Overview of Cognitive and Perceptual Rehabilitation: Key Terms Key Terms

Chapter 1
Overview of Cognitive and Perceptual Rehabilitation
Key Terms
Activity Demands Context Performance Skills
Activity Limitation Environmental Factors Quality of Life
Areas of Occupation Impairment
Client-centered Practice Participation Restriction
Client Factors Performance Patterns
Learning Objectives
At the end of this chapter readers will be able to: 3. Understand which outcome measures are appropri
1. Understand various classification systems that can be ate for this population.
used to guide the evaluation and intervention pro 4. Understand patterns of cognitive and perceptual
cess for those living with functional limitations sec impairments that interfere with everyday function.
ondary to cognitive and perceptual impairments.
2. Apply the principles of client-centered practice to
this population.
“Best practice is a way of thinking about problems in imaginative ways, applying knowledge
creatively to solve performance problems while also taking responsibility for evaluating the
effectiveness of the innovations to inform future practices.”38
functional activities. In general, this assumption

Perspectives of Cognitive and
has not been supported by empirical research.
Perceptual Rehabilitation
An early example is the elegant work of Neistadt.47
The practice area of cognitive and perceptual The researcher had previously identified a relation
rehabilitation has and continues to shift in focus. ship between construction tasks as measured by the
In the recent past, interventions were focused on Wechsler Adult Intelligence Scale-Revised (WAIS-R)
cognitive and perceptual stimulation activities Block Design Test and a standardized assessment of
aimed at the remediation of a particular impair meal preparation, the Rabideau Kitchen Evaluation-
ment. It was assumed that the remediation of an Revised, concluding that constructional abilities may
identified impairment or impairments would contribute to meal preparation performance. Based
generalize into the ability to perform meaningful, on these findings a randomized controlled trial was

cognitive and perceptual rehabilitation: Optimizing function
conducted to examine the effects of interventions to influence function in the real world. In addition, it
focused on retraining meal preparation skills ver is becoming clear that how we measure the success
sus the remediation of constructional deficits in of an intervention must be reconsidered. Significant
adult men with head injuries. Outcomes were meal improvement in a letter cancellation test for a person
preparation competence and objective measures of living with unilateral spatial neglect can no longer be
constructional abilities. Forty-five subjects, ages 18 interpreted as a positive outcome if more meaning
to 52, in long-term rehabilitation programs, were ful functional changes (e.g., improved ability to read,
randomly assigned to one of two treatment groups: manage medications, play board games, manage
remediation of construction abilities (n = 22) via money, etc.) cannot be documented.
training with parquetry block assembly, and a meal As rehabilitation professions began to under
preparation training group (n = 23). Both groups stand the importance of evidence-based practice
received training for three 30-minute sessions per and have refocused on “real-world” functional out
week for 6 weeks, in addition to their regular reha comes, the rehabilitation process has begun to shift
bilitation programs. Results showed task-specific accordingly. Interventions that focus on strategies
learning in both groups and suggested that train for living independently, with a purpose, and
ing in functional activities may be the better way to with improved quality of life despite the presence
improve performance in such activities in this popu perhaps of cognitive and perceptual impairments are
lation. In other words, those trained in construction slowly becoming the clinical standard. Likewise, out
tasks performed better on novel tabletop construc come measures that focus on documenting improved
tion tasks but did not improve on meal preparation functioning outside of a clinic environment and
measures, whereas those trained in the meal prepa those that include test items focused on performing
ration group demonstrated significantly improved functional activities are being embraced.
abilities related to the ability to make a meal at the These positive changes should be welcomed by
end of the intervention despite not improving on clinicians and the individuals to whom they provide
measures of construction ability. Although the results services because making a positive change in the life
of this study are not unexpected based on a current of an individual living with cognitive and percep
understanding of recovery, the study challenged the tual impairments has been notoriously difficult. It
typical interventions that were being taught in aca is expected that as the research literature focused on
demic settings and those that were commonly used testing interventions continues to emerge, further
in the clinic at the time it was published. shifts in practice patterns will occur. Philosophically,
In general, interventions at that time were pro the clinical focus of what is called cognitive and per-
vided in controlled environments consisting of ceptual rehabilitation may be better described as the
tabletop activities that were novel and not focused process of improving function and quality of life in
on function. Examples include engaging individuals those individuals living with cognitive and perceptual
in block design activities, sequencing picture cards, impairments.
puzzle making, design copying, canceling a tar
get stimulus on paper, pegboard designs, memory
World Health Organization’s
drills, and so on. As technology became more read
International Classification of
ily available, specialized cognitive-retraining com
Function as a Framework for
puterized programs were developed, marketed, and
Choosing Assessments, Interventions,
quickly adopted into the clinical setting. In terms
and Documenting Outcomes
of outcomes, interventions were deemed successful
when improvements were documented on specific The World Health Organization’s (WHO) Inter
cognitive and perceptual impairment tests. national Classification of Functioning, Disability,
Similar to the interventions that were being used and Health (ICF)68 is a classification system that
at this time, measurement instruments attempted to describes body functions and structures, activities,
isolate a particular impairment via novel and non and participation. The various domains are inclu
functional test items such as copying words and sive and consider the body itself as well as the indi
designs, picture matching, block building, sequenc vidual and societal perspectives. The ICF embraces
ing pictures, free recall of words, memorizing and the relationship between the person and the context
attending to a number string, and so on. It has and in which daily living occurs and therefore includes
continues to become clear that interventions such as environmental factors as part of the classification
these need to be reconsidered if we as clinicians expect system. The ICF is a useful guide to rehabilitation,
Chapter 1 Overview of Cognitive and Perceptual Rehabilitation
particularly when considering assessments, interven • Participation: Involvement in life situations

tions, and outcomes for people living with cognitive • Participation restrictions: A negative aspect man
and perceptual impairments.6,49 Elements of the clas ifested as an individual experiencing problems
sification system (Table 1-1) include the following68: in life situations
• Body structures: Anatomic parts of the body • Environmental factors: Physical, social, and atti
(organs, limbs, and their components) tudinal environment in which people live and
• Body functions: Physiologic functions of the body conduct their lives; includes environmental as
systems inclusive of psychological functions well as personal factors
• Impairments: A negative aspect related to prob From an evaluation, intervention, and reha
lems in body function or structure such as sig bilitation outcomes perspective, it is important to
nificant deviation or loss consider the relationships between the classifica
• Activities: Execution of a task or action by an tion categories of the ICF rather than focusing on
individual one category at a time (Figure 1-1). For example,
• Activity limitation: A negative aspect mani “Mark” may survive a right frontoparietal stroke
fested as an individual’s difficulty in executing resulting in visuospatial impairments and unilat
activities eral spatial neglect of the left side (impairment of
Table 1-1 Summary of the International Classification of Functioning, Disability, and Health
(ICF) Related to Cognitive and Perceptual Rehabilitation
Element Description/Examples
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 Reading, writing
General tasks and demands Carrying out a daily routine, undertaking a single task, undertaking multiple
tasks
Self-care Washing, dressing, toileting
Mobility Changing body positions, handling objects, walking, driving, using
transportation
Communication Communication with spoken or nonverbal messages, speaking
Domestic life Household tasks, shopping, assisting others
Interpersonal relationships Social and family relationships
Major life areas Education, work and employment, volunteer work, economic life
Community, social, civic life Recreation, leisure, religion
Environmental Factors
Products and technology Aids for use in daily living, mobility, communication, employment, recreation,
education, design, and construction of buildings for private or public use
Support and relationships Family, friends, animals, health care professionals
Attitudes Personal, societal
Service, systems, and policies Housing, legal, civil protection
Data from World Health Organization: International Classification of Functioning, Disability and Health, Geneva, 2001, World Health Organization.
Health condition
(disorder or disease)
Body Functions Activity Participation

