Functional/adaptation approach

The functional approach uses repetitive practice in particular activities, usually daily living tasks, to help the patient become more independent. This approach is designed to treat symptoms rather than the cause of the dysfunction.³³ Some occupational therapists believe their role in cognitive and perceptual rehabilitation lies solely in the realm of a functional approach, involving training in compensatory techniques and only with tasks directly related to functional performance.⁷⁶ This approach appears most compatible with research indicating that family members and financial providers rank independence in ADL as the highest priority for rehabilitation.^29,72

Therapists use the functional approach to train patients to function by compensating. An example of compensation is the use of an alarm watch to remind someone with poor memory to take medication. Compensation circumvents the problem. Some therapists believe the use of compensation should be limited to patients who have accepted the permanence of the perceptual or cognitive deficit.⁷⁷ Only persons who can benefit from compensation should be taught these strategies; they must have a basic understanding of their skills and the permanence of their limitations because the use of compensation for disability requires that the individual recognize the need to compensate. The patient must be a self-starter, must be goal directed, have insight/awareness of the functional consequences of his or her impairments, and must want to learn new strategies. Successful compensation requires practice, repetition, and overlearning of the strategies.¹¹⁶

Environmental adaptation is more appropriate for those who cannot use compensatory strategies because of poor insight of disability. Adaptation involves changing the characteristics of the task or environment. This technique is used in patients with poor learning potential. An example of adaptation is the use of contrasting colors for a plate and placemat for someone with figure-ground difficulties. Establishing a routine and constant environment with repeated participation in familiar activities is often the most successful strategy for these individuals. The adaptive approach relies on caregivers to implement treatment strategies.¹¹⁶

A significant limitation of the functional approach is the task specificity of the strategies and lack of generalizability to other tasks.²⁵ For example, the use of an alarm timer to take medications on time does not help the patient remember a repertoire of other activities, such as to take a shower, start meal preparation, or get to a doctor’s appointment, unless the patient specifically has been trained to do so.

Remedial approach

Remediation (or restoration or transfer of training) emphasizes restoration of the function or skill lost due to the stroke. Remedial treatment relies on several assumptions: the cerebral cortex is malleable and can adapt, and the brain can repair and reorganize itself after injury. Practice and repetition are assumed to result in learning. In turn, learning results in a more organized, functional system. Another assumption is that table-top activities, such as pegboard tasks or computer activities, directly affect the underlying processing skills required for the patient to perform those activities. The most important assumption is that improved task performance of table-top activities will be carried over to improved performance in functional activities.^25,33,67

Although this approach has been successful when used in the initial stages of treatment,³³ most studies show only short-term results, generalization only to similar tasks,¹⁰⁴ or little effectiveness from remedial training for neurobehavioral impairments.^33,44 For this approach to be successful, treatment sessions must be frequent and lengthy.

Neistadt⁶⁷ believes that only those patients who show transfer of learning to tasks that are different in multiple characteristics are appropriate candidates for the remedial approach to processing impairments. Therapists widely agree that practice of a subcomponent skill, such as problem-solving or attention to task, must occur in multiple contexts for successful transfer of learning.¹¹⁶ According to Neistadt,⁶⁸ therapists always should train for transfer of skills because the patient’s home environment is always different from the clinical setting. Those who can transfer learning only to similar tasks should be restricted to a functional/adaptive approach to maximize their training potential.⁶⁶

Recommended approach

Determination of the appropriate treatment approach for the stroke patient with processing impairments relies on the results of the assessment. Important questions include the following:

If the patient has poor learning potential or poor awareness and is unlikely to benefit from the use of cues or task modification, a strictly functional approach involving domain-specific training would be recommended.¹⁰¹ Domain-specific training requires little or no transfer of learning (generalizability) and involves repetitive performance of a specific functional task using a system of vanishing cues. (Vanishing cues are cues that are provided at every step of task performance but then gradually are removed. The goal is to establish a program in which the patient can successfully perform the task with a minimum number of cues.) This type of training is hyperspecific, and the learning associated with it persists only if the task and environmental characteristics remain unchanged.

Traditionally the therapist has used a restorative or functional approach; however, Abreu and colleagues¹ have proposed an integrated functional approach to treatment using principles from both approaches simultaneously. In this approach, areas of occupation and context are used to challenge processing skills. Because individuals engage in occupations as integrated wholes—not as separate attention machines, categorizers, or memory coders—treatments that are not aimed at real life contexts are irrelevant to real life. With this integrated functional approach, treatment may be focused on a subcomponent skill such as sustained attention, but daily occupations are used as the modality. For example, a self-feeding task can be used to improve sustained attention to task. Mealtime is often distracting. Eating can be a difficult task if attention deficits are present. A system of vanishing cues and a gradual increase in the amount of environmental distraction can be used to address inattention to task and activity participation.

