Cognitive and Perceptual Rehab- Module 1: Overview/General Considerations for Intervention

Transcription

1 Cognitive and Perceptual Rehab- Module 1: Overview/General Considerations for Intervention Course Description: This course is derived from the textbook by Glen Gillen Cognitive and Perceptual Rehabilitation: Optimizing Function 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 1 of 47

2 4. Recognize patterns of cognitive and perceptual impairments that interfere with everyday function 5. List the differences between top-down and bottom-up approaches to assessment and evaluation 6. List the pros and cons of the use of pen-and-paper (tabletop) assessment procedures 7. Differentiate between various forms of reliability and validity 8. Recognize the issue of generalization of clinical intervention strategies to everyday functions 9. 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 2 of 47

3 DIRECTIONS FOR COMPLETING THE COURSE: 1. This course is offered in conjunction with and with written permission of Elsevier Science Publishing. 2. Review the goals and objectives for the module. 3. Review the course material. 4. 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. 5. 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. 6. 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. 7. 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. 8. You have up to one year to complete this course from the date of purchase. 9. If you have a question about the material, please it to: info@advantageceus.com 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 info@advantageceus.com or of 47

4 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 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. 3. Understand which outcome measures are appropriate for this population. 4. Understand patterns of cognitive and perceptual impairments that interfere with everyday function. 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 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 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 Evaluation- Revised, concluding that constructional abilities may contribute to meal preparation performance. Based on these findings a randomized controlled trial was 4 of 47

5 2 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, 5 of 47

6 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 3 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 following 68 : 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 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 Table 1-1 ELEMENT Summary of the International Classification of Functioning, Disability, and Health (ICF) Related to Cognitive and Perceptual Rehabilitation DESCRIPTION/EAMPLES BODY STRUCTURES Structures of the nervous system Cortical lobes (frontal, temporal, parietal, occipital), midbrain, basal ganglia and related structures, diencephalon, cerebellum, brainstem, cranial nerves BODY FUNCTIONS Mental functions 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. Seeing functions Visual acuity, visual field, quality of vision, function of the muscles of the eye 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 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. 6 of 47

7 4 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Health condition (disorder or disease) Body Functions & Structure Activity Participation 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 2 practice ( Table 1-2 ). 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 Law and colleagues 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 7 of 47

8 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 5 Table 1-2 DOMAIN Summary of the American Occupational Therapy Association (AOTA) Practice Framework Related to Cognitive and Perceptual Rehabilitation EAMPLES Performance in areas of occupation Basic/personal activities of daily living, instrumental activities of daily living, education, work, play, leisure, social participation Client factorsmental 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. Performance skillsprocess 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 Performance patterns Habits, routines, roles Context Activity demands 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: , Practice Framework Client Factors Performance in Areas of Occupation ICF Body Structures & Body Functions 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 Measure 36 is a standardized tool that embraces a client-centered approach and is discussed later. van den Broek 56 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 Broek 56 affirms that client-centered goal setting is a key to successful rehabilitation outcomes, stating: Goal setting is of central concern as without goals, rehabilitation has no direction and the intervention 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. Another argument for using a client-centered approach to guide the intervention focus with this 8 of 47

9 6 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 ICF 68 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 9 of 47

10 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 7 (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 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? Donald 17 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. 10 of 47

11 8 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Medical Outcomes Study Short Form-36 The Medical Outcomes Study Short Form-36 (SF- 36) 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 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 5- item 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) 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 11 of 47

12 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 9 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 CHART 46 (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 loss 9 as well as stroke 30 and is available in several culture-specific formats. 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 12 of 47

