury, those activities they are doing less,
and those they have given up since their injury. The
ACS uses cards with pictures of tasks that people do
every day. There are different versions of the card
sort based on where interventions are taking place.
An institutional version sorts the cards into categories of done prior to illness and not done. The
recovering version identifies activities not done in
the past 5 years, those given up because of illness,
those beginning to do again, and those activities the
client is doing now.25
In all versions, a current activity level is determined. This assessment takes approximately 30
minutes to administer and results in a score of
percent of activities retained. The ACS has been
found to be a reliable and valid measure with individuals with cognitive loss9 as well as stroke30 and
is available in several culture-specific formats.
9
In addition, an adolescent as well as child version is
in development.25
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure
(COPM)12,36 is a self-report measure used to assess
a client’s perception of recovery and goals. This
client-centered assessment allows the recipient of
treatment (or a caretaker) to identify activities that
are difficult, rate the importance of each activity,
rate own level of performance for each identified
activity, and rate satisfaction with current performance. Overall areas of assessment include self-care,
leisure, and productivity. The tool is not diagnosis
specific and can be used with children, adolescents,
and adults. To be used with success, the client must
be able to understand a 10-point Likert scale scoring format. If this is not possible, a caregiver may be
involved in the assessment process (Figure 1-3).
Barthel Index
The Barthel Index (BI)44 is a measure of basic activities of daily living and mobility. It is scored from
0 to 100, with higher scores indicative of increased
function. The specific items measured include feeding, bathing, grooming, dressing, bowel control,
bladder control, toilet use, transfers, mobility on
even surfaces, and stairs.
Functional Independence Measure
The Functional Independence Measure (FIM)31
is a widely accepted functional assessment measure used during inpatient rehabilitation. The FIM
is an 18-item ordinal scale, used with all diagnoses within a rehabilitation population. FIM scores
range from 1 to 7 (1 = total assist and 7 = complete independence). Scores falling below 6 require
another person for supervision or assistance. The
FIM measures independent performance in selfcare, sphincter control, transfers, locomotion, communication, and social cognition. By adding the
points for each item, the possible total score ranges
from 18 (lowest) to 126 (highest) level of independence. During rehabilitation, admission and
discharge scores are rated by a multidisciplinary
team while observing client function. Functioning
postdischarge can be accurately assessed using a
telephone version of FIM when administered by
qualified interviewers.
Revised Observed Tasks of Daily Living
The Revised Observed Tasks of Daily Living
(OTDL-R)15 is a performance-based test of everyday
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
STEP 1A: Self-Care
IMPORTANCE
Personal Care
(e.g., dressing, bathing,
feeding, hygiene)
Functional Mobility
(e.g., transfers,
indoor, outdoor)
Community Management
(e.g., transportation,
shopping, finances)
STEP 1B: Productivity
Paid/Unpaid Work
(e.g., finding/keeping
a job, volunteering)
Household Management
(e.g., cleaning, doing
laundry, cooking)
Play/School
(e.g., play skills,
homework)
STEP 1C: Leisure
Quiet Recreation
(e.g., hobbies,
crafts, reading)
Active Recreation
(e.g., sports,
outings, travel)
Socialization
(e.g., visiting, phone calls,
parties, correspondence)
Figure 1-3 Canadian Occupational Performance Measure (identifying occupations and rating importance). (From Park S: Enhancing
engagement in instrumental activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier/Mosby.)
problem solving and competence. The test was
designed with a focus on cognitive IADL. The test
includes nine tasks in the categories of medication
use, telephone use, and financial management. The
test does not require special equipment and can be
administered in bed. The tool has been used with
community-dwelling older adults, older adults living in nursing homes or assisted living facilities,
individuals with schizophrenia, and individuals
with brain injuries.24
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Lawton Instrumental Activities of Daily Living Scale
The Lawton Instrumental Activities of Daily Living
Scale40 includes the following items: use of the telephone (look up numbers, dial, answer), traveling
via car or public transportation, food or clothes
shopping (regardless of transport), meal preparation, housework, medication use (preparing and
taking correct dose), management of money (write
checks, pays bills). Each criterion is graded on
Table 1-3
Rating scale
Focus
Format
Country of origin
ADELAIDE
ACTIVITIES
PROFILE
FRENCHAY
ACTIVITIES INDEX
Whiting and
Lincoln (1980)
3-level
Degree of
assistance in
performance
activities
Bond and Clark
(1998)
4-level
Degree of
participation in
activities
Holbrook and
Skillbeck (1983)
4-level
Degree of
participation in
activities
Observation
United Kingdom
Interview
Australia
Interview
United Kingdom
Prepare main
meal
Wash dishes
Prepare main
meal
Wash dishes
Heavy housework
Light housework
Wash clothes
Household or car
maintenance
Heavy housework
Light housework
Wash clothes
Household
or car
maintenance
Gardening
ASSESSMENT ITEMS
Meal preparation
Prepare a meal
Prepare a hot drink
Prepare a snack
Domestic activities
Gardening
Nottingham Leisure Questionnaire
The Nottingham Leisure Questionnaire18 was
developed to measure the leisure activity of stroke
Instrumental Activities of Daily Living Standardized Assessments
RIVERMEAD
ACTIVITIES
OF DAILY
LIVING (ADL)
ASSESSMENT
Authors
a three-point scale: independent, assistance needed,
or dependent. Client self-report and informant (i.e.,
clinician or family member) versions are available.
Table 1-3 gives more choices of standardized IADL
assessments.
Heavy cleaning
Light cleaning
Hand wash clothes
Iron clothes
Hang out washing
Make bed
—
Productive
activities
Shopping/
community
activities
—
Transportation
Use public
transport—bus
Transport self to
shop
Carry shopping
Cope with money
Light gardening
Heavy gardening
Voluntary or paid
employment
Household
shopping
Personal
shopping
Drive a car or
organize
transport
NOTTINGHAM
EXTENDED ADL
SCALE
INSTRUMENTAL
ACTIVITY MEASURE
Nouri and Lincoln
(1987)
4-level
Degree of
difficulty and
assistance
engaging in
activities
Self-report
United Kingdom
Grimby et al
(1996)
7-level
Degree of
assistance in
performance
activities
Make a hot drink
Make a hot snack
Wash dishes
Take hot drinks
between rooms
Housework
Wash small
clothing items
Full clothes wash
Cook a main
meal
Prepare a simple
meal
Manage own
garden
—
—
Local shopping
Shopping
Manage own
money
Drive car or go
on bus
Travel outings or
car rides
Travel on public
transport
Drive a car
Large-scale
shopping
Small-scale
shopping
Use public
transportation
Gainful work
Observation
Sweden
Cleaning house
Washing clothes
—
(Continued)
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Table 1-3
Instrumental Activities of Daily Living Standardized Assessments—Cont’d
RIVERMEAD
ACTIVITIES
OF DAILY
LIVING (ADL)
ASSESSMENT
ADELAIDE
ACTIVITIES
PROFILE
Leisure/social
activities
—
Mobility: outdoors
Outdoor mobility
Crossing roads
Get in and out
of car
Mobility: indoors
—
Indoor mobility
Mobility to lavatory
Move bed to chair
Move floor to chair
—
Drink
Clean teeth
Comb hair
Wash face and
hands
Put on makeup or
shave
Eat
Undress/dress
Wash in bath, get in
and out of bath
Overall wash
Basic self-care
FRENCHAY
ACTIVITIES INDEX
Community social
activities
Outdoor social
activity
Invite guests to
home
Hobby
Telephone calls to
family/friends
Attend religious
events
Outdoor
recreation or
sporting activity
Walk outdoors
NOTTINGHAM
EXTENDED ADL
SCALE
INSTRUMENTAL
ACTIVITY MEASURE
Social occasions
Hobby
Reading books
Go out socially
Use the telephone
Read newspapers
or books
Write letters
—
Walking outside
Locomotion
outdoors
—
Walk outside
Cross roads
Get in and out
of car
Walk on uneven
ground
Climb stairs
—
Feed self
—
—
Studies cited: Whiting S, Lincoln NB: An ADL assessment for stroke patients, Br J Occup Ther 43:44, 1980; Bond MJ, Clark MS: Clinical applications of
the Adelaide activities profile, Clin Rehabil 12(3):228-237, 1998; Holbrook M, Skillbeck CE: An activities index for use with stroke patients, Age Ageing
12(2):166-170, 1983; Nouri FM, Lincoln NB: An extended activities of daily living scale for stroke patients, Clin Rehabil 4:123, 1987; and Grimby G, Andren
E, Holmgren E, et al: Structure of a combination of functional independence measure and instrumental activity measure items in community-living persons:
a study of individuals with cerebral palsy and spina bifida, Arch Phys Med Rehabil 77(11):1109-1114, 1996. From Park S: Enhancing engagement in instrumental activities of daily living: an occupational therapy perspective. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier.
clients. The results for the interrater reliability study
were “excellent” and “excellent” or “good” for the
test retest reliability study. They suggested that the
tool has potential for clinical use. More recently the
Nottingham Leisure Questionnaire has been shortened (37 to 30 items) and the response categories
collapsed (five to three categories) in order to make
it suitable for mail use.
Leisure Competence Measure
The Leisure Competence Measure32 provides information about leisure functioning as well as measure
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
change in leisure function over time. The tool
includes nine areas: social contact, community participation, leisure awareness, leisure attitude, social
behaviors, cultural behaviors, leisure skills, interpersonal kills, and community integration skills.
Items are rated on a seven-point Likert scale.
Leisure Diagnostic Battery
The original version of the Leisure Diagnostic
Battery65 includes 95 items, whereas the newer
shorter version includes 25 items.13 Items are scaled
on three-point scale. Assessment areas include playfulness, competence, barriers, knowledge, and so on.
Measures That Simultaneously Assess
Activity/Participation and Underlying
Impairments or Subskills
There is a short list of available assessments that are
highly recommended because they are unique in
their ability to simultaneously assess more than one
level of function such as activity limitations and the
impairments responsible for the limitations. These
assessments provide clinicians with critical and
substantial information via skilled observation of
functional tasks.
Árnadóttir OT-ADL Neurobehavioral Evaluation
The Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)3–5,22 is an instrument that allows the
Box 1-1
13
therapist to detect impairments that interfere with
task performance to understand factors underlying
activity limitations. It is used with clients who are
16 years and older and are living with functional
limitations secondary to central nervous system
dysfunction such as stroke, traumatic brain injury,
dementia, and multiple sclerosis.
The A-ONE aids the therapist in analyzing the
nature or cause of a functional problem requiring
intervention. Subsequently, therapists can speculate
about the best intervention for activity limitation
and impairments. The A-ONE is a performancebased tool that uses structured observations of
upper and lower body dressing, grooming, hygiene,
feeding, transfers, mobility and communication to
detect the underlying impairments that interfere
with function (Box 1-1).
