The purpose of this study was to determine the reli-
Loewenstein ability and validity of the Loewenstein Occupa-
Occupational T erapy
Cognitive Assessment
(LOTCA) Battery for
Brain-Injured Patients:
Reliability and Validity
Noomi Katz, MaIka Itzkovich,
Sara Averbuch, Betty Elazar
Key Words: cerebrovascular disorder •
cognition • head injury, occupational
therapy. tests, by title, Loewenstein
Occupational Therapy Cognitive
Assessment (LOTCA)
Noami Katz, PhD, OTR, is Assistant Professor, School of Oc·
cupational Therapy, Hebrew University, Mount Scopus,
PO Box 24026, Jerusalem 91240, Israel.
Maika Itzkovich, OTR, is Research Coordinator, Occupa-
tional Therapy Department, Loewenstein Rehabilitation
Hospital, Raanana, Israel.
Sara Averbuch, OTR, is Senior Occupational Therapist, Loe-
wenstein Rehabilitation Hospital, and faculty member, Oc-
cupational Therapy Department, Tel Aviv University,
Ramat Aviv, Israel.
Betty Elazar, OTR, is Director, Occupational Therapy De-
partment, Loewenstein Rehabilitation Hospital, Raanana,
Israel.
This article was accepted for publication October 27, 1988.
184
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tional Therapy Cognitive Assessment (LOTCA) bat-
tery. The battery prOVides an initial profile of the
cognitive abilities of the brain-injured patient that
can be used as a starting point for occupational
therapy intervention and as a screening test for fur-
ther assessment. The LOTCA consists of 20 subtests
and is divided into four areas: orientation, visual
and spatial perception, visuomotor organization,
and thinking operations. The battery takes 30 to 45
minutes to administer. Subjects in the study con-
sisted of two patient groups (20 traumatic head in-
jury patients and 28 cerebrovascular accident pa-
tients) and one control group (55 non-brain-
injured adults). Results showed interrater reliability
coeffiCients of. 82 to .97 for the various subtests and
an alpha coefficient of. 85 and above for the inter-
nal consistency of the areas ofperception, visuomo-
tor organization, and thinking operations. The Wil-
coxon two-sample test showed that all subtests differ-
entiated at the. 0001 level of Significance be-
tween the patient groups and the control group.
This supported the LOTCA 's validity. Furthermore,
factor analysis provided initial construct validation
for three areas of the battery: perception, visuomo-
tor organization, and thinking operations.
T
he purpose of this study was to determine the
reliability and validity of the Loewenstein Oc-
cupational Therapy Cognitive Assessment
(LOTCA) battery for brain-injured patients. The bat-
tery provides (a) a cognitive performance assessment
on which to base occupational therapy intervention
and (b) an objective way to examine clinical change.
The subtests of the LOTCA are specifically related to
rehabilitation purposes. "The tests are expected to
proVide a picture of the patient's abilities and defi-
ciencies with a view towards his capacity to cope with
everyday and occupational tasks" (Askenasy & Rah-
mani, 1988, p. 316).
Traumatic head injuries are a main cause of death
for young persons in the United States and elsewhere,
and cause major and persisting disabilities that re-
quire long periods of treatment and rehabilitation
(Adamovich, Henderson, & Auerbach, 1985). The
high incidence and severity of head injuries warrant
the attention of health professionals such as occupa-
tional therapists (Zoltan & Ryckman Meeder, 1985).
Adults who have had cerebrovascular accidents
(CVAs) make up one of the largest hospitalized popu-
lations, and they require long rehabilitation periods.
This population represents the largest incidence of a
single diagnosis evaluated and treated by occupa-
tional therapists (Allen, 1985; Ottenbacher, 1980;
Siev, Freishtat, & Zoltan, 1986; Trombly, 1983).
March 1989, Volume 43, Number 3
 In both of these populations, perceptual cogni-
tive deficits are the major determinants of confusion
and a lack of rehabilitation progress even in patients
whose motor skills have returned (Siev et aI., 1986).
Cerebral dysfunctions caused by brain lesions pro-
duce intellectual and/or behavioral changes that af-
fect the person's capacity to carry out daily tasks (Na-
jenson, Rahmani, Elaser, & Averbuch, 1984; Rahmani,
1982). Therefore, the effort to restore functional
capacity must include an assessment of cognitive
abilities.
Neuropsychological test batteries have been de-
veloped for various purposes in an attempt to relate
behavioral defiCits to underlying brain dysfunction.
According to Goldstein and Ruthven (1983), the his-
tory of psychological assessment is characterized by
controversy and rapid change, and has gone full circle
from clinical examination and interview, through re-
fined quantitative and qualitative evaluation, back to
more clinical methods that focus on processes as well
as end results (Lezak, 1983). This pattern is exempli-
fied by Luria's 1973 neuropsychological tests, which
were integrated into a set of tests by Christensen