13 10 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 of 47

14 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 11 Lawton Instrumental Activities of Daily Living Scale The Lawton Instrumental Activities of Daily Living Scale 40 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 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. Nottingham Leisure Questionnaire The Nottingham Leisure Questionnaire 18 was developed to measure the leisure activity of stroke Table 1-3 Instrumental Activities of Daily Living Standardized Assessments RIVERMEAD ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT ADELAIDE ACTIVITIES PROFILE FRENCHAY ACTIVITIES INDE NOTTINGHAM ETENDED ADL SCALE INSTRUMENTAL ACTIVITY MEASURE Authors Whiting and Lincoln (1980) Bond and Clark (1998) Holbrook and Skillbeck (1983) Nouri and Lincoln (1987) Rating scale 3-level 4-level 4-level 4-level 7-level Focus Degree of Degree of Degree of Degree of assistance in participation in participation in difficulty and performance activities activities assistance activities engaging in Grimby et al (1996) Degree of assistance in performance activities activities Format Observation Interview Interview Self-report Observation Country of origin United Kingdom Australia United Kingdom United Kingdom Sweden ASSESSMENT ITEMS Meal preparation Prepare a meal Prepare a hot drink Prepare a snack Domestic activities Heavy cleaning Light cleaning Hand wash clothes Iron clothes Hang out washing Make bed Prepare main meal Wash dishes Heavy housework Light housework Wash clothes Household or car maintenance Gardening Light gardening Heavy gardening Productive Voluntary or paid activities employment Shopping/ Carry shopping Household community Cope with money shopping activities Personal Transportation Use public transport bus Transport self to shop shopping Drive a car or organize transport Prepare main meal Wash dishes Heavy housework Light housework Wash clothes Household or car maintenance Gardening Make a hot drink Make a hot snack Wash dishes Take hot drinks between rooms Housework Wash small clothing items Full clothes wash Manage own garden Gainful work Local shopping Drive car or go on bus Travel outings or car rides Shopping Manage own money Travel on public transport Drive a car Cook a main meal Prepare a simple meal Cleaning house Washing clothes Large-scale shopping Small-scale shopping Use public transportation (Continued) 14 of 47

15 12 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Table 1-3 Leisure/social activities Mobility: outdoors Mobility: indoors Basic self-care Instrumental Activities of Daily Living Standardized Assessments Cont d RIVERMEAD ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT ADELAIDE ACTIVITIES PROFILE Community social activities Outdoor social activity Invite guests to home Hobby Telephone calls to family/friends Attend religious events Outdoor recreation or sporting activity Outdoor mobility Crossing roads Get in and out of car 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 FRENCHAY ACTIVITIES INDE Social occasions Hobby Reading books NOTTINGHAM ETENDED ADL SCALE Go out socially Use the telephone Read newspapers or books Write letters Walk outdoors Walking outside Walk outside Cross roads Get in and out of car Walk on uneven ground Climb stairs Feed self INSTRUMENTAL ACTIVITY MEASURE Locomotion outdoors 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): , 1998; Holbrook M, Skillbeck CE: An activities index for use with stroke patients, Age Ageing 12(2): , 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): , 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 Measure 32 provides information about leisure functioning as well as measure 15 of 47

16 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 13 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 Battery 65 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 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 Box 1-1 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). 16 of 47

17 14 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Functional Independence Scale and Neurobehavioral Specific Impairment Subscale Name Ms. Wilson Date 6/13/03 Independence Score (IP): 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. Neurobehavioral Score (NB): 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 COMMENTS AND REASONING DRESSING IP SCORE Shirt (or Dress) Include one armhole, fix shoulder Pants Find correct leghole Socks One-handed technique, balance Shoes Balance Fastenings Match buttonholes, Velcro through loop Other NB IMPAIRMENT NB SCORE Motor Apraxia Ideational Apraxia Unilateral Body Neglect Leaves out left body side Somatoagnosia Spatial Relations Finding correct holes, front/back Unilateral Spatial Neglect Leaves out items in left visual field Abnormal Tone: Right Abnormal Tone: Left Sitting balance/bilateral manipulation Perseveration Organization/Sequencing 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.) 17 of 47

18 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 15 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 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) Name Ms. Wilson Date Birthdate Gender Female Dominance Right Medical Diagnosis: Right CVA 6/20/03. Ischemia. Age 60 Ethnicity Caucasian Profession Dressmaker 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 % 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 Figure 1-4 Cont d (Continued) 18 of 47