The use of a functional approach is supported by today’s health care industry, which seeks documentation of patient’s functional competence in ADL. Only cost-effective interventions that directly affect functional status are embraced in today’s health care environment.

Any functional task can be used to address a myriad of neurobehavioral impairments. For occupational therapists to use their skills in activity analysis to evaluate an activity for its effectiveness in addressing particular cognitive or perceptual deficits is imperative. Box 19-1 contains an example of using everyday function to address neurobehavioral performance skills.

Environment

The importance of the environment or setting in which treatment takes place cannot be underestimated. Patients plan and perform ADL differently⁷³ at home than in the clinical setting.⁶⁹ Exposure to different environments and contexts requires patients to adapt strategies and solve problems,⁵¹ leading to greater independence in a variety of situations.

The adaptation of purposeful activities to ensure success is important in occupational therapy (OT). Success depends on the therapist’s ability to analyze the activities and the patients’ strengths, weaknesses, and needs to present the most relevant and challenging activity.

Generalization

One of the biggest challenges to providing interventions to this population is the issue of generalizing or transfer of what is learned in therapy sessions to other real world situations. Examples include generalizing the use of the skills learned on an inpatient rehabilitation related to meal preparation to making a meal at home on discharge, use of a scanning strategy used to read a newspaper article or to locate an item of clothing in a closet, or use of tactile feedback to identify objects on a meal tray or when shopping for grooming items. The consistent perspective on the idea of generalization is that it will not occur spontaneously but will instead need to be addressed explicitly in an intervention plan.^{66,90,101,102,103}

Suggestions have been made in the literature to enhance generalization of cognitive and perceptual rehabilitation techniques:

Toglia^101,102,103 identified a continuum related to the transfer of learning and emphasized that generalization is not an all or none phenomenon. She discussed grading tasks to promote generalization of learning from those that are very similar to those that are very different. Toglia’s^101,103 criteria for transfer included:

Based on her research and review of the literature, Neistadt⁶⁷ suggested that only those individuals who have the ability to perform far and very far transfers of learning are candidates for the remedial approach to cognitive and perceptual rehabilitation. She suggested that, on the other hand, those who are only capable of near and intermediate transfers of learning are candidates for the adaptive approach, as described earlier. Similarly, near transfers seem to be possible for all individuals regardless of severity of brain damage, while intermediate, far, and very far transfers may be possible only for those with localized brain lesions and preserved abstract thinking, and with those who have been explicitly taught to generalize.⁶⁷ While these statements should continue to be tested empirically, they give clinicians guidelines related to intervention planning.

Activity processing

Activity processing is especially helpful in cognitive rehabilitation because the therapist discusses the purpose and results of the activity with the patient. The therapists can discern awareness by the patient from feedback provided during and after activity participation. Activity processing enhances the patient’s metacognition (knowledge of one’s own cognitive ability and ability to monitor one’s own performance) and general knowledge. Activity processing emphasizes the purpose of the activity in the rehabilitation process.²³ For example, when practicing spatial positioning during a dressing task, the therapists should instruct the patient on the spatial requirements for each step of the activity and the purpose of using the dressing task to improve spatial skills. As the patient performs the task, the patient and the therapist should discuss performance and strategies to perform the activity.

Behavior modification

Use of behavior modification techniques such as prompting, shaping (reinforcing responses that increasingly resemble the sought-after behavior), and contingent reinforcement (reward contingent on an appropriate response) are common in the stroke and/or brain injury population. Behavior modification techniques with intermittent praise and reinforcement to improve independence in daily activity have been successful.^43,53

Group treatment

Group treatment in the stroke population is often effective. It can yield situations more like real life, because they are less structured and can generate unpredictable events and provide distractions. In a group, patients can get feedback from their peers (which is often more meaningful), share similar experiences, and exchange problem-solving and coping strategies. Group treatment allows patients to learn from others’ mistakes, practice monitoring their own behavior, and see that their problems are not unique.

