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
Perceptual Rehabilitation
The practice area of cognitive and perceptual
­rehabilitation has and continues to shift in focus.
In the recent past, interventions were focused on
cognitive and perceptual stimulation activities
aimed at the remediation of a particular impair­
ment. It was assumed that the remediation of an
identified impairment or impairments would
generalize into the ability to perform meaningful,

has not been supported by empirical research.
An early example is the elegant work of Neistadt.47
The researcher had previously identified a relation­
ship between construction tasks as measured by the
Wechsler Adult Intelligence Scale-Revised (WAIS-R)
Block Design Test and a standardized assessment of
meal preparation, the Rabideau Kitchen Evaluation-
Revised, concluding that constructional abilities may
contribute to meal preparation performance. Based
on these findings a randomized controlled trial was
 cognitive and perceptual rehabilitation: Optimizing function
conducted to examine the effects of interventions
focused on retraining meal preparation skills ver­
sus the remediation of constructional deficits in
adult men with head injuries. Outcomes were meal
preparation competence and objective measures of
const­ructional abilities. Forty-five subjects, ages 18
to 52, in long-term rehabilitation programs, were
randomly assigned to one of two treatment groups:
remediation of construction abilities (n = 22) via
training with parquetry block assembly, and a meal
preparation training group (n = 23). Both groups
received training for three 30-minute sessions per
week for 6 weeks, in addition to their regular reha­
bilitation programs. Results showed task-specific
learning in both groups and suggested that train­
ing in functional activities may be the better way to
improve performance in such activities in this popu­
lation. In other words, those trained in construction
tasks performed better on novel tabletop construc­
tion tasks but did not improve on meal preparation
measures, whereas those trained in the meal prepa­
ration group demonstrated significantly improved
abilities related to the ability to make a meal at the
end of the intervention despite not improving on
measures of construction ability. Although the results
of this study are not unexpected based on a current
understanding of recovery, the study challenged the
typical interventions that were being taught in aca­
demic settings and those that were commonly used
in the clinic at the time it was published.
In general, interventions at that time were pro­
vided in controlled environments consisting of
tabletop activities that were novel and not focused
on function. Examples include engaging individuals
in block design activities, sequencing picture cards,
puzzle making, design copying, canceling a tar­
get stimulus on paper, pegboard designs, memory
drills, and so on. As technology became more read­
ily available, specialized cognitive-retraining com­
puterized programs were developed, marketed, and
quickly adopted into the clinical setting. In terms
of outcomes, interventions were deemed successful
when improvements were documented on specific
cognitive and perceptual impairment tests.
Similar to the interventions that were being used
at this time, measurement instruments attempted to
isolate a particular impairment via novel and non­
functional test items such as copying words and
designs, picture matching, block building, sequenc­
ing pictures, free recall of words, memorizing and
attending to a number string, and so on. It has and
continues to become clear that interventions such as
these need to be reconsidered if we as clinicians expect
to influence function in the real world. In addition, it
is becoming clear that how we measure the success
of an intervention must be reconsidered. Significant
improvement in a letter cancellation test for a person
living with unilateral spatial neglect can no longer be
interpreted as a positive outcome if more meaning­
ful functional changes (e.g., improved ability to read,
manage medications, play board games, ­ manage
money, etc.) cannot be documented.
As rehabilitation professions began to under­
stand the importance of evidence-based practice
and have refocused on “real-world” functional out­
comes, the rehabilitation process has begun to shift
accordingly. Interventions that focus on strategies
for living independently, with a purpose, and
with improved quality of life despite the presence
perhaps of cognitive and perceptual impairments are
slowly becoming the clinical standard. Likewise, out­
come measures that focus on documenting improved
functioning outside of a clinic environment and
those that include test items focused on performing
functional activities are being embraced.
These positive changes should be welcomed by
clinicians and the individuals to whom they provide
services because making a positive change in the life
of an individual living with cognitive and percep­
tual impairments has been notoriously difficult. It
is expected that as the research literature focused on
testing interventions continues to emerge, further
shifts in practice patterns will occur. Philosophically,
the clinical focus of what is called cognitive and per-
ceptual rehabilitation may be better described as the
process of improving function and quality of life in
those individuals living with ­cognitive and perceptual
impairments.
World Health Organization’s
International Classification of
Function as a Framework for
Choosing Assessments, Interventions,
and Documenting Outcomes
The World Health Organization’s (WHO) Inter­
national Classification of Functioning, Disability,
and Health (ICF)68 is a classification system that
describes body functions and structures, activities,
and participation. The various domains are inclu­
sive and consider the body itself as well as the indi­
vidual and societal perspectives. The ICF embraces
the relationship between the person and the context
in which daily living occurs and therefore includes
environmental factors as part of the classification
system. The ICF is a useful guide to rehabilitation,
 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
and perceptual impairments.6,49 Elements of the clas­
sification system (Table 1-1) include the following68:
• Body structures: Anatomic parts of the body
(organs, limbs, and their components)
• Body functions: Physiologic functions of the body
systems inclusive of psychological functions
• Impairments: A negative aspect related to prob­
lems in body function or structure such as sig­
nificant deviation or loss
• Activities: Execution of a task or action by an
individual
• Activity limitation: A negative aspect mani­
fested as an individual’s difficulty in executing
activities
• Participation restrictions: A negative aspect man­
ifested as an individual experiencing problems
in life situations
• Environmental factors: Physical, social, and atti­
tudinal environment in which people live and
conduct their lives; includes environmental as
well as personal factors
From an evaluation, intervention, and reha­
bilitation outcomes perspective, it is important to
consider the relationships between the classifica­
tion categories of the ICF rather than focusing on
one category at a time (Figure 1-1). For example,
“Mark” may survive a right frontoparietal stroke
resulting in visuospatial impairments and unilat­
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
& Structure
Environmental
Factors
Contextual factors
Figure 1-1  Interaction between components of the International Classification of Functioning, Disability, and Health. (From World Health
Organization: International Classification of Functioning, Disability and Health, p. 18, Geneva, 2001, World Health Organization.)
body functions). These impairments may in turn
result in Mark’s inability to perform tasks such as
word processing, driving a car, balancing a check­
book, or preparing a meal (activity limitations). The
resultant activity limitations may adversely affect
Mark’s ability to continue gainful employment or
live on his own (participation restrictions).
American Occupational Therapy
Association’s Practice Framework
as a Framework for Choosing
Assessments and Interventions,
and Documenting Outcomes
The American Occupational Therapy Association
(AOTA) has published a framework for guiding
practice (Table 1-2).2 Components of the frame­
work include the following:
• Performance in areas of occupation: Occupations
and daily life activities
• Client factors: Factors such as body structures
and body functions that affect performance in
areas of occupation
• Performance skills: Observable elements of action
that have implicit functional purposes
• Performance patterns: Patterns of behavior
related to daily life activities
• Context: Conditions within or surrounding the
client that affect and influence performance
• Activity demands: Aspects of an activity required
to carry out the activity
The AOTA Practice Framework and the WHO’s
ICF are interrelated despite the use of different ter­
minology (Figure 1-2).
Activity Participation
Personal
Factors
Client-Centered Practice
Client-centered practice is an approach to providing
rehabilitation services,“which embraces a philosophy
of respect for, and partnership with, people receiv­
ing services. Client-centered practice recognizes the
autonomy of individuals, the need for client choice
in making decisions about occupational needs,
the strengths clients bring to a therapy encounter,
the benefits of client-therapist ­partnership, and the
need to ensure that services are accessible and fit the
context in which a client lives.”36
Law and colleagues37 as well as Pollock,50 suggest
that the therapist implementing this approach to
evaluation include the following concepts:
1. Recognizing that the recipients of therapy are
uniquely qualified to make decisions about their
functioning
2. Offering the individual receiving services a
more active role in defining goals and desired
outcomes
3. Making the client-therapist relationship an
­interdependent one to enable the solution of
­performance dysfunction
4. Shifting to a model in which therapists work
with individuals to enable them to meet their
own goals
5. Evaluation (and intervention) focusing on the
contexts in which individuals live, their roles and
interests, and their culture
6. Allowing the individual who is receiving services
to be the “problem definer,” so that in turn the
individual will become the “problem solver”
7. Allowing the client to evaluate his or her own
performance and set personal goals
 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 Functions

