RESEARCH ARTICLE

Relationship of Cognitive and Perceptual Abilities to

Functional Independence inAdults WhoHave Hada Stroke
Ted Brown
1
*

, Jennifer Mapleston
2
, Allison Nairn
3
& Andrew Molloy
1
1
Monash University Peninsula Campus, Department of Occupational Therapy, Frankston, Victoria, Australia
2
Kingston Centre Southern Health, Department of Occupational Therapy, Cheltenham, Victoria, Australia
3
Peninsula Health Department of Occupational Therapy, Frankston, Victoria, Australia
Abstract
Most individuals who have had a stroke present with some degree of residual cognitive and/or perceptual impairment.
Occupational therapists often utilize standardized cognitive and perceptual assessments with clients to establish a
baseline of skill performance as well as to inform goal setting and intervention planning. Being able to predict the
functional independence of individuals who have had a stroke based on cognitive and perceptual impairments would
assist with appropriate discharge planning and follow-up resource allocation. The study objective was to investigate the
ability of the Developmental Test of Visual Perception Adolescents and Adults (DTVP-A) and the Neurobehavioural
Cognitive Status Exam (Cognistat) to predict the functional performance as measured by the Barthel Index of
individuals who have had a stroke. Data was collected using the DTVP-A, Cognistat and the Barthal Index from 32 adults
recovering fromstroke. Two standard multiple regression models were used to determine predictive variables of the func-
tional independence dependent variable. Both the Cognistat and DTVP-A had a statistically signicant ability to predict
functional performance (as measured by the Barthel Index) accounting for 64.4% and 27.9% of each regression model,
respectively. Two Cognistat subscales (Comprehension [beta =0.48; p <0.001)] and Repetition [beta =0.45; p <0.004])
and one DTVP-A subscale (Copying [beta =0.46; p <0.014]) made statistically signicant contributions to the regression
models as independent variables. On the basis of the regression model ndings, it appears that DTVP-As Copying and the
Cognistats Comprehension and Repetition subscales are useful in predicting the functional independence (as measured
by the Barthel Index) in those individuals who have had a stroke. Given the fundamental importance that cognition and
perception has for ones ability to function independently, further investigation is warranted to determine other predictors
of functional performance of individuals with a stroke. Copyright 2012 John Wiley & Sons, Ltd.
Received 7 October 2011; Revised 18 May 2012; Accepted 21 May 2012
Keywords
stroke; function; assessment; Neurobehavioural Cognitive Status Exam (Cognistat); Developmental Test of Visual Perception Adolescents
and Adults (DTVP-A)
*Correspondence
Ted Brown, Monash University, Peninsula Campus, Department of Occupational Therapy, PO Box 527, Frankston, Victoria, 3199, Australia.

Email: ted.brown@monash.edu
Published online 18 June 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1334
Introduction
Cerebrovascular disease (stroke) is a major cause of
disability in older age that can result in some form of
residual disability including motor, cognitive, percep-
tual and/or sensory impairments leading to functional
disability (Srikanth et al., 2004). Cognitive and percep-
tual impairments are a major hindrance to indepen-
dent living after surviving a stroke (Kizony and Katz,
2002; Grieve and Gnanasekaran, 2008). Cognitive
processes are generally dened as the abilities that
enable us to think. Impairments in cognition may
11 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
include the inability to concentrate, remember, learn,
plan, manipulate information, initiate and terminate
activities, use language and recognize errors (Tatemichi
et al., 1994; Stringer, 2003). Perception is a dynamic
process whereby information is received through
sensory impulses and translated into meaning based
on ones understanding of the world (Zoltan, 2007).
Specic types of perceptual skills include visual memory,
visual spatial skills, visualmotor integration (VMI),
visual discrimination, visual closure and visual gure-
ground (Reynolds et al., 2002).
Following a stroke, common cognitive and perceptual
impairments include agnosia, visual spatial problems,
visual memory, VMI, visual gure-ground, unilateral
neglect, constructional problems and apraxia (Trombly
and Ma, 2002). These cognitive and perceptual problems
can result in a multitude of difculties where activities of
daily living (ADL) and occupational performance are
concerned. For example, when dressing, the perceptual
ability of body scheme is required to identify the
correct body parts; spatial relations are required to orient
clothing, and praxis is require to perform the correct
upper limb motor movements to dress (Zoltan, 2007).