Impairments detected during the observation
of these tasks include motor apraxia, ideational
apraxia, unilateral body neglect, somatoagnosia,
spatial relations, unilateral spatial neglect, impaired
motor control, perseveration, and organization and
sequencing. In addition pervasive impairments such
as agnosias, memory loss, disorientation, confabulation, and affective disturbances can be detected
throughout the observations. Figure 1-4 shows an
example of the dressing domain of the A-ONE. Note
that the instrument includes two scales; the Independence Score measures each activity in terms of
functional independence, and the Neurobehavioral
Items Included on the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
The A-ONE uses standardized and structured observations
as the method of assessment during the following daily
living skills:
• Feeding
• Grooming and hygiene (upper body washing, oral/hair
care, shaving, etc.)
• Dressing (upper and lower body)
• Transfers and mobility (bed mobility, transfers,
maneuvering in a wheelchair or during ambulation)
• Functional communication (comprehension and
expression)
Using standardized procedures and uniform conceptual
and operational definitions as guidelines the following specific impairments are evaluated in the context of functional
skills:
• Ideational apraxia
• Motor apraxia
•
•
•
•
•
•
•
•
Unilateral body neglect
Somatoagnosia
Spatial relations dysfunction
Unilateral spatial neglect
Perseveration
Organization and sequencing dysfunction
Topographic disorientation
Motor control impairments
In addition, the following pervasive impairments can be
detected and objectified:
• Agnosias (visual object, associative visual object,
visuospatial)
• Anosognosia
• Body scheme disturbances
• Emotional/affective disturbances
• Impaired attention and alertness
• Memory loss
Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; Árnadóttir G: Impact
of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis,
2004, Elsevier/Mosby; and Árnadóttir G: Rasch analysis of the ADL scale of the A-ONE, Am J Occup Ther (in press).
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Functional Independence Scale and
Neurobehavioral Specific Impairment Subscale
Ms. Wilson
6/13/03
Name______________________________________________________________________
Date _________________________
Independence Score (IP):
Neurobehavioral Score (NB):
4 = Independent and able to transfer activity to
other environmental situations.
3 = Independent with supervision.
2 = Needs verbal assistance.
1 = Needs demonstration or physical assistance.
0 = Unable to perform. Totally dependent on assistance.
0 = No neurobehavioral impairments observed.
1 = Able to perform without additional
information, but some neurobehavioral impairment
is observed.
2 = Able to perform with additional verbal assistance, but
neurobehavioral impairment can be
observed during performance.
3 = Able to perform with demonstration or
minimal to considerable physical assistance.
4 = Unable to perform due to neurobehavioral impairment.
Needs maximum physical assistance.
List helping aids used:
•Wheelchair
•Nonslip for soap and plate
•Adapted toothbrush
•Velcro fastening on shoes
PRIMARY ADL ACTIVITY
SCORING
DRESSING
COMMENTS AND REASONING
IP SCORE
Shirt (or Dress)
4
3
2
1
0
Include one armhole, fix shoulder
Pants
4
3
2
1
0
Find correct leghole
Socks
4
3
2
1
0
One-handed technique, balance
Shoes
4
3
2
1
0
Balance
Fastenings
4
3
2
1
0
Match buttonholes, Velcro through loop
Other
NB IMPAIRMENT
NB SCORE
Motor Apraxia
0
1
2
3
4
Ideational Apraxia
0
1
2
3
4
Unilateral Body Neglect
0
1
2
3
4
Somatoagnosia
0
1
2
3
4
Spatial Relations
0
1
2
3
4
Finding correct holes, front/back
Unilateral Spatial Neglect
0
1
2
3
4
Leaves out items in left visual field
Abnormal Tone: Right
0
1
2
3
4
Abnormal Tone: Left
1
2
3
4
Perseveration
0
0
1
2
3
4
Organization/Sequencing
0
1
2
3
4
Leaves out left body side
Sitting balance/bilateral manipulation
For activity steps
Other
Note: All definitions and scoring criteria for each deficit are in the Evaluation Manual.
Figure 1-4 Example of the dressing domain and summary of findings from the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
for a client with a right cerebrovascular accident (CVA). (From Árnadóttir G: Impact of neurobehavioral deficits on activities of daily living.
In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004, Elsevier.)
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Score measures the individual impairments that are
affecting function. In this example Ms. Wilson has
sustained a right cerebrovascular accident (CVA);
unilateral body neglect, spatial relations impairment, unilateral spatial neglect, organization and
sequencing problems, and left hemiplegia interfere with the dressing performance as indicated by
scores on the Neurobehavioral Specific Impairment
Subscale of the A-ONE. To be administered reliably,
the A-ONE requires a training course.
Assessment of Motor and Process Skills
The Assessment of Motor and Process Skills (AMPS)21
is a client-centered performance assessment of both
15
basic and IADL with an emphasis placed on
IADL tasks. The AMPS is not diagnosis specific.
It is appropriate for clients who are 3 years old
and up and who are experiencing functional limitations. The AMPS entails the client choosing to
perform two or three tasks in collaboration with
a therapist from a list of more than 80 standardized tasks.
In addition, although it does not detect the
client’s underlying impairments it does evaluate
motor and processing skills that affect function.
Motor skills are observable actions a person uses
to move the body or objects during all ADL task
performance. Process skills are observable actions
Árnadóttir OT-ADL
Neurobehavioral Evaluation
(A-ONE)
6–13–03
Ms. Wilson
Name _____________________________________________
Date ________________________________________
60
4–15–1943
Birthdate __________________________________________
Age _________________________________________
Caucasian
Female
Gender ____________________________________________
Ethnicity _____________________________________
Dressmaker
Right
Dominance ________________________________________
Profession ___________________________________
Medical Diagnosis:
Right CVA 6/20/03. Ischemia.
Medications:
Social Situation:
Lives alone in an apartment building on third floor
Has two adult daughters
Summary of Independence:
Needs physical assistance with dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis and perceptual and cognitive impairments. Is more or less
able to feed herself if meals have been prepared. No problems with personal communication,
although perceptual impairments will affect reading and writing skills. Also has lack of
judgment and memory impairment, which affect task performance. Is not able to live alone at
this stage. If personal home support becomes available, will need a home evaluation because
of physical limitation and wheelchair use. Needs recommendations regarding removal of
architectural barriers or suggestions for alternative housing. Unable to return to previous
job as a dressmaker.
FUNCTIONAL INDEPENDENCE SCORE (optional)
FUNCTION
TOTAL SCORE
Dressing
1,1,1,1,1= 5/20
Grooming and Hygiene
1,2,1,1,3,0= 8/24
Transfer and Mobility
1,1,1,1,1= 5/20
Feeding
4,4,4,3= 15/16
Communication
4,4= 8/8
% SCORE
Figure 1-4—Cont’d
(Continued)
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
LIST OF NEUROBEHAVIORAL IMPAIRMENTS OBSERVED:
SPECIFIC IMPAIRMENT
D G T F C
PERVASIVE IMPAIRMENT
ADL
PERVASIVE IMPAIRMENT
Motor Apraxia
Astereognosis
Restlessness
Ideational Apraxia
Visual Object Agnosia
Concrete Thinking
Unilateral Body Neglect
Visual Spatial Agnosia
Decreased Insight
Somatoagnosia
Associative Visual Agnosia
Impaired Judgment
Spatial Relations
Anosognosia
Confusion
Unilateral Spatial Neglect
R/L Discrimination
Impaired Alertness
Abnormal Tone: Right
Short-Term Memory
Impaired Attention
Abnormal Tone: Left
Long-Term Memory
Distractibility
Perseveration
Disorientation
Impaired Initiative
Organization
Confabulation
Impaired Motivation
Topographic Disorientation
Lability
Performance Latency
Other
Euphoria
Absent Mindedness
Sensory Aphasia
Apathy
Other
Jargon Aphasia
Depression
Field Dependency
Anomia
Aggressiveness
Paraphasia
Irritability
Expressive Aphasia
Frustration
ADL
Use ( ) for presence of specific impairments in different ADL domains (D = dressing, G = grooming, T =transfers, F = feeding,
C = communication) and for presence of pervasive impairments detected during the ADL evaluation.
Summary of Neurobehavioral Impairments:
Needs physical assistance for most dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis, spatial relations impairments (e.g., problems differentiating back from front of clothes and finding armholes and legholes), and unilateral
body neglect (i.e., does not wash or dress affected side)finding. Does not attend to objects in
the left visual field and needs verbal cues for performance. Also needs verbal cues for
organizing activity steps. Does not know her way around the hospital. Does not have insight
into how the CVA affects her ADL and is thus unrealistic in day-to-day planning. Has
impaired judgment resulting in unsafe transfer attempts. Leaves the water running after
hygiene and grooming activities if not reminded to turn it off. Is emotionally labile and
appears depressed at times. Is not oriented regarding time and date. Presents with impaired
attention, distraction, and defective short-term memory requiring repeated verbal instructions.
Treatment Considerations:
Occupational Therapist:
A-ONE Certification Number:
Figure 1-4—Cont’d
a person uses to (1) select, interact with, and use
tools and materials, (2) carry out individual actions
and steps, and (3) modify performance when problems are encountered. Process skills should not be
confused with cognitive or perceptual skills.
For example, one process skill included on the
AMPS is the ability “search and locate.” Searching for
and locating necessary items to perform a task relies
on multiple underlying skills such as visual attention,
figure-ground skills, problem solving, intact visual
fields, and so on. The AMPS detects the behavioral
output of these subskills. Following the skilled observation of each ADL task, the client is rated on 16
motor and 20 process skill items for each task performed using a four-point Likert scale. Once the
items are scored for each task, the results are entered
in the AMPS computer scoring program. The program generates a summary report (Figure 1-5, A).
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
In addition, the computer analysis of the motor and
process skill scores results in ADL motor ability and
ADL process ability measures. The measures represent the placement of the person on a continuum of
motor or process ability (Figure 1-5, B).
The AMPS requires no specialized equipment
and can be conducted in any ADL-relevant setting
within 60 minutes. A study42 found that the AMPS
may give a better indication of the client’s ability
to resume independent living than neuropsychological testing alone. The occupational therapy
practitioner who uses the AMPS must attend a
5-day AMPS training course to become certified
in its use.
ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)
PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.
Client:
ID:
John S
Evaluation date:
01/10/2005
1111JS
Occupational therapist:
Kim A
Task 1:
A-3: Pot of boiled/brewed coffee or tea (Average)
Task 2:
F-2: Luncheon meat or cheese sandwich (Average)
Overall performance in each skill area is summarized below using the following scale:
= Adequate skill, no apparent disruption was observed
A
= Ineffective skill, moderate disruption was observed
I
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist
intervention
MOTOR SKILLS:
Skills observed when client moved self and objects
during task performance
A
I
MD
Body Position
STABILIZES: does not lose balance when interacting with task objects
ALIGNS: does not persistently support oneself during task performance
X
X
POSITIONS the arm or body effectively in relation to task objects
X
Obtaining and Holding Objects
REACHES effectively for task objects
X
BENDS or twists the body appropriate to the task
X
GRIPS: securely grasps task objects
X
MANIPULATES task objects as needed for task performance
X
COORDINATES two body parts to securely stabilize task objects
X
Moving Self and Objects
MOVES: effectively pushes/pulls task objects and opens/closes doors or drawers
LIFTS task objects effectively
X
X
WALKS effectively about the task environment
X
TRANSPORTS task objects effectively from one place to another
X
CALIBRATES the force and speed of task-related actions
FLOWS: uses smooth arm and hand movements when interacting with task objects
X
X
Sustaining Performance
ENDURES for the duration of the task performance
X
PACES: maintains an effective rate of task performance
X
Figure 1-5 A, Assessment of Motor and Process Skills (AMPS) summary.