& Structure
Environmental Personal
Factors 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.)
Client-Centered Practice
body functions). These impairments may in turn
result in Mark’s inability to perform tasks such as Client-centered practice is an approach to providing
word processing, driving a car, balancing a check rehabilitation services,“which embraces a philosophy
book, or preparing a meal (activity limitations). The of respect for, and partnership with, people receiv
resultant activity limitations may adversely affect ing services. Client-centered practice recognizes the
Mark’s ability to continue gainful employment or autonomy of individuals, the need for client choice
live on his own (participation restrictions). in making decisions about occupational needs,
the strengths clients bring to a therapy encounter,
the benefits of client-therapist partnership, and the
American Occupational Therapy
need to ensure that services are accessible and fit the
Association’s Practice Framework
context in which a client lives.”36
as a Framework for Choosing
Law and colleagues37 as well as Pollock,50 suggest
Assessments and Interventions,
that the therapist implementing this approach to
and Documenting Outcomes
evaluation include the following concepts:
The American Occupational Therapy Association 1. Recognizing that the recipients of therapy are
(AOTA) has published a framework for guiding uniquely qualified to make decisions about their
practice (Table 1-2).2 Components of the frame functioning
work include the following: 2. Offering the individual receiving services a
• Performance in areas of occupation: Occupations more active role in defining goals and desired
and daily life activities outcomes
• Client factors: Factors such as body structures 3. Making the client-therapist relationship an
and body functions that affect performance in interdependent one to enable the solution of
areas of occupation performance dysfunction
• Performance skills: Observable elements of action 4. Shifting to a model in which therapists work
that have implicit functional purposes with individuals to enable them to meet their
• Performance patterns: Patterns of behavior own goals
related to daily life activities 5. Evaluation (and intervention) focusing on the
• Context: Conditions within or surrounding the contexts in which individuals live, their roles and
client that affect and influence performance interests, and their culture
• Activity demands: Aspects of an activity required 6. Allowing the individual who is receiving services
to carry out the activity to be the “problem definer,” so that in turn the
The AOTA Practice Framework and the WHO’s individual will become the “problem solver”
ICF are interrelated despite the use of different ter 7. Allowing the client to evaluate his or her own
minology (Figure 1-2). performance and set personal goals
Table 1-2 Summary of the American Occupational Therapy Association (AOTA) Practice
Framework Related to Cognitive and Perceptual Rehabilitation
Domain Examples
Performance in areas of occupation Basic/personal activities of daily living, instrumental activities of daily living,
education, work, play, leisure, social participation
Client factors Mental Functions: consciousness, energy and drive, orientation, intellectual
functions, psychosocial functions, personality, attention, memory,
psychomotor, language, perceptual functions (e.g., visuospatial), thought,
abstraction, organization, planning, judgment, problem solving, insight,
calculations, motor planning, etc.
Performance skills Process skills: energy, knowledge, temporal organization, organizing space and
objects, adaptation
Motor skills: posture, mobility, coordination, strength and effort, energy
Communication/interaction skills: physicality, information exchange, relations
Performance patterns Habits, routines, roles
Context Cultural, physical, social, personal, spiritual, temporal, virtual
Activity demands Objects and their properties, space demands, social demands, sequence and
timing, required actions, required body functions and structures
Data from American Occupational Therapy Association: Occupational therapy practice framework: domain and process, Am J Occup Ther 56:609-639, 2002.
Practice Framework ICF
Client Factors Body Structures & Body Functions
Performance in Areas of Occupation Activities
Participation
Context Environmental Factors

Figure 1-2 Relationships between the American Occupational Therapy Association (AOTA) Practice Framework and the World Health
Organization’s International Classification of Functioning, Disability, and Health (ICF).
Through the use of these strategies the evaluation cannot be judged to be effective or ineffective. Moreover,
process becomes more focused and defined, clients the quality and type of goal setting sets the tone of the
become immediately empowered, the goals of ther interaction between the clinician or treating team and
apy are understood and agreed on, and an individ the patient. Goals that are proposed, suggested, or iden
tified by the clinician tend to be those based on what
ually tailored intervention plan may be established.
the clinician believes the patient needs. Of equal, if not
The Canadian Occupational Performance Measure36
more importance, however, is what the patient wants to
is a standardized tool that embraces a client-centered achieve. Patients tend to be motivated toward achieving
approach and is discussed later. or satisfying their wants, and may not be so motivated
van den Broek56 specifically recommends using or quite unmotivated toward achieving other goals. The
a client-centered approach as a way to enhance process of goal setting therefore involves arriving at an
neurorehabilitation outcomes and states that overlap between needs and wants, or where this is not
treatment failure may be secondary to clinicians possible agreeing to work toward wants that represent
focusing interventions on what they believe the a reasonable compromise. Goal setting that ends with
client needs rather than what the client actually treatment goals that consist of needs that the patient does
wants. van den Broek56 affirms that client-centered not want or is indifferent toward is not client centered
but prescriptive, and runs the risk of concluding in an
goal setting is a key to successful rehabilitation
ineffective outcome.”
outcomes, stating:
“Goal setting is of central concern as without goals, Another argument for using a client-centered
rehabilitation has no direction and the intervention approach to guide the intervention focus with this
population is that interventions typically used for related to getting her son to school (choosing his
those living with cognitive-perceptual dysfunction clothing, making lunch, etc.). As the sole financial
are notoriously difficult to generalize to other real- provider, Mary spent the greater part of the rest of
world settings and situations. For example, visual the day in her home office working on the com
scanning training via tabletop activities for those liv puter, fielding phone calls, and organizing pres
ing with unilateral spatial neglect most often will not ent or upcoming jobs. Lunch was usually a quick
automatically generalize to the client’s being able to cold sandwich. Mary stopped working at 3:30 when
use the scanning strategy to find items in the refrig her son arrived home from school. Depending on
erator unless the strategy is specifically taught in the the day she would drive her son to Little League or
context of the activity. In addition, strategies that are drum lessons. Mary always cooked a full dinner and
taught to accomplish a specific task (e.g., using an spent the rest of the evening helping with home
alarm watch to maintain a medication schedule for work and watching television. Mary’s memory
those living with memory loss) will not necessar impairments are preventing her from continuing
ily generalize or “carry over” to another task such as to work. For safety reasons, her mother has moved
remembering therapy appointments. Finally, there in to help with childcare, household organization,
are a large number of clients whose level of brain and financial matters. Mary has recently expressed
damage preclude them from generalizing learned feelings of low self-esteem, saying that “she can’t
tasks.48 This issue of task-specificity related to treat do anything by herself anymore.” Mary has stated
ment interventions must always be considered by that she is most concerned about starting to work
clinicians working with this population. A client- (finances are limited) and she would like to take a
centered approach will help ensure that outcomes, more active parenting role again. Prior to initiating
goals, and tasks used as the focus of therapy are at interventions, Mary participated in three assess
least relevant, meaningful, and specific to each client ments including standardized measures of memory
as well as the caretaker or significant others despite the impairment, instrumental activities of daily living
potential lack of being generalizable for a segment (IADL) (e.g., homemaking and child care), and
of the population living with various cognitive and quality of life (QOL).
perceptual impairments. Possible (noninclusive) outcomes for Mary
based on the ICF68 may include the following:
• Outcome 1: Following cognitive reha
What Are Appropriate Outcomes
bilitation, Mary has improved her scores
When Designing Interventions
on a standardized memory scale (decreased
for People Living with Cognitive
impairment) but changes are not detected on
and Perceptual Impairments?
measures of IADL and QOL (stable activity
Although not as a problematic as the recent past, the limitations/participation restrictions).
practice area of cognitive and perceptual rehabili • Outcome 2: Following cognitive rehabili
tation has been plagued by a lack of well-designed tation, Mary has no detectable changes on the
clinical trials demonstrating positive outcomes. standardized memory scale (stable impair
A starting point is to decide what is considered ment) but changes are detected on mea
an appropriate, meaningful, and ideal outcome to sures of IADL and QOL (decreased activity
measure. This decision will help guide interventions limitations/participation restrictions).
as well. The preceding paragraphs have already dis • Outcome 3: Following cognitive rehabili
cussed the importance of keeping a client-centered tation, Mary has detectable changes on
focus during the rehabilitation process. A client- the standardized memory scale (decreased
centered focus is paramount when considering out impairment) as well as changes that are
comes as well. The following case illustrates various detected on measures of IADL and QOL
possible outcomes: (decreased activity limitations/participation
Mary is a 32-year-old woman who survived an restrictions).
anoxic event that has resulted in moderate/severe Out of the three outcome scenarios, outcome 1 is
short term memory impairments. Mary is a sin the least desirable. In the past this type of outcome
gle mother of a 5-year-old boy. She works from may have been considered successful (i.e., “Mary’s
home (desktop publishing). Mary’s days were quite memory has improved”). This outcome may be
structured before her brain injury. Mornings were indicative of an intervention plan that is over
characterized by basic self-care followed by tasks focused on attempts to remediate memory skills
(e.g., memory drills, computerized memory pro changes in these measures are more relevant than
grams) without consideration of generalization an isolated change on an impairment measure—
to real-life scenarios. If a change at the impair the impairment change must be associated with a
ment level of function does translate or general change in other health domains. Individuals receiv
ize to improved ability to engage in meaningful ing services, family members, and third-party pay
activities, participate successfully in life roles, or ers alike are likely to be more satisfied with changes
enhance quality of life, the importance of the at these arguably more meaningful levels of func
intervention needs to be reconsidered. Outcomes tion. The following standardized, valid, and reli
2 and 3 are more clinically relevant, arguably more able measurement instruments are suggested to
meaningful to Mary and her family, and repre document successful clinical and research out
sent more optimal results of structured rehabilita comes related to improving function in those with
tion services. Outcome 2 may have been achieved functional limitations secondary to the presence of
by focusing interventions on Mary’s chosen tasks. cognitive and perceptual impairments.
Interventions such as teaching compensatory strat For a thorough review of performance-based
egies including the use of assistive technology may measures, refer to Law and associates.39 Unless oth
have been responsible for this outcome. Mary is erwise indicated, they are not impairment-specific
able to engage in chosen tasks despite the presence evaluations; therefore, they have high use when
of stable memory impairments. working with this population.
Finally, outcome 3 represents improvement
(decreased impairment, improved activity perfor
Quality of Life Measures
mance, and improved quality of life) across mul
tiple health domains. Although this outcome may The construct of quality of life is broad and com
be considered the most optimal, the relationships plicated. In her paper “What Is Quality of Life?”
among the three measures are not clear. Clinicians Donald17 summarizes several issues related to qual
may assume that the improved status detected by ity of life:
the standardized measure of memory was also • “Quality of life is a descriptive term that refers
responsible for Mary’s improved ability to per to people’s emotional, social and physical well-
form household chores and childcare. This reason being, and their ability to function in the ordi
ing is not necessarily accurate. The changes within nary tasks of living.
the health domains may in fact be independent of • Health-related quality of life analyses measure
each other. In other words, Mary’s improved abil the impact of treatments and disease processes
ity to manage her household after participating in on these holistic aspects of a person’s life.
treatment may be related to the fact that interven • Quality of life is measured using specially
tions included specifically teaching Mary strate designed and tested instruments, which measure
gies to manage her household. Similar to outcome people’s ability to function in the ordinary tasks
2, this positive change may have occurred with or of living.
without a documented improvement in memory • Quality of life analyses are particularly helpful
skills. for investigating the social, emotional, and physi
Traditionally clinicians and researchers involved cal effects of treatments and disease processes on
in working with those living with cognitive and per people’s daily lives; analyzing the effects of treat
ceptual impairments use standardized measures of ment or disease from the client’s perspective;
cognitive-perceptual impairment (i.e., standardized and determining the need for social, emotional,
tests of attention, memory, apraxia, neglect) as the and physical support during illness.
primary outcome measure to document effective • Quality of life measures can therefore help to
ness of interventions. Although this is one impor decide between different treatments, to inform
tant level of measurement and following chapters clients about the likely effects of treatments, to
will review specific cognitive-perceptual measures monitor the success of treatments from the cli
in detail, it is not sufficient to use these measures ent’s perspective, and to plan and coordinate
as the sole or important indicator of successful care packages.”
interventions. It is critical that clinical programs Clinicians and researchers should consider
and research protocols not only include but also improving quality of life as an overarching theme
focus on measures of activity, participation, and related to rehabilitation in general. Specific assess
quality of life as a key outcome. As stated, positive ments are reviewed below.
Medical Outcomes Study Short Form-36 Reintegration to Normal Living

