Cognitive Rehabilitation:
C
A Model for
Occupational Therapy
Beatriz Colon Abreu,
Joan Pascale Toglia
Key Words: brain damage, chronic.
cognition. perception. rehabilitation
A theoretical mOdel that provides a foundation for
understanding function and dysfunction in cogni-
tion and perception is needed as a prerequisite for
the development of effective assessment and treat-
ment tools to be used with the brain-injured adult,
Such a model and clear definitions are absent in
the occupational therapy literature on adult brain
function and dysfunction.
This paper represents a cognitive rehabilitation
model adapted for occupational therapy from the
fields of neuropsychology and cognitive psychology,
Differentiation of terms, an overview of the model's
theory, and evaluation principles are discussed
Cognitive rehabilitation is presented from an infor-
mation processing perspective, Three other treat-
ment approaches identified in the literature are dis-
cussed and compared with cognitive rehabilitation.
Beatriz Colon Abreu, MA, OTR, FAOTA, is Program Super-
visor for the Advanced Master's Degree in Developmental
Disabilities, Department of Occupational Therapy, New
York University, New York 10003,
Joan Pascale TogJia, OTR, is Chief Occupational Therapist
at New York Hospital, Cornell Medical Center, New York,
The American journal of Occupational Therapy
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ognition and perception are primary concerns
in occupational therapy, A disturbance of
cognitive and perceptual skills, which fre-
quently occurs after brain damage, has a detrimental
effect on a person's independent function (Lorenze &
Cancro, 1962; Warren, 1981), Traditionally, the em-
phasis in evaluating and treating the brain-injured
adult has been on visual perceptual dysfunction,
However, visual perception problems cannot be in-
terpreted in isolation, Cognitive skills such as orienta-
tion, insight, attention, memory, problem solVing, and
organization also need to be considered, Several tests
standardized on adults are available to assess visual
perception, Examples include the Revised Motor Free
Visual Perceptual Test (Bouska & Kwatny, 1980),
Benton Form Discrimination Test, and Benton Facial
Recognition test (Bouska & Kwatny, 1980; Benton,
Hamsher, Varney, & Spreen, 1983), In general, the
objective evaluation methods for evaluating cognitive
skills in the brain-damaged adult are not well docu-
mented in the occupational therapy literature,
The American Journal of Occupational Therapy
and related publications have identified cognition as
an area of practice since 1940 (Allen, 1985; Ayres,
1958; Baum, 1981; Fidler, 1948; Goldstein, Gershaw,
& Sprafkin, 1979; Lundgren & Persechino, 1986;
Lyons, 1984; McDaniel, 1954; Mosey, 1968; Panikoff,
1983; Schwartz, Shipkin, & Cermak, 1979); yet
Ottenbacher (1980) found that the majority of clini-
cians who tested cognition did so by clinical observa-
tions, He found that 54% of the evaluation forms used
with CVA patients did not include a section on cogni-
tion and concluded that "therapists using a subjective
level of evaluation information cannot validly docu-
ment treatment successes in measurable terms"
(p,271),
Differentiation of Terms
Perception is viewed as the personal, subjective, and
sometimes puzzling process by which a person ac-
tively searches and judges the external environment
(Abreu, 1981), A person uses all the performance
components skills-motor skills, sensory integration,
visual perception, cognition, psychological compo-
nents, and social interaction-to perceive the envi-
ronment. The process of perception includes sensory
detection, sensory analysis, hypothesis formation, and
a decision response (Klatzy, 1980),
Visual perception and cognition are both sub-
components of perception, Visual perception is de-
fined as the ability to process and interpret visual in-
formation, Cognition is defined as the method that
the central nervous system uses to process informa-
tion, Cognition involves a number of interrelated
processes, which occur during the acquisition and
439
 manipulation of information. These processes in-
clude the ability to attend to, organize, and assimilate
information (examples of cognitive subskills are flex-
ibility, memory, and abstraction). Cognition is not ex-
clusively localized in the cortex, some processing
occurs at subcortical levels as well (Trexler, 1982).