(1975) and further developed into the Luria-Nebraska
Neuropsychological Battery (LNNB) (Golden, 1984;
Golden, Hammerse, & Purisch, 1980).
Burnell (1985) and Barret (1986) suggested that
the LNNB is an appropriate assessment tool in occupa-
tional therapy. However, the full battery is too exten-
sive and too detailed to be practical for an initial eval-
uation in occupational therapy, which typically fo-
cuses on basic deficits related to dysfunction in the
performance of daily tasks (Najenson et aI., 1984)
Moreover, the LNNB focuses mainly on diagnostic cat-
egories and the localization of lesions (Askenasy &
Rahmani, 1988). The goal of the short screening ver-
sion of the LNNB is only to predict whether giving the
full battery is indicated (Golden, 1987). Therefore,
the LNNB screening test should not be used for occu-
pational therapy treatment planning related to activi-
ties of daily living.
Literature Review
Despite the prevalence of brain-injured patients in
occupational therapy and the major role perceptual
cognitive abilities play in their dysfunctions, current
occupational therapy theories or frames of reference
have not been developed. Allen's 1985 cognitive dis-
ability theory was developed primarily for use with
the mentally ill. It was assumed that the theory ap-
plied to all patients with central nervous system defi-
cits, but attempts to apply it to the head trauma popu-
lation have been made only recently (Katz, 1988)
Abreu and Toglia (1987) presented a model of
cognitive rehabilitation for brain-injured patients
based on Luria's neuropsychological approach, infor-
The Americanjoumal a/Occupational Therapy
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mation processing theories, and acqUisitional frame
of reference. They identified six areas worthy of eval-
uation: orientation, attention, visual processing,
motor planning, cognition, and occupational behav-
ior. These areas were assumed to be in hierarchical
order according to the capacity to process information
and, therefore, to gUide the assessment sequence.
Conditions that facilitated or deteriorated perfor-
mance, as well as strategies used by the patient, were
considered.
Abreu (1987) designed a manual with theoretical
and practical gUidelines for the rehabilitation of per-
ceptual-cognitive dysfunction based on four ap-
proaches: cognitive retraining, neurodevelopmental
principles, biomechanical principles, and motor
learning. The manual includes suggestions for variOUS
assessment instruments and techniques for process
testing each area looking at qualitative and quantita-
tive performance. However, as emphasized by the au-
thor, the techniques have not been tested for validity
and reliability.
An important contribution to occupational ther-
apy literature is Siev et al.'s 1986 book, which pro-
vides information on standardized and nonstandard-
ized procedures for assessing the perceptual and cog-
nitive abilities of adult stroke patients. As the authors
stated, however, most evaluations are nonstandar-
dized, and research is only in its early stages. Some of
the book's authors also contributed to the Perceptual
Motor Evaluation battery, which was developed for
head-injured and other neurologically impaired
adults (Jabri, Ryckman, Panikoff, & Zoltan, 1987).
This evaluation was designed to comprehensively
screen perceptual motor skills, but standardization
has not been completed and only interrater reliability
coefficients have been proVided. Except for three
subtest scores from the groSS/Visual skill area, which
are between .60 and .70, all are above .82. To date,
occupational therapy research studies related to the
brain-injured population have concentrated primarily
on stroke victims; only a few have addressed the
problems of people with traumatic head injuries
(Baum & Hall, 1981; Giles, 1988; Meeder, 1982;
Schwartz, Shipkin, & Cermak, 1979). Most studies
have attempted to describe relationships between
various cognitive disorders and functional perfor-
mance (e.g., between visual perception and activities
of daily living) (Carter, Howard, & O'Neil, 1983;
Carter, Oliveira, Duponte, & Lynch, 1988; Kaplan &
Hier, 1982; Kowalski Lundi & Mitcham, 1984;
Mitcham, 1982). Others have combined factors of
constructional apraXia and body scheme. For exam-
ple, MacDonald (1960) and Warren (1981) found that
body scheme was a better predictor of dressing per-
formance than praxis function as examined by a copy-
ing test, and Bradley (1982) found a difference in the
185
 effectiveness of three-dimensional praxis tests (as
compared to two-dimensional) in predicting upper
extremity dressing skills.
Other researchers have employed more compre-
hensive batteries consisting of subtests assessing vi-
sual perception, praxis, and body scheme (Meeder,
1982; Taylor, 1968; Van Deusen Fox & Harlowe,
1984). Of these, only Taylor used sub tests for con-
ceptual and operational thinking, although these
areas represent major problems for the stroke popula-
tion. Moreover, few studies included non-brain-in-