Performance in Areas of Occupation Activities

Participation

Context Environmental Factors

Figure 1-2  Relationships between the American Occupational Therapy Association (AOTA) Practice Framework and the World Health
Organization’s International Classification of Functioning, Disability, and Health (ICF).

Through the use of these strategies the evaluation
process becomes more focused and defined, ­clients
become immediately empowered, the goals of ther­
apy are understood and agreed on, and an individ­
ually tailored intervention plan may be ­established.
The Canadian Occupational Performance Measure36
is a standardized tool that embraces a client-centered
approach and is discussed later.
van den Broek56 specifically recommends using
a client-centered approach as a way to enhance
neurorehabilitation outcomes and states that
treatment failure may be secondary to clinicians
focusing interventions on what they believe the
client needs rather than what the client actually
wants. van den Broek56 affirms that client-centered
goal setting is a key to successful ­ rehabilitation
­outcomes, stating:
“Goal setting is of central concern as without goals,
rehabilitation has no direction and the ­ intervention
­cannot be judged to be effective or ineffective. Moreover,
the quality and type of goal setting sets the tone of the
interaction between the clinician or treating team and
the patient. Goals that are proposed, suggested, or iden­
tified by the clinician tend to be those based on what
the clinician believes the patient needs. Of equal, if not
more importance, however, is what the patient wants to
achieve. Patients tend to be motivated toward achieving
or satisfying their wants, and may not be so motivated
or quite unmotivated toward achieving other goals. The
process of goal setting therefore involves arriving at an
overlap between needs and wants, or where this is not
possible agreeing to work toward wants that represent
a reasonable compromise. Goal setting that ends with
treatment goals that consist of needs that the patient does
not want or is indifferent toward is not client centered
but prescriptive, and runs the risk of concluding in an
­ineffective outcome.”
Another argument for using a client-centered
approach to guide the intervention focus with this
 cognitive and perceptual rehabilitation: Optimizing function
population is that interventions typically used for
those living with cognitive-perceptual dysfunction
are notoriously difficult to generalize to other real-
world settings and situations. For example, visual
scanning training via tabletop activities for those liv­
ing with unilateral spatial neglect most often will not
automatically generalize to the client’s being able to
use the scanning strategy to find items in the refrig­
erator unless the strategy is specifically taught in the
context of the activity. In addition, strategies that are
taught to accomplish a specific task (e.g., using an
alarm watch to maintain a medication schedule for
those living with memory loss) will not necessar­
ily generalize or “carry over” to another task such as
remembering therapy appointments. Finally, there
are a large number of clients whose level of brain
damage preclude them from generalizing learned
tasks.48 This issue of task-specificity related to treat­
ment interventions must always be considered by
clinicians working with this population. A client-
centered approach will help ensure that outcomes,
goals, and tasks used as the focus of therapy are at
least relevant, meaningful, and specific to each client
as well as the caretaker or significant others despite the
potential lack of being generalizable for a segment
of the population living with various cognitive and
­perceptual impairments.
What Are Appropriate Outcomes
When Designing Interventions
for People Living with Cognitive
and Perceptual Impairments?
Although not as a problematic as the recent past, the
practice area of cognitive and perceptual rehabili­
tation has been plagued by a lack of well-designed
clinical trials demonstrating positive outcomes.
A starting point is to decide what is considered
an appropriate, meaningful, and ideal outcome to
measure. This decision will help guide interventions
as well. The preceding paragraphs have already dis­
cussed the importance of keeping a client-centered
focus during the rehabilitation process. A client-
centered focus is paramount when considering out­
comes as well. The following case illustrates various
possible outcomes:
Mary is a 32-year-old woman who survived an
anoxic event that has resulted in moderate/severe
short term memory impairments. Mary is a sin­
gle mother of a 5-year-old boy. She works from
home (desktop publishing). Mary’s days were quite
­structured before her brain injury. Mornings were
characterized by basic self-care followed by tasks
related to getting her son to school (choosing his
clothing, making lunch, etc.). As the sole financial
provider, Mary spent the greater part of the rest of
the day in her home office working on the com­
puter, fielding phone calls, and organizing pres­
ent or upcoming jobs. Lunch was usually a quick
cold sandwich. Mary stopped working at 3:30 when
her son arrived home from school. Depending on
the day she would drive her son to Little League or
drum lessons. Mary always cooked a full dinner and
spent the rest of the evening helping with home­
work and watching television. Mary’s memory
impairments are preventing her from continuing
to work. For safety reasons, her mother has moved
in to help with childcare, household organization,
and financial matters. Mary has recently expressed
feelings of low self-esteem, saying that “she can’t
do anything by herself anymore.” Mary has stated
that she is most concerned about starting to work
(finances are limited) and she would like to take a
more active parenting role again. Prior to initiating
interventions, Mary participated in three assess­
ments including standardized measures of memory
impairment, instrumental activities of daily living
(IADL) (e.g., homemaking and child care), and
quality of life (QOL).
Possible (noninclusive) outcomes for Mary
based on the ICF68 may include the following:
• Outcome 1: Following cognitive reha­
bilitation, Mary has improved her scores
on a standardized memory scale (decreased
impairment) but changes are not detected on
measures of IADL and QOL (stable activity
limitations/participation restrictions).
• Outcome 2: Following cognitive rehabili­
tation, Mary has no detectable changes on the
standardized memory scale (stable impair­
ment) but changes are detected on mea­
sures of IADL and QOL (decreased activity
­limitations/participation restrictions).
• Outcome 3: Following cognitive rehabili­
tation, Mary has detectable changes on
the standardized memory scale (decreased
impairment) as well as changes that are
detected on measures of IADL and QOL
(decreased ­ activity limitations/­participation
restrictions).
Out of the three outcome scenarios, outcome 1 is
the least desirable. In the past this type of outcome
may have been considered successful (i.e., “Mary’s
memory has improved”). This outcome may be
indicative of an intervention plan that is over­
focused on attempts to remediate memory skills
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 
(e.g., memory drills, computerized ­ memory pro­
grams) without consideration of generalization
to real-life scenarios. If a change at the impair­
ment level of function does translate or general­
ize to improved ability to engage in meaningful
activities, participate successfully in life roles, or
enhance quality of life, the importance of the
intervention needs to be reconsidered. Outcomes
2 and 3 are more clinically relevant, arguably more
meaningful to Mary and her family, and repre­
sent more optimal results of structured rehabilita­
tion services. Outcome 2 may have been achieved
by focusing interventions on Mary’s chosen tasks.
Interventions such as teaching compensatory strat­
egies including the use of assistive technology may
have been responsible for this outcome. Mary is
able to engage in chosen tasks despite the presence
of stable memory impairments.
Finally, outcome 3 represents improvement
(decreased impairment, improved activity perfor­
mance, and improved quality of life) across mul­
tiple health domains. Although this outcome may
be considered the most optimal, the relationships
among the three measures are not clear. Clinicians
may assume that the improved status detected by
the standardized measure of memory was also
responsible for Mary’s improved ability to per­
form household chores and childcare. This reason­
ing is not necessarily accurate. The changes within
the health domains may in fact be independent of
each other. In other words, Mary’s improved abil­
ity to manage her household after participating in
treatment may be related to the fact that interven­
tions included specifically teaching Mary strate­
gies to manage her household. Similar to outcome
2, this positive change may have occurred with or
without a documented improvement in memory
skills.
Traditionally clinicians and researchers involved
in working with those living with cognitive and per­
ceptual impairments use standardized measures of
cognitive-perceptual impairment (i.e., standardized
tests of attention, memory, apraxia, neglect) as the
primary outcome measure to document effective­
ness of interventions. Although this is one impor­
tant level of measurement and following chapters
will review specific cognitive-perceptual measures
in detail, it is not sufficient to use these measures
as the sole or important indicator of successful
interventions. It is critical that clinical programs
and research protocols not only include but also
focus on measures of activity, participation, and
quality of life as a key outcome. As stated, positive
changes in these measures are more relevant than
an isolated change on an impairment measure—
the impairment change must be associated with a
change in other health domains. Individuals receiv­
ing ­services, family members, and third-party pay­
ers alike are likely to be more satisfied with changes
at these arguably more meaningful levels of func­
tion. The following standardized, valid, and reli­
able measurement instruments are suggested to
document successful clinical and research out­
comes related to improving function in those with
functional limitations secondary to the presence of
cognitive and perceptual impairments.
For a thorough review of performance-based
measures, refer to Law and associates.39 Unless oth­
erwise indicated, they are not impairment-specific
evaluations; therefore, they have high use when
working with this population.
Quality of Life Measures
The construct of quality of life is broad and com­
plicated. In her paper “What Is Quality of Life?”
Donald17 summarizes several issues related to qual­