Therefore, this study investigates the predictive relation-
ship between the cognitive and perceptual impairments
of individuals who have had a stroke and their functional
independence when discharged from hospital.
An early examination of the cognitive performance of
clients with a stroke could predict long-term cognitive
performance and, therefore, assist in specifying treat-
ment goals, selecting intervention methods and allocat-
ing rehabilitation resources (Nys et al., 2005). As the
majority of care is provided informally, this information
could be used to assist families to prepare. Caring for a
person after stroke often has a negative impact on the
health of the carer (Simon et al., 2009). By improving
the ability to predict a clients functional outcomes,
clinicians, and in particular occupational therapists,
will be in a better position to prepare clients and their
families for the most likely functional outcomes and,
in turn, facilitate the most appropriate discharge and
follow-up care plan (Dewey et al., 2001).
A direct relationship between perceptual disorders
following stroke and ADL skills such as dressing,
grooming, eating and functional mobility has been
established (Cicerone et al., 2005; Hofgren et al.,
2007). Signicant correlations were found between
orientation (to person, place and time) at admission
and basic ADL at discharge (Katz et al., 1999). Visual
memory decits have been found to be related to a
decrease in daily function 3 months after stroke (Edmans
et al., 2000), and moderate to high correlations were
found between visual motor organization to basic and
instrumental ADL (Katz et al., 2000). However, there is
now a growing body of literature suggesting that,
although many standardized cognitive and perceptual
tests have established psychometric properties and are
good indexes of isolated cognitive and executive compo-
nents, they may not be effective in predicting real-world
functional ability of patients (Cherny et al., 2001;
Douglas et al., 2007). The assessment items on many of
the traditionally used cognitive and perceptual tests are
not contextualized within everyday life contexts. There-
fore, it may be challenging to generalize if someone
presents with problematic cognitive and perceptual skills
assessed using test items that are abstract or decontextua-
lized from living environments.
This study investigates the ability of two standard-
ized cognitive and visual perception tests (that are often
used by occupational therapists to assess clients) to
predict the functional independence of a group of adults
who recently had a stroke. The Developmental Test of
Visual Perception-Adolescents and Adults (DTVP-A)
and the Neurobehavioural Cognitive Status Exam
(Cognistat) were used to assess participants cognition
and perception. The Barthel Index was used to assess
participants functional performance on discharge. The
DTVP-Aand Cognistat will be the independent variables,
and the Barthel Index will be the dependent variable.
Method
Participants
A total of 32 adult patients with a primary diagnosis
of stroke were recruited from an inpatient rehabilita-
tion unit in Peninsula Health, Frankston, Victoria be-
tween September 2008 and March 2009. The
participants were required to have sufcient endurance
and mental acuity to complete the three standardized
cognitive and perceptual tests plus the functional
independence assessment.
Instrumentation
The Cognistat (Engelhart et al., 1994; Engelhart et al.,
1999; Doninger et al., 2000; Doninger et al., 2006) is a
screening tool designed to assess ve areas of cognition:
language, constructional ability, memory, calculation
Cognition Perception and Functional Independence Brown et al.
12 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
and reasoning (Kiernan et al., 1987) (Table I). The
Cognistat is one of the most widely used cognitive
screening tests by medical, nursing and rehabilitation
therapy staff with patients who have had a stroke
(Schwamm et al., 1987; Fong et al., 2001; Larson et al.,
2003; Nokleby et al., 2008). The Cognistat itself includes
Table I. Test subscale descriptions
Cognistat subscales
Orientation The examiner asks general questions to conrm the test takers level of orientation to person, place, date, day and
time; this means that the test taker is correctly oriented to place and time; he or she knows what day it is and
where he or she is (Kiernan et al., 1987).
Attention The test taker is asked to repeat a series of digits (Kiernan et al., 1987).
Fluency Is assessed by recording verbatim an examinees description of a drawing that depicts a shing scene. No numerical
score is given for this section. Instead, the description is evaluated qualitatively with attention paid to word-
nding difculty and paraphasic errors (Kiernan et al., 1987).
Comprehension The test taker is required to respond to simple one-step, two-step and three-step commands that involve
manipulation of common objects placed before the examinee (Kiernan et al., 1987).
Repetition The test taker is asked to repeat short phrases and simple sentences of increasing complexity (Kiernan et al., 1987).
Naming The examiner holds up an object and asks the test taker to name its four major parts, as the examiner points to them
one after another. If the test taker fails, he or she is asked to name eight separate objects, one after another
represented by line drawings (Kiernan et al., 1987).