Decreased awareness

Most authors recommend that self-awareness should be evaluated before initiating an intervention program focused on retraining living skills. Findings from standardized evaluations of self-awareness will clearly guide intervention choices. For example, a person who exhibits insight into an everyday memory deficit may be a candidate for teaching compensatory strategies such as using a diary or notebook However, a person who does not realize he or she is presenting with a severe unilateral neglect may not be able to learn compensatory strategies but may require environmental modifications (e.g., all clothing hung on the right side of the closet) to improve everyday function. In addition, ascertaining the level of insight to a disability is one factor that may determine how motivated one is to participate in the rehabilitation process. In the most simplistic interpretation, one must be aware and concerned about a deficit in everyday function to be motivated to participate in what may be a long and difficult rehabilitation process.

A variety of assessment measures are typically recommended to ascertain a person’s level of self-awareness, including questionnaires (self or clinician rated); interviews; rating scales; functional observations; comparisons of self-ratings and ratings made by others such as significant others, caretakers, or rehabilitation staff; and comparisons of self-ratings and ratings based on objective measures of function or cognitive constructs. In addition, naturalistic observations can provide further information related to how decreased awareness interferes with performance of everyday tasks.

Simmond and Fleming^86,87summarized that a comprehensive and clinically relevant assessment should:

Sohlberg⁸⁹ further suggested that five assessment questions should be answered to comprehensively manage a lack of awareness. Sohlberg’s suggestions for resources to answer each question follow as well:

See Table 19-3 for a summary of assessments used to ascertain level of awareness.

Table 19-3 Recommended Measures of Awareness

Use of prompts and cues is key to successful cognitive and perceptual rehabilitation. Cues can be faded by reducing the number, frequency, or specificity of the prompts.¹¹⁷ For example, a therapist initially may provide detailed cues at every step of task performance, such as “Look to the left to find the soap.” Cues should be tapered and should become less detailed as the patient progresses (e.g., “Have you remembered all the steps?”). Therapists should provide prompts and cues in a calculated and graded fashion. The use of cues and prompts is part of cognitive and perceptual rehabilitation and is an essential way of facilitating patient insight, error detection, and strategy development (Table 19-4). See Box 19-2 for awareness training interventions.

Table 19-4 Prompting Procedures

Adapted from Toglia JP: Attention and memory. In Royen CB, editor: AOTA self-study series: cognitive rehabilitation, Rockville, Md, 1993, American Occupational Therapy Association; and Toglia JP: Generalization of treatment: a multicontext approach to cognitive perceptual impairment in adults with brain injury. Am J Occup Ther 45(6):505, 1991.

Apraxia

According to Ayres,⁸ praxis is one of the most important connections between brain and behavior; it is what allows persons to interact with the physical world. Apraxia is a dysfunction of purposeful movement that does not result primarily from motor, sensory, or comprehension impairments.⁶ Although many different types of apraxia have been named and defined, the labels used to classify them are not universally accepted.¹¹ For relevance in this chapter, however, they fit into two general categories: motor and ideational apraxia. See Chapter 18 for examples of how the various types of apraxia affect daily living skills.

Patients with apraxia are often unaware of their deficits,⁹⁶ creating a dilemma for planning therapeutic interventions. However, one study concluded that patients with more severe cognitive (and motor) impairments showed the most significant improvement in ADL.¹⁰⁸ The study demonstrated the obvious potential for improvement with severely apraxic patients using compensatory strategy training for ADL skills and therefore negates the idea that severely apraxic patients have poor potential for improvement. Box 19-3 lists general treatment guidelines for patients with apraxia. See Box 19-4 for a specific example of a performance-based assessment.

If physical guiding of the limbs is used during a task, incorporate the suggested principles of guiding,²² including:

Figure 19-1 Patient is guided through a hair-brushing task.

Figure 19-2 Guiding of the patient’s hand along a supported surface (leg) as he reaches for a shoe.

Encourage tactile exploration of functional objects and tools to enhance performance as somatosensory feedback from the tool may play a role in organizing movements.⁴² Related to the above, object affordances (the functional use of particular objects within a context) positively affects motor performance.⁴² Using meaningful objects and tasks will yield better results than movements performed in isolation.⁶¹ As those with apraxia have compromised learning of old and new tasks, increased repetitions and practice will be necessary. Goals should be scaled accordingly. Encourage practice of learned skills outside of therapy and throughout the day. For those with ideomotor apraxia, experiment with decreasing the degrees of freedom (i.e., number of joints) used to perform the task (i.e., encourage a woman who is attempting to apply makeup to keep her elbow on the table). Grade the number of tools and distracters used in a task (i.e., finger feeding [no tools], followed by eating applesauce with only a spoon available, followed by eating applesauce with the choice of one to three utensils, followed by eating a meal requiring the choice of various tools for different aspects of the task [spoon to stir coffee, knife to cut and spread butter, etc.], followed by a meal with the necessary and usual utensils and distracter tools such as comb and toothbrush).⁴⁰

Further interventions for apraxia

The following paragraphs summarize evidenced-based interventions for those living with functional limitations secondary to apraxia.