jured subjects (Concha, 1986; Kaplan & Hier, 1982;
Schwartz et aI., 1979; Taylor, 1968).
This review revealed that occupational therapists
use an array of instruments and methods to evaluate
perceptual and cognitive abilities, and that only a few
tests were developed in occupational therapy and
studied for their measurement properties. The most
systematic attempt to determine instrument validity
has been the studies of the St. Marys CVA Evaluation
(Hariowe & Van Deusen, 1984; Van Deusen & Har-
lowe, 1986, 1987). This evaluation was designed for
use in an acute care setting and includes self-care
activities, motor strength, arm and hand strength, bi-
lateral awareness, and perception (including stereog-
nosis and body scheme). The studies of the St. Marys
battery focused on the construct validity of the battery
as a whole and of each of its parts. However, no con-
trol group was compared with the acute CVA group,
and no reliability studies were reported.
More recently, Boys, Fisher, Holzberg, & Reid,
(1988) reported that the Ontario Society of Occupa-
tional Therapy (OSOT) Perceptual Evaluation (which
comprises six areas: sensory function, scanning func-
tion, apraxia, body awareness, spatial relations, and
visual agnosia) has high internal correlations and dif-
ferentiates between neurologically impaired and
non-neurologically impaired people. These findings
indicate the battery's reliability and validity. However,
patients with aphasia or traumatic head injury were
excluded from the study for unexplained reasons, and
as in previous batteries, thinking operations and
problem solving were not evaluated.
The LOTCA was developed at Loewenstein Reha-
bilitation Hospital (LRH) in Israel to assess the basic
cognitive abilities of brain-injured patients. The term
basic cognitive abilities is defined as those "intellec-
tual functions thought to be prerequisite for manag-
ing everyday encounters with the environment" (Na-
jenson et aI., 1984, p. 315). Cognition is conceived of
as a general term that covers attention, perception,
thinking, and memory.
Information from the battery and from a func-
tional evaluation of the patient's activities of daily liv-
ing is used to plan the occupational therapy treat-
ment. Treatment at LRH is aimed at improving the
186
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patients' daily functioning and their ability to cope
with occupational tasks. EmphasiS is placed on cogni-
tive training through the performance of purposeful
tasks in daily activities.
The LOTCA battery is based on clinical experi-
ence as well as on Luria's neuropsychological and
Piaget's developmental theories and evaluation pro-
cedures (Golden, 1984; Inhelder & Piaget, 1964). The
battery is composed of 20 subtests including the Riska
Object Classification (ROC) (Williams Riska & Allen,
1985), which was added to enhance the evaluation of
categorization abilities with attributes such as shape,
color, or number, in addition to tangible object cate-
gorization. This made it analogous to the sequence
operation of the battery, which has both a tangible
pictorial subtest and a geometrical subtest. At the time
the study was conducted, however, the battery con-
sisted of 19 subtests. (Orientation initially had only
one subtest.)
Children's performances on the LOTCA were as-
sessed recently to determine the age norms of the
various subtests and to verify the hierarchical order of
acquisition of the various cognitive competencies in-
cluded in the battery. Results suggested a progression
with age from 6 to 12 years in both level and speed of
performance (Averbuch, 1988).
The LOTCA is divided into four areas: orienta-
tion, perception, visuomotor organization, and think-
ing operations. Procedures for assessing aphasic pa-
tients have been incorporated into the tests. The bat-
tery takes a total of 30 to 45 minutes, and can be
administered in 2 or 3 short sessions if necessary. A 4-
or 5-point rating scale is used for scoring each subtest.
A profile of the battery is given in Figure 1.
The purpose of this study was to investigate the
reliability and validity of the LOTCA's measurement
properties.
Method
Subjects
The sample consisted of three groups. Two groups
comprised brain-injured adults: 20 patients diagnosed
with craniocerebral injury (CCl) and 28 patients
diagnosed with CVA. A third group, the control, con-
sisted of 55 non-brain-injured adults who were se-
lected according to age (between 20 and 70 years),
sex, and social position class. Social position is a
measure determined by a person's years of education
and type of occupation. For each of the five social
position classes, the scale lists the type of occupations
included and the range of years of education. An
equation that combines both variables is used to de-
termine a person's social position class (Hollingshead
& Redlich, 1958; Williams Riska & Allen, 1985, p. 329,
proVides the scale).
March 1989, Volume 43, Number 3
 Instructions: For each item, circle the appropriate number.