Constructional ability The screening item is a visual memory task wherein a stimulus sheet is presented for 10 seconds, and the examinee is
asked to draw the stimuli from memory. If this task is failed, then the test taker is then asked to assemble plastic
tiles into mosaic designs, one after another, as each is shown on a card. Faster completion yields greater points
(Kiernan et al., 1987).
Memory The test taker is asked to repeat a series of digits and the rst part of a verbal memory task will be given. This task will
be asked about again later as the test administration progresses. For items he or she cannot recall, the examiner
provides prompts or clues. The test taker is asked to recall four words after an interval of approximately
10 minutes (Kiernan et al., 1987).
Calculations The test taker is asked to complete simple verbal mathematic questions involving multiplication, addition,
subtraction and division (Kiernan et al., 1987).
Similarities The test taker is asked to explain how two concepts are alike. Greater points are awarded if their concept is abstract
rather than concrete. If the test taker fails the initial screen, four additional word pairs are presented in which the
similarity is progressively more difcult to identify (Kiernan et al., 1987).
Judgements The test taker is asked to answer questions that demonstrate practical judgement in solving basic problem scenarios
or everyday predicaments in the form of What would you do if. . . Scores for this subtest are weighted based on
their appropriateness (Kiernan et al., 1987).
DTVP-A subscales
Copying Individuals are shown a simple gure and asked to draw it on a piece of paper. The gure serves as a model for the
drawing. Subsequent gures are increasingly complex, eventually becoming three dimensional (Reynolds et al.,
2002 p11). Some of the geometric shapes that individuals are required to draw include a right angle triangle and a
parallelogram (Reynolds et al., 2002).
Figure-ground Individuals are shown stimulus gures and asked to nd as many of the gures as they can on a page where they
gures are hidden in a complex, confusing background (Reynolds et al., 2002 p11).
Visualmotor search The individual is shown a page covered in numbered circles, randomly arranged on the page. The individual
connects the circles with a line, in numerical sequence, as quickly as possible. To enhance the visual search
component of the task, distractor circles without numbers are included (Reynolds et al., 2002 p11).
Visual closure Individuals are shown a stimulus gure and asked to select the exact gure from a series of gures that have been
incompletely drawn. To complete the match, examinees have to visualize the missing parts of the gures in the
series (Reynolds et al., 2002 p11).
Visualmotor speed Individuals are shown (a) four different geometric designs, two of which have special marks in them, and (b) a page
lled completely with the four designs, none of which have marks in them. Examinees are to draw the marks in as
many appropriate designs as the can within the set time period (Reynolds et al., 2002 p11).
Form constancy Individuals are shown a stimulus gure and asked to nd it twice in a series of gures. In the series, the targeted
gure appears in a different size, position, and/or shape, and it may be hidden in a distracting background
(Reynolds et al., 2002 p12). In other words, individuals are required to identify a gure despite being obscured by
size, position, shading or a distracting background (Reynolds et al., 2002).
Cognistat, Neurobehavioural Cognitive Status Exam; DTVP-A, Developmental Test of Visual Perception Adolescents and Adults.
Brown et al. Cognition Perception and Functional Independence
13 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
10 subscales: orientation, attention, comprehension,
repetition, naming, construction, memory, calculations,
similarities and judgements. The raw score for each
subscale is on a scale with ranges of 04 or 513 to
equalize the results. The scores are then presented as a
prole, divided into four performance ability ranges:
average, mild, moderate or severe impairment. The
Cognistat was found to be appropriate for use with
people who have had a stroke (Hinkle, 2002). In addition
to brevity (1020 minutes) and ease of administration,
the Cognistat has well established validity and reliability
(Schwamm et al., 1987; Mysiw et al., 1999; Man et al.,
2006; Nokleby et al., 2008).
The DTVP-A, a recently revised version of a percep-
tual standardized test battery referred to as the Develop-
mental Test of Visual Perception 2nd edition, assesses
perception in participants aged 11 to 74 years of age
(Reynolds et al., 2002). The DTVP-A consists of six
subscales (Table I), three of which are motor-free
(gure-ground, visual closure and form constancy) and
three involving VMI skills (copying, visualmotor search
and visual motor speed). The VMI-related subscales of
the DTVP-A require the respondent to use their motor
skills within their responses to test items, whereas the
motor-free do not (Reynolds et al., 2002). The normative
scores reported in the DTVP-A test manual were derived
from a sample of 1,664 adolescents and adults that
resided across 19 American states (Reynolds et al.,
2002). Evidences of content validity, predictive validity
and construct validity are reported in the DTVP-A
manual (Reynolds et al., 2002).