(Continued)
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)
PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.
Client:
John S
Evaluation date:
01/10/2005
ID:
1111JS
Occupational therapist:
Kim A
Task 1:
A-3: Pot of boiled/brewed coffee or tea (Average)
Task 2:
F-2: Luncheon meat or cheese sandwich (Average)
Overall performance in each skill area is summarized below using the following scale:
= Adequate skill, no apparent disruption was observed
A
= Ineffective skill, moderate disruption was observed
I
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist
intervention
PROCESS SKILLS:
Skills observed when client (a) selected, interacted
with, and used task tools and materials; and (b)
modified task actions, when needed, to complete the
A
I
MD
Sustaining Performance
PACES: maintains an effective rate of task performance
X
ATTENDS: does not look away from task performance
HEEDS the goal of the specified task
X
X
Applying Knowledge
CHOOSES appropriate tools and materials needed for task performance
USES task objects according to their intended purposes
X
X
HANDLES task objects with care
X
INQUIRES: asks for needed task-related information
X
Temporal Organization
INITIATES actions or steps of task without hesitation
X
CONTINUES task actions through to completion
X
SEQUENCES the steps of the task in a logical manner
X
TERMINATES task actions or steps appropriately
X
Organizing Space and Objects
SEARCHES and effectively LOCATES task tools and materials
X
GATHERS tools and materials effectively into the task workspace
X
ORGANIZES tools and materials in an orderly and spatially appropriate fashion
X
RESTORES: puts away tools and materials and cleans the workspace
X
NAVIGATES: maneuvers the hand and body around obstacles in the task environment
X
Adapting Performance
NOTICES and RESPONDS to task-relevant cues from the environment
ADJUSTS: changes workplaces or adjusts switches and dials to overcome problems
X
X
ACCOMMODATES: modifies one's actions to overcome problems
X
BENEFITS: prevents task-related problems from persisting
X
Figure 1-5—Cont’d
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
19
OCCUPATIONAL THERAPY EVALUATION OF ADL ABILITY
(Results and Interpretation of an Assessment of Motor
and Process Skills (AMPS) Evaluation)
Therapist: Kim A, OTR
Client: John S
Age: 72
Date of Evaluation: 01/10/2005
AMPS EVALUATION
The Assessment of Motor and Process Skills (AMPS) was administered to John S as a means of evaluating his ability to perform
activities of daily living (ADL) tasks. As part of the AMPS assessment, the occupational therapist conducted an interview to gain
a better understanding of the everyday tasks (occupations) that have been presenting a challenge for him, as well as those
everyday tasks that he has been performing with little difficulty. He was offered a choice of familiar and relevant tasks that he had
identified as presenting problems in everyday life. He chose to perform 2 of the tasks that were offered: Pot of boiled/brewed
coffee or tea, and Luncheon meat or cheese sandwich. When the AMPS was administered, the occupational therapist assessed
the amount of effort, independence, efficiency, and safety that he exhibited during the performance of these tasks.
OVERALL QUALITY OF PERFORMANCE
John showed evidence of moderately unsafe, markedly effortful, and moderately inefficient ADL task performance and he needed
frequent assistance to complete the 2 ADL tasks.
SPECIFIC SKILLS THAT MOST IMPACTED PERFORMANCE
More specifically, John's performance of the above noted ADL tasks was limited by:
• Momentary or transient loss of balance and/or the need to support himself on external objects while moving through the
environment or interacting with task objects (Stabilizes)
• Difficulty positioning body in relation to the workspace (Positions)
• Increased effort when reaching for or placing task objects (Reaches)
• Increased effort propelling the wheelchair (Moves)
• Ineffective walking or ambulating skill; instability when walking (Walks)
• Increased effort and/or instability when transporting task objects from one place to another
(Transports)
•
•
•
•
Difficulty completing tasks without obvious evidence of physical fatigue (Endures)
Failure to maintain a consistent and effective rate of performance (Paces)
Pauses during actions or task steps, delaying task progression (Continues)
Decreased skill accommodating for and preventing problems from occurring, and problems
persisted or recurred during task performances (Accommodates and Benefits)
OVERALL ADL MOTOR ABILITY
ADL motor ability is an overall measure of a person's observed skill when moving oneself or task objects as needed for ADL task
performance. John's ADL motor ability measure of -0.38 logits is plotted in relationship to the AMPS motor cutoff measure on the
AMPS Graphic Report. His ADL motor ability is below the AMPS motor cutoff. This indicates that he has increased effort when he
performs ADL tasks. To put this in perspective, approximately 95% of well, healthy persons of John's age have ADL motor ability
measures between 1.07 and 3.27 logits. This indicates that his ADL motor performance is lower than age expectations.
OVERALL ADL PROCESS ABILITY
ADL process ability is a global measure of a person's observed skill in efficiently (a) selecting, interacting with, and using tools and
materials; (b) carrying out individual task actions and steps; (c) and modifying performance when problems are encountered.
On the AMPS Graphic Report, John's ADL process ability measure of 0.27 logits is below AMPS process scale cutoff.
This indicates that he is experiencing decreased safety, independence and/or efficiency when he performs familiar ADL tasks.
As a basis for comparison, 95% of well, healthy persons of John's age have ADL process ability measures between 0.59 and 2.55
logits, thus his ADL process ability measure is lower than age expectations.
SUMMARY OF MAIN FINDINGS
• John's ADL motor and ADL process ability measures are both below the AMPS process cutoff and below age expectations,
indicating that he is experiencing increased effort, decreased efficiency, decreased safety, and/or the need for assistance when
performing chosen, familiar, and life relevant ADL tasks.
•
Occupational therapy services may be indicated to enhance and/or prevent further decline
of John's ADL task performance.
If there are any questions regarding this evaluation, please do not hesitate to contact me.
Kim A, OTR
A
Figure 1-5—Cont’d
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)
GRAPHIC REPORT
Client:
John S
Occupational therapist:
Kim A
Date
Evaluation 1 01/10/2005
ADL MOTOR
More likely to be safe and
independent living in the
community
ADL performance
more efficient
2
3
2 <
Some
increased
physical effort
performing
ADL
1
PROCESS
0.27
ADL PROCESS
3
4
Less physical
effort
performing
ADL
MOTOR
−0.38
ADL
Process
1 < Cutoff
ADL
Motor
Cutoff
Some concerns for safe
and/or independent living in
the community
1
0
0
−1
−1
−2
Some inefficiencies;
93% of persons
below cutoff need
assistance
1
More physical
effort
performing
ADL
Less likely to be safe and/or
independent living in the
community
ADL performance
less efficient
−2
−3
−3
−4
The numbers on the ADL motor and ADL process scales are units of ADL ability (logits). The results are reported as ADL motor
and ADL process measures plotted in relation to the AMPS scale cutoffs. Measures below the cutoffs indicate that there was
diminished quality or effectiveness of performance of instrumental and/or personal activities of daily living (ADL). See the AMPS
Narrative Report for further information regarding the interpretation of a single AMPS evaluation.
B
Figure 1-5—Cont’d B, Computer-generated graphic report of AMPS. (From Fisher AG: Overview of performance skills and client factors.
In Pendleton H, Schultz-Krohn W, editors: Pedretti’s occupational therapy: practice skills for physical dysfunction, ed 6, St Louis, 2006,
Elsevier/Mosby.)
Executive Function Performance Test and Kitchen
Task Assessment
The Executive Function Performance Test
(EFPT)10 was developed subsequently to the
Kitchen Task Assessment (KTA).8 Both measures
are standardized performance-based assessments
that examine cognitive functioning through the
observation of cues needed for a person to carry
out a functional task. Specifically observed is the
ability to initiate the task when asked, organize
the task, perform the necessary steps of the task,
sequence the steps in a logical order, develop
awareness related to safety and judgment, and
recognize completion of the task. Cueing is systematic and includes visual, gestural, and physical
cues that are provided in a hierarchic fashion.
These cues provide support to the client when
task execution begins to fail.
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
The original KTA was completed by observing one task, making store-bought pudding on a
stovetop. The KTA was validated on those living
with dementia. More recently the EFPT was developed using the same cueing system from the KTA.
The tasks have been expanded to include preparing
or heating up a light meal (cooked oatmeal), managing medications, using the telephone, and paying
bills. The tool has been used for those with stroke
and was recently found to be sensitive to the cognitive difficulties experienced in everyday life for those
living with multiple sclerosis (see Chapter 10).
Performance Assessment of Self-Care Skills
The Performance Assessment of Self-Care Skills
(PASS)20,26,51 is also a performance-based observational test with a home and clinic version. The PASS
is composed of 26 core tasks within four functional
domains:
• Functional mobility (5 tasks)
• Personal self-care (3 tasks)
• IADL with a cognitive emphasis (14 tasks: shopping, bill paying, check writing, balancing a
checkbook, mailing, telephone use, medication
management, 2 tasks related to obtaining information from the media, small home repairs,
home safety, playing bingo, oven use, stove use,
and use of sharp utensils)
• IADL with a physical emphasis
Performance is rated for independence, safety, and
adequacy. If an individual requires assistance to complete a task, the PASS provides a hierarchy of prompts.
The types of prompts, beginning with the least assistive and progressing to the most assistive are (1) verbal supportive, (2) verbal nondirective, (3) verbal
directive, (4) gestures, (5) task object or environmental rearrangement, (6) demonstration, (7) physical
guidance, (8) physical support, and (9) total assist.
The PASS is criterion referenced and may be
given in total, or selected tasks may be used alone
or in combination. The PASS can be used with adolescents and adults with various diagnoses including stroke, head injury, and multiple sclerosis. The
interactive assessment used when administering the
PASS allows clinicians to identify the point of task
breakdown and the types of assistance that enable
improvement in task performance. Self-report,
proxy-report, and clinical judgment versions of the
PASS are available.