ity of life:
• “Quality of life is a descriptive term that refers
to people’s emotional, social and physical well-
being, and their ability to function in the ordi­
nary tasks of living.
• Health-related quality of life analyses measure
the impact of treatments and disease processes
on these holistic aspects of a person’s life.
• Quality of life is measured using specially
designed and tested instruments, which measure
people’s ability to function in the ordinary tasks
of living.
• Quality of life analyses are particularly helpful
for investigating the social, emotional, and physi­
cal effects of treatments and disease processes on
people’s daily lives; analyzing the effects of treat­
ment or disease from the client’s perspective;
and determining the need for social, ­emotional,
and physical support during illness.
• Quality of life measures can therefore help to
decide between different treatments, to inform
clients about the likely effects of treatments, to
monitor the success of treatments from the cli­
ent’s perspective, and to plan and coordinate
care packages.”
Clinicians and researchers should consider
improving quality of life as an overarching theme
related to rehabilitation in general. Specific assess­
ments are reviewed below.
 cognitive and perceptual rehabilitation: Optimizing function
Medical Outcomes Study Short Form-36
The Medical Outcomes Study Short Form-36 (SF-
36)59 is a widely used survey instrument for assess­
ing a client’s health-related quality of life. The SF-36
measures eight domains: physical functioning, role
physical, bodily pain, general health, vitality, social
functioning, role emotional, and mental health,
and has two summary scores (physical and men­
tal). The SF-36 has demonstrated its reliability and
validity in multiple populations and can be admin­
istered in various ways. The SF-1258 and SF-2060 are
abbreviated versions of the SF-36 health profile.
Sickness Impact Profile
The Sickness Impact Profile (SIP)11 is used to evalu­
ate the effect of disease on physical and emotional
functioning. The measure includes two overall
domains: physical and psychosocial. The measure
has 12 categories including sleep and rest, eating,
work, home management, recreation and pastimes,
ambulation, mobility, body care and movement,
social interaction, alertness behavior, emotional
behavior, and communication. The instrument
yields an overall score, 2 domain scores, and 12
category scores; items are weighted according to a
standardized weighting scheme. A stroke-specific
version (Stroke Adapted Sickness Impact Profile) is
available.57
Nottingham Health Profile
The Nottingham Health Profile (NHP)27,28 was
developed to be used in epidemiologic studies of
health and disease and consists of two parts. Part
1 contains 38 yes/no items in six dimensions: pain,
physical mobility, emotional reactions, energy,
social isolation, and sleep. Part 2 contains 7 gen­
eral yes/no questions concerning daily living prob­
lems including paid employment, jobs around the
house, personal relationships, social life, sex life,
hobbies, and holidays. The two parts may be used
independently.
Stroke Impact Scale
The Stroke Impact Scale (SIS)19,33 is a stroke-specific
measure that provides information on function and
quality of life. This self report measure including 59
items that form eight subgroups including strength,
hand function, basic and instrumental activities of
daily living, mobility, communication, emotion,
memory and thinking, and participation. The SIS
is valid, reliable, and sensitive to change in stroke
populations and is reliable when responses are
­provided by proxy.
Reintegration to Normal Living
The Reintegration to Normal Living (RNL)66,67
assessment is used to document reentry into every­
day life following a sudden illness or event. This
functional status measure quantitatively assesses the
degree of reintegration to normal living achieved
by clients after illness or trauma and is useful. This
tool assesses global function and the individual’s
satisfaction with basic self-care, in-home mobility,
leisure activities, travel, and productive pursuits.
Clients are provided with 11 statements to which
they respond. The test can be completed using a
pen-and-paper format or an interview format.
Satisfaction with Life Scale
The Satisfaction with Life Scale (SWLS)16 is a 5-
item scale that uses a 7-point Likert scale response
format. Individual scores are added to create a total
score ranging from 5 to 35. A score of 20 represents
a neutral point at which the respondent is equally
satisfied and dissatisfied. The items in the SWLS are
limited to general life satisfaction.
Activity and Participation Measures
Outcomes related to cognitive perceptual rehabilita­
tion must be detectable and evidenced by decreasing
activity limitations and participation restrictions. Out­
comes are individualized and based on the activities
(basic activities of daily living [ADL], IADL, paid
and unpaid work, and play and leisure) that clients
want to be able to do or need to do to live a safe and
productive life. Measurement instruments that focus
on the activity and participation levels are critical to
document the effectiveness of cognitive-perceptual
rehabilitation interventions. Examples follow.
Community Integration Questionnaire
The Community Integration Questionnaire (CIQ)62-64
consists of 15 items relevant to home integration, social
integration, and productive activities. It is scored to
provide subtotals for each of these, as well as for com­
munity integration overall. Scoring is primarily based
on frequency of performing activities or roles, with
secondary weight given to whether activities are done
jointly with others, and the nature of these other per­
sons. The CIQ can be completed, by either the client or
a proxy, in about 15 minutes.
Craig Handicap Assessment and
Reporting Technique
The Craig Handicap Assessment and Reporting
Technique (CHART)61 measures the degree to
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 
which impairments and activity limitations result in
decreased participation. The original CHART had
27 questions and included the following domains:
(1) physical independence: ability to sustain a
customarily effective independent existence; (2)
mobility: ability to move about effectively in one’s
surroundings; (3) occupation: ability to occupy
time in the manner customary to that person’s sex,
age, and culture; (4) social integration: ability to
participate in and maintain customary social rela­
tionships; and (5) economic self-sufficiency: ability
to sustain customary socioeconomic activity and
independence.
The revised CHART46 (32 questions) contains a
sixth domain designed to assess orientation: cog­
nitive independence. Each of the domains or sub­
scales of the CHART has a maximum score of 100
points. High subscale scores indicate less handicap,
or higher social and community participation. The
CHART can be administered by interview, either in
person or by telephone, and takes approximately
15 minutes to administer. Participant-proxy agree­
ment across disability groups on the CHART has
provided evidence in support of the use of proxy
data for people with various types of disabilities.
A shorter version of the instrument, the CHART
Short Form, has 19 items that yield the same
­subscales as the original CHART.
Activity Card Sort
The Activity Card Sort (ACS)9,30 uses a Q-sort
methodology to assess participation in 80 instru­
mental, social, and high and low physical demand
leisure activities. Clients sort the cards into different
piles to identify activities that were done prior to
insult or injury, those activities they are doing less,
and those they have given up since their injury. The
ACS uses cards with pictures of tasks that people do
every day. There are different versions of the card
sort based on where interventions are taking place.
An institutional version sorts the cards into cate­
gories of done prior to illness and not done. The
recovering version identifies activities not done in
the past 5 years, those given up because of illness,
those beginning to do again, and those activities the
client is doing now.25
In all versions, a current activity level is deter­
mined. This assessment takes approximately 30
minutes to administer and results in a score of
percent of activities retained. The ACS has been
found to be a reliable and valid measure with indi­
viduals with cognitive loss9 as well as stroke30 and
is available in several culture-specific formats.
In ­addition, an adolescent as well as child version is
in development.25
Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure
(COPM)12,36 is a self-report measure used to assess
a client’s perception of recovery and goals. This
client-centered assessment allows the recipient of
treatment (or a caretaker) to identify activities that
are difficult, rate the importance of each activity,
rate own level of performance for each identified
activity, and rate satisfaction with current perfor­
mance. Overall areas of assessment include self-care,
leisure, and productivity. The tool is not diagnosis
specific and can be used with children, adolescents,
and adults. To be used with success, the client must
be able to understand a 10-point Likert scale scor­
ing format. If this is not possible, a caregiver may be
involved in the assessment process (Figure 1-3).
Barthel Index
The Barthel Index (BI)44 is a measure of basic activ­
ities of daily living and mobility. It is scored from
0 to 100, with higher scores indicative of increased
function. The specific items measured include feed­
ing, bathing, grooming, dressing, bowel control,
bladder control, toilet use, transfers, mobility on
even surfaces, and stairs.
Functional Independence Measure
The Functional Independence Measure (FIM)31
is a widely accepted functional assessment mea­
sure used during inpatient rehabilitation. The FIM
is an 18-item ordinal scale, used with all diagno­
ses within a rehabilitation population. FIM scores
range from 1 to 7 (1 = total assist and 7 = com­
plete independence). Scores falling below 6 require
another person for supervision or assistance. The
FIM measures independent performance in self-
care, sphincter control, transfers, locomotion, com­
munication, and social cognition. By adding the
points for each item, the possible total score ranges
from 18 (lowest) to 126 (highest) level of inde­
pendence. During rehabilitation, admission and
discharge scores are rated by a multidisciplinary
team while observing client function. Functioning
postdischarge can be accurately assessed using a
telephone version of FIM when administered by
qualified interviewers.
Revised Observed Tasks of Daily Living
The Revised Observed Tasks of Daily Living
(OTDL-R)15 is a performance-based test of ­everyday
10 cognitive and perceptual rehabilitation: Optimizing function