The Barthel Index is designed to measure functional
ability of patients undergoing inpatient rehabilitation
(Mahoney and Barthel, 1965). It consists of 10 items
(e.g. feeding, bathing, grooming, dressing, bowel conti-
nence, bladder continence, toilet use, transfers from bed
to chair, mobility on level surfaces and use of stairs), which
sum to a total of 100. The closer a persons score is to 100
the higher their functional ability. It has been frequently
used in studies with patients who have had a stroke (Shah
et al., 1989; Sulter et al., 1999). The Barthel Index is
sensitive, reliable and valid (Granger et al., 1979a, 1979b;
Collin et al., 1988; Shah et al., 1989; Fricke and Unsworth,
1997; van der Putten et al., 1999; Hsueh et al., 2002).
Procedures
Ethics approval was obtained from the Monash
University Human Research Ethics Committee and
Peninsula Health Research Ethics Committee. The
Cognistat and DTVP-A were administered to the parti-
cipants by an occupational therapist trained to admin-
ister these tests within 1 week of the participants
admission to an inpatient rehabilitation unit. The
Barthel Index data were generated by the multidisci-
plinary team at the inpatient rehabilitation unit on
the day of discharge from the rehabilitation unit. The
order in which the two tests were administered was
randomized to prevent a test-order effect (a potential
source of bias) confounding the results. It took partici-
pants on average 30 minutes in all to complete the
Cognistat and DTVP-A.
Data analysis
The Statistical Package for Social Sciences (SPSS; Version
17.0) was used for data storage, tabulation and the
generation of descriptive statistics. Preliminary analysis
correlated the subscales of the Cognistat and DTVP-A
with the Barthel Index using Pearsons r. Subscales that
had a statistically signicant correlation with the Barthel
Index were entered into linear multiple regression
models. Analyses were completed to ensure that no viola-
tion of the assumptions of normality, linearity, multicol-
linearity and homoscedasticity was present. Results were
considered statistically signicant if p <0.05.
Results
Participants
The 32 participants were aged between 46 and 91 years,
with a mean age of 73 years (SD=4.5). Approximately
half were male (n =17; 53.1%), all had English as their
rst language and for the majority, this was their rst
stroke (n =24; 75.0%). The prevalence of a stroke
lesion in the left (n =14; 43.8%) and right (n =18;
56.2%) hemispheres across the sample was similar,
and approximately half (n =18; 56.3%) of the partici-
pants had the dominant side of their body effected by
their stroke.
The average length of stay for participants at the
inpatient rehabilitation unit was 29.4 days (SD=8.02).
During the week, Monday to Friday, participants
received approximately 90 minutes of nursing care
(45 minutes in the morning and 45 minutes in the
evening), 60 minutes of occupational therapy services,
90 minutes of physiotherapy services and an additional
30 minutes of other health-related services (such as
Cognition Perception and Functional Independence Brown et al.
14 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
social work, psychology, pastoral care or dietetics) each
day. On weekends, participants received only nursing
services and no therapy services.
Test scores
The mean scores and standard deviations of the Cognistat
and DTVP-A subscales are presented in Table II. The
mean Barthel Index score was 83 (SD=26.05).
Correlations
The Barthel Index was signicantly correlated with the
Cognitstat orientation, comprehension, repetition and
construction subscales and the DTVP-A copying, visual
closure and form constancy subscales (Table III). The
four Cognistat subscales and three DTVP-A subscales
were all independent variables in two regression analy-
ses to determine whether or not they were signicant
predictors of the Barthel Index dependent variable.