The Medical Outcomes Study Short Form-36 (SF- The Reintegration to Normal Living (RNL)66,67
36)59 is a widely used survey instrument for assess assessment is used to document reentry into every
ing a client’s health-related quality of life. The SF-36 day life following a sudden illness or event. This
measures eight domains: physical functioning, role functional status measure quantitatively assesses the
physical, bodily pain, general health, vitality, social degree of reintegration to normal living achieved
functioning, role emotional, and mental health, by clients after illness or trauma and is useful. This
and has two summary scores (physical and men tool assesses global function and the individual’s
tal). The SF-36 has demonstrated its reliability and satisfaction with basic self-care, in-home mobility,
validity in multiple populations and can be admin leisure activities, travel, and productive pursuits.
istered in various ways. The SF-1258 and SF-2060 are Clients are provided with 11 statements to which
abbreviated versions of the SF-36 health profile. they respond. The test can be completed using a
pen-and-paper format or an interview format.
Sickness Impact Profile
The Sickness Impact Profile (SIP)11 is used to evalu Satisfaction with Life Scale
ate the effect of disease on physical and emotional The Satisfaction with Life Scale (SWLS)16 is a 5-
functioning. The measure includes two overall item scale that uses a 7-point Likert scale response
domains: physical and psychosocial. The measure format. Individual scores are added to create a total
has 12 categories including sleep and rest, eating, score ranging from 5 to 35. A score of 20 represents
work, home management, recreation and pastimes, a neutral point at which the respondent is equally
ambulation, mobility, body care and movement, satisfied and dissatisfied. The items in the SWLS are
social interaction, alertness behavior, emotional limited to general life satisfaction.
behavior, and communication. The instrument
yields an overall score, 2 domain scores, and 12
Activity and Participation Measures
category scores; items are weighted according to a
standardized weighting scheme. A stroke-specific Outcomes related to cognitive perceptual rehabilita
version (Stroke Adapted Sickness Impact Profile) is tion must be detectable and evidenced by decreasing
available.57 activity limitations and participation restrictions. Out
comes are individualized and based on the activities
Nottingham Health Profile (basic activities of daily living [ADL], IADL, paid
The Nottingham Health Profile (NHP)27,28 was and unpaid work, and play and leisure) that clients
developed to be used in epidemiologic studies of want to be able to do or need to do to live a safe and
health and disease and consists of two parts. Part productive life. Measurement instruments that focus
1 contains 38 yes/no items in six dimensions: pain, on the activity and participation levels are critical to
physical mobility, emotional reactions, energy, document the effectiveness of cognitive-perceptual
social isolation, and sleep. Part 2 contains 7 gen rehabilitation interventions. Examples follow.
eral yes/no questions concerning daily living prob
lems including paid employment, jobs around the Community Integration Questionnaire
house, personal relationships, social life, sex life, The Community Integration Questionnaire (CIQ)62-64
hobbies, and holidays. The two parts may be used consists of 15 items relevant to home integration, social
independently. integration, and productive activities. It is scored to
provide subtotals for each of these, as well as for com
Stroke Impact Scale munity integration overall. Scoring is primarily based
The Stroke Impact Scale (SIS)19,33 is a stroke-specific on frequency of performing activities or roles, with
measure that provides information on function and secondary weight given to whether activities are done
quality of life. This self report measure including 59 jointly with others, and the nature of these other per
items that form eight subgroups including strength, sons. The CIQ can be completed, by either the client or
hand function, basic and instrumental activities of a proxy, in about 15 minutes.
daily living, mobility, communication, emotion,
memory and thinking, and participation. The SIS Craig Handicap Assessment and
is valid, reliable, and sensitive to change in stroke Reporting Technique
populations and is reliable when responses are The Craig Handicap Assessment and Reporting
provided by proxy. Technique (CHART)61 measures the degree to
which impairments and activity limitations result in In addition, an adolescent as well as child version is
decreased participation. The original CHART had in development.25
27 questions and included the following domains:
(1) physical independence: ability to sustain a Canadian Occupational Performance Measure
customarily effective independent existence; (2) The Canadian Occupational Performance Measure
mobility: ability to move about effectively in one’s (COPM)12,36 is a self-report measure used to assess
surroundings; (3) occupation: ability to occupy a client’s perception of recovery and goals. This
time in the manner customary to that person’s sex, client-centered assessment allows the recipient of
age, and culture; (4) social integration: ability to treatment (or a caretaker) to identify activities that
participate in and maintain customary social rela are difficult, rate the importance of each activity,
tionships; and (5) economic self-sufficiency: ability rate own level of performance for each identified
to sustain customary socioeconomic activity and activity, and rate satisfaction with current perfor
independence. mance. Overall areas of assessment include self-care,
The revised CHART46 (32 questions) contains a leisure, and productivity. The tool is not diagnosis
sixth domain designed to assess orientation: cog specific and can be used with children, adolescents,
nitive independence. Each of the domains or sub and adults. To be used with success, the client must
scales of the CHART has a maximum score of 100 be able to understand a 10-point Likert scale scor
points. High subscale scores indicate less handicap, ing format. If this is not possible, a caregiver may be
or higher social and community participation. The involved in the assessment process (Figure 1-3).
CHART can be administered by interview, either in
person or by telephone, and takes approximately Barthel Index
15 minutes to administer. Participant-proxy agree The Barthel Index (BI)44 is a measure of basic activ
ment across disability groups on the CHART has ities of daily living and mobility. It is scored from
provided evidence in support of the use of proxy 0 to 100, with higher scores indicative of increased
data for people with various types of disabilities. function. The specific items measured include feed
A shorter version of the instrument, the CHART ing, bathing, grooming, dressing, bowel control,
Short Form, has 19 items that yield the same bladder control, toilet use, transfers, mobility on
subscales as the original CHART. even surfaces, and stairs.
Activity Card Sort Functional Independence Measure