Theoretically, visual perception and cognition are
difficult to separate. Perceiving visual information in-
valves cognitive processes such as attention and
memory (Trexler). However, clinically, one can dif-
ferentiate between "visual perceptual dysfunction"
and "cognitive dysfunction_" For example, in visual
perceptual dysfunction, the patient may have diffi-
culty in tasks requiring attention, memory organiza-
tion, or problem solVing involVing visual information_
The patient may not demonstrate problems in audi-
tory reception, attention, or memory. In contrast,
cognitive dysfunction is exemplified by difficulty in
processing information regardless of the sensory mo-
dality.
Theoretical Foundation for Cognitive
Rehabilitation
For the purposes of this study, we combined the anal-
ysis of the perceptual process from an information
processing perspective with Luria's (1970) functional
classification of the brain to form the theoretical
foundation for a cognitive rehabilitation model.
Figure 1 illustrates that the central nervous sys-
Figure 1
Perceptual Process
DECISION
RESPONSE
"It's a lily"
DATA DRIVEN RESPONSE
CONCEPTUAL DRIVEN RESPONSE
Hypothesis
Analysis
Sensory
Detection
Note From Cognitive Rehabilitation Manual Cp. 12) by B. C. Abreu
and J P. Toglia, 1984, New York: authors. Copyright 1984 byau-
thors. Reprinted by permission.
440
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tem processes information in three stages. First, the
nervous system registers the stimulus event. Sec-
ondly, at the analysis level, the system interprets and
organizes the raw sensory information. Finally, at the
hypothesis formation level, the system compares the
stimulus with experiences in long-term memory and
relates the stimulus to the overall purpose and goal
(Klatzy, 1980). Failure in processing can occur at any
pOint of these three stages of information processing.
The process of perception elicits two different
styles of responses: a data-driven response and a con-
ceptually driven response (Norman, 1969, 1979). The
data-driven response, also known as bottom-up analy-
sis, is dependent on the external stimulus. It repre-
sents the processing of information based on incom-
ing data through detailed analysis such as pattern rec-
ognition_ The conceptually driven response, also
known as top-down analysis, proceeds from the inter-
nal expectation of the incoming data (Norman, 1969,
1979). The response depends on the context of the
stimulus event and is shaped by the person's culture,
personality, and prior experience (Norman, 1979)-
The ability to process information cannot be ex-
plained by either response alone_ Perceptual pro-
cesses elicit both types of responses. The processes'
frequency depend on the person's characteristics in
cerebral lateralization, cerebral damage, and the cog-
nitive task.
This view of perceptual processing is compatible
with Luria's (1970) concept of brain blocks (see Fig-
ure 2). The first block includes the brain stem and the
old cortex. It regulates wakefulness and the response
to stimuli. The second block, including the temporal,
parietal, and occipital lobes, plays a key role in the
analysis, coding, and storage of information. The third
block or frontal lobe is involved in the formation of
intentions and programs. All three blocks work to·
gether in any given task (Luria, 1970, 1980).
The continuum provided by the three stages of
the perceptual process and Luria's brain blocks classi-
fication prOVide the foundation for identifying the six
critical evaluation areas in the adult population with
acqUired brain injury (see Figure 3).
These areas include (a) orientation and insight,
(b) attention, (c) motor planning, (d) visual process-
ing, (e) cognition, and (f) occupational behavior
(Abreu, 1985)_
The emphasis of the evaluation depends upon
factors such as the pre morbid status, the expected
discharge environment, the perceptual dysfunction,
and the location or nature of the brain damage.
The model of cognitive rehabilitation proposed
in this paper uses teaching/learning tools which are
based on information processing theory. The empha-
sis is on broadening a person's ability to handle in-
creasing amounts of information by incorporating ef.
July 1987, Volume 41, Number 7
 Figure 2 ficient mental strategies and developing an efficient
Classification of Brain Blocks
behavioral repertoire (Adamovich, Henderson, &
Averbach, 198'5; Bolger, 1982; Najenson, Rahmani,
Elazar, & Averbach, 1984; Rahmani, 1982).