Cognistat regression model results
A preliminary analysis found only four of the Cognistats
10 subscales that had a statistically signicant correla-
tion with the Barthel Index, the dependent variable
in the regression model. As such, only the Cognitstat
orientation, comprehension, repetition and construction
Table II. Descriptive data for the Developmental Test of Visual Perception Adolescents and Adults (DTVP-A) and Neurobehavioural
Cognitive Status Exam (Cognistat)
Cognitiveperceptual subscales Mean score SD Minimum score Maximum score
Cognistat
Orientation 9.85 2.16 5.0 12.0
Attention 7.59 1.04 4.0 8.0
Comprehension 5.37 1.00 3.0 6.0
Repetition 10.44 2.39 3.0 12.0
Naming 7.59 .93 5.0 8.0
Constructional ability 3.44 2.27 0.0 6.0
Memory 7.37 3.52 0.0 12.0
Calculations 3.18 1.11 0.0 4.0
Similarities 4.44 2.25 0.0 8.0
Judgement 3.92 1.54 0.0 6.0
DTVP-A
Copying 13.48 7.42 0.0 31.0
Figure-ground 8.85 12.87 0.0 68.0
Visualmotor search 109.92 48.32 1.0 180.0
Visual closure 9.92 5.53 0.0 16.0
Visualmotor speed 29.59 20.79 4.0 71.0
Form constancy 9.70 6.25 0.0 18.0
General visual perception raw score 180.48 37.20 107.0 233.0
Motor-reduced visual perceptual raw score 27.48 21.22 1.0 100.0
Visualmotor integration raw score 153.00 43.79 29.0 214.0
SD, standard deviation.
Table III. Correlation of the Developmental Test of Visual
Perception Adolescents and Adults (DTVP-A) and Neurobehavioural
Cognitive Status Exam (Cognistat) subscales with the Barthel Index
(n=32)
Cognitiveperceptual subscales Pearson r correlation coefcient
Cognistat
Orientation 0.472**
Attention 0.306
Comprehension 0.721**
Repetition 0.695**
Naming 0.042
Constructional ability 0.536**
Memory 0.168
Calculations 0.231
Similarities 0.301
Judgement 0.0349
DTVP-A
Copying 0.458**
Figure-ground 0.066
Visualmotor search 0.300
Visual closure 0.430*
Visualmotor speed 0.300
Form constancy 0.395*
*p <0.05.
**p <0.01.
Brown et al. Cognition Perception and Functional Independence
15 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
subscales were entered into the regression model
as independent variables. The total variance in the
Barthel Index explained by the model was 64.4%,
F(4, 27) =15.00, p <0.001. Only two variables made
a statistically signicant contribution to the model,
which were the Cognistat comprehension (beta =0.48;
p <0.001) and repetition (beta =0.45; p <0.001) sub-
scales. The Cognistat regression model results are
presented in Table IV.
DTVP-A regression model results
A preliminary analysis found three subscales of the
DTVP-A that had statistically signicant correlations
with the Barthel Index. Accordingly, the DTVP-A
copying, visual closure and form constancy subscales
were entered into a regression model as independent
variables. The total variance in the Barthel Index
accounted for by the regression model was 27.9%,
F(3, 28) =5.00, p =0.007. The DTVP-A copying
subscale (beta =0.46; p <0.014) was the only indepen-
dent variable to make a statistically signicant contribu-
tion to the Barthel Index dependent variable regression
model. The DTVP-A regression model results are
presented in Table V.
Discussion
Occupational therapists often assess cognition and
perception with respect to patients occupational per-
formance, which is the ability to function in the tasks,
activities and roles that dene the person as an individ-
ual (Zoltan, 2007). Cognitive and perceptual abilities
are assessed in individuals who have had a stroke under
the assumption that they are essential prerequisite skills
necessary for successful daily task performance. There-
fore, investigating if cognitive and perceptual skills are
predictive of stroke patients functional independence
skills is warranted. In this study, a test of cognition
and visual perception exhibited statistically signicant
correlations with the participants functional indepen-
dence, as measured by the Barthel Index. The Cognistat
regression model explained 64.4% of the total variance,
whereas the DTVP-A regression model accounted for a
more modest 27.9% of the total variance.
Cognistats comprehension and repetition
subscales as predictors of function
The Cognistat explained a sizable proportion of the
total variance; however, only two of its 11 subscales made
a statistically signicant contribution to the functional
Table IV. Cognistat as a predictor of functional performance as measured by the Barthel Index (n =32)
Independent variables b Std. error Stdz. beta coeff. t p-value
Orientation 1.038 1.779 0.085 0.583 0.564
Comprehension 11.862 3.192 0.483 3.717 0.001
Repetition 4.938 1.544 0.453 3.199 0.004
Constructional ability 1.433 1.607 0.124 0.891 0.381
R
2
0.690
Adjusted R
2
0.644
p-value 0.000
Stdz. beta coeff., standardized beta coefcient; Std. error, standard error.