Strategy training.

van Heugten and colleagues¹⁰⁵ described an intervention study designed for use by occupational therapists and based on teaching patients strategies to compensate for the presence of apraxia. In addition to interest checklists, the decision as to which activities to focus on was a joint decision between the therapist and patient. The focus of the intervention was determined by the specific problems observed during standardized ADL observations (see Box 19-4). Specifically, interventions focused on errors related to:

Initiation: inclusive of developing a plan of action and selection of necessary and correct objects

Execution: performance of the plan

Control: inclusive of controlling and correcting the activity to ensure an adequate result

Difficulties related to initiation were treated via specific instructions. Instructions were hierarchical in nature and could include verbal instructions, alerting the patient with tactile or auditory cues, gesturing, pointing, handing objects starting the activity together, etc. Assistance was the intervention provided when problems related to execution of the activity occurred. Also hierarchical, assistance could range from various types of verbal assist, stimulating verbalization of steps, naming the steps of the activity, to physical assistance such as guiding movements (see Figs. 19-1 and 19-2). Feedback is provided when patients have difficulty with control (i.e., patients do not detect or correct the errors they make during the activity) and can be verbal feedback related to the results of performance, verbal feedback focused on having the patient use a variety of senses to evaluate the results, or physical feedback focused on knowledge of results. The specific strategy training intervention protocol is included in Box 19-5. The strategy training approach for apraxia has been tested with promising results.³²

Box 19-5 Protocol for Strategy Training for Those Living with Functional Deficits Secondary to Apraxia

The specific interventions are built up in a hierarchical order, depending on the patient’s level of functioning. The therapist can use instructions, assistance, and feedback.

Instructions

The occupational therapist can give the following instructions:

Start with a verbal instruction.

Shift to a relevant environment for the task at hand.

Alert the patient by:

Touching

Using the patient’s name

Asking questions about the instruction

Use gestures, point to the objects.

Demonstrate (part of) the task.

Show pictures of the activity.

Write down the instruction.

Place the objects near the patient, point to the objects, put the objects in the proper sequence.

Hand the objects one at a time to the patient.

Start the activity together with the patient one or more times.

Adjust the task to make it easier for the patient.

Finally, take over the task because all efforts did not lead to the desired result.

Assistance

The following forms of assistance can be given by the therapist:

There is no need to assist the patient during the execution of the activity.

Verbal assistance is needed:

By offering rhythm and not interrupting performance.

To stimulate verbalization of the steps in the activity.

To name the steps in the activity or name the objects.

To direct the attention to the task at hand.

Use gestures, mimics, and vary intonation in your speech.

Show pictures of the proper sequence of steps in the activity.

Physical assistance is needed:

By guiding the limbs.

In positioning the limbs.

To use the neurodevelopmental treatment method.

To use aids to support the activity.

To take over until the patient starts performing.

To provoke movements.

Finally, take over the task.

Feedback

Feedback can be offered in the following ways:

No feedback is necessary because the result is adequate.

Verbal feedback is needed in terms of the result (knowledge of results).

Verbal feedback by telling the patient to consciously use the senses to evaluate the result (tell the patient see, hear, feel, smell, or taste).

Physical feedback is needed in terms of the result (knowledge of results):

To evaluate the posture of the patient.

To evaluate the position of the limbs.

To support the limbs.

Physical feedback is given by pointing or handing the objects to the patient.

Verbal feedback is needed in terms of performance (knowledge of performance).

Physical feedback is needed in terms of performance (knowledge of performance).

Place the patient in front of a mirror.

Make video recordings of the patient’s performance and show the recordings.

Take over the control of the task and correct possible errors.

From van Heugten C, Dekker J, Deelman B, et al: Outcome of strategy training in stroke patients with apraxia: a phase II study. Clin Rehabil 12(4):294-303, 1998.