STEP 1A: Self-Care IMPORTANCE

Personal Care
(e.g., dressing, bathing,
feeding, hygiene)

Functional Mobility
(e.g., transfers,
indoor, outdoor)

Community Management
(e.g., transportation,
shopping, finances)

STEP 1B: Productivity

Paid/Unpaid Work
(e.g., finding/keeping
a job, volunteering)

Household Management
(e.g., cleaning, doing
laundry, cooking)

Play/School
(e.g., play skills,
homework)

STEP 1C: Leisure

Quiet Recreation
(e.g., hobbies,
crafts, reading)

Active Recreation
(e.g., sports,
outings, travel)

Socialization
(e.g., visiting, phone calls,
parties, correspondence)

Figure 1-3  Canadian Occupational Performance Measure (identifying occupations and rating importance). (From Park S: Enhancing
engagement in instrumental activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach,
ed 2, St Louis, 2004, Elsevier/Mosby.)

problem solving and competence. The test was
designed with a focus on cognitive IADL. The test
includes nine tasks in the categories of medication
use, telephone use, and financial management. The
test does not require special equipment and can be
administered in bed. The tool has been used with
community-dwelling older adults, older adults liv­
ing in nursing homes or assisted living facilities,
individuals with schizophrenia, and individuals
with brain injuries.24
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 11

Lawton Instrumental Activities of Daily Living Scale
The Lawton Instrumental Activities of Daily Living
Scale40 includes the following items: use of the tele­
phone (look up numbers, dial, answer), traveling
via car or public transportation, food or clothes
shopping (regardless of transport), meal prepara­
tion, housework, medication use (preparing and
taking correct dose), management of money (write
checks, pays bills). Each criterion is graded on ­
a three-point scale: independent, assistance needed,
or dependent. Client self-report and informant (i.e.,
clinician or family member) versions are available.
Table 1-3 gives more choices of standardized IADL
assessments.
Nottingham Leisure Questionnaire
The Nottingham Leisure Questionnaire18 was
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)
12 cognitive and perceptual rehabilitation: Optimizing function