Naturalistic Action Test
The Naturalistic Action Test (NAT)53 is a measurement of naturalistic action production across a
21
wide range of client impairment that was developed subsequently to the Multi-level Action Test. It
is based on research demonstrating that recovering
stroke and brain injury clients and those with progressive dementia are highly prone to errors of
action when performing routine ADL. The NAT
is a performance-based test of naturalistic action
in which the tasks are associated with disorders
of higher cortical function. The materials, layout,
and cueing procedures are standardized. Scoring
is simple and objective and can be performed
reliably with little formal training. Tasks that are
observed include making toast with butter and jelly
and instant coffee with cream and sugar, wrapping
a gift, and preparing and packing a child’s lunchbox and schoolbag. Instructions are spoken and
reinforced with drawings. Items are scored for
accomplishment of necessary steps, and this score
is combined with an error score that tracks 12 commission errors. The test has been validated on those
with right and left strokes and those with traumatic
brain injury.
Structured Observational Test of Function
The Structured Observational Test of Function
(SOTOF)34,35 is a valid and reliable tool that assesses
the following:
• Occupational performance (deficits in simple
ADL)
• Performance components (perceptual, cognitive, motor, and sensory impairment)
• Behavioral skill components (reaching, scanning, grasp, sequence)
• Neuropsychological deficits (spatial relations
apraxia, agnosia, aphasia, spasticity, memory loss)
Impairments are detected by the structured
observation of simple ADL (e.g., eating from a
bowl, pouring a drink and drinking, upper body
dressing, washing and drying hands).
This relative quick tool aims to answer the following questions:
1. How does the subject perform ADL tasks?
2. What behavioral skill components are intact?
Which have been affected by neurologic damage?
3. Which perceptual, cognitive, motor, and sensory
impairments are present?
4. Why is function impaired?
OVERVIEW OF MODELS THAT
GUIDE PRACTICE
Various models that guide this practice area have
been described in the literature. The reader is
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
referred to Katz29 for comprehensive descriptions of
these models. The following paragraphs are summaries of commonly used approaches.
Dynamic Interactional Approach
The Dynamic Interactional Approach55 views cognition as a product of the interaction among the
person, activity, and environment. Therefore, performance of a skill can be promoted by changing
either the demands of the activity, the environment in which the activity is carried out, or the
person’s use of particular strategies to facilitate
skill performance. To illustrate the interaction
among the three factors (person, activity, and
environment), the reader is encouraged to think
about how the efficiency and effectiveness of skill
performance vary based on the following task
descriptions:
• Driving your own automatic transmission midsize car versus renting and driving a standard
transmission pickup truck
• Performing a morning self-care routine in your
own home versus the same routine carried out
in a hotel room
• Cooking a meal versus cooking a meal while
simultaneously babysitting twin 2-year-old boys
Toglia55 describes several constructs associated
with this model including the following:
• Structural capacity or the physical limits in the
ability to process and interpret information
• Personal context or characteristics of the person
such as coping style, beliefs, values, and lifestyle
• Self-awareness or understanding your own
strengths and limitations, as well as metacognitive skills such as the ability to judge task
demands, evaluate performance, and anticipate
the likelihood of problems (see Chapter 4)
• Processing strategies or underlying components
that improve task performance such as attention, visual processing, memory, organization,
and problem solving
• The activity itself considering the demands,
meaningfulness, and how familiar the activity is
• Environmental factors such as the social, physical, and cultural aspects.
Toglia55 summarizes that “to understand cognitive function and occupational performance,
one needs to analyze the interaction among person, activity, and environment. If the activity and
environmental demands change, the type of cognitive strategies needed for efficient performance
changes as well. Optimal performance is observed
when there is a match between all three variables.
Assessment and treatment reflect this dynamic
view of cognition.” This approach may be used with
adults, children, and adolescents.
Toglia used the Dynamic Interactional Model to
develop the Multicontext Treatment Approach.54,55
Combining both remedial and compensatory strategies, this approach focuses on teaching a particular strategy to perform a task and practicing
this strategy across different activities, situations,
and environments over time. Toglia summarizes
the components of this approach to include the
following:
• Awareness training or using structured experiences in conjunction with self-monitoring
techniques so that clients may redefine their
knowledge of their strengths and weaknesses
(see Chapter 4).
• Personal context. Treatment activities are chosen
based on client’s interest and goals. A particular
emphasis is placed on the relevance and purpose
of the activities. Managing monthly bills may be
an appropriate activity for a single person living
alone, whereas crossword puzzles may be used as
an activity for a retiree who previously enjoyed
this activity.
• Processing strategies are practiced during a variety of functional activities and situations. Toglia
defines processing strategies as strategies that
help a client to control cognitive and perceptual symptoms such as distractibility, impulsivity, inability to shift attention, disorganization,
attention to only one side of the environment,
or a tendency to over focus on one part of an
activity.
• Activity analysis is used to choose tasks that
systematically place increased demands on the
ability to generalize strategies that enhance
performance.
• Transfer of learning occurs gradually and systematically as the client practices the same strategy during activities that gradually differ in
physical appearance and complexity.
• Interventions occur in multiple environments to
promote generalization of learning.
Quadraphonic Approach
The Quadraphonic Approach was developed by
Abreu and colleagues1 for use with those living
with cognitive impairments after brain injury. This
approach is described as including both a “micro”
perspective (i.e., a focus on the remediation of
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
subskills such as attention, memory, etc.) and a
“macro” perspective (i.e., a focus on functional skills
such as ADL, leisure, etc.). The approach supports the
use of remediation as well as compensatory strategies.
The micro perspective incorporates four
theories:
1. Teaching-learning theory is used to describe
how clients use cues to increase cognitive awareness and control.
2. Information-processing theory describes how
an individual perceives and reacts to the environment. Three successive processing strategies
are described including detection of a stimulus,
discrimination and analysis of the stimulus, and
selection and determination of a response.
3. Biomechanical theory is used to explain the
client’s movement, with an emphasis on the
integration of the central nervous system, musculoskeletal system, and perceptual-motor skills.
4. Neurodevelopmental theory is concerned with
quality of movement.
The macro perspective is based on narrative and
functional analysis to explain behavior based on the
following four characteristics:
1. Lifestyle status or personal characteristics related
to performing everyday activities
2. Life-stage status such as childhood, adolescence,
adulthood, and married
3. Health status such as the presence of premorbid
conditions
4. Disadvantage status or the degree of functional
restrictions resulting from impairment
Cognitive-Retraining Model
The Cognitive-Retraining Model7 is used for adolescents and adults living with neurologic and
neuropsychological dysfunction. Based on neuropsychological, cognitive, and neurobiologic rationales,
this model focuses on cognitive training by enhancing remaining skills, and by teaching cognitive strategies, learning strategies, or procedural strategies.
Neurofunctional Approach
The neurofunctional approach23 is applied to those
living with severe cognitive impairments secondary
to brain injuries. The approach focuses on training clients in highly specific compensatory strategies (not expecting generalization) and specific task
training. Contextual and metacognitive factors are
specifically considered during intervention planning. The approach does not target the underly-
23
ing cause of the functional limitation but focuses
directly on retraining the skill itself.
PATTERNS OF COGNITIVE-PERCEPTUAL
IMPAIRMENTS BASED ON DIAGNOSES
AND AREA(S) OF BRAIN PATHOLOGY
A critical aspect of the evaluation process involves
determining the impairment(s) that are interfering
with an individual’s ability to participate in meaningful activities. Several clients may have similar
activity level scores, but the impairments causing
the limitations may be quite different (Table 1-4).
Identifying the correct impairment(s) will help clinicians determine which interventions are required
including necessary adaptations, which strategy
choices are appropriate, and to begin to determine
the focus of rehabilitation. Depending on the diagnoses, clinicians can begin to expect usual presentations of patterns of cognitive and perceptual
impairments although variations from these typical
patterns may occur.
Stroke
If neuroimaging data are available they may provide
information related to which structures are compromised. Using knowledge of neuroanatomy and neurologic processing, the clinician may begin to hypothesize
which impairments will be present and how they
interfere with function (Tables 1-5 and 1-6).
Even a basic understanding of cortical function related to understanding the various functions
associated with different areas of the brain can help
clinicians in the clinical reasoning process associated to identifying impairments that affect daily
functioning (Tables 1-7 and 1-8).3,4
Multiple Sclerosis
Those living with multiple sclerosis may experience
slowed information processing, decreased attention, decreased concentration, difficulty shifting
attention, difficulty dividing attention, decreased
explicit memory, decreased episodic memory,
loss of executive functioning (concept formation, reasoning, problem solving, planning, and
sequencing.14,52
Parkinson’s Disease
In general, individuals living with Parkinson’s disease often present with normal or only slightly
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Table 1-4
CLIENT
COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Clinical Situation: A Client Requires Moderate Assistance for Grooming Tasks
Based on the Functional Independence Measure (FIM)
DIAGNOSIS
POTENTIAL IMPAIRMENTS
A
Right frontoparietal stroke
Unilateral neglect, figure-ground
impairment, spatial relations
dysfunction, distractibility
B
Left frontoparietal stroke
Motor planning deficits, ideational
apraxia, impaired organization and
sequencing
BEHAVIORS INTERFERING WITH
FUNCTION
Inability to “find” grooming items
on the left side of the sink,
inability to integrate the left
water faucet, inability to locate
white soap on the white sink,
incorrect endpoint (overshooting
or undershooting) when placing
the toothbrush under the running
water, distracted by irrelevant
environmental stimuli
Uses grooming objects incorrectly
(eats soap), brushes teeth
without turning on the water,
cannot manipulate grooming
tools in hand, doesn’t initiate task
Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; and Árnadóttir
G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2,
St Louis, 2004, Elsevier/Mosby.
decreased performance in language, gnosis, and
praxis functions, although memory and executive
functions more prominently affected. More specifically, attention functions are commonly decreased.
In addition free recall (immediate and delayed)
is impaired as is visuospatial processing, motor
planning, shifting attention, alternating tasks, and
verbal fluency.45
Huntington’s Disease
In this disease, selective cognitive abilities are progressively impaired, whereas others remain intact.
Abilities affected include executive function (planning, cognitive flexibility, abstract thinking, rule
acquisition, initiating appropriate actions, and
inhibiting inappropriate actions), psychomotor
function (slowing of thought processes to control muscles), perceptual and spatial skills of self
and surrounding environment, selection of correct methods of remembering information (but
not actual memory itself), and ability to learn new
skills. Problems in attention, working memory,
verbal learning, verbal long-term memory, and
learning of random associations are the earliest
cognitive manifestations.41
Traumatic Brain Injury
Severe cognitive and perceptual deficits are
common after traumatic brain injury (TBI)
including deficits of attention, memory, information-processing speed, and problems in selfperception. In addition posttrauma for anxiety,
expressive deficit, emotional withdrawal, depressive mood, hostility, suspiciousness, fatigability, hallucinatory behavior, motor retardation,
unusual thought content, lability of mood, and
comprehension deficits have been documented.
A recent longitudinal study43 of those with severe
TBI documented a tendency of improvement
for inattention, somatic concern, disorientation,
guilt feelings, excitement, poor planning, and
articulation deficits. In addition, for the impairments of conceptual disorganization, disinhibition, memory deficit, agitation, inaccurate
self-appraisal, decreased initiative, blunted affect,
and tension the authors noted a tendency for further deterioration in the posttraumatic followup. Changes between 6 and 12 months post-TBI
were statistically significant for disorientation
(improvement), inattention or reduced alertness
(improvement), and excitement (deterioration).