The Activity Card Sort (ACS)9,30 uses a Q-sort The Functional Independence Measure (FIM)31
methodology to assess participation in 80 instru is a widely accepted functional assessment mea
mental, social, and high and low physical demand sure used during inpatient rehabilitation. The FIM
leisure activities. Clients sort the cards into different is an 18-item ordinal scale, used with all diagno
piles to identify activities that were done prior to ses within a rehabilitation population. FIM scores
insult or injury, those activities they are doing less, range from 1 to 7 (1 = total assist and 7 = com
and those they have given up since their injury. The plete independence). Scores falling below 6 require
ACS uses cards with pictures of tasks that people do another person for supervision or assistance. The
every day. There are different versions of the card FIM measures independent performance in self-
sort based on where interventions are taking place. care, sphincter control, transfers, locomotion, com
An institutional version sorts the cards into cate munication, and social cognition. By adding the
gories of done prior to illness and not done. The points for each item, the possible total score ranges
recovering version identifies activities not done in from 18 (lowest) to 126 (highest) level of inde
the past 5 years, those given up because of illness, pendence. During rehabilitation, admission and
those beginning to do again, and those activities the discharge scores are rated by a multidisciplinary
client is doing now.25 team while observing client function. Functioning
In all versions, a current activity level is deter postdischarge can be accurately assessed using a
mined. This assessment takes approximately 30 telephone version of FIM when administered by
minutes to administer and results in a score of qualified interviewers.
percent of activities retained. The ACS has been
found to be a reliable and valid measure with indi Revised Observed Tasks of Daily Living
viduals with cognitive loss9 as well as stroke30 and The Revised Observed Tasks of Daily Living
is available in several culture-specific formats. (OTDL-R)15 is a performance-based test of everyday
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 administered in bed. The tool has been used with
designed with a focus on cognitive IADL. The test community-dwelling older adults, older adults liv
includes nine tasks in the categories of medication ing in nursing homes or assisted living facilities,
use, telephone use, and financial management. The individuals with schizophrenia, and individuals
test does not require special equipment and can be with brain injuries.24
Chapter 1 Overview of Cognitive and Perceptual Rehabilitation 11
Lawton Instrumental Activities of Daily Living Scale a three-point scale: independent, assistance needed,
The Lawton Instrumental Activities of Daily Living or dependent. Client self-report and informant (i.e.,
Scale40 includes the following items: use of the tele clinician or family member) versions are available.
phone (look up numbers, dial, answer), traveling Table 1-3 gives more choices of standardized IADL
via car or public transportation, food or clothes assessments.
shopping (regardless of transport), meal prepara
tion, housework, medication use (preparing and Nottingham Leisure Questionnaire
taking correct dose), management of money (write The Nottingham Leisure Questionnaire18 was
checks, pays bills). Each criterion is graded on developed to measure the leisure activity of stroke
Table 1-3 Instrumental Activities of Daily Living Standardized Assessments

Rivermead
Activities
of Daily Adelaide Nottingham
Living (ADL) Activities Frenchay Extended ADL Instrumental
Assessment Profile Activities Index Scale Activity Measure
Authors Whiting and Bond and Clark Holbrook and Nouri and Lincoln Grimby et al
Lincoln (1980) (1998) Skillbeck (1983) (1987) (1996)
Rating scale 3-level 4-level 4-level 4-level 7-level
Focus Degree of Degree of Degree of Degree of Degree of
assistance in participation in participation in difficulty and assistance in
performance activities activities assistance performance
activities engaging in 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 main Prepare main Make a hot drink Cook a main
Prepare a hot drink meal meal Make a hot snack meal
Prepare a snack Wash dishes Wash dishes Wash dishes Prepare a simple
Take hot drinks meal
between rooms
Domestic activities Heavy cleaning Heavy housework Heavy housework Housework Cleaning house
Light cleaning Light housework Light housework Wash small Washing clothes
Hand wash clothes Wash clothes Wash clothes clothing items
Iron clothes Household or car Household Full clothes wash
Hang out washing maintenance or car
Make bed maintenance
Gardening — Light gardening Gardening Manage own —
Heavy gardening garden
Productive — Voluntary or paid Gainful work — —
activities employment
Shopping/ Carry shopping Household Local shopping Shopping Large-scale
community Cope with money shopping Manage own shopping
activities Personal money Small-scale
shopping shopping
Transportation Use public Drive a car or Drive car or go Travel on public Use public
transport—bus organize on bus transport transportation
Transport self to transport Travel outings or Drive a car
shop car rides
(Continued)
Table 1-3 Instrumental Activities of Daily Living Standardized Assessments—Cont’d

Rivermead
Activities
of Daily Adelaide Nottingham
Living (ADL) Activities Frenchay Extended ADL Instrumental
Assessment Profile Activities Index Scale Activity Measure
Leisure/social — Community social Social occasions Go out socially —

activities activities Hobby Use the telephone
Outdoor social Reading books Read newspapers
activity or books
Invite guests to Write letters
home
Hobby
Telephone calls to
family/friends
Attend religious
events
Outdoor
recreation or
sporting activity
Mobility: outdoors Outdoor mobility Walk outdoors Walking outside Walk outside Locomotion
Crossing roads Cross roads outdoors
Get in and out Get in and out
of car of car
Walk on uneven
ground
Mobility: indoors Indoor mobility — — Climb stairs —
Mobility to lavatory
Move bed to chair
Move floor to chair
Basic self-care Drink — — Feed self —
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
Studies cited: Whiting S, Lincoln NB: An ADL assessment for stroke patients, Br J Occup Ther 43:44, 1980; Bond MJ, Clark MS: Clinical applications of
the Adelaide activities profile, Clin Rehabil 12(3):228-237, 1998; Holbrook M, Skillbeck CE: An activities index for use with stroke patients, Age Ageing
12(2):166-170, 1983; Nouri FM, Lincoln NB: An extended activities of daily living scale for stroke patients, Clin Rehabil 4:123, 1987; and Grimby G, Andren
E, Holmgren E, et al: Structure of a combination of functional independence measure and instrumental activity measure items in community-living persons:
a study of individuals with cerebral palsy and spina bifida, Arch Phys Med Rehabil 77(11):1109-1114, 1996. From Park S: Enhancing engagement in instru-
mental 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.
c lients. The results for the interrater reliability study collapsed (five to three categories) in order to make
were “excellent” and “excellent” or “good” for the it suitable for mail use.
test retest reliability study. They suggested that the
tool has potential for clinical use. More recently the Leisure Competence Measure
Nottingham Leisure Questionnaire has been short The Leisure Competence Measure32 provides infor
ened (37 to 30 items) and the response categories mation about leisure functioning as well as measure
change in leisure function over time. The tool therapist to detect impairments that interfere with
includes nine areas: social contact, community par task performance to understand factors underlying
ticipation, leisure awareness, leisure attitude, social activity limitations. It is used with clients who are
behaviors, cultural behaviors, leisure skills, inter 16 years and older and are living with functional
personal kills, and community integration skills. limitations secondary to central nervous system
Items are rated on a seven-point Likert scale. dysfunction such as stroke, traumatic brain injury,
dementia, and multiple sclerosis.
Leisure Diagnostic Battery The A-ONE aids the therapist in analyzing the
The original version of the Leisure Diagnostic nature or cause of a functional problem requiring
Battery65 includes 95 items, whereas the newer intervention. Subsequently, therapists can speculate
shorter version includes 25 items.13 Items are scaled about the best intervention for activity limitation
on three-point scale. Assessment areas include play and impairments. The A-ONE is a performance-
fulness, competence, barriers, knowledge, and so on. based tool that uses structured observations of
upper and lower body dressing, grooming, hygiene,
feeding, transfers, mobility and communication to
Measures That Simultaneously Assess
detect the underlying impairments that interfere
Activity/Participation and Underlying
with function (Box 1-1).
Impairments or Subskills
Impairments detected during the observation
There is a short list of available assessments that are of these tasks include motor apraxia, ideational
highly recommended because they are unique in apraxia, unilateral body neglect, somatoagnosia,
their ability to simultaneously assess more than one spatial relations, unilateral spatial neglect, impaired
level of function such as activity limitations and the motor control, perseveration, and organization and
impairments responsible for the limitations. These sequencing. In addition pervasive impairments such
assessments provide clinicians with critical and as agnosias, memory loss, disorientation, confabu
substantial information via skilled observation of lation, and affective disturbances can be detected
functional tasks. throughout the observations. Figure 1-4 shows an
example of the dressing domain of the A-ONE. Note
Árnadóttir OT-ADL Neurobehavioral Evaluation that the instrument includes two scales; the Indepen
The Árnadóttir OT-ADL Neurobehavioral Evalua dence Score measures each activity in terms of
tion (A-ONE)3–5,22 is an instrument that allows the 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 • Unilateral body neglect
as the method of assessment during the following daily • Somatoagnosia
living skills: • Spatial relations dysfunction
• Feeding • Unilateral spatial neglect
• Grooming and hygiene (upper body washing, oral/hair • Perseveration
care, shaving, etc.) • Organization and sequencing dysfunction
• Dressing (upper and lower body) • Topographic disorientation
• Transfers and mobility (bed mobility, transfers, • Motor control impairments
maneuvering in a wheelchair or during ambulation) In addition, the following pervasive impairments can be
• Functional communication (comprehension and detected and objectified:
expression) • Agnosias (visual object, associative visual object,
Using standardized procedures and uniform conceptual visuospatial)
and operational definitions as guidelines the following spe- • Anosognosia
cific impairments are evaluated in the context of functional • Body scheme disturbances
skills: • Emotional/affective disturbances
• Ideational apraxia • Impaired attention and alertness
• Motor apraxia • 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).
Functional Independence Scale and

