Impact of

Neurobehavioral
Deficits on
Activities of Daily
Living
► Ⅰ. Activities of Daily Living
► Ⅱ . Neurobehavior : The process of
linking occupation to neuronal activity
► Ⅲ . Theoretical relationship between
occupational performance and
neurobehavior
► Ⅳ . Detecting the effect of
neurobehavioral deficits on activity
performance
► Ⅴ . Processing during task performance
► Ⅵ . Dysfunction of the activities of daily
living area of occupation as a result of
cerebrovascular accidents
► Ⅶ . Patterns of impairments resulting
 chapter objectives
1. Establish a relationship between neurobehavioral
concepts and activity performance.
2. Apply the theory on which the A-ONE is based as a
structure for clinical observations of stroke patients.
3. Provide conceptual and operational definitions for
neurobehavioral impairments and disability.
4. Apply clinical reasoning skills based on the A-ONE
theory for hypothesis testing.
5. Relate the ICF and the Occupational Therapy
Practice Framework to the A-ONE theory and
neurobehavioral concepts.
6. Provide examples of how strokes can cause different
patterns of impairments affecting task performance.
 Ⅰ . Activities of Daily Living
* Basic or personal activities of daily living
· oriented toward taking care of one's own body
· bathing, showering, bowel and bladder management,
dressing, eating, feeding, functional mobility,
personal device care, personal hygiene, grooming,
sexual activity, sleep/rest, toilet hygiene
* Instrumental activities of daily living
· education, work, play, leisure, social participation
* Performance contexts
· cultural, physical, social, personal, spiritual,
temporal, curtual conditions
· Table 18-1 : relates the Frameworks terminology to
the classification systems of the ICF and A-ONE.
* Summary
· Occupational performance : the ability of an individual
to accomplish activities by interaction of client factors,
performance skills, performance patterns, and context
of that individual.
 Ⅱ . Neurobehavior : The
process of linking occupation
to neuronal activity
* Neurobehavior
· behavior based on neurological function
· different tasks → different types of sensory stimuli →
different mechanisms of the central nervous system
→ behavioral responses → feedback → new sensory
stimuli
· Fig. 18-1 : illustrates the elements
* Neurobehavioral deficit
· A functional impairment manifested as defective task
performance resulting from a neurologic processing
dysfunction.
· affects client factors (affect, body scheme,
cognition, emotion, gnosis, language, memory, motor
movement, perception, personality, praxis, sensory
awareness, spatial relatioins, visuospatial skills)
 Ⅲ . Theoretical relationship
between occupational
performance and neurobehavior
* A-ONE theory
· the ability to perform daily activities, neurobehavioral
impairments, and the CNS origin of the neurobehavioral
dysfunction
 Ⅳ . Detecting the effect of
neurobehavioral deficits on
activity performance

* A systematic analysis of occupational

performance
· help therapists assess functional
independence related to task performance
· detect dysfunctional neurologic client factors
 
* Activity analysis
① task - focused
· the range of skills and components needed to
perform the activity, typical performance methods,
performance context, cultural meaning of the
activity
② theory - focused
· performed with intervention potential in mind
· focused performance problems based on
definitions of function and dysfunction
③ individual - focused
· focused on client
· integrated with the client's goal
* Activity analysis in the A-ONE
· to identify different client factors and possible
manifestations of CNS dysfunction during ADL
performance
· Therapist keeps in mind different possible
neurologic factors and impairments and the
theoretical definitions of functional and dysfunctional
behavior
· meaningful task
· Fig. 18-2
ⅰ . Function of the Cerebral Cortex : The
Foundation of Task Performance
· detect the type and degree of severity of
neurobehavioral impairments that interfere with
activity performance
· body factors are based on neurologic function,
which takes place at different levels of the CNS
· three levels of functional complexity in the cortex
based on Luria's theories
- primary, secondary, tertiary cortical zones or
projection areas
ⅱ . Functional Localization for Neurologic
Processing of Client Body Factors
* primary areas
․ direct processing of primary sensory and motor
information
․ include the primary somesthetic sensory cortex in
the postcentral gyrus of the parietal lobe
․ the primary visual cortex around the calcarine fissure
on the medial side of the occipital lobe
․ the primary auditory cortex in the superior themporal
gyrus of the temporal lobe
․ the primary motor cortex in the precentral gyrus of
the frontal lobe
* cortical areas
․ The primary association areas that ( except for the
motor association cortex) receive information from
the primary areas and integrate it with information
from other areas
․ The secondary association areas are adjacent to and
connected with primary cortical areas.
․ a single sensory or motor function
․ include the visual association cortex surrounding the
primary visual cortex in the occipital lobe, the
auditory association cortex in the temporal lobe, the
somatosensory association area in the superior
parietal lobule, and the premotor cortex in the frontal
lobe
* Association areas
․ involved in complex integration of information from
many different cortical areas
① prefrontal cortex
․ dorsolateral prefrontal cortex : involve in complex
motor functions, concept formation, abstraction,
intelligence, judgement, attention, intention,
sequencing, and timing and organization of activity
steps and behavior as well as emotional processing
② limbic cortex
․ limbic association cortex : includes the
orbitofrontal part of the prefrontal cortex, the
temporal pole, and the parahippocampal
gyrus on the medial aspects of the temporal lobes
and the cingulate gyrus of the cortex concerned
with memory and with motivation and emotional
aspects
 ③ parietotemporaloccipital cortex
․ parietotemporo-occipital cortex : complex sensory