The authors concluded that neurobehavioral
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Table 1-5
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment
ARTERY
Middle cerebral artery:
upper trunk
LOCATION
POSSIBLE IMPAIRMENTS
DYSFUNCTION OF EITHER HEMISPHERE
Contralateral hemiplegia, especially of the face and the
upper extremity
Contralateral hemisensory loss
Visual field impairment
Poor contralateral conjugate gaze
Ideational apraxia
Lack of judgment
Perseveration
Field dependency
Impaired organization of behavior
Depression
Lability
Apathy
Lateral aspect of frontal and
parietal lobe
RIGHT HEMISPHERE DYSFUNCTION
Left unilateral body neglect
Left unilateral visual neglect
Anosognosia
Visuospatial impairment
Left unilateral motor apraxia
LEFT HEMISPHERE DYSFUNCTION
Bilateral motor apraxia
Broca’s aphasia
Frustration
Middle cerebral artery:
lower trunk
Lateral aspect of temporal
and occipital lobes
DYSFUNCTION OF EITHER HEMISPHERE
Contralateral visual field defect
Behavioral abnormalities
RIGHT HEMISPHERE DYSFUNCTION
Visuospatial dysfunction
LEFT HEMISPHERE DYSFUNCTION
Wernicke’s aphasia
Middle cerebral artery:
both upper and lower
trunks
Lateral aspect of the involved
hemisphere
Impairments related to both upper and lower trunk
dysfunction as listed in previous two sections
(Continued )
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26
Table 1-5
COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
ARTERY
LOCATION
POSSIBLE IMPAIRMENTS
Anterior cerebral artery
Medial and superior aspects of
frontal and parietal lobes
Contralateral hemiparesis, greatest in foot
Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances
Internal carotid artery
Combination of middle cerebral
artery distribution and anterior
cerebral artery
Globus pallidus, lateral geniculate
body, posterior limb of the
internal capsule, medial
temporal lobe
Impairments related to dysfunction of middle and
anterior cerebral arteries as listed above
Anterior choroidal artery,
a branch of the internal
carotid artery
Posterior cerebral artery
Medial and inferior aspects of
right temporal and occipital
lobes, posterior corpus
callosum and penetrating
arteries to midbrain and
thalamus
Hemiparesis of face, arm, and leg
Hemisensory loss
Hemianopsia
DYSFUNCTION OF EITHER SIDE
Homonymous hemianopsia
Visual agnosia (visual object agnosia, prosopagnosia,
color agnosia)
Memory impairment
Occasional contralateral numbness
RIGHT SIDE DYSFUNCTION
Cortical blindness
Visuospatial impairment
Impaired left-right discrimination
Basilar artery proximal
Pons
LEFT SIDE DYSFUNCTION
Finger agnosia
Anomia
Agraphia
Acalculia
Alexia
Quadriparesis
Bilateral asymmetric weakness
Bulbar or pseudobulbar paralysis (bilateral paralysis of
face, palate, pharynx, neck, or tongue)
Paralysis of eye abductors
Nystagmus
Ptosis
Cranial nerve abnormalities
Diplopia
Dizziness
Occipital headache
Coma
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Table 1-5
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
ARTERY
LOCATION
POSSIBLE IMPAIRMENTS
Basilar artery distal
Midbrain, thalamus, and caudate
nucleus
Vertebral artery
Lateral medulla and cerebellum
Systemic hypoperfusion
Watershed region on lateral side
of hemisphere, hippocampus
and surrounding structures in
medial temporal lobe
Papillary abnormalities
Abnormal eye movements
Altered level of alertness
Coma
Memory loss
Agitation
Hallucination
Dizziness
Vomiting
Nystagmus
Pain in ipsilateral eye and face
Numbness in face
Clumsiness of ipsilateral limbs
Hypotonia of ipsilateral limbs
Tachycardia
Gait ataxia
Coma
Dizziness
Confusion
Decreased eoncentration
Agitation
Memory impairment
Visual abnormalities caused by disconnection from
frontal eye fields
Simultanognosia
Impaired eye movements
Weakness of shoulder and arm
Gait ataxia
From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.
Table 1-6
Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment
LOCATION
Anterolateral thalamus, either side
Lateral thalamus
Bilateral thalamus
Internal capsule or basis pontis
Posterior thalamus
POSSIBLE IMPAIRMENTS
Minor contralateral motor abnormalities
Long latency period
Slowness
Right side
Visual neglect
Left side
Aphasia
Contralateral hemisensory symptoms
Contralateral limb ataxia
Memory impairment
Behavioral abnormalities
Hypersomnolence
Pure motor stroke
Numbness or decreased sensibility of face and arm
Choreic movements
Impaired eye movements
Hypersomnolence
(Continued )
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Table 1-6
COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment—Cont’d
LOCATION
POSSIBLE IMPAIRMENTS
Posterior thalamus—Cont’d
Decreased consciousness
Decreased alertness
Right side
Visual neglect
Anosognosia
Visuospatial abnormalities
Left side
Aphasia
Jargon aphasia
Good comprehension of speech
Paraphasia
Anomia
Dysarthria
Apathy
Restlessness
Agitation
Confusion
Delirium
Lack of initiative
Poor memory
Contralateral hemiparesis
Ipsilateral conjugate deviation of the eyes
Contralateral hemiparesis
Contralateral hemisensory loss
Decreased consciousness
Ipsilateral conjugate gaze
Motor impersistence
Right side
Visuospatial impairment
Left side
Aphasia
Quadriplegia
Coma
Impaired eye movement
Ipsilateral limb ataxia
Gait ataxia
Vomiting
Impaired eye movements
Caudate
Putamen
Pons
Cerebellum
From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.
deficits after TBI do not show a general tendency to
disappear over time and that some aspects related
to self-appraisal, conceptual disorganization and
affect may even deteriorate.
REVIEW QUESTIONS
1. Name and describe three assessments that may
be used to document improvements in quality
of life and participation.
2. What are the expected patterns of cognitive or
perceptual impairments if a person presents
with a right middle cerebral artery stroke? Left
middle cerebral artery stroke?
3. How can the principles of client-centered practice be integrated into the development of an
intervention plan for a person with attention
deficits after a brain injury?
4. Give two examples of how the ICF levels of function are interrelated.
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CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION
Table 1-7
Typical Impairments Based on Damage to the Right Versus Left Hemispheres
HEMISPHERE
TYPICAL IMPAIRMENTS
Right hemisphere
Attention deficits
Unilateral spatial neglect
Unilateral body neglect
Visuospatial impairments
Left visual field cut
Left-sided motor apraxia
Loss of left-sided motor control
Loss of left-sided sensation
Reduced insight
Expressive aphasia
Receptive aphasia
Bilateral motor apraxia Ideational apraxia
Decreased organization and sequencing
Loss of right sided motor control
Loss of right-sided sensation
Right visual field cut
Left hemisphere
Table 1-8
LOBE
Frontal
Temporal
Occipital
Parietal
29
Typical Functions Based on the Cortical Lobes
TYPICAL FUNCTIONS
Ideation, planning, executive functions in general, organizing, problem solving, selective
attention, speech (left: Broca’s area), motor execution, short-term memory, motivation,
judgment, personality, and emotions
Emotion, memory, visual memory (right), verbal memory (left), interpretation of music
(right), receptive language (left: Wernicke’s area)
Visual reception, visual recognition of shapes and colors
Visual-spatial functions (right), reception and recognition of tactile information, praxis (left)
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CHAPTER 2
General Considerations: Evaluations and Interventions
for Those Living with Functional Limitations Secondary
to Cognitive and Perceptual Impairments
KEY TERMS
Adaptation
Bottom-up Approaches
Compensation
Ecologic Validity
Generalization
Performance Based Assessments
Reliability
Remediation
Top-down Approaches
Validity
LEARNING OBJECTIVES
4. Discuss the issue of generalization of clinical intervention strategies to everyday function.
5. Understand the interplay of the environmental context and task performance as it relates to assessment
and interventions.
At the end of this chapter readers will be able to:
1. Understand the differences between top-down and
bottom-up approaches to assessment and evaluation.
2. Constructively critique the use of pen-and-paper
(tabletop) assessment procedures.
3. Be able to differentiate among various forms of reliability and validity.
“Therapists involved in the assessment and treatment of patients with neurobehavioral dysfunctions
have an ethical responsibility to assure themselves that they are using the most effective methods.…
To establish the effectiveness of evaluation and treatment, valid and reliable tools are necessary. Such
tools are also necessary in order to identify the dysfunctions that cause impaired independence, which
is a prerequisite for goal formation and for choosing the most pertinent treatment.”3
have been described in the literature39 and are applicable to those living with cognitive and perceptual
impairments.
Principles of a top-down approach include the
following procedures.39 Using standardized and non-
APPROACHES TO EVALUATION PROCEDURES
Evaluation procedures can be broadly defined by two
categories: top-down approaches and bottom-up
approaches. Both approaches to evaluation process
32
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CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS
standardized instruments (checklists, interviews,
etc.), the therapist obtains information regarding
role competency and meaningfulness as the starting point for evaluation. Roles (e.g., student, volunteer, homemaker, parent, boyfriend, baseball
team member, etc.) that comprised an individual’s life before his or her neurologic event become
the starting point for assessment. Discrepancies
between past and present performance are determined, and this information is used to guide
treatment.
Once an individual’s roles are defined, the specific tasks that define a person’s life and those
required to engage in these roles are identified (e.g.,
making a shopping list, managing bills, keeping
score, taking notes, reading a newspaper, responding to e-mail on a computer) and evaluated by
standardized and nonstandardized direct observation and self-report methods. If a person cannot
perform a particular task, the level and type of support required to perform the task is determined.
The reasons that a task cannot be performed are
then determined (e.g., apraxia, memory loss, visuospatial dysfunction). In other words, a connection
is determined between the components of function
and task performance.
In contrast, a bottom-up approach first focuses
on an evaluation of specific cognitive and perceptual impairments using standardized assessments
and nonstandardized observations. This is followed by an assessment of functional limitations.
Using this approach exclusively makes it difficult to
determine the clinical and functional connection
between the underlying impairments and noted
performance deficits.39
A comprehensive evaluation dictates that a
clinician must use both top-down and bottom-up
approaches. In general, it is recommended that
the starting point of the evaluation process should
focus on top-down procedures. This allows the
therapist to collect critical information related to the
functional areas that are targeted for change, allows
the individual who is receiving services to understand the focus of interventions and outcomes, and
provides the clinician with ideas related to integrating functional activities into the intervention plan.