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
were “excellent” and “excellent” or “good” for the
test retest reliability study. They suggested that the
tool has potential for clinical use. More recently the
Nottingham Leisure Questionnaire has been short­
ened (37 to 30 items) and the response categories
collapsed (five to three categories) in order to make
it suitable for mail use.
Leisure Competence Measure
The Leisure Competence Measure32 provides infor­
mation about leisure functioning as well as ­measure
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 13
change in leisure function over time. The tool
includes nine areas: social contact, community par­
ticipation, leisure awareness, leisure attitude, social
behaviors, cultural behaviors, leisure skills, inter­
personal kills, and community integration skills.
Items are rated on a seven-point Likert scale.
Leisure Diagnostic Battery
The original version of the Leisure Diagnostic
Battery65 includes 95 items, whereas the newer
shorter version includes 25 items.13 Items are scaled
on three-point scale. Assessment areas include play­
fulness, competence, barriers, knowledge, and so on.
Measures That Simultaneously Assess
Activity/Participation and Underlying
Impairments or Subskills
There is a short list of available assessments that are
highly recommended because they are unique in
their ability to simultaneously assess more than one
level of function such as activity limitations and the
impairments responsible for the limitations. These
assessments provide clinicians with critical and
substantial information via skilled observation of
functional tasks.
Árnadóttir OT-ADL Neurobehavioral Evaluation
The Árnadóttir OT-ADL Neurobehavioral Evalua­
tion (A-ONE)3–5,22 is an instrument that allows the
Box 1-1 Items Included on the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
The A-ONE uses standardized and structured observations
as the method of assessment during the following daily
­living skills:
• Feeding
• Grooming and hygiene (upper body washing, oral/hair
care, shaving, etc.)
• Dressing (upper and lower body)
• Transfers and mobility (bed mobility, transfers,
maneuvering in a wheelchair or during ambulation)
• Functional communication (comprehension and
expression)
Using standardized procedures and uniform conceptual
and operational definitions as guidelines the following spe-
cific impairments are evaluated in the context of functional
skills:
• Ideational apraxia
• Motor apraxia
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).
therapist to detect impairments that interfere with
task performance to understand factors underlying
activity limitations. It is used with clients who are
16 years and older and are living with functional
limitations secondary to central nervous system
dysfunction such as stroke, traumatic brain injury,
dementia, and multiple sclerosis.
The A-ONE aids the therapist in analyzing the
nature or cause of a functional problem requiring
intervention. Subsequently, therapists can speculate
about the best intervention for activity limitation
and impairments. The A-ONE is a performance-
based tool that uses structured observations of
upper and lower body dressing, grooming, hygiene,
feeding, transfers, mobility and communication to
detect the underlying impairments that interfere
with function (Box 1-1).
Impairments detected during the observation
of these tasks include motor apraxia, ideational
apraxia, unilateral body neglect, somatoagnosia,
spatial relations, unilateral spatial neglect, impaired
motor control, perseveration, and organization and
sequencing. In addition pervasive impairments such
as agnosias, memory loss, disorientation, confabu­
lation, and affective disturbances can be detected
throughout the observations. Figure 1-4 shows an
example of the dressing domain of the A-ONE. Note
that the instrument includes two scales; the Indepen­
dence Score ­ measures each activity in terms of
functional independence, and the Neurobehavioral
• Unilateral body neglect
• Somatoagnosia
• Spatial relations dysfunction
• Unilateral spatial neglect
• Perseveration
• Organization and sequencing dysfunction
• Topographic disorientation
• Motor control impairments
In addition, the following pervasive impairments can be
detected and objectified:
• Agnosias (visual object, associative visual object,
visuospatial)
• Anosognosia
• Body scheme disturbances
• Emotional/affective disturbances
• Impaired attention and alertness
• Memory loss
14 cognitive and perceptual rehabilitation: Optimizing function

Functional Independence Scale and

Neurobehavioral Specific Impairment Subscale

Ms. Wilson 6/13/03

Name______________________________________________________________________
Date _________________________

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

4 = Independent and able to transfer activity to
other environmental situations.
3 = Independent with supervision.
2 = Needs verbal assistance.
1 = Needs demonstration or physical assistance.
0 = Unable to perform. Totally dependent on assistance.
0 = No neurobehavioral impairments observed.
1 = Able to perform without additional
information, but some neurobehavioral impairment
is observed.
2 = Able to perform with additional verbal assistance, but
neurobehavioral impairment can be
observed during performance.
3 = Able to perform with demonstration or
minimal to considerable physical assistance.
4 = Unable to perform due to neurobehavioral impairment.
Needs maximum physical assistance.

List helping aids used:

•Wheelchair
•Nonslip for soap and plate
•Adapted toothbrush
•Velcro fastening on shoes

PRIMARY ADL ACTIVITY SCORING 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.)
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 15

Score ­measures the individual impairments that are
affecting function. In this example Ms. Wilson has
sustained a right cerebrovascular accident (CVA);
unilateral body neglect, spatial relations impair­
ment, unilateral spatial neglect, organization and
sequencing problems, and left hemiplegia inter­
fere with the dressing performance as indicated by
scores on the Neurobehavioral Specific Impairment
Subscale of the A-ONE. To be administered reliably,
the A-ONE requires a training course.
Assessment of Motor and Process Skills
The Assessment of Motor and Process Skills (AMPS)21
is a client-centered performance assessment of both
basic and IADL with an emphasis placed on
IADL tasks. The AMPS is not diagnosis specific.
It is appropriate for clients who are 3 years old
and up and who are experiencing functional limi­
tations. The AMPS entails the client choosing to
perform two or three tasks in collaboration with
a therapist from a list of more than 80 standard­
ized tasks.
In addition, although it does not detect the
client’s underlying impairments it does evaluate
motor and processing skills that affect function.
Motor skills are observable actions a person uses
to move the body or objects during all ADL task
performance. Process skills are observable actions

Árnadóttir OT-ADL
Neurobehavioral Evaluation
(A-ONE)
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)
16 cognitive and perceptual rehabilitation: Optimizing function

LIST OF NEUROBEHAVIORAL IMPAIRMENTS OBSERVED:

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

Motor Apraxia Astereognosis Restlessness
Ideational Apraxia Visual Object Agnosia Concrete Thinking
Unilateral Body Neglect Visual Spatial Agnosia Decreased Insight
Somatoagnosia Associative Visual Agnosia Impaired Judgment
Spatial Relations Anosognosia Confusion
Unilateral Spatial Neglect R/L Discrimination Impaired Alertness
Abnormal Tone: Right Short-Term Memory Impaired Attention
Abnormal Tone: Left Long-Term Memory Distractibility
Perseveration Disorientation Impaired Initiative
Organization Confabulation Impaired Motivation
Topographic Disorientation Lability Performance Latency
Other Euphoria Absent Mindedness
Sensory Aphasia Apathy Other
Jargon Aphasia Depression Field Dependency
Anomia Aggressiveness
Paraphasia Irritability
Expressive Aphasia Frustration

Use ( ) for presence of specific impairments in different ADL domains (D = dressing, G = grooming, T =transfers, F = feeding,
C = communication) and for presence of pervasive impairments detected during the ADL evaluation.

Summary of Neurobehavioral Impairments:

Needs physical assistance for most dressing, grooming, hygiene, transfer, and mobility tasks
because of left-sided paralysis, spatial relations impairments (e.g., problems 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:

Figure 1-4—Cont’d

a person uses to (1) select, interact with, and use
tools and materials, (2) carry out ­individual actions
and steps, and (3) modify performance when prob­
lems are encountered. Process skills should not be
confused with cognitive or ­perceptual skills.
For example, one process skill included on the
AMPS is the ability “search and locate.” Searching for
and locating necessary items to perform a task relies
on multiple underlying skills such as visual ­attention,
figure-ground skills, problem solving, intact visual
fields, and so on. The AMPS detects the behavioral
output of these subskills. Following the skilled obser­
vation of each ADL task, the client is rated on 16
motor and 20 process skill items for each task per­
formed using a four-point Likert scale. Once the
items are scored for each task, the results are entered
in the AMPS computer scoring program. The pro­
gram generates a summary report (Figure 1-5, A).
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 17

In addition, the computer analysis of the motor and
process skill scores results in ADL motor ability and
ADL process ability measures. The measures repre­
sent the placement of the person on a continuum of
motor or process ability (Figure 1-5, B).
The AMPS requires no specialized equipment
and can be conducted in any ADL-relevant setting
within 60 minutes. A study42 found that the AMPS
may give a better indication of the client’s ability
to resume independent living than neuropsycho­
logical testing alone. The occupational therapy
practitioner who uses the AMPS must attend a
5-day AMPS training course to become certified
in its use.