functions based on information from two or more

of the socondary association areas of the three
posterior lobes
․ Fig. 18-3 : illustrates functional organization of the
cerebral cortex
․ plasticity permits deviations from the usual
localization sites under certain conditions such as
injury or developmental abnormality
* Summary
․ Table 18-2
 
ⅲ . Processing of Praxis
- several CNS areas help process particular
neurologic body functions
* the processing model for the praxis
․ 2 steps
① ideation
․ refer to concept formation related to an activity
․ requires function of the frontal lobes (prefrontal
and premotor areas) and of areas around the
lateral fissure
② planning and programming of movement
․ result of praxis is motor execution
․ visuokinesthetic motor engrams or memory
molecules for movement
․ stored in the left inferior part of the parietal lobe
․ Fig. 18-4
 Ⅴ . Processing during task
performance
* Motor praxis
 ․ only one type of neurologic body function related to
neurobehavior
 ․ client factor and the degree depend on the task to be
performed
 ․ several processing mechanisms involved the
performance of a particular activity
* Ex. brushing hair
    · visual : information travels through the visual
pathway to the primary visual cortex
   · memories and ideational processes : gets the idea
to want to brush the hair
    · verbal : travels over the auditory pathway to the
primary auditory area of the cortex in the temporal
lobe where it is processed by the association areas
    · somesthetic : recieces tactile and proprioceptive
information is analyzed by association areas and
integrated with prior experiences
* ideation : intent to perform an action, and preparation
of a sequenced plan of action occur
* Fig. 18-5 : illustrates some of the processing
components that take place during the activity of
brushing hair
 Ⅵ . Dysfunction of the activities
of daily living area of
occupation as a result of
cerebrovascular accidents
* neurologic body functions
  ① neuromuscular funcitons
  ② sensory functions and pain
  ③ mental functions
  ④ voice and speech functions
* related Table 18-2
* conceptual definitions : generalized and abstract
* operational definitions : how particular concepts are
measured and observed
ⅰ . Conceptual definitions of terms

* frontal lobes process functions related to

neuromusculoskeletal and movement-related client
factor functions including muscle and movement
functions

* dysfunction of the frontal lobes

 ․ affect neuromusculoskeletal body functions
processed in the primary motor and premotor areas
 ․ the distribution of impairments is related to lesion
localization in the primary motor cortex
 ․ Table 18-3 : includes definitions of impairments or
dysfunction of neurologic client factors and relates
these to different cerebral lobe
* Parietal lobe
 ․ process somatosensory and complex sensory
information from multimodal stimuli
 ․ related to dysfunctions of client factors, in particular
somesthetic sensory functions and specific mental
functions
 ․ dysfunction of the inferior parietal lobe : related to
perceptural and motor processing of client factors, in
particular specific mental functions related to
sequencing of complex movement, memory, and
perception
* Occipital lobe
 ․ primary and secondary processing areas for visual
information
 ․ visual processing is located mainly in the inferior
parietal lobe
 ․ dysfunction : impairments are related to visual
sensory functions and specific mental functions
related to perception of visual information referring to
the Framework classification of client factors
 ․ lesions of the association areas : ex. visual agnosia
* Temporal lobes
 ․ two types of processing - auditory and limbic
 ․ related to sensory functions of hearing, voice and
speech functions. global mental functions of
temperament and personality, and specific mental
functions of memory, perception of hearing, and
emotional fucntions
 ․ lateral sides of the hemispheres  : primary and
secondary processing sites for auditory stimuli and
perceptual processing of such information
 ․ Ex. anomia
ⅱ . Manifestation of Neurobehavioral
impairments during task performance :
operational definitions of concepts
* operational definitions
 ․ how concepts are measured and observed
 ․ based on A-ONE
 ․ For successful completion of each of the tasks,
involvement of several neurologic client factors in
necessary
 ․ The following examples indicate the effect of
different impairments on task performance in the
various performance areas
 ․ Some impairments affect specific ADL areas
 ․ Other impairments are more pervasive and may
appear in any ADL performance area or may need to
be addressed specifically
- Personal Hygiene and Grooming Performance
Area
* hygiene and grooming domain of the A-ONE
  ․ personal hygiene and grooming, toilet hygiene, and
bathing or showering
  ․ washing the face and body and bathing or
showering
  ․ oral hygiene (including brushing teeth)
  ․ combing hair, shaving, applying cosmetics,
deodorants, or perfumes, and performing toilet
hygiene
* Dysfunction of neuromusculoskeletal and movement-
related functions
  ․ Fig. 18-6
* Dysfunction of sensory functions
  ․ impaired tactile and proprioceptive sensation,
astereognosis, or hemianopsia with a loss of a visual
field, or a loss of part of a visual field may be present
  ․ affect object manipulation
  ․ suffer from inattention or neglect will be aware of
the impairment and attempt to compensate for it (ex.
by using vision for sensory feedback)