19 16 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION LIST OF NEUROBEHAVIORAL IMPAIRMENTS OBSERVED: SPECIFIC IMPAIRMENT D G T F C PERVASIVE IMPAIRMENT ADL PERVASIVE IMPAIRMENT ADL 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 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 ). 19 of 47

20 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 17 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 study 42 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: John S Evaluation date: 01/10/2005 ID: 1111JS Occupational therapist: Kim A Task 1: Task 2: A-3: Pot of boiled/brewed coffee or tea (Average) F-2: Luncheon meat or cheese sandwich (Average) Overall performance in each skill area is summarized below using the following scale: A I MD = Adequate skill, no apparent disruption was observed = Ineffective skill, moderate disruption was observed = 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 POSITIONS the arm or body effectively in relation to task objects Obtaining and Holding Objects REACHES effectively for task objects BENDS or twists the body appropriate to the task GRIPS: securely grasps task objects MANIPULATES task objects as needed for task performance COORDINATES two body parts to securely stabilize task objects Moving Self and Objects MOVES: effectively pushes/pulls task objects and opens/closes doors or drawers LIFTS task objects effectively WALKS effectively about the task environment TRANSPORTS task objects effectively from one place to another CALIBRATES the force and speed of task-related actions FLOWS: uses smooth arm and hand movements when interacting with task objects Sustaining Performance ENDURES for the duration of the task performance PACES: maintains an effective rate of task performance Figure 1-5 A, Assessment of Motor and Process Skills (AMPS) summary. (Continued) 20 of 47

21 18 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: Task 2: A-3: Pot of boiled/brewed coffee or tea (Average) F-2: Luncheon meat or cheese sandwich (Average) Overall performance in each skill area is summarized below using the following scale: A I MD = Adequate skill, no apparent disruption was observed = Ineffective skill, moderate disruption was observed = 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 ATTENDS: does not look away from task performance HEEDS the goal of the specified task Applying Knowledge CHOOSES appropriate tools and materials needed for task performance USES task objects according to their intended purposes HANDLES task objects with care INQUIRES: asks for needed task-related information Temporal Organization INITIATES actions or steps of task without hesitation CONTINUES task actions through to completion SEQUENCES the steps of the task in a logical manner TERMINATES task actions or steps appropriately Organizing Space and Objects SEARCHES and effectively LOCATES task tools and materials GATHERS tools and materials effectively into the task workspace ORGANIZES tools and materials in an orderly and spatially appropriate fashion RESTORES: puts away tools and materials and cleans the workspace NAVIGATES: maneuvers the hand and body around obstacles in the task environment Adapting Performance NOTICES and RESPONDS to task-relevant cues from the environment ADJUSTS: changes workplaces or adjusts switches and dials to overcome problems ACCOMMODATES: modifies one's actions to overcome problems BENEFITS: prevents task-related problems from persisting Figure 1-5 Cont d 21 of 47

22 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 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 22 of 47

23 20 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS) GRAPHIC REPORT Client: Occupational therapist: John S Kim A Date Evaluation 1 01/10/2005 MOTOR 0.38 PROCESS 0.27 ADL MOTOR 4 ADL PROCESS 3 Less physical effort performing ADL 3 More likely to be safe and independent living in the community 2 ADL performance more efficient 2 ADL Motor < Cutoff 1 < ADL Process Cutoff Some increased physical effort performing ADL 1 Some concerns for safe and/or independent living in the community 1 0 Some inefficiencies; 93% of persons below cutoff need assistance More physical effort performing ADL 2 Less likely to be safe and/or independent living in the community 3 ADL performance less efficient 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. 23 of 47

24 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 21 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 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 24 of 47

25 22 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION referred to Katz 29 for comprehensive descriptions of these models. The following paragraphs are summaries of commonly used approaches. Dynamic Interactional Approach The Dynamic Interactional Approach 55 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. 55 Toglia 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 colleagues 1 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 25 of 47

26 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 23 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 Model 7 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 approach 23 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 underlying 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 26 of 47