That being said, in many cases it is difficult to differentiate among impairments, thus making treatment
planning difficult. For example, if an individual
is observed to have difficulty identifying or using
objects required to eat a meal independently, it is
necessary to determine if the problem is related to
decreased visual acuity, visual agnosia, ideational
33
apraxia, or other impairments. Determining which
impairment is affecting mealtime will further dictate the treatment (e.g., illumination, providing
contrast, and magnification versus using tactile
information to recognize objects, etc.). In these
cases, a bottom-up approach may be used to glean
information related to the presence or absence
and effect of various impairments. See Chapter 1
for information regarding recommended standardized assessments (e.g., Árnadóttir OT-ADL
Neurobehavioral Evaluation [A-ONE], Assessment
of Motor and Process Skills [AMPS], Executive
Functions Performance Test, etc.) that simultaneously assess functional activities in addition to the
underlying impairments or processing dysfunction
that affects functional performance.
Psychometric Properties of
Measurement Instruments
Although multiple standardized measurement
instruments are available to evaluate those living
with cognitive and perceptual impairments (see
Chapter 1 and all subsequent chapters), it is all too
common for clinicians to use only nonstandardized observations, piecemeal assessments (choosing one or two items from a variety of tests and
combining them for use based on a clinics needs),
nonstandardized procedures to administer a standardized assessment, or a valid and reliable assessment for a population or diagnostic category for
which the instrument has not been formally tested.
Whereas nonstandardized observations are commonly used and may help clinicians determine an
individual’s needs, they must be used in conjunction with a standardized measure that is both valid
and reliable.
A valid test measures what it was intended to
measure. A reliable test yields consistent results.
A test may reliable and valid, valid or reliable, or
neither valid nor reliable. Box 2-1 reviews types of
validity and reliability.
A particular emphasis should be placed on the
ecologic validity of an instrument. This term refers
to the degree to which the cognitive demands
of the test theoretically resemble the cognitive
demands in the everyday environment, sometimes termed functional cognition. A test with high
ecologic validity identifies difficulty in performing real-world functional and meaningful tasks.
Ecologic validity also refers to the degree to which
existing tests are empirically related to measures of
everyday functioning via a statistical analysis.11
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Box 2-1
COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Quick Review of Validity and Reliability
VALIDITY
Face validity: Does the instrument appear to measure
what it’s supposed to measure? Is the content appropriate for the purpose of the instrument? Do the items look
like they test what they are supposed to? Is the test a good
translation of the construct being measured? Determining
face validity depends on intuitive judgment.
Content validity: Usually determined via expert review
and literature reviews, and refers to whether the full content of a construct’s definition is included or represented
in the measure.
Criterion validity: Is the measure consistent with what we
already know and what we expect? Is the instrument valid
against a known external criterion? Includes two subcategories of validity: predictive and concurrent.
Predictive validity: Predicts a known association
between the construct you’re measuring and something
else. Determines how someone will do in the future on the
basis of a particular instrument.
Concurrent validity: Associated with preexisting indicators; something that already measures the same concept.
Construct validity: Refers to whether the measure relates
to a variety of other measures as specified in a theory.
Subcategories: discriminant and convergent validity
Discriminant validity: The measure does not associate
with constructs that shouldn’t be related.
Convergent validity: The measure associates with related
constructs.
Ecologic validity: The degree to which the cognitive demands
of the test theoretically resemble the cognitive demands in
the everyday environment. “Functional cognition” identifies
difficulty in performing real world tasks or the degree to which
existing tests are empirically related to measures of everyday
functioning.
RELIABILITY (DETERMINED QUANTITATIVELY)
Interrater/interobserver: Refers to consistent results
between various testers.
Test-retest: Refers to the stability of the test over time. If a
test is administered at two different times without an intervention in between, it should yield the same results.
Parallel forms: Used to assess the consistency of the
results of two forms or versions of a test constructed in the
same way from the same content domain. Parallel forms
are used to control for a testing effect or practice effect;
in other words controlling for participants gaining knowledge from the testing procedure itself, which may influence
outcomes.
Internal consistency: Refers to the extent to which tests
assess the same construct, skill, or quality. Used to assess
the consistency of results across items within a test.
Data from Chaytor N, Schmitter-Edgecombe M: The ecological validity of neuropsychological tests: a review of the literature on everyday cognitive skills,
Neuropsychol Rev 13:181-197, 2003, and Gliner JA, Morgan GA: Research methods in applied settings: an integrated approach to design and analysis,
Mahwah, NJ, 2000, Lawrence Erlbaum.
Performance-Based Assessment
Compared with Pen-and-Paper or Tabletop
Assessment Procedures
Even after a cursory review of the items included on
assessments that evaluate cognitive and perceptual
impairments after a neurologic event, it becomes
clear that two approaches to assessment are used in
both clinical and research settings. Pen-and-paper
or tabletop assessments most typically include items
that attempt to detect the presence of a particular
impairment (i.e., they are deficit specific). Test items
are usually contrived and nonfunctional tasks such
as copying geometric forms, creating pegboard constructions, constructing block designs, matching
picture halves, performing drawing tasks, sequencing pictures, remembering number strings, performing cancellation tasks, identifying overlapping
figures, completing body puzzles, and so on. It may
be argued that this type of test has low ecologic
validity. Does the ability to sequence a series of
picture cards predict the ability to plan, cook, and
clean up a family meal? Does failure to accurately
create a three-dimensional block design from a twodimensional cue card mean that an individual won’t
be able to dress or bathe independently?
The use of this type of assessment procedure as
the basis for clinical assessment needs to be questioned if the goal of the cognitive and perceptual
assessment is to determine if or how impairment(s)
will affect functioning in the real world. This type
of assessment does not give enough detail to be able
to predict what kinds of daily life problems will
be encountered or provide information regarding
the nature and frequency of problems.43 Kingstone
and colleagues ask “to what extent does the simple, impoverished, and highly artificial experimental task…have to do with the many complex,
rich, real life experiences that people share?”22
Particular concerns related to this type of assessment are addressed in the following paragraphs. In
contrast, a performance-based test uses common
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CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS
daily functional activities as the method of assessment. The use of structured observations to detect
underlying impairments is a not only clinically
valid3,4,32,35,41 but also provides the clinician with
detailed information regarding how the underlying impairments directly affects task performance.
For instance, Sunderland and associates used structured observations of action errors during dressing performance of those living with stroke.35 They
found that for those with right hemispheric damage,
dressing was disrupted by visuospatial problems or
poor sustained attention, whereas those with left
hemisphere damage and ideomotor apraxia were
unable to learn the correct procedure to compensate for hemiparesis when dressing. Specific findings from these observations were then used to
develop individualized intervention plans. The
authors concluded that observation of a naturalistic
but controlled task (dressing with a standard item
of clothing) allows greater insight into the effect of
specific neuropsychological deficits.
When examining test items it is clear that the items
included in pen-and-paper or tabletop assessments
use novel tasks (i.e., not related to a person’s habits
and routines) as the focus of assessment (Table 2-1).
In general, task performance is degraded during
novel tasks as compared with previously learned or
overlearned tasks. Performance of novel tasks requires
increased attentional control, compromises secondary task performance (e.g., memory), preempts the
ability to use proceduralized control, and decreases
overall task performance.6 Using novel tasks as the
starting point or basis of assessment for those living
with neurologic impairments may not provide an
accurate clinical picture of functional status. Instead,
responses to novel tasks may be better used for individuals who are living with milder impairments or
during later stages of the assessment process.
Pen-and-paper or tabletop assessments attempt
to isolate and diagnose the presence or absence of
a particular cognitive or perceptual impairment;
therefore, by definition they do not allow integration of motor, visual, cognitive, or perceptual skills.
Engaging in daily activities successfully requires the
ability to perform multiple cognitive, perceptual,
and motor functions at the same time (e.g., remembering a recipe while maneuvering around a grocery
store, conversing while driving, taking notes when
getting directions over the phone, managing a laptop
computer while teaching, etc). Similarly, daily living
tasks require one to process, integrate, use, and adapt
to multiple different types of information simultaneously. Wrapping a gift puts demands on our visual
Table 2-1
A Comparison of Test Items
Included on Common
Cognitive and Perceptual
Assessments
TYPE OF
ASSESSMENT
Tabletop/pen-andpaper assessments
Performance-based
assessments
35
EXAMPLES
Block designs
Pegboards
Puzzles
Matching pictures
Gesture copying
Memorizing word lists or number
strings
Matchstick designs
Leather lacing
Drawing pictures
Drawing geometric designs
Bisecting lines
Cancellation tests
Identifying overlapping figures
Sequencing picture cards
Dressing
Feeding
Grooming
Bed mobility
Transfers
Hot and cold meal preparation
Table setting
Sweeping
Shopping
Managing medications
Menu reading
Repotting a plant
Writing on a computer
Telephone use
Telling the time
Managing money
Reading an article
Finding a number in a phone book
Keeping score during a game
Remembering and navigating a new
environment
system, our ability to interpret spatial information,
motor planning skills, sustained attention skills,
and so on. Clinicians must decide if deficit specific
pen-and-paper tests that do not simultaneously challenge motor or postural control or other cognitiveperceptual skills can provide accurate information
regarding real-life function. Performing a cognitive
or motor task in isolation does not ensure concurrent
performance. Findings from dual task performance
research must be considered.
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Haggard and coworkers20 analyzed the ability of
those living with stroke, subarachnoid hemorrhages,
and head injuries to perform cognitive tasks (spoken word generation, mental calculations, remembering the order of paired words, and visuospatial
tasks) and motor tasks in isolation and then simultaneously. The authors documented decrements in
both cognitive and motor function in subjects with
CNS dysfunction during dual task conditions as
compared to performing a single cognitive or motor
task. In other words, evaluating cognitive and motor
function separately (which commonly occurs in the
clinical setting), yields different results as compared
to evaluating these skills simultaneously. When
performed simultaneously, performance may be
degraded.
Lindenberger and colleagues examined the dual
task of memorizing while walking in healthy adults
classified as young (ages 20 to 30 years), middle-aged
(40 to 50 years), and older (60 to 70 years) adults.23
Dual-task costs increased with age in both cognitive
and motor function. Specifically, with advancing age,
participants showed greater reductions in memory
accuracy when they were walking.
Similarly Baddeley and associates examined
older adults with cognitive impairment performing
a visual search task and auditory processing task
separately and then simultaneously.5 The authors
documented a similar trend as the previously mentioned studies (i.e., older adults had a decreased ability to perform visual and auditory processing tasks
simultaneously as compared with performing the
tasks separately). This same paper examined singletask performance of motor task and digit span task
followed by simultaneously dual-task performance.
During dual-task conditions, adults with cognitive
impairments demonstrated decreased performance
on both tasks.
Southwood and Dagenais examined the singletask versus dual-task performance in adults with
apraxia.34 Single tasks consisted of a manual motor
reaction time task and a voice reaction time task,
followed by dual-task performance. The authors
documented an increase in apraxic errors during
dual-task conditions.
Holtzer and colleagues examined dual-task performance in older adults with cognitive impairments.21 Specifically, they used two sets of tasks that
challenged different perceptual processing skills.