Neurobehavioral Specific Impairment Subscale
Ms. Wilson 6/13/03

Name______________________________________________________________________
Date _________________________
Independence Score (IP): Neurobehavioral Score (NB):

4 = Independent and able to transfer activity to 0 = No neurobehavioral impairments observed.
other environmental situations. 1 = Able to perform without additional
3 = Independent with supervision. information, but some neurobehavioral impairment
2 = Needs verbal assistance. is observed.
1 = Needs demonstration or physical assistance. 2 = Able to perform with additional verbal assistance, but
0 = Unable to perform. Totally dependent on assistance. 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) 4 3 2 1 0 Include one armhole, fix shoulder

Pants 4 3 2 1 0 Find correct leghole
Socks 4 3 2 1 0 One-handed technique, balance
Shoes 4 3 2 1 0 Balance
Fastenings 4 3 2 1 0 Match buttonholes, Velcro through loop
Other
NB IMPAIRMENT NB SCORE
Motor Apraxia 0 1 2 3 4
Ideational Apraxia 0 1 2 3 4
Unilateral Body Neglect 0 1 2 3 4 Leaves out left body side
Somatoagnosia 0 1 2 3 4
Spatial Relations 0 1 2 3 4 Finding correct holes, front/back
Unilateral Spatial Neglect 0 1 2 3 4 Leaves out items in left visual field
Abnormal Tone: Right 0 1 2 3 4
Abnormal Tone: Left 0 1 2 3 4 Sitting balance/bilateral manipulation
Perseveration 0 1 2 3 4
Organization/Sequencing 0 1 2 3 4 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.)
Score measures the individual impairments that are basic and IADL with an emphasis placed on
affecting function. In this example Ms. Wilson has IADL tasks. The AMPS is not diagnosis specific.
sustained a right cerebrovascular accident (CVA); It is appropriate for clients who are 3 years old
unilateral body neglect, spatial relations impair and up and who are experiencing functional limi
ment, unilateral spatial neglect, organization and tations. The AMPS entails the client choosing to
sequencing problems, and left hemiplegia inter perform two or three tasks in collaboration with
fere with the dressing performance as indicated by a therapist from a list of more than 80 standard
scores on the Neurobehavioral Specific Impairment ized tasks.
Subscale of the A-ONE. To be administered reliably, In addition, although it does not detect the
the A-ONE requires a training course. client’s underlying impairments it does evaluate
motor and processing skills that affect function.
Assessment of Motor and Process Skills Motor skills are observable actions a person uses
The Assessment of Motor and Process Skills (AMPS)21 to move the body or objects during all ADL task
is a client-centered performance assessment of both performance. Process skills are observable actions
Árnadóttir OT-ADL
Neurobehavioral Evaluation
(A-ONE)
Ms. Wilson
Name _____________________________________________ 6–13–03
Date ________________________________________
4–15–1943
Birthdate __________________________________________ 60
Age _________________________________________
Female
Gender ____________________________________________ Caucasian
Ethnicity _____________________________________
Right
Dominance ________________________________________ Dressmaker
Profession ___________________________________
Medical Diagnosis:
Right CVA 6/20/03. Ischemia.
Medications:
Social Situation:
Lives alone in an apartment building on third floor
Has two adult daughters
Summary of Independence:
Needs physical assistance with dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis and perceptual and cognitive impairments. Is more or less
able to feed herself if meals have been prepared. No problems with personal communication,
although perceptual impairments will affect reading and writing skills. Also has lack of
judgment and memory impairment, which affect task performance. Is not able to live alone at
this stage. If personal home support becomes available, will need a home evaluation because
of physical limitation and wheelchair use. Needs recommendations regarding removal of
architectural barriers or suggestions for alternative housing. Unable to return to previous
job as a dressmaker.
FUNCTIONAL INDEPENDENCE SCORE (optional)

FUNCTION TOTAL SCORE % 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)
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 dif-
ferentiating 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 instruc-
tions.
Treatment Considerations:
Occupational Therapist:
A-ONE Certification Number:

a person uses to (1) select, interact with, and use figure-ground skills, problem solving, intact visual
tools and materials, (2) carry out individual actions fields, and so on. The AMPS detects the behavioral
and steps, and (3) modify performance when prob output of these subskills. Following the skilled obser
lems are encountered. Process skills should not be vation of each ADL task, the client is rated on 16
confused with cognitive or perceptual skills. motor and 20 process skill items for each task per
For example, one process skill included on the formed using a four-point Likert scale. Once the
AMPS is the ability “search and locate.” Searching for items are scored for each task, the results are entered
and locating necessary items to perform a task relies in the AMPS computer scoring program. The pro
on multiple underlying skills such as visual attention, gram generates a summary report (Figure 1-5, A).
In addition, the computer analysis of the motor and within 60 minutes. A study42 found that the AMPS
process skill scores results in ADL motor ability and may give a better indication of the client’s ability
ADL process ability measures. The measures repre to resume independent living than neuropsycho
sent the placement of the person on a continuum of logical testing alone. The occupational therapy
motor or process ability (Figure 1-5, B). practitioner who uses the AMPS must attend a
The AMPS requires no specialized equipment 5-day AMPS training course to become certified
and can be conducted in any ADL-relevant setting 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: A-3: Pot of boiled/brewed coffee or tea (Average)

Task 2: F-2: Luncheon meat or cheese sandwich (Average)
Overall performance in each skill area is summarized below using the following scale:
A = Adequate skill, no apparent disruption was observed
I = Ineffective skill, moderate disruption was observed
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist
intervention
MOTOR SKILLS: Skills observed when client moved self and objects A I MD
during task performance
Body Position
STABILIZES: does not lose balance when interacting with task objects X
ALIGNS: does not persistently support oneself during task performance X
POSITIONS the arm or body effectively in relation to task objects X
Obtaining and Holding Objects
REACHES effectively for task objects X
BENDS or twists the body appropriate to the task X
GRIPS: securely grasps task objects X
MANIPULATES task objects as needed for task performance X
COORDINATES two body parts to securely stabilize task objects X
Moving Self and Objects
MOVES: effectively pushes/pulls task objects and opens/closes doors or drawers X
LIFTS task objects effectively X
WALKS effectively about the task environment X
TRANSPORTS task objects effectively from one place to another X
CALIBRATES the force and speed of task-related actions X
FLOWS: uses smooth arm and hand movements when interacting with task objects X
Sustaining Performance
ENDURES for the duration of the task performance X
PACES: maintains an effective rate of task performance X
Figure 1-5 A, Assessment of Motor and Process Skills (AMPS) summary.

(Continued)

PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.
Client: John S Evaluation date: 01/10/2005

ID: 1111JS Occupational therapist: Kim A
Task 1: A-3: Pot of boiled/brewed coffee or tea (Average)

Task 2: F-2: Luncheon meat or cheese sandwich (Average)
Overall performance in each skill area is summarized below using the following scale:
A = Adequate skill, no apparent disruption was observed
I = Ineffective skill, moderate disruption was observed
MD = Markedly deficient skill, observed problems were severe enough to be unsafe or to require therapist
intervention
PROCESS SKILLS: Skills observed when client (a) selected, interacted A I MD

with, and used task tools and materials; and (b)
modified task actions, when needed, to complete the
Sustaining Performance
PACES: maintains an effective rate of task performance X
ATTENDS: does not look away from task performance X
HEEDS the goal of the specified task X
Applying Knowledge
CHOOSES appropriate tools and materials needed for task performance X
USES task objects according to their intended purposes X
HANDLES task objects with care X
INQUIRES: asks for needed task-related information X
Temporal Organization
INITIATES actions or steps of task without hesitation X
CONTINUES task actions through to completion X
SEQUENCES the steps of the task in a logical manner X
TERMINATES task actions or steps appropriately X
Organizing Space and Objects
SEARCHES and effectively LOCATES task tools and materials X
GATHERS tools and materials effectively into the task workspace X
ORGANIZES tools and materials in an orderly and spatially appropriate fashion X
RESTORES: puts away tools and materials and cleans the workspace X
NAVIGATES: maneuvers the hand and body around obstacles in the task environment X
Adapting Performance
NOTICES and RESPONDS to task-relevant cues from the environment X
ADJUSTS: changes workplaces or adjusts switches and dials to overcome problems X
ACCOMMODATES: modifies one's actions to overcome problems X
BENEFITS: prevents task-related problems from persisting X
OCCUPATIONAL THERAPY EVALUATION OF ADL ABILITY