* Dysfunction of the client factor of sequencing

complex movement
  ․ Fig. 18-6, B
  ․ require sequencing and planning of fine finger and
wrist movements so that the razer is turned toward
the face for effective use
  ․ motor apraxia may influence the ability to comb or
brush hair
* Premotor perseveration : manifested as repetition of
the movements of washing the face
* Prefrontal perseveration : perseveration of whole acts
  ․ Fig. 18-6, C
* Dysfunction of the perceptual processing
  ․ If the perceptual processing is present, a spatial
relation disorder, difficulty with left-right
discrimination, unilateral body inattention or neglect,
unilateral visual inattention or neglect, anosognosia,
or somatoagnosia may be expected.
  ․ Fig. 18-6, D
* Impairments related to neglect or inattention
  ․ result from dysfunction of the specific mental
function factor of perception or attention
  ․ not use the affected limb according to available
control   ․ Fig. 18-6, E
* Somatoagnosia
  ․ differentiate between the mirror image and self
  ․ Fig. 18-6, F
  ․ defined in the A-ONE as severe dysfunction that
usually is accompanied by ideational apraxia and
often by spatial relation disorders

* Dysfunctions of global and specific mental function

  ․ effect on grooming and hygiene tasks include
ideational apraxia, organization and sequencing
problems related to activity steps, impaired
judgement, decreased level of arousal, lack of
attention, distraction, field dependency, impaired
memory, and impaired intention
  ․ Ideational apraxia appear during grooming and
hygiene activities.
  ․ Fig. 18-6, G
* Lack of judgement
  ․ appear as an inability to make realistic decisions
based on environmental information, providing that
perception of those impulses is adequate.
  ․ Fig. 18-6, H
* Field dependency
  ․ attention component and a perseveration
component
  ․ dysfunction : distracted from performing a particular
task by specific stimuli that they are compelled to act
on or incorporate into the previous activity
* Short-term memory problems
  ․ not remember the sequence of activity steps or
instructions throughout activity performance
  ․ have to remind an individual several times to comb
the hair, even though the individual does not have
comprehension problems
* Lack of initiation
  ․ occur during performance of grooming and hygiene
tasks
  ․ The individual has a plan of action but cannot start the
plan.
  ․ associated with ideational problems as well
- Dressing Performance Area
► Fig. 18-7 . .

- Functional Mobility Performance Area

► Fig. 18-8

- Eating Performance Area

* Fig. 18-9
 Ⅶ . Patterns of impairments
resulting from cerebrovascular
accidents
* cerebral blood supply depends on three arteries in each
hemisphere
  ․ the middle and anterior cerebral arteries (branches of
the internal carotid artery)
  ․ the posterior cerebral artery (branch of the basilar
artery)
  ․ vertebral arteries
* two major types of cerebrovascular dysfunction cause
neurologic lesions
  ① ischemia
    ․ insufficient blood supply to the brain
    ․ responsible for 70~80% of all strokes
    ․ subdivided into thrombosis, or blood flow
obstruction caused by a local process in one or more
blood vessels
  ② hemorrhage
    ․ bleeding, caused by a ruptured blood vessel
    ․ accounts for the remaining 15~20% of strokes
    ․ results in swelling and compression of brain tissue
    ․ subdivided into subarachnoid hemorrhage,
intraparenchymal hemorrhage, or bleeding in the
cerebral tissue
* Table 18-4, 18-5 : indicate patterns of impairments
as they relate to dysfunction of different cerebral
arteries and different CNS areas as a result of various
vascular pathologic conditions
Thank you.