The first set of tasks consisted of a visual cancellation test and an auditory digit span examined
under single and dual task conditions. The second set of tasks was composed of a parallel form
of the visual cancellation test and letter fluency.
The authors concluded that those with cognitive
impairment incurred significantly greater dual-task
costs (i.e., degraded performance while performing
both tasks) compared with control groups.
To summarize, in healthy older adults, people living with a variety of neurologic diagnoses,
adults with cognitive impairments, and those living
with apraxia, levels of cognitive function decrease
when they are involved in tasks that place demands
on more than one underlying skill. One can argue
that typical daily living tasks such as cooking, driving, a morning self-care routine, childcare, and so
on are even more demanding than the dual-task
conditions that are examined in highly controlled
research protocols. Therefore clinicians need to
reconsider if the results from a highly controlled
deficit specific (single task) test can be generalized to a real-world setting. Holtzer and colleagues
summarized that dual-task measures were accurate
and better than the traditional neuropsychological
measures at discriminating cognitive impairments
from normal controls.21 They further concluded
that dual-task measures can provide additional and
important information regarding cognitive status
that is not available from routinely used standardized neuropsychological measures. In further contrast, a performance-based measure that uses daily
living tasks as test items not only increases the ecologic validity of the test but also may provide even
more accurate information related to real-life functional performance as compared with the exclusive
use of deficit-specific pen-and-paper tests.
The focus of a tabletop examination is on diagnosing the impairment as opposed to determining
the effect of a deficit on a particular living skill as
is the focus of a performance-based test. The diagnostic abilities of a pen-and-paper test also may be
questioned.3,4 For example, body puzzles have been
suggested to diagnose the presence of body scheme
disorders. Failure to accurately complete the puzzle
may be caused by a variety of reasons beyond the
loss of a body scheme. Visuospatial impairments,
loss of sustained attention, decreased visual acuity,
decreased arousal, or lack of motivation to engage
in a task that is not meaningful all may contribute to
poor performance. A similar problem involves tests
that detect impairments via two-dimensional test
items, particularly tests of visual perception, and
attempt to provide information related to living in
a three-dimensional world.
The previous paragraphs question the assumed
relationship between findings on deficit-specific
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novel pen-and-paper tasks and real-world function.
Findings from published empirical research continue
to question this relationship as well. These studies
have attempted to clarify the relationships between
impairments and activity limitations and impairments and participation restrictions. Reviews of the
literature10,24,42 have determined that these relationships are small to moderate, ranging from Pearson
correlations of 0.2 to 0.5, at best. Other specific relationships that have been examined and determined to
have a limited relationship include impaired executive functions as tested by deficit-specific impairment
measures and activity limitations or participation
restrictions,27 as well as poor attention span as assessed
via digit span and tests of everyday attention.19 Finally,
impairment based measures of neuropsychological
function have been found to be generally poor predictors of vocational functioning in those living with
traumatic brain injury.18
Overall, the ecologic validity of deficit specific test
results has not been well examined. Findings from
this type of assessment may underestimate7 or overestimate36 the degree of impairment. Generalizing test
findings to compromised real-world function should
be done with restraint.36 In other words, predicting
real-world function based on a pen-and-paper assessment, if done at all, should be done with extreme
caution if the particular functional skill in question has not been observed by the clinician. Bennett
summarizes that “the ecological validity…can be
extended by observing the patient’s approach to tasks
in the assessment environment and by observing the
patient in his or her normal activities.”7
The Influence of the Environment on Functional
Performance and Assessment Outcomes
There is a dynamic interplay between a person, his
or her impairments, task(s) being evaluated, and the
environment in which the evaluation takes place.13
For example, the severity of left spatial neglect and
the presence of extinction (see Chapter 6) is increased
in a situation in which distracters in the right visual
field must be processed.16 Those living with right
brain damage and concurrent attention deficits typically present with degraded functional performance
in environments that provide increased sensory stimulation (e.g., a quiet reading room versus a cafeteria).
The relationship between task performance, underlying skills, and the environment in which the task
has been performed has been empirically tested.
Park and colleagues examined the effect of home
versus clinical settings on the instrumental activi-
37
ties of daily living (IADL) performance of older
adults.28 Twenty older adults living in the community were evaluated in their homes and in an occupational therapy clinic with the Assessment of Motor
and Process Skills (AMPS) (see Chapter 1). The
motor and process ability measures were compared
between the two settings. The authors found that the
subjects’ motor ability measures tended to remain
stable from clinic to home settings, but the process
ability measures tended not to remain stable from
clinic to home settings. The authors concluded that
process skill abilities are affected by the environment
to a greater degree than are motor skill abilities. In
this particular study the familiar home environment
tended to support IADL performance (i.e., improved
performance was noted in familiar home settings).
Gillen and Wasserman examined the effect of
the environment on functional mobility (specifically the ability to transfer) in individuals with a
central nervous system (CNS) disorder within two
varying environments.17 The two environmental
conditions were a traditional clinic setting, and a
more naturalistic simulated apartment. Overall,
100 transfer observations were objectively measured using the Functional Independence Measure
(FIM) method. Forty-four percent (44%) of the
participants performed better in the clinic setting;
20% performed better in the simulated apartment.
Analysis of FIM data revealed that 36% of the participants transferred consistently in both environments. However, overall 64% of the participants
were inconsistent in the same transfer task across
the two environments. This research further supports the concept that the environment affects
functional performance. Performance of activities of daily living (ADL) and functional mobility
tasks such as transfers may differ across various
environmental contexts.
Brown and coworkers examined 20 people with
severe mental illness on two tasks (making a purchase in a store and using the bus).9 The participants were evaluated on each task with two methods
of assessment: interview or simulation (using the
Kohlman Evaluation of Living Skills) and observation in the natural environment. Results demonstrated inconsistent performance across assessment
approaches and task performance. The researchers highlighted the importance of considering the
influence of the environment when evaluating the
complexity of real-world performance. Of particular concern was a trend toward false positives that
was found when participants were judged independent on the standardized assessment but could not
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perform the same tasks in the natural environment.
The authors concluded that clinicians “should be
cautious when making judgments of independence
on the basis of interview and observation of simulated tasks. Evaluating IADL performance in the
persons’ natural environment may provide more
accurate information.”
Sbordone emphasized that the typical assessment environment (a quiet room without environmental distracters) is not the real world. Specific
concerns with a typical testing environment include
the following31:
• The conditions of testing are set up in such a way
as to optimize performance.
• The environment in which testing occurs tends
to be distraction-free.
• The tasks used are highly structured.
• The person administering the test provides clear
and immediate feedback.
• Time demands are minimized.
• Repeated and clarified instructions are used to
optimize performance.
• Problems with task initiation, organization,
and follow-through are minimized as the cli-
Table 2-2
nician provides multiple cues for task progression and the tests tend to include discrete items
that are performed one at a time as opposed to a
sequence of events7.
INTERVENTION OVERVIEW
General Approaches to Intervention:
Remediation and Compensation or Adaptation
Common interventions for those living with cognitive and perceptual impairments are grossly
classified as those focused on remediation of an
underlying impairment or compensatory or adaptive strategies used to function despite the effect of
cognitive perceptual deficits (Table 2-2).
Although describing and critiquing specific
interventions is the focus of the rest of this book, in
general, there is little research in the published literature that supports the sole use of a remediation
program. Traditionally, the remediation and adaptive approaches have been viewed as completely
separate approaches, and clinicians had to make a
decision as to which one to choose when develop-
Traditional Classifications of Interventions
REMEDIATION
Also known as a restorative or transfer of training approach
Focused on decreasing the severity of impairment(s)
Focused on the cause of the functional limitation. Assumes
cortical reorganization takes place.
Typically uses deficit specific cognitive and perceptual
retraining activities chosen based on the pattern of
impairment
Examples of interventions: cognitive and perceptual tabletop
“exercises,” parquetry blocks, specialized computer
software programs, cancellation tasks, block designs,
pegboard design copying, puzzles, sequencing cards,
gesture imitation, picture matching, design copying, etc.
Requires the ability to learn and generalize the intervention
strategies to a real-world situation
Assumes that improvement in a particular cognitiveperceptual activity will “carry over” to functional activities
ADAPTATION
Also known as a functional approach
Focused on decreasing activity limitations and participation
restrictions
Focused on the symptoms of the problem
Typically uses functional activities chosen based what the
clients receiving services want to do, need to do, or have to
do in their own environment
Examples of interventions: meal preparation, dressing,
generating a shopping list, balancing a checkbook, finding
a number in the phonebook. Environmental adaptations
(e.g., placing all necessary grooming items on the right
side of the sink for a person with neglect), compensatory
strategy training approaches (e.g., using a scanning
strategy such as the “lighthouse strategy” to improve
attention to the left side of the environment for those living
with unilateral neglect; an alarm watch to remember to
take a medication for those with memory impairment).
A compensatory strategy requires insight to the functional
deficits and accepting that the impairment is relatively
permanent. Environmental modifications do not require
insight or learning on the part of the person receiving
services.
Does not assume that the underlying impairment is even
affected by the intervention
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CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS
ing an intervention plan. More recently this dichotomy has been challenged, with newer approaches
embracing the use of both approaches.1,2 In a study
comparing remedial and compensatory interventions for those living with brain injury, it was found
that 80% of the participants used compensatory
strategies regardless of intervention (remediation
or compensatory). In this study, those who used
these strategies demonstrated better performance
than those who did not.12 Clinicians must also consider that focusing interventions on adaptations or
strategy training does not necessarily mean remediation will not occur.15 Although the remediation approach assumes that perceptual retraining
activities may affect functional performance (even
though as stated above empirical support for this
relationship is quite weak), engagement in functional activities most likely affects cognitive and
perceptual processing as well.14 An intervention
study for apraxia40 illustrates this point. The focus
of the intervention was a strategy-training approach
to improve functional performance despite the
presence of apraxia (see Chapter 5). The emphasis
of the intervention was on task performance and
not explicitly focused on improving praxis. The
outcome demonstrated a large effect size related to
improving the performance of functional skills in
addition to a small to moderate effect size related to
measures of apraxia and motor function. Note: the
improvement in functional skills should be considered the more clinically relevant outcome.
Choosing the appropriate intervention approach
relies on the results of the assessment. BrockmannRubio and Gillen suggest that the following questions
should be answered prior to choosing an approach8:
• Does the person receiving services have the
potential to learn?
• Is he or she aware of errors during task
performance?
• If so, does he or she have the potential to seek
solutions to those errors?
If poor learning potential is exhibited, insight
to deficits do not respond to metacognitive training (see Chapter 4), and the use of cues and task
performance strategies is not effective or consistent,
a strictly functional approach involving task-specific
training may be recommended. This approach
requires little or no transfer of learning and involves
repetitive performance of a specific functional task
using a system of vanishing cues or cues that are
provided at every step of task performance but then
gradually removed.8 The goal is to maximize task
performance with a minimum number of cues.