SCore
Subtests low high Comments

Orientation
Time 1 2 3 4
Place 1 2 3 4
Perception
Object identification 1 2 3 4
Shape identification 1 2 3 4
Overlapping figures 1 2 3 4
Object constancy 1 2 3 4
Spatial perception 1 2 3 4
Praxis 1 2 3 4

Visuomotor Organization
Copying geometric forms 1 2 3 4
Reproducing a two-dimensional 1 2 3 4
model
Constructing a pegboard design 1 2 3 4
Constructing a colored block design 1 2 3 4
Constructing a plain block design 1 2 3 4
Reproducing a puzzle 1 2 3 4
Drawing a clock 1 2 3 4

Thinking Operations
Categorization 1 2 3 4 5
ROC: Unstructured 1 2 3 4 5
Structured 1 2 3 4 5
Pictorial sequence 1 2 3 4
Geometrical sequence 1 2 3 4

Indicate length of time given in one session or more

Based on observation during test performance, circle the ap propriate number:
Attention and concentration 1 2 3 4

Figure 1. LOTCA Battery Scoring Sheet. ROC = Riska Object Classification_

As can be seen in Table 1, which summarizes the group. This is typical for the type of injUry. Mean years
demographic characteristics of the subjects, the dis- of education were similar in each group, but CVA
tribution of social position classes was not equaL The patients were generally lower in social position.
table shows also that the CCl group contained more
male subjects and younger subjects than the CVA Procedures
Every patient diagnosed with CVA or CCl who was
Table 1 admitted to the LRH during a 3-month period was
Subjects' Demographic Characteristics assessed with the LOTCA battery upon referral to oc-
CCI Group CVA Group Control Group cupational therapy, and again after 2 months of treat-
Variable (n = 20) (n = 28) (n = 55) ment. The second test was intended to proVide a per-
Sex formance profile after initial recovery, which would
Male 15 14 26 suggest more long-lasting problem areas.
Female 5 14 29
Age i (SD) 254 (93) 57.5 (73) 426 (126) Six occupational therapists trained to administer
Years of the evaluation tested the subjects. lnterrater reliability
education 96 (30) 92 (4.0) 13.3 (44) was determined prior to data collection in two ways.
Social
position First, three pairs of raters tested 10 subjects, and each
class I 0 2 10 separately scored the subjects' performance on the 19
II 0 0 15 subtests. Spearman's rank correlation coefficient be-
III 2 3 13
IV 4 5 9
tween the raters showed interrater reliability ranging
V 4 18 8 from .82 to .97 for the various subtests. Second, a
Soldiers 10 video recording of the assessment of one patient was
Note. CCI = craniocerebral injUry. CVA = cerebrovascular accident made. Each of the six therapists indiVidually viewed