27 24 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Table 1-4 Clinical Situation: A Client Requires Moderate Assistance for Grooming Tasks Based on the Functional Independence Measure (FIM) CLIENT DIAGNOSIS POTENTIAL IMPAIRMENTS BEHAVIORS INTERFERING WITH FUNCTION 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 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 study 43 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 27 of 47

28 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 25 Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment ARTERY LOCATION POSSIBLE IMPAIRMENTS Middle cerebral artery: upper trunk Middle cerebral artery: lower trunk Lateral aspect of frontal and parietal lobe Lateral aspect of temporal and occipital lobes 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 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 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 ) 28 of 47

29 26 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Table 1-5 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 Anterior choroidal artery, a branch of the internal carotid artery Posterior cerebral artery Basilar artery proximal Combination of middle cerebral artery distribution and anterior cerebral artery Globus pallidus, lateral geniculate body, posterior limb of the internal capsule, medial temporal lobe Medial and inferior aspects of right temporal and occipital lobes, posterior corpus callosum and penetrating arteries to midbrain and thalamus Pons Impairments related to dysfunction of middle and anterior cerebral arteries as listed above 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 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 29 of 47

30 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 27 Table 1-5 ARTERY LOCATION POSSIBLE IMPAIRMENTS Basilar artery distal Midbrain, thalamus, and caudate nucleus Papillary abnormalities Abnormal eye movements Altered level of alertness Coma Memory loss Agitation Hallucination Vertebral artery Lateral medulla and cerebellum Dizziness Vomiting Nystagmus Pain in ipsilateral eye and face Numbness in face Clumsiness of ipsilateral limbs Hypotonia of ipsilateral limbs Tachycardia Gait ataxia Systemic hypoperfusion Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment Cont d Watershed region on lateral side of hemisphere, hippocampus and surrounding structures in medial temporal lobe 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 LOCATION Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment POSSIBLE IMPAIRMENTS Anterolateral thalamus, either side Lateral thalamus Bilateral thalamus Internal capsule or basis pontis Posterior thalamus 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 ) 30 of 47

31 28 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Table 1-6 LOCATION Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment Cont d POSSIBLE IMPAIRMENTS Posterior thalamus Cont d Caudate Putamen Pons Cerebellum 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 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. 31 of 47

32 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION 29 Table 1-7 HEMISPHERE Right hemisphere Left hemisphere Typical Impairments Based on Damage to the Right Versus Left Hemispheres TYPICAL IMPAIRMENTS 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 Table 1-8 LOBE Frontal Temporal Occipital Parietal 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) REFERENCES 1. Abreu BC, Peloquin SM : The quadraphonic approach: a holistic rehabilitation model for brain injury. In Katz N, editors: Cognition and occupation across the life span, Bethesda, Md, 2005, AOTA Press. 2. American Occupational Therapy Association : Occupational therapy practice framework: domain and process, Am J Occup Ther 56 : , Árnadóttir G : The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby. 4. 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. 5. Árnadóttir G: Rasch analysis of the ADL scale of the A-ONE, Am J Occup Ther (in press). 6. Arthanat S, Nochajski SM, Stone J : The international classification of functioning, disability and health and its application to cognitive disorders, Disabil Rehabil 26 (4) : , Averbuch MA, Katz N : Cognitive rehabilitation: a retraining model for clients with neurological disabilities. In Katz N, editor: Cognition and occupation across the life span, Bethesda, Md, 2005, AOTA Press. 8. Baum C, Edwards DF : Cognitive performance in senile dementia of the Alzheimer s type: the kitchen task assessment, Am J Occup Ther 47 (5 ): , Baum C, Edwards D : The activity card sort, St Louis, 2001, Washington University at St. Louis. 10. Baum CM, Edwards DF, Morrison T, et al : The reliability, validity, and clinical utility of the Executive Function Performance Test: a measure of executive function in a sample of persons with stroke, Am J Occup Ther (in press). 11. Bergner M, Bobbitt RA, Carter WB, et al : The sickness impact profile: development and final revision of a health status measure, Med Care 19 : , Carswell A, McColl MA, Baptiste S, et al : The Canadian occupational performance measure: a research and clinical literature review, Can J Occup Ther 71 (4 ): , of 47

