Cognitive and Perceptual Rehabilitation. Optimizing Function

313 Pages·2008·8.291 MB·English

by  Glen Gillen, EdD, OTR, FAOTA (Auth.)

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St. Louis, Missouri 63146
COGNITIVE AND PERCEPTUAL REHABILITATION: ISBN: 978-0-323-04621-3
OPTIMIZING FUNCTION
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Preface
OPening and BackgrOund cOncePtual aPPrOach
Cognitive and Perceptual Rehabilitation: Optimizing Cognitive and Perceptual Rehabilitation: Optimiz­
Function aims to provide an up-to-date and com- ing Function was written with three overarching
prehensive overview of the process that has tra- and interrelated approaches in mind: evidence-
ditionally been called cognitive and perceptual based, function-based, and client-centered. Given
rehabilitation but may be better described as the this, the textbook focuses on being a comprehen-
process of improving function in those who are liv­ sive resource of valid and reliable tools that use
ing with cognitive and perceptual impairments. Until functional activities as the basis of assessment.
the recent past, this area of practice has been domi- A particular emphasis has been placed on tools that
nated by assessments, interventions, and outcomes have ecological validity (i.e., reflective of behaviors
that were far removed from everyday function. This observed in everyday function). This focus limits
limitation is steadily being overcome as current cli- the inclusion of assessments that are not perfor-
nicians, researchers, and scientists are once again mance based and that use contrived tasks as the
placing a renewed focus on function-based assess- basis for assessment. This textbook also embraces
ments, evidence-based interventions that promote the inclusion of standardized client and significant
improved performance of necessary and meaning- others reports of daily function. Similarly, this text-
ful activities, decreasing participation restrictions, book highlights and focuses on interventions that
and ultimately improving quality of life. have been empirically tested and that document a
Cognitive and Perceptual Rehabilitation: Optimi­ positive change related to decreasing activity limi-
zing Function aims to be a clinical and educational tations and participation restrictions. An emphasis
resource that summarizes, highlights, and con- has been placed on interventions that use meaning-
structively critiques the state of the art of this area ful activities as the primary change agent to improve
of practice. The overall goal of writing this textbook function.
was to provide clinicians and students with the tools
necessary to make a positive impact on the lives of
OrganizatiOn
those to whom they are providing care.
Chapters 1 and 2 (Overview of Cognitive and
Perceptual Rehabilitation and General Considerations:
WhO Will Benefit frOm this BOOk?
Evaluations and Interventions for Those Living with
A variety of neurologists, neuropsychologists, Functional Limitations Secondary to Cognitive and
occupational therapists, psychologists, psychiatrist, Perceptual Impairments) provide the necessary foun-
and speech and language pathologists from across dations to using an evidence-based and function-
the world are working in and contributing to the based approach to work with this population and
knowledge base of this area of practice. The pri- are therefore considered prerequisites to all of the
mary audiences for this textbook are students and other chapters. Chapter 3 (Managing Visuospatial
clinicians who are learning about or directly work- Impairments to Optimize Function) provides neces-
ing with clients who are living with functional lim- sary foundation information related to visual impair-
itations secondary to cognitive and/or perceptual ments that must be considered before assessing and
impairments. Other professionals who may find developing intervention plans for other problem
this textbook helpful in the evaluation and inter- areas. Similarly, Chapter 4 (Self­Awareness and Insight:
vention processes include vocational counselors, Foundations for Intervention) focuses on the problem
nurses, physical therapists, and therapeutic recre- of poor awareness and developing awareness as the
ation specialists. Case managers and those making starting point for all interventions. These chapters are
referrals to rehabilitation services may also find the also then considered foundations for the subsequent
information contained in this textbook helpful. chapters.
vii
viii pREFACE
Chapters 5 through 10 emphasize functional • Samples of function-based assessments.
limitations caused by various impairments and • Summary tables of assessments highlighting
patterns of impairments including apraxia, neglect, their clinical utility and focus as well as their
agnosia, impaired attention, impaired memory, psychometric properties.
and impairments of the executive functions. Theses
chapters are all written as a user-friendly clini-
learning aids
cal guide that primarily focus on assessment and
interventions. Learn ing aids include the following:
Finally, Chapter 11 (Application of Concepts: • Key terms
Case Studies) provides further clinical applica- • Learning objectives
tions and integration based on case studies that • Review questions
take place in various treatment environments from • Case studies
acute care to community reintegration. This chap-
ter further examines the process of evaluation and
nOte
intervention planning for clients who have func-
tional limitations secondary to typical patterns of Note to reader: This book compiles informa-
impairments. tion from a variety of disciplines and countries.
Multiple terms have been used to describe the
person who is receiving services and who is par-
distinctive features
ticipating in research. These terms include patient,
Key features of this book include the following: client, person, subject, participant, etc. The terms
• Inclusion of evidence-based intervention protocols. originally used in the reviewed literature have
• Evidence-based intervention tables focused on been maintained. This in no way undermines the
improving daily function follow each chap- importance of a client-centered approach, which
ter. These include a summary of research and I consider a best practice standard. Adopting a cli-
summary of outcomes. These tables were built ent- and significant other-centered approach is
based on published methodologies of critically a thread and consistent message throughout this
analyzing the existing research literature. textbook.
Acknowledgments
The author would first and foremost like to creating a stimulating albeit fun environment.
acknowledge the clinicians and scientists who Particularly I need to thank Janet Falk-Kessler for
have directly or indirectly shaped the way he con- encouragement and guidance. I look forward to
ceptualizes function based rehabilitation. These working with her for many more years.
include (but are not limited to) Guðrún Árnadóttir, For more than a decade, the editorial team at
M. Carolyn Baum, Anne G. Fisher, Gordon Muir Elsevier has been supportive of my work. The guid-
Giles, and Joan P. Toglia. ance I always receive from both Kathy Falk and
I must also acknowledge my colleagues on the Melissa Kuster has been invaluable. Thank you
faculty of the Programs in Occupational Therapy, (again!).
Columbia University College of Physicians & Finally, I would like to acknowledge the editorial
Surgeons for consistent support, ideas, and for assistance of Jasmine A. Gore and Eva Hatenboer.
ix
C h a p t e r 1
Overview of Cognitive and Perceptual Rehabilitation
KKeeyy TTeerrmmss
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
LLeeaarrnniinngg OObbjjeeccTTiivveess
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 client­centered 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 Scale­Revised (WAIS­R)
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. Forty­five subjects, ages 18 interpreted as a positive outcome if more meaning­
to 52, in long­term 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 evidence­based practice
received training for three 30­minute sessions per and have refocused on “real­world” functional out­
week for 6 weeks, in addition to their regular reha­ comes, the rehabilitation process has begun to shift
bilitation programs. Results showed task­specific 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 cognitive­retraining 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 1­1) 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 1­1). 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.
 COgnItIvE AnD PERCEPtuAL REhAbILItAtIOn: OPtImIzIng FunCtIOn
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 Client­centered 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. Client­centered 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 client­therapist 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 1­2).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 client­therapist 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 1­2). performance and set personal goals
ChAPtER 1 OvERvIEw OF COgnItIvE AnD PERCEPtuAL REhAbILItAtIOn 
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 Functio ns
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 client­centered
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 client­centered 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 client­centered 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 client­centered
rehabilitation has no direction and the intervention approach to guide the intervention focus with this