The American journal a/Occupational Therapy 187

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 the recording and scored it. The therapists reached
100% agreement for 14 subtests, 86% for 4 subtests,
and 72% for 1 subtest This last subtest was changed,
and thereafter the therapists reached 86% agreement.
These levels of agreement and the correlation coeffi-
cients above .80 were considered acceptable, and en-
abled systematic data collection.
Data Analysis
Descriptive statistics and non parametric statistical
procedures were used because the data were mea-
sured on an ordinal scale, the sample sizes were mod-
erate, and no assumption of an underlying normal
distribution could be made for a group of brain-in-
jured patients.
Results
Demographic Variables
The chi-square analysis of the relationships between
demographic variables and performance on the bat-
tery revealed that, in the control group, age was non-
significant, years of education was significant for all
19 subtests at the .0001 level, and social position was
significant only for the areas of visuomotor organiza-
tion and thinking operations at the .02 level. This in-
dicated that, among the normal subjects, years of edu-
cation was the main variable related to perceptual
cognitive performance. In the patient samples, none
of the variables was significantly related to perfor-
mance, which indicated the predominance of the
brain damage over other preexisting conditions.
Descrzption ofPerformance
Table 2 shows means and standard deviations for all
subtests of the two patient groups at each of the two
testing times, and for the control group. The control
group performed almost perfectly on all subtests ex-
cept categorization, geometrical sequence, and classi-
fication. It seemed that, although the differences were
small, variability increased with the complexity of the
tests.
In the CCI group, the scores on the first assess-
ment ranged from a low mean of 2.1 (range 1 to 5) on
categorization to a high of 3.6 on visual identification
of objects. In the CVA group, scores ranged from a low

Table 2
Means and Standard Deviations of the LOTCA Subtests for Three Populations
CCI Group Assessments CVA Group Assessments
Control Group
Subtests 2 2 Assessments
ORIENTATION

Time and place 24 (14) 33 (12) 33 (11) 36 (10) 4.0

PERCEPTION

Object identification 36 (89) 4.0 39 (42) 39 (.26) 4.0

Shape identification 31 (79) 35 (60) 29 (97) 33 (.72) 39 (0.3)
Overlapping figures 30 (12) 38 (44) 29 (11) 34 (79) 39 (0.3)
Object constancy 29 (14) 35 (10) 28 (14) 32 (11) 39 (0.3)
Spatial perception 29 (14) 35 (95) 35 (I.I) 36 (95) 39 (0. I)
Praxis 29 (14) 38 (64) 34 (87) 37 (60) 39 (0.1)
VISliOMOTOR ORGANIZATION

Copying geometric forms 2.5 (13) 32 (95) 2.8 (10) 30 (96) 39 (0.3)
Reproducing a two-
dimensional model 27 (14) 34 (88) 2.6 (12) 31 (97) 39 (0.4)
Constructing a pegboard
design 24 (13) 33 (11) 24 (I I) 28 (11) 38 (0.5)
Constructing a colored
block design 2.6 (14) 33 (11) 25 (1.3) 27 (14) 38 (0.5)
Constructing a plain
block design 24 (12) 30 (1.3) 2.0 (1.3) 23 (12) 37 (06)
Reproducing a puzzle 24 (13) 30 (12) 20(1.1) 24 (13) 38 (0.6)
DraWing a clock 23 (13) 30 (12) 25 (1.0) 28(1.1) 38 (0.5)
THINKING OPERATIONS

Categorization (I -5) 2.1 (14) 29 (17) 21 (14) 28 (14) 4.2 (10)

ROC: Unstructured (1-5) 23 (1.5) 29 (13) 20 (12) 24 (15) 39 (10)
Structured (1-5) 2.7 (17) 31 (1.7) 18 (13) 23 (16) 4.2 (10)
Pictorial sequence 2.6 (14) 36 (12) 27 (14) 31 (13) 39 (03)
Geometrical sequence 2.2 (12) 24 (1.5) 16 (87) 2.1 (12) 36 (0.8)
NOle. Wilcoxon test differentiated at .0001 level of significance between controls and both patients groups on all subtests (except object
identification) during Assessment 1, and above the .02 level of significance during Assessment 2 CCI = craniocerebral injury. CVA = cerebro-
vascular accident.