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Kloseck M, Crilly RG, Hutchinson-Troyer L : Measuring therapeutic recreation outcomes in rehabilitation: further testing of the leisure competence measure, Ther Recreation J 35 ( 1 ): 31-42, Lai S, Studenski S, Duncan P, et al : Persisting consequences of stroke measured by the stroke impact scale, Stroke 33 (7) : , Laver AJ : The Structured Observational Test of Function, Gerontology Special Interest Section Newsletter 17 (1 ), Laver AJ : Clinical reasoning with simple perceptual impairment. In Unsworth C, editor: Cognitive and perceptual dysfunction: a clinical reasoning approach to evaluation and intervention, Philadelphia, 1999, F.A. Davis. 36. Law M : The Canadian occupational performance measure, ed 2, Ottawa, 1994, CAOT Publications ACE. 37. Law M, Baptiste S, Mills J : Client-centered practice: what does it mean and does it make a difference? Can J Occup Ther 62 (5 ): , Law M, Baum C : Measurement in occupational therapy. In Law M, Baum C, Dunn W, editors: Measuring occupational performance: supporting best practice in occupational therapy, Thorofare, NJ, 2005, Slack. 39. Law M, Baum C, Dunn W : Measuring occupational performance: supporting best practice in occupational therapy, Thorofare, NJ, 2005, Slack. 40. Lawton MP : Instrumental activities of daily living scale: self-rated version, Psychopharmacol Bull 24 (4 ): , Lemiere J, D e cr uyena ere M, Evers-Kie b o oms G, e t al : Cognitive changes in patients with Huntington s disease (HD) and asymptomatic carriers of the HD mutation a longitudinal follow-up study, J Neurol 251 (8) : , Linden A, Boschian K, Eker C, et al : Assessment of motor and process skills reflects brain-injured patients ability to resume independent living better than neuropsychological tests, Acta Neurol Scand 111 (1) :48-53, Lippert-Gruner M, Kuchta J, Hellmich M, et al : Neurobehavioural deficits after severe traumatic brain injury (TBI), Brain Inj 20 (6) : , of 47