A pretest/posttest study design¹⁰⁵ demonstrated significant improvements and large effects for three different ADL measures (Barthel Index; a standardized evaluation of personal hygiene, dressing, preparing food, and a patient chosen activity; and an ADL questionnaire that was filled out by both therapists and patients). In addition, significant improvements were documented on tests of apraxia (small to medium effects) and motor function (small effects). Improved ADL function was still significant after correcting for the improvement on the apraxia measures, motor measure, and time poststroke. Of the patients in this study, 84% perceived complete recovery or substantial improvement because of the intervention. While the intervention did not explicitly focus on decreasing the apraxic impairment, the strategy training approach during participation in functional activities decreased both activity limitations and severity of impairment.

Donkervoort and colleagues³² also tested this intervention via a large randomized clinical trial comparing usual OT to strategy training integrated into usual OT. After intervention, those receiving strategy training improved significantly on ADL observations (small to medium effect size) and the Barthel Index (medium effect size) as compared to those who received usual care.

A posthoc analysis of Donkervoort and colleagues data performed by Geusgens and colleagues³⁹ focused on whether or not the strategy training approach resulted in transfer of training to untrained tasks. The analyses revealed that both intervention groups (traditional OT and traditional OT combined with strategy training) demonstrated significantly improved scores on nontrained tasks. Change scores of the nontrained activities were significantly larger in the strategy training group as compared to usual OT.

Errorless completion and training of details.

Goldenberg and Hagman⁴² tested a method of specifically training ADL for those living with apraxia. They specifically examined spreading margarine on a slice of bread, putting on a T-shirt, and brushing teeth or applying hand cream. When an activity was being trained, the focus was on errorless completion of the whole activity. As opposed to trial and error learning, errorless learning or completion is a technique in which the person learns the activity by doing it. The therapist intervenes to prevent errors from occurring during the learning process. Specific interventions included:

Guiding the hand through a difficult aspect of the activity (see Figs. 19-1 and 19-2)

Sitting beside the patient (parallel position) and doing the same action simultaneously with the patient

Demonstrating the required action and asking the patient to copy it afterwards

In addition, the intervention focused on training of details. This was aimed at directing the patient’s attention to “the functional significance of single perceptual details and to critical features of the actions associated with them” (p.133).⁴² Specific difficult steps of the activity were trained using this approach. To promote knowledge of object use, key details of ADL objects, such as the bristles on a toothbrush and the teeth on a comb, were explored and examined. Actions connected to the details were then practiced (i.e., searching for and positioning a shirt sleeve for a person with dressing difficulties) outside of therapy. Specific necessary motor actions were also practiced in other activities and contexts (i.e., squeezing paint from tubes as a similar action as squeezing toothpaste).

Goldenberg and Hagman⁴² tested this intervention by examining 15 patients with apraxia with repeated measures of ADL function. Success of therapy was based on the reduction of errors of specific tasks. The authors differentiated between reparable errors (the patients succeeds in continuing the task) or fatal errors (the patient is unable to proceed without help, or the task is completed but did not fulfill its purpose). Across the whole group, the number of fatal errors decreased significantly while the number of reparable errors did not significantly change.

Direct training of the whole activity versus exploration training.

Goldenberg and colleagues⁴¹ developed and compared two therapy interventions aimed at restoring the ability to engage in complex ADL for those living with apraxia. Exploration training focused on having patients infer function from structure and solve mechanical problems embedded in tasks. During treatment, the therapist directed the patient’s attention to functionally significant details of the object (i.e., prongs on a fork, serrations on a butter knife, bristles on a toothbrush). The therapist explained the functional significance via verbal, gestural, and pointing cues. The patients did not practice use of the tools. Specific interventions related to exploration training included explanation, touching, and comparing objects with photographs.

The direct training focused on the patient carrying out the whole activity with a minimum of errors. The technique is similar to errorless completion as reviewed previously and includes guided movements, with the therapist sitting beside the patient to perform the task simultaneously. During the training, particularly difficult components of the activity were practiced, but the whole activity was always completed. Specific interventions for direct training included guided performance of the whole activity, passive guidance, guidance by example, and rehearsal of steps.

Goldenberg and colleagues⁴¹ tested these interventions related to the training of four complex ADL. The authors found that exploration training had no effect on performance, while direct training resulted in a significant reduction of errors and the amount of assist required to complete the task. Follow-up three months later revealed that gains were maintained.

Task-specific training.