188 March 1989, Volume 43, Number 3

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 of 1.6 on geometrical sequence to a high of 3.9 on
identification of objects. In the first assessment, both
CCI and CVA patients showed impairment on almost
all subtests, with greater variability among them. By
the second assessment, 2 months later, some im-
provement on the average was seen, more so in the
CCI group than in the CVA group.
Internal Consistency Reliability
Alpha coefficients were calculated for three areas in-
cluded in the battery. An alpha coefficient of .87 was
found for perception, which consisted of 5 subtests
(object identification, shape identification, overlap-
ping figures, object constancy, and spatial percep-
tion). An alpha coefficient of .95 was found for visuo-
motor organization, which consisted of 7 subtests
(copying geometric forms; reproducing a 2-dimen-
sional model, constructing a pegboard design, con-
structing a colored block design, constructing a plain
block design, reproducing a puzzle, and draWing a
clock). The third area, thinking operations, which
consisted of 5 subtests (categorization, ROC unstruc-
tured and ROC structured, pictorial sequence, and
geometrical sequence), had an alpha coefficient
of .85.
These high reliability coefficients support the
structure of the battery. On the other hand, correla-
tion coefficients ranging from 40 to .80 among the
subtests suggest that they are not all equivalent, and
therefore, that all parts of the battery should be
retained.
Validity
To evaluate the battery's ability to differentiate be-
tween known groups, the Wilcoxon two-sample test
was used to compare each patient group with the
control group. Results showed that all subtests except
identification of objects differentiated at the .000 1
level of significance between the control group and
each of the patient groups at the first assessment (z
scores ranged from 4.0 to 6.2), and above the .02 level
for the second assessment (z scores ranged from 25
to 4.5). The Kruskal-Wallis test was administered
among the three groups and showed the same level of
significance at both assessment times. This finding
supported the battery's validity in assessing percep-
tual cognitive impairment and in differentiating be-
tween known groups.
Criterion validity was examined within the CCl
group for the visuomotor organization area with the
Block Design subtest of the Wechsler Adult Intelli-
gence Scale (WAIS) (Wechsler, 1981). A correlation
coefficient of r = .68 was found between the score on
the Block Design subtest and the mean score on the
Visuomotor Organization subtests. To examine the
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process of performance and evaluate the speed factor,
which was not measured on the LOTCA, the standard
procedure of the Block Design subtest was varied, and
patients were given an unlimited amount of time to
complete the designs, although the patients were un-
aware of this (Lezak, 1983). Thus, two scores were
given, one for performance in the standard time and a
second if the patient's score increased in the unlim-
ited time situation. This procedure resulted in a sec-
ond score for some of the patients. In these cases, a
stronger correlation was found (r = .77). Interest-
ingly, when the same procedure was used with a
group of 20 chronic schizophrenic adult inpatients
(r = .69 and r = .78, respectively), almost identical
results were found (Katz, 1988). This procedure,
which was first employed by Katz (1985) with a sam-
ple of depressive patients to study the effects of slow-
ness on performance, appears useful for patient
evaluation.
Construct Validity
Principal component factor analysis with orthogonal
varimax rotation was performed to determine the con-
struct validity of the battery. This validation procedure
determined whether the subtests measure what they
were intended to measure and cluster into the three
assumed underlying areas of perception, visuomotor
organization, and thinking operations. The analysis
included 18 subtests (orientation was excluded be-
cause it had only 1 subtest) and was performed sepa-
rately for the patient groups and for the control group.
For the patient groups, the results of both assessments
were included (n = 96). Table 3 presents the results
of the analyses for the patient and control groups on
three factors.
Factor 1 in the patient groups, the Visuomotor
Organization and Sequence subtests, explained 44%
of the variance. All 7 of the Visuomotor Organization
subtests loaded above .63. Praxis loaded on Factor 2,
together with spatial perception, object identification,
and overlapping figures. Shape identification loaded
on Factor 3 with categorization and classification.
Object constancy was the only subtest that loaded
lower (53) and equally on both Factors 1 and 2.
These results within the patient groups may be
explained by the fact that, in all of the Perception
subtests as well as in the Praxis subtest, subjects were
reqUired to identify, comprehend, point to given ob·
jects, or imitate movements, but in the Visuomotor
Organization and Thinking Operations subtests they
were asked to perform a task, manipulate objects, or
copy and build things involVing motor, spatial, and
logical knowledge. These latter requirements are
more complex, and integrate the higher mental pro-
cesses of problem solving, planning, and motor orga-
189
 Table 3
Factor Loadings From a Principal Component Factor Analysis With Orthogonal Varimax Rotation of the LOTCA Battery
Patients (n = 96) Control Subjects (n = 55)
SuI-nests Factor 1 Factor 2 Factor 3 Factor 1 Factor 2 Factor 3
PEHCEI'TION
ObjeCt identification .09 79" 05
Shape identification .02 55 .62- 18 .81 - 07
Overlapping figures 33 67- 38 .89" .20 29
Object constancy 53 53 35 96" .21 02
Spatial perception 33 68- 11 .96- .21 02
Praxis .48 69- 11 .96- .21 02
VIS110MOTOH ORGANIZATION
Copying geometric forms .73- .42 25 21 52 .70-
Producing a 2·
dimensional model .68- 33 31 .11 .54- - 34
Constructing a pegboard
design .80- 29 .27 .44 .48- - 38
Constructing a colored
block design .80- .28 .27 54 .07 .63-
Constructing a plain
block design .81- 19 28 25 .45 .74-
Reproducing a puzzle .86- 18 .24 .57- - .46 .47
Drawing a clock .n- .31 30 .51 .58-- .01
TIIINKING OI'EHATIONS
Categorization .59 19 .61* .17 .77- .22
ROC: Unstructured .46 19 .73- .21 .74- 43
Structured 47 13 .77- 19 .84- 15
Pictorial sequence .73- 40 .27 89- 20 29
Geometrical sequence .63- 05 58 .27 .71- .22
Percent variance 44 12 10 33 23 6
- Loadings above .60. - - Loadings around .50 highest for a subtest.