39
A limitation of this approach is that the success of
performing a skill is dependent on approaching the
task exactly the same way in the same environment
each time.
Abreu and colleagues proposed an integrated
functional approach to treatment in which principles from both remediation and adaptive approaches
are used simultaneously.2 In this approach, meaningful and functional activities challenge underlying cognitive and perceptual impairments. With this
integrated functional approach, interventions may
be focused on a specific impairment such as sustained attention, but relevant tasks are used as the
modality to affect change. Brockmann-Rubio and
Gillen use the example of self-feeding as a task that
may improve sustained attention to task.8 Mealtime
is often distracting. Eating can be a difficult task if
attention deficits are present. A system of vanishing cues and a gradual increase in the amount of
environmental distraction can address inattention
to task and activity participation. Most functional
tasks can address multiple impairments. A detailed
task analysis is required when evaluating an activity
for its effectiveness in addressing particular cognitive or perceptual deficits (Box 2-2 and Figure 2-1).
Issues Regarding Generalization of Task
Performance and Strategy Training
One of the biggest challenges to providing interventions to this population is the issue of generalizing
or transfer of what is learned in therapy sessions to
other real-world situations. Examples include generalizing the skills learned on an inpatient rehabilitation unit related to meal preparation to making a
meal at home upon discharge, generalizing a scanning strategy used to read a newspaper article to
locating an item of clothing in a closet, and generalizing tactile feedback to identify objects on a
meal tray to using this strategy when shopping for
grooming items. The consistent perspective on the
idea of generalization is that it will not occur spontaneously but instead needs to be addressed explicitly in an intervention plan.26,33,37,38
Suggestions have been made in the literature to
enhance generalization of cognitive and perceptual
rehabilitation techniques.
• Avoid repetitively teaching the same activity in
the same environment.37,38 Consistently practicing bed mobility and wheelchair transfers in a
person’s hospital room does not guarantee that
the skill will generalize to the ability to transfer
to a toilet in a shopping mall.
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Box 2-2
COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
Toothbrushing Task: Used to Challenge Underlying Impairments
SPATIAL RELATIONS AND SPATIAL POSITIONING
Positioning of toothbrush and toothpaste while applying
paste to toothbrush
Placement of toothbrush in mouth
Positioning of bristles in mouth
Placement of toothbrush under faucet
SPATIAL NEGLECT
Visual search for and use of toothbrush, toothpaste, and
cup in affected hemisphere
Visual search and use of faucet handle in affected
hemisphere
ORGANIZATION AND SEQUENCING
Sequencing of task (removal of cap, application of toothpaste to toothbrush, turning on water, and putting toothbrush in mouth)
Continuing task to completion
ATTENTION
Attention to task (for greater difficulty, distractions such as
conversation, flushing toilet, or running water may be
added)
Refocus on task after distraction
FIGURE-GROUND
Distinguishing white toothbrush and toothpaste from sink
BODY NEGLECT
Brushing of affected side of mouth
INITIATION AND PERSEVERANCE
Initiation of task on command
Cleaning parts of mouth for appropriate period of time and
then moving bristles to another part of mouth
Discontinuation of task when complete
MOTOR APRAXIA
Manipulation of toothbrush during task performance
Manipulation of cap from toothpaste
Squeezing toothpaste onto toothbrush
IDEATIONAL APRAXIA
Appropriate use of objects (toothbrush, toothpaste, cup)
during task
VISUAL AGNOSIA
Use of touch to identify objects
PROBLEM SOLVING
Search for alternatives if toothpaste or toothbrush is
missing
From Brockmann-Rubio K, Gillen G: Treatment of cognitive-perceptual impairments: a function-based approach. In Gillen G, Burkhardt A, editors: Stroke
rehabilitation: a function-based approach, ed 2, p. 430, St Louis, 2004, Elsevier Science/Mosby.
• Practice the same strategy across multiple tasks.29
For example, if the “lighthouse strategy”(see
Chapter 6) is successful during the treatment of
an individual with spatial neglect to accurately
read an 8½ by 11–inch menu, the same strategy
should consistently and progressively practiced
to read a newspaper, followed by reading the
labels on spices in a spice rack, followed by
a street sign, and so on.
• Practice the same task and strategies in multiple
natural environments.37,38 Practice of organized
visual scanning for an inpatient should be done
in the therapy clinic, in the person’s hospital
room, in the facility’s lobby and gift shop, in the
therapist’s office, and so on.
• Include metacognitive training in the intervention plan to improve awareness (see Chapter 4).
Toglia has identified a continuum related to the
transfer of learning and emphasizes that generalization is not an all-or-none phenomenon.37,38 She
discusses grading tasks to promote generalization
of learning from those that are very similar to those
that are very different. Toglia’s criteria for transfer
include the following37,38:
• Near transfer: Only one or two of the characteristics are changed from the originally practiced
task. The tasks are similar. Toglia gives the example of making coffee as compared with making
hot chocolate or lemonade.38
• Intermediate transfer: Three to six characteristics
are changed from the original task. The tasks are
somewhat similar, such as making coffee as compared with making oatmeal.
• Far transfer: The tasks are conceptually similar
but share only one similarity. The tasks are
different, such as making coffee as compared
with making a sandwich.
• Very far transfer: The tasks are very different,
such as making coffee as compared with setting
a table.
Neistadt has suggested, based on her research and
review of the literature, that only those individuals
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CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS
41
Possible behavioral deficits interfering with function
Premotor perseveration: pulling up sleeve
Spatial-relation difficulties: differentiating front from back on shirt
Spatial-relation difficulties: getting an arm into the right armhole
Unilateral spatial neglect: not seeing shirt located on neglected side (or a part of the shirt)
Unilateral body neglect: not dressing the neglected side or not completing the dressing on that side
Comprehension problem: not understanding verbal information related to performance
Ideational apraxia: not knowing what to do to get shirt on or not knowing what the shirt is for
Ideomotor apraxia: having problems with the planning of finger movements in order to perform
Tactile agnosia (astereognosis): having trouble buttoning shirt without watching the performance
Organization and sequencing: dressing the unaffected arm first and getting into trouble with dressing the affected
arm; inability to continue the activity without being reminded
Lack of motivation to perform
Distraction: becomes interrupted by other things
Attention deficit: difficulty attending to task and quality of performance
Irritated or frustrated when having trouble performing or when not getting the desired assistance
Aggressive when therapist touches client in order to assist (tactile defensiveness)
Difficulties recognizing foreground from background or a sleeve of a unicolor shirt from the rest of the shirt
Figure 2-1 Putting on a shirt. (From Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living,
St Louis, 1990, Mosby.)
who have the ability to perform far and very far
transfers of learning are candidates for the remedial approach to cognitive and perceptual rehabilitation.26 But she suggests that those who are
only capable of near and intermediate transfers of
learning are candidates for the adaptive approach
as described earlier. Similarly, near transfers seem
to be possible for all individuals regardless of severity of brain damage, whereas intermediate, far, and
very far transfers may be possible only for those
with localized brain lesions, preserved abstract
thinking, and with those who have been explicitly
taught to generalize.25 Although these statements
should continue to be tested empirically, they
give clinicians guidelines related to intervention
planning.
Evidence-Based Practice and Levels of Evidence
In the recent past, many of the interventions commonly used with this population were anecdotal
in nature only. For instance, the transfer of training approach (as described earlier) was consistently
recommended and applied in clinic settings despite
there being little evidence to support its use, particularly related to the effect it has on daily performance. Fortunately, a recent focus on evidence-based
practice continues to provide clinicians with more
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COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION
objective data regarding interventions that are effective (these interventions are reviewed throughout
the rest of this text). Evidence-based practice can be
defined as “the conscientious, explicit, and judicious
use of current best evidence in making decisions
about the care of individual patients. The practice of
evidence-based medicine means integrating individual clinical expertise with the best available external
clinical evidence from systematic research.”30
When interpreting research that has examined
various interventions, it important to understand
that there are different levels of evidence. Sackett
outlined the following levels of evidence to rank
research articles30:
• Level I: Large randomized controlled trials
(RCTs) with low false positives.
• Level II: Small RCTs with high false positives.
• Level III: Nonrandomized concurrent cohort
comparisons between subjects that did and did
not receive intervention.
• Level IV: Nonrandomized historical cohort
comparisons between current subjects who did
receive intervention with former subjects who
did not.
• Level V: Case series without controls.
Another consideration when reviewing the
evidence related to cognitive and perceptual rehabilitation interventions is related to the type of
outcome measure. Three categories of assessments
with varying levels of ecological validity have been
utilized in the published empirical research:
• Impairment based measures composed of
contrived tabletop or pen and paper tasks.
Examples include cancellation tasks, drawing tasks, block designs, memorizing number
strings, etc. (See Chapter 1.)
• Simulated activity performance measures such
as the Baking Tray Task and the Behavioral
Inattention Test. (See Chapter 6.)
• Sructured observations of tasks in context such as the A-ONE and the AMPS (see
Chapter 1) and the Catherine Bergego Scale
(see Chapter 6).
The majority of studies that have been published
have only examined changes at the impairment
level (e.g., improved ability to perform a cancellation task for a clinical trial designed for those with
neglect). As stated in Chapter 1, these studies must
be interpreted with caution because the results cannot be generalized to the activity or participation
and quality-of-life levels of function. Future clinical
trials related to this area of practice should consider
measures across the levels of function to confirm if
the intervention is effective. A specific focus must be
on outcomes that objectify a meaningful decrease in
activity limitations and participation restrictions as
well as document an improvement in quality of life.
CONSIDERATIONS RELATED TO APHASIA
The presence of language impairments (particularly receptive language deficits) results in consistent
problems related to both assessment and interventions for this population. Problems particularly arise
when novel tasks are used to asses impairments and
when novel and contrived tasks are used for attempts
at remediation. Consistent with the previous paragraphs, both assessment and interventions should
be consistent of meaningful and familiar tasks performed in context. This approach will begin to control for aphasia by decreasing the need to verbally
explain the task at hand. For example, an attention
task that requires the person to cancel or cross out
the letter “R” on a sheet of paper requires a verbal or
written explanation because of its novelty. Another
approach is to use morning grooming tasks at the
sink followed by observation during breakfast to
ascertain levels of attention. If the tasks are provided
at the correct time of day and the person’s own
grooming items are used, the task “speaks for itself ”
and the need for verbal explanation is decreased.
REVIEW QUESTIONS
1. What factors are examined to determine if an
assessment has high ecologic validity?
2. What are three interventions that promote generalization of a strategy used to improve basic
ADL for someone living with unilateral neglect
in the clinic to a home environment?
3. What is the sequence of evaluation when using a
top-down approach versus a bottom-up approach
to assessment?
4. How does the dual-task paradigm apply to
assessment of those living with cognitive and
perceptual impairments?
5. What are three concerns related to the exclusive
use of tabletop assessments to form functional
goals?
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