34 CHAPTER 1 OVERVIEW OF COGNITIVE AND PERCEPTUAL REHABILITATION Mahoney FI, Barthel DW : Functional evaluation: the Barthel index, Maryland State Med J 14 :61-65, Marinus J, Visser M, Verwey NA, et al : Assessment of cognition in Parkinson s disease, Neurology 61 (9) : , Mellick D, Walker N, Brooks CA, et al : Incorporating the cognitive independence domain into CHART, J Rehabil Outcomes Meas 3 (3 ):12-21, Neistadt ME : Occupational therapy treatments for constructional deficits, Am J Occup Ther 46 (2) : , Neistadt ME : Perceptual retraining for adults with diffuse brain injury, Am J Occup Ther 48 (3) : , Peterson DB : International classification of functioning, disability and health: an introduction for rehabilitation psychologists, Rehabil Psychology 50 (2 ): , Pollock N : Client-centered assessment, Am J Occup Ther 47 (4) : , Rogers JC, Holm MB : Evaluation of activities of daily living (ADL) and instrumental activities of daily living (IADL). In Crepeau EB, Cohn ES, Schell BAB, editors: Willard and Spackman s occupational therapy, ed 10, Philadelphia, 2003, Lippincott Williams & Wilkins. 52. Schiffer, RB : Cognitive loss. In van den Noort S, Holland N, editors: Multiple sclerosis in clinical practice, New York, 1999, Demos Medical Publishing. 53. Schwar tz MF, Segal M, Veramonti T, et al : The Naturalistic Action Test: A standardised assessment for everyday action impairment, Neuropsychol Rehabil 12 (4 ): , Toglia J : Generalization of treatment: a multicontext approach to cognitive perceptual impairment in adults with brain injury, Am J Occup Ther 45 ( 6 ): , Toglia J : A dynamic interactional approach to cognitive rehabilitation. In Katz N, editor: Cognition and occupation across the life span, Bethesda, Md, 2005, AOTA Press. 56. van den Broek MD : Why does neurorehabilitation fail? J Head Trauma Rehabil 20 (5 ): , van Straten A, de Haan RJ, Limburg M, et al : A stroke-adapted 30-item version of the sickness impact profile to assess quality of life (SAS-SIP30), Stroke 28 : , Ware JE, Kosinski M, Keller SD : SF-12: how to score the SF-12 physical and mental health summary scales, ed 2, Boston, 1995, The Health Institute New England Medical Center. 59. Ware JE, Sherbourne CD : The MOS 36-item shortform health survey (SF-36): I. Conceptual framework and item selection, Med Care 30 (6 ): , Ware JE, Sherbourne CD, Davies AR : Developing and testing the MOS 20-item short-form health survey: a general population application. In Stewart AL, Ware JE, editors: Measuring functioning and well-being: the medical outcomes study approach, Durham, NC, 1992, Duke University Press. 61. Whiteneck GG, Charlifue SW, Gerhart KA, et al : Quantifying handicap: a new measure of long-term rehabilitation outcomes, Arch Phys Med Rehabil 73 : , Willer B, Linn R, Allen K : Community integration and barriers to integration for individuals with brain injury. In Finlayson MAJ, Garner SH, editors: Brain injury rehabilitation: clinical considerations, Baltimore, Md, 1994, Williams & Wilkins. 63. Willer B, Ottenbacher KJ, Coad ML : The community integration questionnaire: a comparative examinat ion, Am J Phys Med Rehabil 73 : , Willer B, Rosenthal M, Kreutzer JS, et al : Assessment of community integration following rehabilitation for traumatic brain injury, J Head Trauma Rehabil 8 :75-87, Witt PA, Ellis G : Leisure Diagnostic Battery Users Manual and Scales, 1989, State College, Pennsylvania : Venture Publishing. 66. Wood-Dauphinee S, Opzoomer MA, Williams J, et al : Assessment of global function: the reintegration to normal living index, Arch Phys Med Rehabil 69 (8 ): , Wood-Dauphinee S, Williams J : Reintegration to normal living as a proxy to quality of life, J Chronic Disabil 40 (6) : , World Health Organization : International Classification of Functioning, Disability and Health, Geneva, 2001, World Health Organization. 34 of 47

35 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 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. 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. 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 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 have been described in the literature 39 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 of 47

36 CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS 33 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 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 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 infor mation 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 of 47

37 34 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Box 2-1 Quick Review of Validity and Reliability VALI D IT Y 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: , 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 37 of 47

38 CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS 35 daily functional activities as the method of assessment. The use of structured observations to detect underlying impairments is a not only clinically valid 3,4,32,35,41 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 T h e y 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 TYPE OF ASSESSMENT Tabletop/pen-andpaper assessments Performance-based assessments A Comparison of Test Items Included on Common Cognitive and Perceptual Assessments EAMPLES 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. 38 of 47

39 36 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Haggard and coworkers 20 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 39 of 47

40 CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS 37 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 literature 10,24,42 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 underestimate 7 or overestimate 36 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 activities 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 40 of 47

41 38 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION 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 following 31 : 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- 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 events 7. 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- Table 2-2 REMEDIATION Traditional Classifications of Interventions ADAPTATION 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 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 41 of 47

42 CHAPTER 2 GENERAL CONSIDERATIONS: EVALUATIONS AND INTERVENTIONS 39 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 apraxia 40 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. Brockmann- Rubio and Gillen suggest that the following questions should be answered prior to choosing an approach 8 : 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. 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. 42 of 47

43 40 COGNITIVE AND PERCEPTUAL REHABILITATION: OPTIMIZING FUNCTION Box 2-2 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 BODY NEGLECT Brushing of affected side of mouth MOTOR APRAIA Manipulation of toothbrush during task performance Manipulation of cap from toothpaste Squeezing toothpaste onto toothbrush IDEATIONAL APRAIA Appropriate use of objects (toothbrush, toothpaste, cup) during task 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 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 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 following 37,38 : 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 43 of 47

44 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 44 of 47