Normally, the perceptual processing system can
handle only a limited amount of information at any
.Midbrain
given time. This limitation in capacity can be seen in
everyday situations. For example, when two people
talk at the same time, a listener may process half of
each conversation but is unable to fully comprehend
both conversations simultaneously. Healthy persons
use their limited processing capacity in the most ef-
___ Reticular fective manner by employing strategies to structure
Formation
and organize information (selectively processing only
FIRST BRAIN BLOCK relevant information, clustering or grouping informa·
tion into smaller units, formulating new associations
with previous experiences) (Adamovich et ai, 198'5;
Bolger, 1982; Trexler, 1982; Van Zomeren, 1981) The
quality and quantity of the information processing di-
rectly influences learning.
The brain-damaged person has less available
Parietal Lobe
--.,.--,/ processing capacity than the normal person The
amount of information that can be assimilated at any
one time is significantly reduced after brain damage
(Van Zomeren, 1981; Rahmani, 1982) This reduction
in information processing capacity can result in global
or specific deficits depending on the nature of the
brain damage. Global deficits are nOt related to any
'Occipital
Lobe particular lesion or sensory modality; but they are
generally characteristic of head injury In contrast,
specific deficits in mOtor, language, Visual, or sensory
areas are more typical of a cerebral vascular accident
SECOND BRAIN BLOCK Frequently, a combination of both types of deficits are
seen (Boll, O'Leary, & Barth, 1981). The brain-dam-
aged person has difficulty structuring and organizing
information. Strategies to efficiently process informa-
tion are not employed automatically Clinically, the
patient may nOt automatically attend to the relevant
feature of the task, group similar items together, for-
Precentral Central
Sulcus', ~/Sulcus mulate a plan, or break the task down into steps.
',-----'-- Therefore, the teaching of strategies is of critical im·
Premotor portance in assisting brain-damaged persons in assim-
Region ._-- ilating information.
The use of strategies with brain-damaged adults
is documented from both a cognitive remediation
and cognitive rehabilitation perspective (Diller &
Preirontal/
Region
Gordon, 1981a, ] 981b) Cognitive rehabilitation and
cognitive remediation and training are not synonyms.
Cognitive rehabilitation includes remediation and
training and goes beyond the specific strategies used
for cognitive deficits (Diller & Gordon, 1981a).
THIRD BRAIN BLOCK All the cognitive rehabilitation models, as well as
cognitive retraining methods, use learning prinCiples
(Allen, 1985; Carter, Howard & O'Neill, 1983; Carter,
Note. From "The FunctIonal Organization of the Bram" by A. R.
Luria, 1970, Scientific Amencan, 222(3), p. 67 Copyright by Sczen· Caruso, Languirand & Berard, 1980; Diller & Gordon,
tific American. All rights reserved. Reprinted by permission. 1981a, 1981b).

The American jouma{ of Occupational Thempy 441

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 Figure 3
Evaluation Model (Six Essential Areas to Test)
4.
5. Cognition
memory Motor
Planning
3.
Visual
Processing
'-_.... t
2.
Attention
6. Occupational
1.
Behavior
ADL work
leisure play
Orientation
Note. From Cognitive Rehabililation Manual (p. 15) by B. C. Abreu
and J. P Toglia, 1984, New York: authors. Copyright 1984 byau·
thors. Reprinted by permission.
Cognitive remediation and training use table top
activities, constant environments, and similar activi-
ties for testing and training purposes (Carter et aI.,
1980; Carter et aI., 1983). The cognitive rehabilitation
model uses tasks with a variety of environments, body
positions, and active movement patterns.
Assessment
Traditionally, occupational therapists have assessed
cognitive-perceptual processes in adults using a
"skill-specific approach." A test battery typically con-
sists of separate categories such as figure ground, po-
sition in space, spatial relations, body scheme, or
constructional praxis. The patient who fails on a fig-
ure ground task is considered to have a figure ground
problem. The person who fails on a constructional
praxis test, is considered to have constructional
apraxia (Siev, Freishtat, & Zoltan, 1986). This ap-
proach fails to emphasize quality of performance. For
example, a person can do poorly on both a figure
ground task and a constructional task for the same
reason, namely, because he or she has a tendency to
focus on details irrespective of the whole.