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

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

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

ID: 1111JS Occupational therapist: Kim A

Task 1: 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)
18 cognitive and perceptual rehabilitation: Optimizing function

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

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

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

ID: 1111JS Occupational therapist: Kim A

Task 1: 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

Figure 1-5—Cont’d
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 19

OCCUPATIONAL THERAPY EVALUATION OF ADL ABILITY

(Results and Interpretation of an Assessment of Motor
and Process Skills (AMPS) Evaluation)

Therapist: Kim A, OTR

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

SPECIFIC SKILLS THAT MOST IMPACTED PERFORMANCE

More specifically, John's performance of the above noted ADL tasks was limited by:
• Momentary or transient loss of balance and/or the need to support himself on external objects while moving through the
environment or interacting with task objects (Stabilizes)
• Difficulty positioning body in relation to the workspace (Positions)
• Increased effort when reaching for or placing task objects (Reaches)
• Increased effort propelling the wheelchair (Moves)
• Ineffective walking or ambulating skill; instability when walking (Walks)
• Increased effort and/or instability when transporting task objects from one place to another
(Transports)
• Difficulty completing tasks without obvious evidence of physical fatigue (Endures)
• Failure to maintain a consistent and effective rate of performance (Paces)
• Pauses during actions or task steps, delaying task progression (Continues)
• Decreased skill accommodating for and preventing problems from occurring, and problems
persisted or recurred during task performances (Accommodates and Benefits)
OVERALL ADL MOTOR ABILITY
ADL motor ability is an overall measure of a person's observed skill when moving oneself or task objects as needed for ADL task
performance. John's ADL motor ability measure of -0.38 logits is plotted in relationship to the AMPS motor cutoff measure on the
AMPS Graphic Report. His ADL motor ability is below the AMPS motor cutoff. This indicates that he has increased effort when he
performs ADL tasks. To put this in perspective, approximately 95% of well, healthy persons of John's age have ADL motor ability
measures between 1.07 and 3.27 logits. This indicates that his ADL motor performance is lower than age expectations.
OVERALL ADL PROCESS ABILITY
ADL process ability is a global measure of a person's observed skill in efficiently (a) selecting, interacting with, and using tools and
materials; (b) carrying out individual task actions and steps; (c) and modifying performance when problems are encountered.
On the AMPS Graphic Report, John's ADL process ability measure of 0.27 logits is below AMPS process scale cutoff.
This indicates that he is experiencing decreased safety, independence and/or efficiency when he performs familiar ADL tasks.
As a basis for comparison, 95% of well, healthy persons of John's age have ADL process ability measures between 0.59 and 2.55
logits, thus his ADL process ability measure is lower than age expectations.
SUMMARY OF MAIN FINDINGS
• John's ADL motor and ADL process ability measures are both below the AMPS process cutoff and below age expectations,
indicating that he is experiencing increased effort, decreased efficiency, decreased safety, and/or the need for assistance when
performing chosen, familiar, and life relevant ADL tasks.
• Occupational therapy services may be indicated to enhance and/or prevent further decline
of John's ADL task performance.
If there are any questions regarding this evaluation, please do not hesitate to contact me.
Kim A, OTR
A
Figure 1-5—Cont’d
20 cognitive and perceptual rehabilitation: Optimizing function