(Results and Interpretation of an Assessment of Motor
and Process Skills (AMPS) Evaluation)
Therapist: Kim A, OTR

Client: John S
Age: 72
Date of Evaluation: 01/10/2005
AMPS EVALUATION
The Assessment of Motor and Process Skills (AMPS) was administered to John S as a means of evaluating his ability to perform
activities of daily living (ADL) tasks. As part of the AMPS assessment, the occupational therapist conducted an interview to gain
a better understanding of the everyday tasks (occupations) that have been presenting a challenge for him, as well as those
everyday tasks that he has been performing with little difficulty. He was offered a choice of familiar and relevant tasks that he had
identified as presenting problems in everyday life. He chose to perform 2 of the tasks that were offered: Pot of boiled/brewed
coffee or tea, and Luncheon meat or cheese sandwich. When the AMPS was administered, the occupational therapist assessed
the amount of effort, independence, efficiency, and safety that he exhibited during the performance of these tasks.
OVERALL QUALITY OF PERFORMANCE
John showed evidence of moderately unsafe, markedly effortful, and moderately inefficient ADL task performance and he needed
frequent assistance to complete the 2 ADL tasks.
SPECIFIC SKILLS THAT MOST IMPACTED PERFORMANCE

More specifically, John's performance of the above noted ADL tasks was limited by:
• Momentary or transient loss of balance and/or the need to support himself on external objects while moving through the
environment or interacting with task objects (Stabilizes)
• Difficulty positioning body in relation to the workspace (Positions)
• Increased effort when reaching for or placing task objects (Reaches)
• Increased effort propelling the wheelchair (Moves)
• Ineffective walking or ambulating skill; instability when walking (Walks)
• Increased effort and/or instability when transporting task objects from one place to another
(Transports)
• Difficulty completing tasks without obvious evidence of physical fatigue (Endures)
• Failure to maintain a consistent and effective rate of performance (Paces)
• Pauses during actions or task steps, delaying task progression (Continues)
• Decreased skill accommodating for and preventing problems from occurring, and problems
persisted or recurred during task performances (Accommodates and Benefits)
OVERALL ADL MOTOR ABILITY
ADL motor ability is an overall measure of a person's observed skill when moving oneself or task objects as needed for ADL task
performance. John's ADL motor ability measure of -0.38 logits is plotted in relationship to the AMPS motor cutoff measure on the
AMPS Graphic Report. His ADL motor ability is below the AMPS motor cutoff. This indicates that he has increased effort when he
performs ADL tasks. To put this in perspective, approximately 95% of well, healthy persons of John's age have ADL motor ability
measures between 1.07 and 3.27 logits. This indicates that his ADL motor performance is lower than age expectations.
OVERALL ADL PROCESS ABILITY
ADL process ability is a global measure of a person's observed skill in efficiently (a) selecting, interacting with, and using tools and
materials; (b) carrying out individual task actions and steps; (c) and modifying performance when problems are encountered.
On the AMPS Graphic Report, John's ADL process ability measure of 0.27 logits is below AMPS process scale cutoff.
This indicates that he is experiencing decreased safety, independence and/or efficiency when he performs familiar ADL tasks.
As a basis for comparison, 95% of well, healthy persons of John's age have ADL process ability measures between 0.59 and 2.55
logits, thus his ADL process ability measure is lower than age expectations.
SUMMARY OF MAIN FINDINGS
• John's ADL motor and ADL process ability measures are both below the AMPS process cutoff and below age expectations,
indicating that he is experiencing increased effort, decreased efficiency, decreased safety, and/or the need for assistance when
performing chosen, familiar, and life relevant ADL tasks.
• Occupational therapy services may be indicated to enhance and/or prevent further decline
of John's ADL task performance.
If there are any questions regarding this evaluation, please do not hesitate to contact me.
Kim A, OTR
A

GRAPHIC REPORT
Client: John S Date MOTOR PROCESS

Occupational therapist: Kim A Evaluation 1 01/10/2005 −0.38 0.27
ADL MOTOR ADL PROCESS

4 3
Less physical More likely to be safe and ADL performance

effort independent living in the more efficient
performing community
ADL 3 2
ADL ADL
Motor Process
2 < Cutoff 1 < Cutoff
Some Some concerns for safe Some inefficiencies;

increased and/or independent living in 1 93% of persons
physical effort 1 the community 0 below cutoff need
performing assistance
ADL
0 −1
−1 −2
More physical Less likely to be safe and/or ADL performance