There are many standardized cognitive percep-
tual assessment tools available in psychology. These
tests emphasize normative comparison, for example,
the brain-damaged individual is compared with non-
brain-damaged peers on a selected cognitive-percep-
tual dimension. This approach is useful in determin-
ing the presence and severity of dysfunction, but test
scores alone reveal little about the patient'S function-
ing (Lezak, 1983).
442
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Because it is not the role of the occupational
therapist to diagnose the disabling condition but to
evaluate function and dysfunction as a foundation for
treatment, a portion of the occupational therapy
cognitive-perceptual evaluation should emphasize
quality more than quantity and function more than
dysfunction.
In developing such an occupational therapy test,
the following should be considered:
1. Test items need to be arranged in a hierarchi-
cal manner. This means that the client's capacity to
process information is tested by first using test items
that require minimal processing effort.
2. Tests should not be terminated when the
client fails to perform the task after standard instruc-
tions are given. It is not enough to know that the
client cannot perform a task.
3. Test scores with yes/no data alone reveal little
about the person's function and should be eliminated.
The therapist needs to know how the person solved a
problem or approached the task. It is necessary to
identify (a) conditions that improve the processing of
information and facilitate performance and (b) con-
ditions under which skills deteriorate.
4. Strategies that the client uses should be evalu-
ated to determine if and when they are effective or
maladaptive (Lezak, 1983; Luria, 1980).
Such an evaluation can be accomplished by giv-
ing the client additional specific standardized cues to
see if they affect performance. The overall score is
reduced when the client cannot perform the test task
with standardized instruction, but the client's ability
to reach the correct solution when gUided by the ther-
apist is noted This method can help in predicting
how much a person will profit from instructions and
cues (Brown & French, 1979; Lezak, 1983; Lyons,
1984; Meichenbaum & Asarnow, 1979). Cues can be
used to (a) provide feedback, (b) direct attention to
relevant features, (c) pace the speed of performance,
and (d) direct attention toward relevant features
(Diller, 1985) Test modifications made and reasons
for using cues need to be identified and standardized.
An information-processing approach to evalua-
tion consists of a series of tasks that are graded in
accordance with information-processing demands.
The follOWing are characteristics that can be manipu-
lated to increase or decrease processing demands in
both evaluation and treatment (Barth & Boll, 1981;
Hagen, 1982).
1. Rate-Increase, decrease, or speed main-
tenance of item(s) presented and client's
response
2 . Amount-The number of items in the
presentation
3. Duration-The time during which an attitude
july 1987, Volume 41, Number 7
 exists (e.g., attention span, concentration,
persistence)
4. Sensory Modality-The demands, quality,
and/or integration required from different av-
enues of sensations (e.g., selection of differ-
ent sensations based on client's dysfunction)
5. CompleXity-The degree of difficulty at-
tributed to the task (familiarity, abstractness)
The thorough investigation of all areas provides a
clearer understanding of the patient's strengths as
well as weaknesses and delineates the conditions that
facilitate task performance. A treatment program can
be more efficiently designed on the basis of the com-
prehensive evaluation's results.
Treatment
Treatment is designed to ameliorate deficiencies
along the continuum of the perceptual system. Activi-
ties that gradually increase demands on the informa-
tion processing system are systematically presented.
The treatment program offers gradations from simple
to complex, automatic to effortful, and from the abil-
ity to respond to the external environment to the abil-
ity to manipulate the internal environment (Ben-
Yishay & Diller, 1983). Three treatment phases are
identified in the model. Phase 1 emphasizes the abil-
ity to detect and respond appropriately to the environ-
ment. Clients at this level typically demonstrate con-
fusion and only gross attention to the environment.
Treatment tasks are automatic and require only mini-
mal processing capaCity. Phase 2 addresses the ability
to discriminate, organize, and manipulate information
in the external environment. Clients at this level dem-
onstrate the ability to detect and respond to relevant
information; however, they have difficulty discrimi-
nating information in the external environment.