Table V. DTVP-A as a predictor of functional performance as measured by the Barthel Index (n =32)
Independent variables b Std. error Stdz. beta coeff. t p-value
Copying 1.652 0.628 0.456 2.632 0.014
Visual closure 0.351 1.633 0.073 0.215 0.831
Form constancy 1.785 1.335 0.434 1.337 0.192
R
2
0.349
Adjusted R
2
0.279
p-value 0.007
Stdz. beta coeff., standardized beta coefcient; DTVP-A, Developmental Test of Visual Perception Adolescents and Adults, Std. error,
standard error.
Cognition Perception and Functional Independence Brown et al.
16 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
independence regression model. Intuitively, one would
not expect language skills such as those represented by
the Cognistats comprehension and repetition subscales
to predict ones ability to undertake ADL. The partici-
pants cognitive impairment must be such that it affects
both their language skills and their ability to undertake
ADL. However, given the signicance of the other cogni-
tive skills assessed by the Cognistats other eight subscales
(e.g. orientation, attention, naming, construction, mem-
ory, calculations, similarities, and judgements) in rela-
tion to ADL and functional independence, one would
have expected statistically signicant contributions to
the regression model from them as well.
The standardized beta coefcients of each signicant
independent variable provide a measure of the contri-
bution each variable makes to the regression model.
In the case of the Cognistats comprehension and rep-
etition subscales, their beta values were 0.48 (p <0.001)
and 0.45 (p <0.004), respectively. In other words, a
change (either an increase or decrease) in the Cogni-
stats comprehension and repetition subscale scores
would also predict a similar change of the same degree
in the Barthel Index score.
The Cognistats comprehension subscale requires
the test taker to respond to simple one-step, two-step
and three-step commands that involve the manipula-
tion of common objects placed before the examinee
(Kiernan et al., 1987). The Cognistats comprehension
subscale would involve verbal comprehension skills,
auditory memory skills and the ability to execute a
motor response in relation to the steps in the command.
Often these skills are impaired in someone who has had a
stroke. A number of day-to-day living skills require
comprehension of verbal instructions and the manipula-
tion of objects including talking on the telephone, using a
computer, writing down instructions one is given and
functional mobility.
Pedersen et al. (1996) found signicant correlations
between orientation (to person, place and time) at
admission to hospital following a stroke and basic ADL
at discharge. Gerritsen et al. (2003) examined the speed
of information processing in 88 patients with stroke
and 71 control participants. Four reaction time tasks
with different levels of complexity were used: two visuo-
motor and two semantic categorisation tasks. The results
obtained by Gerritsen et al. showed that stroke led to
slower decision making speeds in patients. The ndings
of both of these investigations are similar to the
Cognistats comprehension subscale being a signicant
independent variable of the Barthel Index dependent
variable because the comprehension subscale involves
both orientation and speed of information processing.
Owsley et al. (2002) investigated whether visual-
processing speed, as well as memory and inductive
reasoning, was independently associated with the time
required by older adults to complete instrumental
ADL. Five timed instrumental activities of daily living
(TIADL) tasks were completed by 173 older adults
(ages 6590 years) along with assessments of visual-
processing speed, memory and inductive reasoning.
Owsley et al. (2002) found that only visual-processing
speed was independently associated with TIADL scores.
In other words, those older adults with slow visual
information processing speed were more likely to require
longer times to complete everyday tasks. Again, this is
relevant to the Cognistats comprehension subscale in
that it requires information processing speed skills to
complete it successfully. Because the Cognistats repeti-
tion subscale asks the test taker to repeat short phrases
and simple sentences of increasing complexity, this
would require auditory memory, information processing
skills and short-term memory skills. To be able to recall
and repeat phrases that have been heard previously also
requires short-term and long-term memory skills.
McDowd et al. (2003) examined two aspects of
attentional functioning (divided attention and switching
attention) in older adult stroke survivors (n =55) and
healthy older adults (n =39). In addition, the authors
investigated the relation between attention and func-
tional outcomes following stroke. The ndings of
McDowd et al. revealed stroke-related decits in both
types of attention as well as signicant associations
between attentional functioning and both physical and
social outcome measures. They concluded that poorer
attentional performance was associated with a more
negative impact of stroke on daily functioning. Atten-
tional functioning would be required to successfully
complete the Cognistats repetition subscale.