effort independent living in the less efficient
performing community
ADL
−2 −3
−3 −4
The numbers on the ADL motor and ADL process scales are units of ADL ability (logits). The results are reported as ADL motor
and ADL process measures plotted in relation to the AMPS scale cutoffs. Measures below the cutoffs indicate that there was
diminished quality or effectiveness of performance of instrumental and/or personal activities of daily living (ADL). See the AMPS
Narrative Report for further information regarding the interpretation of a single AMPS evaluation.
B
Figure 1-5—Cont’d B, Computer-generated graphic report of AMPS. (From Fisher AG: Overview of performance skills and client factors.
In Pendleton H, Schultz-Krohn W, editors: Pedretti’s occupational therapy: practice skills for physical dysfunction, ed 6, St Louis, 2006,
Elsevier/Mosby.)
Executive Function Performance Test and Kitchen ability to initiate the task when asked, organize
Task Assessment the task, perform the necessary steps of the task,
The Executive Function Performance Test sequence the steps in a logical order, develop
(EFPT)10 was developed subsequently to the awareness related to safety and judgment, and
Kitchen Task Assessment (KTA).8 Both measures recognize completion of the task. Cueing is sys
are standardized performance-based assessments tematic and includes visual, gestural, and physical
that examine cognitive functioning through the cues that are provided in a hierarchic fashion.
observation of cues needed for a person to carry These cues provide support to the client when
out a functional task. Specifically observed is the task execution begins to fail.
The original KTA was completed by observ wide range of client impairment that was devel
ing one task, making store-bought pudding on a oped subsequently to the Multi-level Action Test. It
stovetop. The KTA was validated on those living is based on research demonstrating that recovering
with dementia. More recently the EFPT was devel stroke and brain injury clients and those with pro
oped using the same cueing system from the KTA. gressive dementia are highly prone to errors of
The tasks have been expanded to include preparing action when performing routine ADL. The NAT
or heating up a light meal (cooked oatmeal), man is a performance-based test of naturalistic action
aging medications, using the telephone, and paying in which the tasks are associated with disorders
bills. The tool has been used for those with stroke of higher cortical function. The materials, layout,
and was recently found to be sensitive to the cogni and cueing procedures are standardized. Scoring
tive difficulties experienced in everyday life for those is simple and objective and can be performed
living with multiple sclerosis (see Chapter 10). reliably with little formal training. Tasks that are
observed include making toast with butter and jelly
Performance Assessment of Self-Care Skills and instant coffee with cream and sugar, wrapping
The Performance Assessment of Self-Care Skills a gift, and preparing and packing a child’s lunch
(PASS)20,26,51 is also a performance-based observa box and schoolbag. Instructions are spoken and
tional test with a home and clinic version. The PASS reinforced with drawings. Items are scored for
is composed of 26 core tasks within four functional accomplishment of necessary steps, and this score
domains: is combined with an error score that tracks 12 com
• Functional mobility (5 tasks) mission errors. The test has been validated on those
• Personal self-care (3 tasks) with right and left strokes and those with traumatic
• IADL with a cognitive emphasis (14 tasks: shop brain injury.
ping, bill paying, check writing, balancing a
checkbook, mailing, telephone use, medication Structured Observational Test of Function
management, 2 tasks related to obtaining infor The Structured Observational Test of Function
mation from the media, small home repairs, (SOTOF)34,35 is a valid and reliable tool that assesses
home safety, playing bingo, oven use, stove use, the following:
and use of sharp utensils) • Occupational performance (deficits in simple
• IADL with a physical emphasis ADL)
Performance is rated for independence, safety, and • Performance components (perceptual, cogni
adequacy. If an individual requires assistance to com tive, motor, and sensory impairment)
plete a task, the PASS provides a hierarchy of prompts. • Behavioral skill components (reaching, scan
The types of prompts, beginning with the least assis ning, grasp, sequence)
tive and progressing to the most assistive are (1) ver • Neuropsychological deficits (spatial relations
bal supportive, (2) verbal nondirective, (3) verbal apraxia, agnosia, aphasia, spasticity, memory loss)
directive, (4) gestures, (5) task object or environmen Impairments are detected by the structured
tal rearrangement, (6) demonstration, (7) physical observation of simple ADL (e.g., eating from a
guidance, (8) physical support, and (9) total assist. bowl, pouring a drink and drinking, upper body
The PASS is criterion referenced and may be dressing, washing and drying hands).
given in total, or selected tasks may be used alone This relative quick tool aims to answer the fol
or in combination. The PASS can be used with ado lowing questions:
lescents and adults with various diagnoses includ 1. How does the subject perform ADL tasks?
ing stroke, head injury, and multiple sclerosis. The 2. What behavioral skill components are intact?
interactive assessment used when administering the Which have been affected by neurologic damage?
PASS allows clinicians to identify the point of task 3. Which perceptual, cognitive, motor, and sensory
breakdown and the types of assistance that enable impairments are present?
improvement in task performance. Self-report, 4. Why is function impaired?
proxy-report, and clinical judgment versions of the
PASS are available.
Overview of Models That
Naturalistic Action Test Guide Practice
The Naturalistic Action Test (NAT)53 is a measure Various models that guide this practice area have
ment of naturalistic action production across a been described in the literature. The reader is
referred to Katz29 for comprehensive descriptions of when there is a match between all three variables.
these models. The following paragraphs are sum Assessment and treatment reflect this dynamic
maries of commonly used approaches. view of cognition.” This approach may be used with
adults, children, and adolescents.
Toglia used the Dynamic Interactional Model to
Dynamic Interactional Approach
develop the Multicontext Treatment Approach.54,55
The Dynamic Interactional Approach55 views cog Combining both remedial and compensatory strat
nition as a product of the interaction among the egies, this approach focuses on teaching a par
person, activity, and environment. Therefore, per ticular strategy to perform a task and practicing
formance of a skill can be promoted by changing this strategy across different activities, situations,
either the demands of the activity, the environ and environments over time. Toglia summarizes
ment in which the activity is carried out, or the the components of this approach to include the
person’s use of particular strategies to facilitate following:
skill performance. To illustrate the interaction • Awareness training or using structured expe
among the three factors (person, activity, and riences in conjunction with self-monitoring
environment), the reader is encouraged to think techniques so that clients may redefine their
about how the efficiency and effectiveness of skill knowledge of their strengths and weaknesses
performance vary based on the following task (see Chapter 4).
descriptions: • Personal context. Treatment activities are chosen
• Driving your own automatic transmission mid based on client’s interest and goals. A particular
size car versus renting and driving a standard emphasis is placed on the relevance and purpose
transmission pickup truck of the activities. Managing monthly bills may be
• Performing a morning self-care routine in your an appropriate activity for a single person living
own home versus the same routine carried out alone, whereas crossword puzzles may be used as
in a hotel room an activity for a retiree who previously enjoyed
• Cooking a meal versus cooking a meal while this activity.
simultaneously babysitting twin 2-year-old boys • Processing strategies are practiced during a vari
Toglia55 describes several constructs associated ety of functional activities and situations. Toglia
with this model including the following: defines processing strategies as strategies that
• Structural capacity or the physical limits in the help a client to control cognitive and percep
ability to process and interpret information tual symptoms such as distractibility, impulsiv
• Personal context or characteristics of the person ity, inability to shift attention, disorganization,
such as coping style, beliefs, values, and lifestyle attention to only one side of the environment,
• Self-awareness or understanding your own or a tendency to over focus on one part of an
strengths and limitations, as well as metacog activity.
nitive skills such as the ability to judge task • Activity analysis is used to choose tasks that
demands, evaluate performance, and anticipate systematically place increased demands on the
the likelihood of problems (see Chapter 4) ability to generalize strategies that enhance
• Processing strategies or underlying components performance.
that improve task performance such as atten • Transfer of learning occurs gradually and sys
tion, visual processing, memory, organization, tematically as the client practices the same strat
and problem solving egy during activities that gradually differ in
• The activity itself considering the demands, physical appearance and complexity.
meaningfulness, and how familiar the activity is • Interventions occur in multiple environments to
• Environmental factors such as the social, physi promote generalization of learning.
cal, and cultural aspects.
Toglia55 summarizes that “to understand cog
Quadraphonic Approach
nitive function and occupational performance,
one needs to analyze the interaction among per The Quadraphonic Approach was developed by
son, activity, and environment. If the activity and Abreu and colleagues1 for use with those living
environmental demands change, the type of cog with cognitive impairments after brain injury. This
nitive strategies needed for efficient performance approach is described as including both a “micro”
changes as well. Optimal performance is observed perspective (i.e., a focus on the remediation of
subskills such as attention, memory, etc.) and a ing cause of the functional limitation but focuses
“macro” perspective (i.e., a focus on functional skills directly on retraining the skill itself.
such as ADL, leisure, etc.). The approach supports the
use of remediation as well as compensatory strategies.
Patterns of Cognitive-Perceptual
The micro perspective incorporates four
Impairments Based on Diagnoses
theories:
and Area(s) of Brain Pathology
1. Teaching-learning theory is used to describe
how clients use cues to increase cognitive aware A critical aspect of the evaluation process involves
ness and control. determining the impairment(s) that are interfering
2. Information-processing theory describes how with an individual’s ability to participate in mean
an individual perceives and reacts to the envi ingful activities. Several clients may have similar
ronment. Three successive processing strategies activity level scores, but the impairments causing
are described including detection of a stimulus, the limitations may be quite different (Table 1-4).
discrimination and analysis of the stimulus, and Identifying the correct impairment(s) will help cli
selection and determination of a response. nicians determine which interventions are required
3. Biomechanical theory is used to explain the including necessary adaptations, which strategy
client’s movement, with an emphasis on the choices are appropriate, and to begin to determine
integration of the central nervous system, mus the focus of rehabilitation. Depending on the diag
culoskeletal system, and perceptual-motor skills. noses, clinicians can begin to expect usual pre
4. Neurodevelopmental theory is concerned with sentations of patterns of cognitive and perceptual
quality of movement. impairments although variations from these typical
The macro perspective is based on narrative and patterns may occur.
functional analysis to explain behavior based on the
following four characteristics:
Stroke
1. Lifestyle status or personal characteristics related
to performing everyday activities If neuroimaging data are available they may provide
2. Life-stage status such as childhood, adolescence, information related to which structures are compro
adulthood, and married mised. Using knowledge of neuroanatomy and neuro
3. Health status such as the presence of premorbid logic processing, the clinician may begin to hypothesize
conditions which impairments will be present and how they
4. Disadvantage status or the degree of functional interfere with function (Tables 1-5 and 1-6).
restrictions resulting from impairment Even a basic understanding of cortical func
tion related to understanding the various functions
associated with different areas of the brain can help
Cognitive-Retraining Model
clinicians in the clinical reasoning process associ
The Cognitive-Retraining Model7 is used for ado ated to identifying impairments that affect daily
lescents and adults living with neurologic and functioning (Tables 1-7 and 1-8).3,4
neuropsychological dysfunction. Based on neuropsy
chological, cognitive, and neurobiologic rationales,
Multiple Sclerosis
this model focuses on cognitive training by enhanc
ing remaining skills, and by teaching cognitive strate Those living with multiple sclerosis may experience
gies, learning strategies, or procedural strategies. slowed information processing, decreased atten
tion, decreased concentration, difficulty shifting
attention, difficulty dividing attention, decreased
Neurofunctional Approach
explicit memory, decreased episodic memory,
The neurofunctional approach23 is applied to those loss of executive functioning (concept forma
living with severe cognitive impairments secondary tion, reasoning, problem solving, planning, and
to brain injuries. The approach focuses on train sequencing.14,52
ing clients in highly specific compensatory strate
gies (not expecting generalization) and specific task
Parkinson’s Disease
training. Contextual and metacognitive factors are
specifically considered during intervention plan In general, individuals living with Parkinson’s dis
ning. The approach does not target the underly ease often present with normal or only slightly
Table 1-4 Clinical Situation: A Client Requires Moderate Assistance for Grooming Tasks
Based on the Functional Independence Measure (FIM)
Behaviors Interfering with
Client Diagnosis Potential Impairments Function
A Right frontoparietal stroke Unilateral neglect, figure-ground Inability to “find” grooming items
impairment, spatial relations on the left side of the sink,
dysfunction, distractibility 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
B Left frontoparietal stroke Motor planning deficits, ideational Uses grooming objects incorrectly
apraxia, impaired organization and (eats soap), brushes teeth
sequencing 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.
Traumatic Brain Injury

decreased performance in language, gnosis, and
praxis functions, although memory and executive Severe cognitive and perceptual deficits are
functions more prominently affected. More specifi common after traumatic brain injury (TBI)
cally, attention functions are commonly decreased. including deficits of attention, memory, infor
In addition free recall (immediate and delayed) mation-processing speed, and problems in self-
is impaired as is visuospatial processing, motor perception. In addition posttrauma for anxiety,
planning, shifting attention, alternating tasks, and expressive deficit, emotional withdrawal, depres
verbal fluency.45 sive mood, hostility, suspiciousness, fatigabil
ity, hallucinatory behavior, motor retardation,
unusual thought content, lability of mood, and
Huntington’s Disease
comprehension deficits have been documented.
In this disease, selective cognitive abilities are pro A recent longitudinal study43 of those with severe
gressively impaired, whereas others remain intact. TBI documented a tendency of improvement
Abilities affected include executive function (plan for inattention, somatic concern, disorientation,
ning, cognitive flexibility, abstract thinking, rule guilt feelings, excitement, poor planning, and
acquisition, initiating appropriate actions, and articulation deficits. In addition, for the impair
inhibiting inappropriate actions), psychomotor ments of conceptual disorganization, disinhi
function (slowing of thought processes to con bition, memory deficit, agitation, inaccurate
trol muscles), perceptual and spatial skills of self self-appraisal, decreased initiative, blunted affect,
and surrounding environment, selection of cor and tension the authors noted a tendency for fur
rect methods of remembering information (but ther deterioration in the posttraumatic follow-
not actual memory itself), and ability to learn new up. Changes between 6 and 12 months post-TBI
skills. Problems in attention, working memory, were statistically significant for disorientation
verbal learning, verbal long-term memory, and (improvement), inattention or reduced alertness
learning of random associations are the earliest (improvement), and excitement (deterioration).
cognitive manifestations.41 The authors concluded that neurobehavioral
Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment
Artery Location Possible Impairments
Dysfunction of either hemisphere