Treatment tasks reqUire moderate processing capac-
ity. Phase 3 emphasizes the ability to manipulate and
organize internal information, for example, thoughts,
emotions, and ideas. Clients at this level have diffi-
culty in planning, organizing, and problem solving.
Treatment tasks reqUire maximum effort, concentra-
tion, and analysis (Ben-Yishay & Diller, 1983; Luria,
1980).
Treatment may begin at any of the phases de-
pending on the client'S level of processing capacity.
Although the phases represent an information-pro-
cessing continuum, they do not constitute a fixed
hierarchy.
Treatment activities begin at the breakdown
point in performance and are matched with the
client's information processing capacity (Hagen,
1982). An activity that requires cues 50% of the time
or more is considered to be well above the client's
level. Activities are graded by increasing the rate, du-
The American Journal of Occupational Therapy
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ration, and amount of information presented prior to
increasing the compleXity and amount of integration
required from sensory modalities. Activities are also
graded by increasing the amount of sensory integra-
tion reqUired from another sensory modality such as
auditory, kinesthetic, and visual modalities.
Three treatment tools are advocated in this
model. These are the teaching/learning process, the
environment, and the use of the self (refers to body
alignment, positioning, and active movement pat-
tern). These tools are matched, graded, and varied to
meet the individual client's needs.
Teaching/Learning
The teaching/learning process is an interaction be-
tween the client and the therapist designed to help
the client acquire new and more adaptive knowledge,
strategies, skills, and attitudes (Mosey, 1986).
Webster's New Collegiate Dictionary (1980) de-
fines teaching as the process of instructing by precept,
example, or experience. It facilitates the acqUisition
of knowledge, skills, and attitudes. Learning is the
process whereby the individual person modifies his
or her response to stimuli or acquires new patterns of
behavior as a result of previous interaction with the
environment (Schwartz, 1985). These changes are re-
corded in the nervous system and are not attributable
to maturation or medications. Learning is reduced in
the brain-injured adult because the capacity to pro-
cess and organize new information is diminished.
Because teaching facilitates learning, modifications
that are made in the teaching process to account for
the new learning impediments can enhance the
brain-injured client's learning process.
A therapist as a teacher can only design a situation
believed to enhance learning for that particular client;
the client does the actual learning. The therapist can
only help a client to want to learn through the design
of appropriate learning techniques (Mosey, 1986).
The emphasis in treatment is not on individual
tasks but on the cognitive strategies which underlie
task performance. Strategies are organized sets of
rules that operate to select and gUide the ability to
process information (Gagne & Briggs, 1974). Strate-
gies that may be emphasized in treatment include
planning ahead, choosing a starting point, controlling
the speed of response, checking work, searching for
more information before verbaliZing a plan prior to
performing an activity, generating alternatives, and
scanning from left to right (Adamovich et aI., 1985;
Craine & Gudeman, 1981; Diller & Gordon, 1981a).
These strategies are not specific to any particular task;
therefore, they can be emphasized in a variety of dif-
ferent tasks and environments. Computer actiVities,
gross motor tasks, group activities, games and crafts
443
 can all be used (Lundgren & Persechino, 1986; Toglia,
1985). Training attempts to ensure that a generaliza-
tion of strategies occurs. The client is given the oppor-
tunity to use learned strategies in different situations
that involve similar skills. The client is not moved to
the next step until there is some evidence of general-
ization.
A major thrust in treatment is helping the client
learn how to monitor and control his or her own per-
formance. This involves teaching the client to recog-
nize and correct errors in performance. Error detec-
tion can be facilitated by the therapist through the use
of feedback. Feedback can be general or specific
(Craine, 1985; Diller & Gordon, 1981 b; Diller &
Johnston, 1983). An example of general feedback is a
therapist telling a client who displays poor visual pro-
cessing in picture recognition that the error was due
to his or her poor eye movements in scanning the
important features of the object in the picture. An
example of specific feedback is a therapist telling
such a client to direct his or her eye to the critical
aspect of the picture and pointing out what was
missed.