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

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
Task Assessment
The Executive Function Performance Test
(EFPT)10 was developed subsequently to the
Kitchen Task Assessment (KTA).8 Both measures
are standardized performance-based assessments
that examine cognitive functioning through the
observation of cues needed for a person to carry
out a functional task. Specifically observed is the
ability to initiate the task when asked, organize
the task, perform the necessary steps of the task,
sequence the steps in a logical order, develop
awareness related to safety and judgment, and
recognize completion of the task. Cueing is sys­
tematic and includes visual, ­gestural, and ­physical
cues that are provided in a hierarchic fashion.
These cues provide support to the client when
task execution begins to fail.
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 21
The original KTA was completed by observ­
ing one task, making store-bought pudding on a
stovetop. The KTA was validated on those living
with dementia. More recently the EFPT was devel­
oped using the same cueing system from the KTA.
The tasks have been expanded to include preparing
or heating up a light meal (cooked oatmeal), man­
aging medications, using the telephone, and paying
bills. The tool has been used for those with stroke
and was recently found to be sensitive to the cogni­
tive difficulties experienced in everyday life for those
living with multiple sclerosis (see Chapter 10).
Performance Assessment of Self-Care Skills
The Performance Assessment of Self-Care Skills
(PASS)20,26,51 is also a performance-based observa­
tional test with a home and clinic version. The PASS
is composed of 26 core tasks within four functional
domains:
• Functional mobility (5 tasks)
• Personal self-care (3 tasks)
• IADL with a cognitive emphasis (14 tasks: shop­
ping, bill paying, check writing, balancing a
checkbook, mailing, telephone use, medication
management, 2 tasks related to obtaining infor­
mation from the media, small home repairs,
home safety, playing bingo, oven use, stove use,
and use of sharp utensils)
• IADL with a physical emphasis
Performance is rated for independence, safety, and
adequacy. If an individual requires assistance to com­
plete a task, the PASS provides a hierarchy of prompts.
The types of prompts, beginning with the least assis­
tive and progressing to the most assistive are (1) ver­
bal supportive, (2) verbal nondirective, (3) verbal
directive, (4) gestures, (5) task object or environmen­
tal rearrangement, (6) demonstration, (7) physical
guidance, (8) physical support, and (9) total assist.
The PASS is criterion referenced and may be
given in total, or selected tasks may be used alone
or in combination. The PASS can be used with ado­
lescents and adults with various diagnoses includ­
ing stroke, head injury, and multiple sclerosis. The
interactive assessment used when administering the
PASS allows clinicians to identify the point of task
breakdown and the types of assistance that enable
improvement in task performance. Self-report,
proxy-report, and clinical judgment versions of the
PASS are available.
Naturalistic Action Test
The Naturalistic Action Test (NAT)53 is a measure­
ment of naturalistic action production across a
wide range of client impairment that was devel­
oped subsequently to the Multi-level Action Test. It
is based on research demonstrating that ­recovering
stroke and brain injury clients and those with pro­
gressive dementia are highly prone to errors of
action when performing routine ADL. The NAT
is a ­ performance-based test of naturalistic action
in which the tasks are associated with disorders
of higher cortical function. The materials, layout,
and cueing procedures are standardized. Scoring
is simple and objective and can be performed
reliably with little formal training. Tasks that are
observed include making toast with butter and jelly
and instant coffee with cream and sugar, wrapping
a gift, and preparing and packing a child’s lunch­
box and schoolbag. Instructions are spoken and
­reinforced with ­ drawings. Items are scored for
accomplishment of necessary steps, and this score
is combined with an error score that tracks 12 com­
mission errors. The test has been validated on those
with right and left strokes and those with traumatic
brain injury.
Structured Observational Test of Function
The Structured Observational Test of Function
(SOTOF)34,35 is a valid and reliable tool that assesses
the following:
• Occupational performance (deficits in simple
ADL)
• Performance components (perceptual, cogni­
tive, motor, and sensory impairment)
• Behavioral skill components (reaching, scan­
ning, grasp, sequence)
• Neuropsychological deficits (spatial relations
apraxia, agnosia, aphasia, spasticity, memory loss)
Impairments are detected by the structured
observation of simple ADL (e.g., eating from a
bowl, pouring a drink and drinking, upper body
dressing, washing and drying hands).
This relative quick tool aims to answer the fol­
lowing questions:
1. How does the subject perform ADL tasks?
2. What behavioral skill components are intact?
Which have been affected by neurologic damage?
3. Which perceptual, cognitive, motor, and sensory
impairments are present?
4. Why is function impaired?
Overview of Models That
Guide Practice
Various models that guide this practice area have
been described in the literature. The reader is
22 cognitive and perceptual rehabilitation: Optimizing function
referred to Katz29 for comprehensive descriptions of
these models. The following paragraphs are sum­
maries of commonly used approaches.
Dynamic Interactional Approach
The Dynamic Interactional Approach55 views cog­
nition as a product of the interaction among the
person, activity, and environment. Therefore, per­
formance of a skill can be promoted by changing
either the demands of the activity, the environ­
ment in which the activity is carried out, or the
person’s use of particular strategies to facilitate
skill performance. To illustrate the interaction
among the three factors (person, activity, and
environment), the reader is encouraged to think
about how the efficiency and effectiveness of skill
performance vary based on the following task
descriptions:
• Driving your own automatic transmission mid­
size car versus renting and driving a standard
transmission pickup truck
• Performing a morning self-care routine in your
own home versus the same routine carried out
in a hotel room
• Cooking a meal versus cooking a meal while
simultaneously babysitting twin 2-year-old boys
Toglia55 describes several constructs associated
with this model including the following:
• Structural capacity or the physical limits in the
ability to process and interpret information
• Personal context or characteristics of the person
such as coping style, beliefs, values, and lifestyle
• Self-awareness or understanding your own
strengths and limitations, as well as metacog­
nitive skills such as the ability to judge task
demands, evaluate performance, and anticipate
the likelihood of problems (see Chapter 4)
• Processing strategies or underlying components
that improve task performance such as atten­
tion, visual processing, memory, organization,
and problem solving
• The activity itself considering the demands,
meaningfulness, and how familiar the activity is
• Environmental factors such as the social, physi­
cal, and cultural aspects.
Toglia55 summarizes that “to understand cog­
nitive function and occupational performance,
one needs to analyze the interaction among per­
son, activity, and environment. If the activity and
environmental demands change, the type of cog­
nitive strategies needed for efficient performance
changes as well. Optimal performance is observed
when there is a match between all three variables.
Assessment and treatment reflect this dynamic
view of cognition.” This approach may be used with
adults, children, and adolescents.
Toglia used the Dynamic Interactional Model to
develop the Multicontext Treatment Approach.54,55
Combining both remedial and compensatory strat­
egies, this approach focuses on teaching a par­
ticular strategy to perform a task and practicing
this strategy across different activities, situations,
and environments over time. Toglia summarizes
the components of this approach to include the
following:
• Awareness training or using structured expe­
riences in conjunction with self-monitoring
techniques so that clients may redefine their
knowledge of their strengths and weaknesses
(see Chapter 4).
• Personal context. Treatment activities are chosen
based on client’s interest and goals. A particular
emphasis is placed on the relevance and purpose
of the activities. Managing monthly bills may be
an appropriate activity for a single person living
alone, whereas crossword puzzles may be used as
an activity for a retiree who previously enjoyed
this activity.
• Processing strategies are practiced during a vari­
ety of functional activities and situations. Toglia
defines processing strategies as strategies that
help a client to control cognitive and percep­
tual symptoms such as distractibility, impulsiv­
ity, inability to shift attention, disorganization,
attention to only one side of the environment,
or a tendency to over focus on one part of an
activity.
• Activity analysis is used to choose tasks that
systematically place increased demands on the
ability to generalize strategies that enhance
performance.
• Transfer of learning occurs gradually and sys­
tematically as the client practices the same strat­
egy during activities that gradually differ in
physical appearance and complexity.
• Interventions occur in multiple environments to
promote generalization of learning.
Quadraphonic Approach
The Quadraphonic Approach was developed by
Abreu and colleagues1 for use with those living
with cognitive impairments after brain injury. This
approach is described as including both a “micro”
perspective (i.e., a focus on the remediation of
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 23
subskills such as attention, memory, etc.) and a
“macro” perspective (i.e., a focus on functional skills
such as ADL, leisure, etc.). The approach supports the
use of remediation as well as compensatory strategies.
The micro perspective incorporates four
theories:
1. Teaching-learning theory is used to describe
how clients use cues to increase cognitive aware­
ness and control.
2. Information-processing theory describes how
an individual perceives and reacts to the envi­
ronment. Three successive processing strategies
are described including detection of a stimulus,
discrimination and analysis of the stimulus, and
selection and determination of a response.
3. Biomechanical theory is used to explain the
client’s movement, with an emphasis on the
integration of the central nervous system, mus­
culoskeletal system, and perceptual-motor skills.
4. Neurodevelopmental theory is concerned with
quality of movement.
The macro perspective is based on narrative and
functional analysis to explain behavior based on the
following four characteristics:
1. Lifestyle status or personal characteristics related
to performing everyday activities
2. Life-stage status such as childhood, adolescence,
adulthood, and married
3. Health status such as the presence of premorbid
conditions
4. Disadvantage status or the degree of functional
restrictions resulting from impairment
Cognitive-Retraining Model
The Cognitive-Retraining Model7 is used for ado­
lescents and adults living with neurologic and
neuropsychological dysfunction. Based on neuropsy­
chological, cognitive, and neurobiologic rationales,
this model focuses on cognitive training by enhanc­
ing remaining skills, and by teaching cognitive strate­
gies, learning strategies, or procedural strategies.
Neurofunctional Approach
The neurofunctional approach23 is applied to those
living with severe cognitive impairments secondary
to brain injuries. The approach focuses on train­
ing clients in highly specific compensatory strate­
gies (not expecting generalization) and specific task
training. Contextual and metacognitive factors are
specifically considered during intervention plan­
ning. The approach does not target the underly­
ing cause of the functional limitation but focuses
directly on retraining the skill itself.
Patterns of Cognitive-Perceptual
Impairments Based on Diagnoses
and Area(s) of Brain Pathology
A critical aspect of the evaluation process involves
determining the impairment(s) that are interfering
with an individual’s ability to participate in mean­
ingful activities. Several clients may have similar
activity level scores, but the impairments causing
the limitations may be quite different (Table 1-4).
Identifying the correct impairment(s) will help cli­
nicians determine which interventions are required
including necessary adaptations, which strategy
choices are appropriate, and to begin to determine
the focus of rehabilitation. Depending on the diag­
noses, clinicians can begin to expect usual pre­
sentations of patterns of cognitive and perceptual
impairments although variations from these typical
patterns may occur.
Stroke
If neuroimaging data are available they may provide
information related to which structures are compro­
mised. Using knowledge of neuroanatomy and neuro­
logic processing, the clinician may begin to hypothesize
which impairments will be present and how they
interfere with function (Tables 1-5 and 1-6).
Even a basic understanding of cortical func­
tion related to understanding the various functions
associated with different areas of the brain can help
clinicians in the clinical reasoning process associ­
ated to identifying impairments that affect daily
functioning (Tables 1-7 and 1-8).3,4
Multiple Sclerosis
Those living with multiple sclerosis may experience
slowed information processing, decreased atten­
tion, decreased concentration, difficulty shifting
attention, difficulty dividing attention, decreased
explicit memory, decreased episodic memory,
loss of executive functioning (concept forma­
tion, reasoning, problem solving, planning, and
sequencing.14,52
Parkinson’s Disease
In general, individuals living with Parkinson’s dis­
ease often present with normal or only slightly
24 cognitive and perceptual rehabilitation: Optimizing function