Middle cerebral artery: Lateral aspect of frontal and Contralateral hemiplegia, especially of the face and the
upper trunk parietal lobe 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
Middle cerebral artery: Lateral aspect of temporal
lower trunk and occipital lobes Dysfunction of either hemisphere
Contralateral visual field defect
Behavioral abnormalities
Right hemisphere dysfunction

Visuospatial dysfunction
Left hemisphere dysfunction

Wernicke’s aphasia
Middle cerebral artery: Lateral aspect of the involved Impairments related to both upper and lower trunk
both upper and lower hemisphere dysfunction as listed in previous two sections
trunks
(Continued )
Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Anterior cerebral artery Medial and superior aspects of Contralateral hemiparesis, greatest in foot
frontal and parietal lobes Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances
Internal carotid artery Combination of middle cerebral Impairments related to dysfunction of middle and
artery distribution and anterior anterior cerebral arteries as listed above
cerebral artery
Anterior choroidal artery, Globus pallidus, lateral geniculate Hemiparesis of face, arm, and leg
a branch of the internal body, posterior limb of the Hemisensory loss
carotid artery internal capsule, medial Hemianopsia
temporal lobe
Dysfunction of either side

Posterior cerebral artery Medial and inferior aspects of Homonymous hemianopsia
right temporal and occipital Visual agnosia (visual object agnosia, prosopagnosia,
lobes, posterior corpus color agnosia)
callosum and penetrating Memory impairment
arteries to midbrain and Occasional contralateral numbness
thalamus
Right side dysfunction

Cortical blindness
Impaired left-right discrimination
Left side dysfunction

Finger agnosia
Anomia
Agraphia
Acalculia
Alexia
Quadriparesis
Basilar artery proximal Pons 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
Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Basilar artery distal Midbrain, thalamus, and caudate Papillary abnormalities

nucleus 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 Watershed region on lateral side Coma
of hemisphere, hippocampus Dizziness
and surrounding structures in Confusion
medial temporal lobe Decreased eoncentration
Agitation
Memory impairment
Visual abnormalities caused by disconnection from
frontal eye fields
Simultanognosia
Impaired eye movements
Weakness of shoulder and arm
Gait ataxia
From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.
Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment

Location Possible Impairments
Anterolateral thalamus, either side Minor contralateral motor abnormalities

Long latency period
Slowness
Right side
Visual neglect
Left side
Aphasia
Lateral thalamus Contralateral hemisensory symptoms
Contralateral limb ataxia
Bilateral thalamus Memory impairment
Behavioral abnormalities
Hypersomnolence
Internal capsule or basis pontis Pure motor stroke
Posterior thalamus Numbness or decreased sensibility of face and arm
Choreic movements
Hypersomnolence
(Continued )
Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment—Cont’d

Location Possible Impairments
Posterior thalamus—Cont’d Decreased consciousness

Decreased alertness
Right side
Visual neglect
Anosognosia
Visuospatial abnormalities
Left side
Aphasia
Jargon aphasia
Good comprehension of speech
Paraphasia
Anomia
Caudate Dysarthria
Apathy
Restlessness
Agitation
Confusion
Delirium
Lack of initiative
Poor memory
Contralateral hemiparesis
Ipsilateral conjugate deviation of the eyes
Putamen Contralateral hemiparesis
Contralateral hemisensory loss
Decreased consciousness
Ipsilateral conjugate gaze
Motor impersistence
Right side
Left side
Aphasia
Pons Quadriplegia
Coma
Impaired eye movement
Cerebellum Ipsilateral limb ataxia
Gait ataxia
Vomiting
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 2. What are the expected patterns of cognitive or
disappear over time and that some aspects related perceptual impairments if a person presents
to self-appraisal, conceptual disorganization and with a right middle cerebral artery stroke? Left
affect may even deteriorate. middle cerebral artery stroke?
3. How can the principles of client-centered prac
tice be integrated into the development of an
Review Questions
intervention plan for a person with attention
1. Name and describe three assessments that may deficits after a brain injury?
be used to document improvements in quality 4. Give two examples of how the ICF levels of func
of life and participation. tion are interrelated.
Table 1-7 Typical Impairments Based on Damage to the Right Versus Left Hemispheres
Hemisphere Typical Impairments
Right hemisphere Attention deficits

Unilateral spatial neglect
Unilateral body neglect
Visuospatial impairments
Left visual field cut
Left-sided motor apraxia
Loss of left-sided motor control
Loss of left-sided sensation
Reduced insight
Left hemisphere 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 Typical Functions Based on the Cortical Lobes

Lobe Typical Functions
Frontal 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
Temporal Emotion, memory, visual memory (right), verbal memory (left), interpretation of music
(right), receptive language (left: Wernicke’s area)
Occipital Visual reception, visual recognition of shapes and colors
Parietal Visual-spatial functions (right), reception and recognition of tactile information, praxis (left)
7. Averbuch MA, Katz N: Cognitive rehabilitation:

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Chapter 1

Overview of Cognitive and Perceptual Rehabilitation

functional activities. In general, this assumption

particularly when considering assessments, interven­ • Participation: Involvement in life situations

Body Functions Activity Participation

Practice Framework ICF

Client Factors Body Structures & Body Functions

Performance in Areas of Occupation Activities

Context Environmental Factors

Medical Outcomes Study Short Form-36 Reintegration to Normal Living

Activity Card Sort Functional Independence Measure

STEP 1A: Self-Care IMPORTANCE

STEP 1B: Productivity

STEP 1C: Leisure

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments­—Cont’d

Leisure/social — Community social Social occasions Go out socially —

Functional Independence Scale and

Ms. Wilson 6/13/03

Independence Score (IP): Neurobehavioral Score (NB):

List helping aids used:

PRIMARY ADL ACTIVITY SCORING COMMENTS AND REASONING

Shirt (or Dress) 4 3 2 1 0 Include one armhole, fix shoulder

FUNCTIONAL INDEPENDENCE SCORE (optional)

LIST OF NEUROBEHAVIORAL IMPAIRMENTS OBSERVED:

SPECIFIC IMPAIRMENT D G T F C PERVASIVE IMPAIRMENT ADL PERVASIVE IMPAIRMENT ADL

Summary of Neurobehavioral Impairments:

A-ONE Certification Number:

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

Client: John S Evaluation date: 01/10/2005

Task 1: A-3: Pot of boiled/brewed coffee or tea (Average)

Figure 1-5 A, Assessment of Motor and Process Skills (AMPS) summary.

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

Client: John S Evaluation date: 01/10/2005

Task 1: A-3: Pot of boiled/brewed coffee or tea (Average)

PROCESS SKILLS: Skills observed when client (a) selected, interacted A I MD

OCCUPATIONAL THERAPY EVALUATION OF ADL ABILITY

Therapist: Kim A, OTR

SPECIFIC SKILLS THAT MOST IMPACTED PERFORMANCE

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

Client: John S Date MOTOR PROCESS

ADL MOTOR ADL PROCESS

Less physical More likely to be safe and ADL performance

Some Some concerns for safe Some inefficiencies;

More physical Less likely to be safe and/or ADL performance

Traumatic Brain Injury

Dysfunction of either hemisphere

Right hemisphere dysfunction

Left hemisphere dysfunction

Right hemisphere dysfunction

Left hemisphere dysfunction

Dysfunction of either side

Right side dysfunction

Left side dysfunction

Basilar artery distal Midbrain, thalamus, and caudate Papillary abnormalities

Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment

Anterolateral thalamus, either side Minor contralateral motor abnormalities

Table 1-6 Cerebrovascular Dysfunction in Noncortical Areas: Patterns of Impairment—Cont’d

Posterior thalamus—Cont’d Decreased consciousness

particularly when considering assessments, interven • Participation: Involvement in life situations

Table 1-3 Instrumental Activities of Daily Living Standardized Assessments—Cont’d