Poole⁷⁴ examined the ability of those living with apraxia to master the technique of one-handed shoe tying (commonly a necessary skill to be mastered after brain injury). She compared those living with a stroke without apraxia, those living with stroke with apraxia, and healthy adults. The task was taught using published standardized procedures via demonstration and simultaneously verbalizing instructions. Repetition was used until the task was achieved. The mean number of trials to learn the task was higher for those with apraxia (M =6.4) as compared to those stroke survivors without apraxia (M =3.2) versus healthy controls (M =1.2).While the number of trial required to learn the task was greater, the majority of those with apraxia were able to retain the task.

Wilson¹¹⁰ documented a task-specific training program for a young woman status post an anoxic brain injury. The program focused on two tasks: drinking from a cup and sitting on a chair followed by positioning it correctly at the table. Functional performance was improved for this woman via the techniques of breaking down the steps of the tasks followed by practice of the steps, chaining procedures, and verbal mediation. The author noted that generalization to untrained tasks was not evident.

Perseveration

Perseveration is demonstrated by the inability to shift from one concept to another or to change or cease a behavior pattern once having started it. Perseveration also refers to the inability to translate knowledge into action (initiation of a task). The person is “stuck in set”—unable to discard the previous set of behaviors—or is unable to “activate” for a new situation. The person stuck in set attempts to solve another problem with information relevant to a previous problem.

Bringing perseveration to a conscious level and training the patient to inhibit the perseverative behavior has been successful.⁴⁸ Other strategies include redirecting attention, assisting the patient in initiating a new movement or task, and engaging the patient in tasks that involve repetitive action (e.g., washing the face or body, stirring food, or sanding wood) to promote successful task participation.

Unilateral neglect

Unilateral neglect has been defined as “the failure to report, respond, or orient to novel or meaningful stimuli presented to the side opposite a brain lesion, when this failure cannot be attributed to either sensory or motor defects.”⁴⁷ Unilateral neglect is most often seen when right-side brain damage occurs; therefore, the most frequent clinical presentation is that of left unilateral neglect. Although the mechanisms underlying neglect are still debated, a common hypothesis is that neglect is related to attention-based impairments and has been described as a lateralized attention deficit. Behaviors observed during everyday activities lend support to the attentional hypothesis, including the following:

The fact that those living with neglect most often present with left neglect also supports the attentional hypothesis because the right hemisphere is thought to be dominant for attention. That being said, right unilateral neglect is possible.⁹² Beis and associates¹⁵ documented right neglect in 10% to 13.2% of those they examined. They concluded that right neglect caused by left hemispheric involvement is an elusive phenomenon and is less consistent than right hemispheric neglect. In addition, the frequency of occurrence of right neglect was, as expected, much lower than that reported in a study using the same assessment battery in right brain damage stroke clients.

Unilateral neglect can present with or without a concurrent visual field cut (see Chapter 16 and Table 19-5). In addition, neglect can interfere with attending to personal space (body neglect), near space, and/or far space (Table 19-6). Therefore, the recommended assessment method is a performance-based approach to give the therapist multiple opportunities to evaluate the impact of neglect on tasks that occur in the various aspects of space. Examples include the A-ONE (see Chapter 18) and the Catherine Bergego Scale (Fig. 19-3). Evidenced interventions to decrease the functional impact of neglect include the following.

Table 19-5 Suggestions to Differentiate between Neglect and Visual Field Loss Based on Analysis of Behaviors

Table 19-6 Spatial Aspects of Neglect during Functional Activities*

* Spatial neglect includes both near and far extrapersonal space.

From Gillen G: Cognitive and perceptual rehabilitation: optimizing function, St. Louis, 2009, Mosby/Elsevier.

Figure 19-3 Catherine Bergego Scale. A test of functional neglect including personal, peripersonal, and extrapersonal aspects of neglect. Score of 0 is given if no spatial bias is noted. Score of 1 is given when the patient always first explores the right hemispace before going slowly and hesitatingly toward the left space and shows occasional left sided omissions. Score of 2 is given if the patient shows clear and constant left-sided omissions and collisions. Score of 3 is given when the patient is totally unable to explore the left hemispace.

(From Bergego C, Azouvi P, Samuel C, et al: Validation d’une échelle d’évaluation fonctionnelle de l’héminégligence dans la vie quotidienne: l’échelle CB. Ann Readapt Med Phys 38:183-189, 1995.)