The DTVP-As copying subscale as a
predictor of function
The DTVP-A explained a smaller percentage of the
total variation; however, only one subscale made a
statistically signicant contribution to the regression
model. The standardized beta coefcient DTVP-A
copying subscale was 0.48 (p <0.014). This infers that
when an increase or decrease in the DTVP-A copying
Brown et al. Cognition Perception and Functional Independence
17 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
subscale score occurs, then a mirrored increase or
decrease of a similar magnitude in the Barthel Index
score would occur as well.
The DTVP-A copying subscale assesses participants
ability to copy onto a piece of paper increasingly
complex geometric gures that are presented to them
that is analogous to VMI skills (Hall et al., 1996; Malloy
et al., 2003). VMI is the degree to which visual percep-
tion (information) and limb movement (ngerhand
movements) are well coordinated together (Beery and
Beery, 2010). VMI falls under the umbrella term of
perceptualmotor skills and is closely related to percep-
tion. For example, if a person was asked to copy a
sentence from a book onto a piece of paper, he or she
would require visual perceptual skills to correctly
understand the letters, words and correct spacing on
the page to successfully copy the sentence. VMI dys-
function is the inability to use vision to perform motor
tasks; hence, functional VMI enables an individual to
coordinate visual stimuli with the corresponding motor
action in a timely and skilful manner (Hammill et al.,
2006). An individual who has had a stroke will often
present with VMI problems.
Given the importance of the other visual perceptual
and visualmotor skills assessed by the DTVP-As other
ve subscales (e.g. gure-ground, visual closure, form
constancy, visualmotor search and visual motor
speed) in relation to functional independence, statisti-
cally signicant contributions were expected from
them as well. However, this was not the case. Donnelly
(2002) obtained similar results to the DTVP-As ve
other subscales (other than the copying subscale) when
investigating whether a standardized perceptual skills
test could predict the functional performance of a
group of 46 participants with a stroke. The cognitive
measure was the Rivermead Perceptual Assessment
Battery (RPAB), and functional performance was
measured by the Functional Independence Measure
(FIM). The presence or absence of a visualperceptual
disorder as assessed by the RPAB was unable to predict
functional performance (Donnelly, 2002). However,
when the presence or absence of a visualperceptual
disorder, as assessed by the RPAB, was included in the
model with FIM
SM
admission scores, it was found to be
as signicant as age in predicting discharge FIM
SM
scores. The model incorporating visualperceptual status
and FIM
SM
admission scores together was found to
account for 56.6% of the variance associated with FIM
SM
discharge scores (Donnelly, 2002, p. 77). It was also
found that stroke patients with a visual perceptual
problem, as assessed by the RPAB, achieved signicantly
lower scores on the FIM
SM
at discharge from rehabilita-
tion than people without a visualperceptual disorder
(Donnelly, 2002, p. 71).
Skills assessed by the DTVP-As copying subscale
involve eyehand coordination, manual dexterity and
visual perceptual skills. For example, when someone
writes down a list of items needed to buy at the super-
market or when someone lls out an application form,
all of these skills are needed. Hence, abilities assessed by
the DTVP-As copying subscale are related to a number
of ADLs including dressing, functional mobility, meal
preparation, written communication and following
written instructions. Wade and Hewer (1987) found that
visual memory decits (a type of visual perceptual skill)
were related to a decrease in daily function 3 months
after stroke. This is germane to the Barthel Index because
it measures ADLs and functional performance.
Katz et al. (2000) investigated whether a cognitive
standardized test, as measured by the Loewenstein
Occupational Therapy Cognitive Assessment could
predict functional performance as measured by the
FIM following right hemisphere stroke in a group of
40 participants admitted to a rehabilitation hospital.
Participants were tested at three points in time: at
admission to rehabilitation, at discharge from rehabili-
tation and 6 months post-discharge. The FIM was
also administered at three periods. Spearmans correla-
tions found the highest degree of association between
visualmotor organization and the FIM Motor and
the FIM Total scale scores. After regression analysis,
visualmotor organization accounted for 37% of the
variance of FIM total scale score (Katz et al., 2000).
Predictive results suggest that unilateral neglect is the
main predictor of ADL; however, in the non-neglect
group, the more complex integrated visualmotor and
thinking skills were signicantly related to functional
outcomes (Katz et al., 2000). In summary, moderate
to high correlations existed between visuomotor
organization and thinking operations related to basic
and instrumental ADL. This is similar to the ndings
of this study where the DTVP-As copying subscale
also involves both visuomotor organization and think-
ing operations.