nizational abilities (Najenson et al., 1984). A very sim-
ilar factor structure can be seen in the factor analysis
of items measuring perceptual functions that was per-
formed by Eriksson, Bernspang, and Fugl-Meyer,
(1988). In their analysis, visuomotor organization
items (termed high-order perception) loaded on Fac-
tor 1, and visual and spatial perception items (termed
low-order perception) loaded on Factor 2, which ex-
plained 49% and 16.3% of the variance, respectively,
for a group of 109 stroke patients. (Some of their
items were adapted from an earlier version of the
LOTCA).
In the control group, the results were different.
Three Perception subtests loaded highly (above .89)
on Factor 1, along with Praxis and pictorial sequence,
which explained 33% of the variance. Factor 2 con-
sisted of the Shape Identification and Thinking Oper-
ations, subtests and had lower loadings (around .50)
for reproducing a two-dimensional model, construct-
ing a pegboard design, and draWing a clock. Factor 3
was composed of 3 Visuomotor Organization sub-
tests: block design, constructing a plain block design,
and copying geometric forms.
The profile of the control group was different in
the importance of the factors accounting for the vari-
ance, which seemed to be due to the fact that all
subjects performed high on almost all subtests (a
ceiling effect). Differences among them may be bet-
ter explained by- basic perceptual differences or by
the most elementary praxis and pictorial sequence
thinking test, in which the variability was very small,
than by the somewhat more complex tests in which
the variability was greater (see Table 2). However,
because the number of control subjects was small for
a factor analysis, the results should be confirmed with
a larger group. Interestingly, in both groups, shape
identification loaded on the same factor as thinking
operations. The reason for this appears to be that the
test included four familiar shapes, such as circle,
square, triangle, and rectangle, but also four more
difficult ones, such as rhomboid, trapezoid, hexagon,
and half-circle, so that it became more than a basic
identification task. As scored in the study, shape
identification seemed to require higher formal knowl-
edge; therefore, it clustered together with the same
factor as thinking operations.
Comparison between the groups showed that,
within the patient group, the area of visuomotor orga-
nization explained the most variance in performance,
and the other two areas (perception and thinking
operations) explained almost equal percentages of
the variance. In contrast, within the control group,
perception explained the most variance, followed by
thinking operations; visuomotor organization contrib-