Table 1-4 Clinical Situation: A Client Requires Moderate Assistance for Grooming Tasks
Based on the Functional Independence Measure (FIM)
Behaviors Interfering with
Client Diagnosis Potential Impairments Function

A Right frontoparietal stroke
B Left frontoparietal stroke
Unilateral neglect, figure-ground
impairment, spatial relations
dysfunction, distractibility
Motor planning deficits, ideational
apraxia, impaired organization and
sequencing
Inability to “find” grooming items
on the left side of the sink,
inability to integrate the left
water faucet, inability to locate
white soap on the white sink,
incorrect endpoint (overshooting
or undershooting) when placing
the toothbrush under the running
water, distracted by irrelevant
environmental stimuli
Uses grooming objects incorrectly
(eats soap), brushes teeth
without turning on the water,
cannot manipulate grooming
tools in hand, doesn’t initiate task

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby; and Árnadóttir
G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2,
St Louis, 2004, Elsevier/Mosby.

Traumatic Brain Injury

decreased performance in language, gnosis, and
praxis functions, although memory and executive
functions more prominently affected. More specifi­
cally, attention functions are commonly decreased.
In addition free recall (immediate and delayed)
is impaired as is visuospatial processing, motor
­planning, shifting attention, alternating tasks, and
­verbal fluency.45
Huntington’s Disease
In this disease, selective cognitive abilities are pro­
gressively impaired, whereas others remain intact.
Abilities affected include executive function (plan­
ning, cognitive flexibility, abstract thinking, rule
acquisition, initiating appropriate actions, and
inhibiting inappropriate actions), psychomotor
function (slowing of thought processes to con­
trol muscles), perceptual and spatial skills of self
and surrounding environment, selection of cor­
rect methods of remembering information (but
not actual memory itself), and ability to learn new
skills. Problems in attention, working memory,
verbal learning, verbal long-term memory, and
learning of random associations are the earliest
cognitive manifestations.41
Severe cognitive and perceptual deficits are
common after traumatic brain injury (TBI)
including deficits of attention, memory, infor­
mation-­processing speed, and problems in self-
perception. In addition posttrauma for anxiety,
expressive deficit, emotional withdrawal, depres­
sive mood, hostility, suspiciousness, fatigabil­
ity, hallucinatory behavior, motor retardation,
unusual thought content, lability of mood, and
comprehension deficits have been documented.
A recent longitudinal study43 of those with severe
TBI documented a tendency of improvement
for inattention, somatic concern, ­disorientation,
guilt feelings, excitement, poor planning, and
articulation deficits. In addition, for the impair­
ments of conceptual disorganization, disinhi­
bition, memory deficit, agitation, inaccurate
self-appraisal, decreased initiative, blunted affect,
and tension the authors noted a tendency for fur­
ther deterioration in the posttraumatic follow-
up. Changes between 6 and 12 months post-TBI
were statistically significant for disorientation
(improvement), inattention or reduced alertness
­(improvement), and ­ excitement (deterioration).
The authors concluded that neurobehavioral
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 25

Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment
Artery Location Possible Impairments

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 )
26 cognitive and perceptual rehabilitation: Optimizing function
Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Artery Location
Anterior cerebral artery Medial and superior aspects of
frontal and parietal lobes
Internal carotid artery Combination of middle cerebral
artery distribution and anterior
cerebral artery
Anterior choroidal artery, Globus pallidus, lateral geniculate
a branch of the internal body, posterior limb of the
carotid artery internal capsule, medial
temporal lobe
Posterior cerebral artery Medial and inferior aspects of
right temporal and occipital
lobes, posterior corpus
callosum and penetrating
arteries to midbrain and
thalamus
Basilar artery proximal Pons
Possible Impairments
Contralateral hemiparesis, greatest in foot
Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances
Impairments related to dysfunction of middle and
anterior cerebral arteries as listed above
Hemiparesis of face, arm, and leg
Hemisensory loss
Hemianopsia
Dysfunction of either side
Homonymous hemianopsia
Visual agnosia (visual object agnosia, prosopagnosia,
color agnosia)
Memory impairment
Occasional contralateral numbness
Right side dysfunction
Cortical blindness
Visuospatial impairment
Impaired left-right discrimination
Left side dysfunction
Finger agnosia
Anomia
Agraphia
Acalculia
Alexia
Quadriparesis
Bilateral asymmetric weakness
Bulbar or pseudobulbar paralysis (bilateral paralysis of
face, palate, pharynx, neck, or tongue)
Paralysis of eye abductors
Nystagmus
Ptosis
Cranial nerve abnormalities
Diplopia
Dizziness
Occipital headache
Coma
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 27

Table 1-5 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—Cont’d
Artery Location Possible Impairments

Basilar artery distal Midbrain, thalamus, and caudate 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
Impaired eye movements
Hypersomnolence

(Continued )
28 cognitive and perceptual rehabilitation: Optimizing function

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
Visuospatial impairment
Left side
Aphasia
Pons Quadriplegia
Coma
Impaired eye movement
Cerebellum Ipsilateral limb ataxia
Gait ataxia
Vomiting
Impaired eye movements

From Árnadóttir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based
approach, ed 2, St Louis, 2004, Elsevier/Mosby.

deficits after TBI do not show a general tendency to
disappear over time and that some aspects related
to self-appraisal, conceptual ­disorganization and
affect may even deteriorate.
Review Questions
1. Name and describe three assessments that may
be used to document improvements in quality
of life and participation.
2. What are the expected patterns of cognitive or
perceptual impairments if a person presents
with a right middle cerebral artery stroke? Left
middle cerebral artery stroke?
3. How can the principles of client-centered prac­
tice be integrated into the development of an
intervention plan for a person with attention
deficits after a brain injury?
4. Give two examples of how the ICF levels of func­
tion are interrelated.
 Chapter 1  Overview of Cognitive and Perceptual Rehabilitation 29

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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