Organization/sequencing deficits

The ability to organize thoughts requires the integration of multiple skills, including praxis, sequencing, and problem-solving. Sequencing refers to the ability to plan and carry out events in proper order, progression, and time.⁶ Sequencing and organization deficits represent the breakdown of a complex integration of skills, including use of sensory feedback and organization. Patients with sequencing and organization deficits can be trained to use a daily planner, tape recordings, or cue cards (depending on whether they perform better with auditory or visual cues) to help sequence the steps of daily tasks. Gradually increasing the number of steps in a task can increase a patient’s tolerance and ability to perform more complex tasks (Box 19-6). Note those living with ideational apraxia will also present with organization and sequencing deficits.

Spatial relations syndrome

Spatial relations syndrome is the label given to disorders with impairment in the perception of spatial relationship of objects. These disorders include impairments with figure-ground, position in space, spatial relations, and form and space constancy skills. Topographical disorientation also is classified sometimes as part of spatial relations syndrome. Recommendations for spatial impairments include training patients to move slowly through their environments, encouraging patients to touch objects in the environment frequently, teaching patients to handle objects by the base, and using verbal cues or feedback instead of gestures.⁷⁰ Perceptual impairments are often difficult for families to understand. Educating the caregivers about these disorders and instructing them on how they can help their loved ones (Box 19-7) is especially important. See Chapter 16.

Agnosia

Agnosia typically is defined as the inability to recognize sensory stimuli. Agnosia presents as a defect of one particular sensory channel, such as visual, auditory, or tactile. Examples include finger agnosia, visual agnosia, somatoagnosia, simultanagnosia, and tactile agnosia. These disorders are rarely seen in isolation, and little data have been published regarding treatment techniques for agnosia. However, because the defining principle of agnosia is impairment of one specific sensory modality, treatment usually focuses on teaching the patient to use the intact sensory modalities. For example, in tactile agnosia—the inability to recognize objects by handling them—the patient is taught to use visual, olfactory, and auditory senses to recognize objects (Box 19-8 and Box 19-9).

Memory impairments

Although memory impairments are not as common in persons who have sustained strokes as they are in those with closed-head injuries, dementia, or encephalitis, difficulty retaining information is nonetheless common in the stroke population.

Human memory is composed of multiple and distinct systems^10,90 that are required to support daily activities and participate in the community. Examples include remembering your significant other’s birthday, remembering to take your medications, remembering to feed the dog, remembering how to type, remembering events that occurred during a vacation, and so on. Even this “simple” list of memory tasks requires intact functioning of multiple memory systems and includes knowledge of facts and events, procedures, and remembering future intentions. Clearly, memory serves as a key cognitive support to facilitate independent living.

The steps or stages of memory have been well-documented.^10,90 The flow of these stages follows (Table 19-8):

Table 19-8 Stages of Memory

Data from Sohlberg MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological approach, New York, 2001, Guilford Press.

A variety of memory impairments have been documented and each impact daily function differently (Table 19-9).

Table 19-9 Terminology Related to Memory Impairments

Data from Baddeley AD: The psychology of memory. In Baddeley AD, Kopelman MD, Wilson BA, editors: The essential handbook of memory disorders for clinicians, Hoboken, NJ, 2004, John Wiley; Bauer RM, Grande L, Valenstein E: Amnesic disorders. In Heilman KM, Valenstein E, editors: Clinical neuropsychology, ed 4, New York, 2003, Oxford University Press; Markowitsch HJ: Cognitive neuroscience of memory. Neurocase 4(6):429-435, 1998; and Sohlberg MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological approach, New York, 2001, Guilford Press.

Interventions focused on those with memory deficits can be categorized as restorative approaches to improve underlying memory deficits, strategy training, use of nonelectronic memory aids, and electronic memory aids or assistive technology. Techniques aimed at improving the underlying memory impairment such as memory drills have been unsuccessful in terms of generalizing to meaningful activities. An improvement may be detected on a laboratory-based measure of memory without a corresponding change in daily function or subjective memory reports.

As will be discussed later, the most promising interventions to improve function in those living with memory deficits rely at least partially on compensatory techniques. When using a compensatory approach, choosing the correct system of compensation is critical. Kime⁵⁷ suggested a comprehensive evaluation that includes the following:

Attention deficits

Attention is an essential element in successful task performance. Poor ability to attend to a task often is misinterpreted as a lack of motivation or neglect. Accurate assessment of an attention impairment is important to implementing appropriate treatment techniques. One method that may be helpful in managing attention problems is changing the way occupational therapists speak to patients. The goal is to couple the patient’s attention with the intended action; instructions should be in the logical sequence of the action. Instead of instructing a patient to “Scoot forward,” the therapist would say, “Your bottom [pause]. Move it forward to the edge of the chair.” The wording should correspond with the order in which the steps are to be executed and should allow the patient to attend to each step. The pause is important to allow the patient enough time to shift focus and process the information.²⁵

Use of systematic training incorporating a series of tasks with progressively increasing attentional demands has resulted in improvements in memory and attention to task,¹⁶ although other studies have failed to demonstrate support for remedial training in attention.¹⁰²

Family members often are frustrated when their loved ones are distracted easily or are unable to focus on a task. Family members must be informed that stroke survivors do not behave erratically on purpose. Teaching the family the way to create a supportive environment is important (Box 19-12).