Error detection can also be facilitated by self-
monitoring techniques such as activity prediction. In
activity prediction the client identifies and quantifies
anticipated results. The prediction will include ex-
pected errors in timing and accuracy. A comparison of
prediction and actual performance helps the client
gain awareness of his or her errors and facilitates per-
formance (Brown & French, 1979; Diller & Johnston,
1983; Lyons, 1984).
Error correction is facilitated by helping the
client generate alternate methods for approaching the
task. A client who is aware of his or her errors but
persists in making the same error benefits from being
shown that there is more than one way to solve or
correct a problem (Diller &Johnston, 1983; Konow &
Pribram, 1970). This can be done by proViding several
alternatives to the client or by encouraging the client
to generate alternative responses.
Environment
Teaching/learning strategies are emphasized in a va-
riety of different environments, including cultural,
social, and physical environments. Different environ-
ments elicit different information-processing de-
mands. It is of critical importance for this treatment
approach to mix, match, and vary the demands of the
environment.
The material surroundings in which the individ-
uallives or is likely to live in the future constitute the
physical environment. The complexity of the environ-
ment, the degree of safety, and the opportunity for the
client to be surrounded by objects that are meaningful
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to him or her are important factors in the intervention
process. The social environment is the matrix of peo-
ple whom an individual is relating to or will need to
relate to in the future (Mosey, 1986) The cultural
environment involves the client's integrated pattern
of human behavior: the social structures, values,
mores, and expectations that are accepted by his
group (Mosey, 1986).
Activities and tasks should use all three types of
environments to facilitate the client's ability to adapt
to a variety of situations. The demands of each envi-
ronment can be increased or decreased depending on
the client's cognitive perceptual deficits.
For example, a person who can perform an activ-
ity in a quiet one-to-one session with the therapist
may have difficulty with the same activity when it is
presented in a group situation. The social environ-
ment can place more demands on the individual. The
demands of the task need to be balanced with the
demands of the environment. Games designed to
emphasize cultural differences can also be used to
enhance the client's awareness and motivation.
Body Alignment, Positioning, and Active
Movement Patterns
Normal body alignment is the balanced orientation of
the head, upper and lower trunk, and upper and lower
extremities. This balanced orientation establishes a
secure, symmetrical, and nonstereotypic or fixed pos-
ture in any particular direction, plane, or axis. The
ability to shift and assume various orientations in a
rapid fashion is disturbed in brain-damaged clients.
Their body alignment suffers a biomechanical disar-
rangement of varying degrees depending on the ex-
tent and severity of the muscle tone abnormalities
caused by the brain damage (Ryerson, 1984). Tech-
niques such as those developed by Bobath as well as
proprioceptive neuromuscular facilitation involve
maneuvers to assist the client to paSSively or actively
assume a better body alignment by using specific key
points of control. Cognitive rehabilitation interlaces
these neurodevelopmental concepts and suggests that
the client be realigned before engaging him or her in
cognitive remediation to facilitate higher cortical
function. Many brain-damaged clients have typically
poor body alignment, a factor which affects visual pro-
cessing and other higher cortical functions.
Positioning or the bearing of the body in various
positions, supine, prone, side-lying, sitting, or stand-
ing, is an attribute of a mature and well-integrated
nervous system. Positioning has traditionally been
used in rehabilitation for assessment and intervention
of motor performance dysfunction (Ryerson, 1984).
We have used positioning for cognitive rehabilitation
purposes. A position that has a wide base of support
july 1987, Volume 41, Number 7
 and low center of gravity is more secure and enables
the brain-injured client to attend to other variables
such as cognitive training activities. We have noted
that when the client's position is varied either by
changing the support base or by shifting the weight
on different extremities, the quality of the processing
of visual and cognitive information is influenced. For
example, when shifted to a less stable position,
clients have been noted to suffer a breakdown in vi·
sual processing or cognitive tasks they mastered in a
more secure position. Therefore, it is suggested that
the therapist use the same cognitive remediation ac·
tivities, starting with various positions in good body
alignment and subsequently changing the activity to
reflect increasing perceptual demands. This will en·
courage information processing under various condi·
tions and increase the fleXibility and competencies of
the client.