Gauggel et al. (2000) found similar results to the
present study in their cohort of 87 patients with stroke.
They suggested that it is not surprising that tasks
involving ne motor skills (such as VMI) are able to
Cognition Perception and Functional Independence Brown et al.
18 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
predict functional independence (as measured by the
Barthel Index) because of the high level of upper-
extremity ne motor involvement in components of
cognitive standardized tests and the Barthel Index
functional performance indices. VMI skills are required
to successfully complete the DTVP-As copying sub-
scale. In another study, Bernspang et al. (1987) investi-
gated the importance of motor, perceptual and
cognitive functions for self-care ability in a sample of
109 participants 2 weeks post-stroke. Discriminant
analyses showed that the actual level of self-care pro-
ciency could be correctly predicted in 70% of the cases
by the four indexes: motor function, low-order percep-
tual function, high-order perceptual function and
orientation. Low-order perceptual function was assessed
using four items that involved form recognition, size
estimation, colour recognition and perception of body
parts. High-order perceptual function was assessed using
seven items that included spatial relations, block design,
gure-ground relations, draw-a-clock, draw-a-person,
gure copying, visual closure and object constancy. The
dominating predictor was motor function, and the next
highest was high-order perceptual functioning. Again,
similar to the study ndings of Bernspang et al., the skills
required to complete the assessed DTVP-As copying
subscale also require motor and perceptual skills.
According to Eriksson et al. (1988), the DTVP-As
copying subscale falls under the high-order perceptual
function category.
Limitations and future research
A larger sample size may include participants with a
larger variety of outcomes after stroke and increase
the models ability to assess the relationship between
cognition and perception with functional outcomes.
There are four notable limitations of this study: 1)
convenience sampling was used to recruit participants;
2) the sample size was small and participants were all
inpatients at one rehabilitation site in metropolitan
Melbourne; 3) the participants in the study were not
separated into separate groups based on whether they
sustained a left-sided or right-sided stroke; and 4)
client level factors (e.g. age, level of function prior to
stroke, gender) as well as facility level factors (such as
length of stay) were not included as dependent factors
in the two regression models. The ability of cognitive
and/or perceptual standardized tests to predict the
functional performance of people who have had a
stroke is not well understood (Katz et al., 1999, 2000;
Donnelly, 2002; Koh, 2008). Further studies could be
completed with a larger, more heterogeneous sample
size from a larger geographical area as well as adding
qualitative elements to increase the depth and richness
of the data obtained. It is also recommended that
participants who have sustained a left-sided stroke
and a right-sided stroke could be compared to further
investigate the relationship between cognition and
perception with functional outcomes. It is also suggested
that other measures of functional independence could be
used such as the FIM or the Assessment of Motor and
Process Skills.
Conclusion
This study investigated the relationship between the
DTVP-A and the Cognistat and the functional indepen-
dence (as measured by the Barthel Index) in a group of
adults who recently had a stroke. Both the Cognistat
and DTVP-A had a statistically signicant ability to
predict functional performance as measured by the
Barthel Index accounting for 64.4% and 27.9% of each
of the regression models, respectively. Two Cognistat
subscales (comprehension [beta =0.48; p <0.001] and
repetition [beta =0.45; p <0.004]) and one DTVP-A
subscale (copying [beta =0.46; p <0.014]) made statisti-
cally signicant contributions to the regression models.
On the basis of the regression model ndings, the
implications for practice are that the DTVP-A and the
Cognistat have a signicant relationship with the
functional independence in those individuals who have
had a stroke. Given the fundamental importance that
cognition and perception has for ones ability to
function independently, further investigation is needed
to determine other predictors of functional perfor-
mance of individuals with a stroke.
Conict of interest
The authors of this manuscript have no conicts of
interest.
Key points
the DTVP-As Copying and the Cognistats Compre-
hension and Repetition subscales had statistically
signicant relationships with functional performance
as measured by the Barthel Index in individuals who
have had a stroke
Brown et al. Cognition Perception and Functional Independence
19 Occup. Ther. Int. 20 (2013) 1122 2012 John Wiley & Sons, Ltd.
an individuals cognition and perception appears to
have a relationship with ones ability to function
independently
occupational therapists need to take into consideration
the cognitive and perceptual skills of individuals who
have had a stroke during the assessment, goal setting
and intervention phases of therapy provision
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