Attention has been described as having four distinct domains: alertness, selective attention, sustained attention, and divided or alternating attention. Therapists must train patients in each domain skill individually, and generalization from one domain to another should not be expected after training.⁶³

Concrete thinking

Inflexible thought processes characterize persons who use concrete thinking. They have difficulty generalizing information from one situation to another and rely heavily on available sensory information.

Persons with impaired abstraction skills usually have poor ability to recognize and learn the cognitive and perceptual skills needed for a specific task. Therefore, they may benefit only from learning splinter (nongeneralizable) skills in treatment and may demonstrate training only in those tasks that are similar to those learned.⁶⁷ Box 19-13 reviews suggestions for family members to facilitate communication and task performance with this population.

Executive function impairments

Executive functions is an umbrella term that refers to complex cognitive processing requiring the coordination of several subprocesses to achieve a particular goal.^34a This term has been defined as “a product of the coordinated operation of various processes to accomplish a particular goal in a flexible manner”^38a or “those functions that enable a person to engage successfully in independent, purposive, self-serving behavior.”^60a These higher-order mental capacities allow one to adapt to new situations and achieve goals. They include multiple specific functions such as decision-making, problem-solving, planning, task switching, modifying behavior in the light of new information, self-correction, generating strategies, formulating goals, and sequencing complex actions.^12,60a Clearly these executive functions support engagement in daily life activities and participation in the community, most important during new, nonroutine, complex, and unstructured situations.^60a (Table 19-10). Intervention approaches for these problems are somewhat lacking in the stroke survivor population. Available information is summarized in Boxes 19-14 and 19-15.

Table 19-10 Examples of Executive Functions Related to Everyday Living: Preparing a Salad

Box 19-15 Further Strategies to Manage Functional Deficits Secondary to Dysexecutive Symptoms*

1. Organize living and work spaces such as:

Labeling and organizing drawers, cabinets.

Organizing shelves in kitchen cabinets and the refrigerator based on categories (e.g., by meal, food category, products used together).

Use paper-based organization systems such as organizers, calendars, and appointment books.

Color code or use in/out tray systems for work and home tasks (e.g., blue dots indicate priority work such as bills to be paid, or files in the bottom tray can be reviewed next week).

Use organizing technology such as personal data assistants, alarm watches, handheld organizers, and personal information manager software (these may include e-mail applications, a calendar, task and contact management, note taking, and a journal).

Post lists of usual and typical sequenced tasks in appropriate locations (e.g., a morning ADL routine posted on the bathroom mirror, night tasks such as lock the door and make lunch posted on the nightstand, arrive-at-work tasks such as check e-mail and phone messages posted on the computer screen).

Use timer functions while cooking.

2. Decrease environmental distractions.

Keep office door closed.

Use “do not disturb” signs when appropriate.

Turn off background radio and television.

Shut window blinds.

Keep workspaces (desks, kitchen counters, coffee tables) clear of clutter.

Use phone-answering systems.

Post office hours.

3. Plan and organize the day

Avoid multitasking

Families should establish structured routines (e.g., dinner at 7 pm each day, laundry is done on Saturday mornings).

Avoid situations in which multiple people are speaking at once.

Use clear and concise instructions.

Integrate relaxation breaks throughout the day.

Establish several “check your work and progress” points throughout the day (time to tick off checklists for completed tasks, check organizer for tasks that still need to be completed).

Data from Cicerone KD, Giacino JT: Remediation of executive function deficits after traumatic brain injury. NeuroRehabilitation 2(3):12-22, 1992; Sohlberg MM, Mateer CA: Management of dysexecutive symptoms. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological approach, New York, 2001, Guilford Press; and Worthington A: Rehabilitation of executive deficits: the effect on disability. In Halligan PW, Wade, DT, editors: Effectiveness of rehabilitation for cognitive deficits, Oxford, 2005, Oxford University Press.