190 March 1989, Volume 43, Number 3

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 uted less to the variance explained. However, in both
groups the total amount explained is above 60%,
which is substantial.
Discussion
The measurement properties of the LOTCA were
found to be reliable for all subtests in the agreement
between raters and in the internal consistency of the
three major areas: perception, visuomotor organiza-
tion, and thinking operations. The LOTCA was also
found to be valid in differentiating between healthy
adult persons and brain-injured patients. This finding,
along with the results of a previous study in which the
performance profiles of psychiatric patients were
shown to differ from those of CCI patients (Averbuch
& Katz, 1988), suggests that the LOTCA differentiates
level of performance as well, as some localization
patterns related to brain lesions emerge. In addition,
the beginning work on the determination of construct
validity with factor analysis demonstrated a three-fac-
tor solution in accordance with the assumed underly-
ing areas, even though the solution differed in the
strength of its explanation of the variance in perfor-
mance between patients and controls.
The LOTCA battery is used also as a measure of
the patient's status over time. In those cases in which
difficulties are present at initial assessment, the
LOTCA can be employed as an objective measure for
follOWing up on patient progress. It is recommended
that the assessment be repeated after an interval of at
least 2 months to avoid simple memory carryover.
However, learning as a possible explanation for
higher scores must always be considered because
many similar tasks are practiced during treatment.
Nevertheless, it is precisely this learning, if general-
ized, that is the purpose of treatment, so it should not
be regarded as a threat to validity as defined in mea-
surement theory.
As a result of the data analysis, some changes
were made on the score sheet (see Figure 1). The
Object Identification subtest seemed to be very easy
for all three subject groups, and thus may be retained
only as a start-up task. The Shape Identification sub-
test, as discussed earlier, seems to contain two levels
of difficulty (four easy items and four harder ones), in
which the second set of shapes probably requires
more formal knowledge. Therefore, a score of 4 will
be given if the subject identifies all shapes either by
naming, understanding, or matching. Orientation was
divided into time and place, and each will be scored
separately. A scoring key for rating attention and con-
centration was added to allow analysis of these areas.
Attention and concentration are not tested with a spe-
cific subtest but should be evaluated by observing the
patients during performance of the LOTCA. Thus, the
final battery consists of 20 Jubtests and an observa-
The Americanjournal of Occupational Therapy
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tion-based score for attention and concentration.
Length of time and number of sessions are also re-
corded on the scoring sheet.
The next step in the validation process of the
LOTCA battery includes continued data collection at
the LRH and in other countries to enlarge the database
on the adult brain-injured population and on stroke
patients. Regarding construct validation with the fac-
tor analysis procedure, additional studies with larger
patient populations and control groups are necessary
to prOVide further support for the structure of the bat-
tery based on the four underlying areas of orientation,
perception, visuomotor organization, and thinking
operations. The relationship between the LOTCA
scores and functional evaluation and activities of daily
living rating scales also need to be studied, as do
changes in performance related to the rehabilitative
process.
Acknowledgments
We thank Sara Grinbaum, Dorit Hefner, and Batia Bor, the
occupational therapists at the Loewenstein Rehabilitation
Hospital who participated in the study. We also thank Pro-
fessor Levi Rahmani, who consulted in the development of
the battery. This study was supported by the Occupational
Therapy Central Office of Kupat Holim, the Health Insur-
ance Institute of the General Federation of Labour in Israel.
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