Cognitive remediation activities can be upgraded
or downgraded through the types of active movement
patterns one demands from the activity. The total
movement patterns can be performed with bilateral,
unilateral, distal, and prOXimal, or symmetrical, asym-
metrical, and reciprocal movements. Each of these
movement patterns has different processing demands
(Wells & Luttgens, 1976).
For example, a person's speed of response in
cognitive perceptual activities may vary depending on
the compleXity of the movement pattern reqUired. A
simple movement pattern such as a bilateral symmet-
rical movement reqUired in catching a ball may elicit a
fast response. When the movement is upgraded to
involve an asymmetrical pattern such as in batting a
ball, the response may be slower because the de·
mands of motOr planning are greater.
Other Treatment Approaches
The three other approaches identified in the occupa·
tional therapy literature for the training of clients who
have perceptual deficits are the functional approach,
perceptual motor training, and sensory integration
therapy. Each of these approaches has limitations.
The emphasis of the junctional approach is on
the task rather than on the subskills involved in the
task. Cognitive-perceptual dysfunction is identified
by assessing activities in daily living performance. In·
tervention involves adapting the client's environ-
ment, for example, using color·coded clothes for the
repetitive practice of activities in daily living tasks.
Splinter skills are fragmented abilities that are learned
by repetition without generalization, for example,
learning by rote (Siev et aI., 1986).
A limitation of this approach is a lack of general-
ization. Splinter skills, in conjunction with adapting
the environment, can enhance performance in a spe·
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cdic task. However, because splinter skills cannot
possibly be taught for all areas, techniques that in-
volve cognitive remediation with an emphasis on gen-
eralization are more effective strategies for improving
overall function.
The focus of perceptual motor training is on the
direct remediation of observed perceptual deficits
(Price, 1977). These areas of the deficits include fig-
ure ground, form constancy, spatial relationships, po·
sition in space, right-left discrimination, body
scheme, unilateral neglect, and constructional praxis.
This approach was adapted from the work of
Frostig in treating perceptual motor deficits in chilo
dren. Many of the deficit areas mentioned were iden-
tified from research with children. Other areas were
identified through studies on brain·damaged individ-
uals (e.g., constructional praXis, unilateral neglect).
Intervention involves training in specific areas
through table top actiVities. The emphasis is on corti·
cal skills, namely, visual perception and visual motor
skills. Improvement in specific skills is expected to
go from general to functional tasks (Scardina, 1981;
Siev et aI., 1986).
The limitation of this approach is that cognitive
skills such as attention, memory, and problem solVing
are not addressed. Moreover, deficits are perceived as
isolated issues with no references as to how brain
damage affects the cognitive perceptual system.
Subskills are not analyzed and the relationship be-
tween the disturbances is not examined.
Sensory integration therapy is an approach de-
signed for learning· disabled children. The literature,
however, links sensory integration therapy with other
diagnoses such as autism, mental retardation, and psy-
chiatric disorders (Price, 1977; AOTA, 1982) Sensory
integration emphasizes the organization of sensory
processing as the foundation for cognitive and visual
perceptual skills.
Price (1980) states that "sensory integration has a
firm base and wide application in acqUired brain dys-
function" (p. 287).
The effectiveness of the sensory integration ap-
proach with the brain-injured adult has not been doc-
umented or researched. Ottenbacher (1982) cautions
that although sensory integration techniques are
Widely used, additional studies are needed to show
that these techniques are successful with populations
other than learning-disabled children. He refers to the
professional and personal risk in applying any treat-
ment procedure that has not been demonstrated to be
therapeutically effective by traditional standards.
One must also caution against applying any
theory or technique that was designed for children to
an adult population without extensive modification.
The recovery of cognitive-perceptual function after
brain damage cannot simply be described as a recapit-
445
 ulation of an ontogenetic sequence. The neurological
organization, activation, and inhibition of the brain
varies according to age. Luria (973) implies that the
adult is less dependent on the function of lower brain
centers than the child. This is exemplified by the dif-
ferent effects of lesions in identical areas in the
child's brain versus the adult's brain (Luria, 1980;
Moore, 1986).
In addition, an adult has acquired a fund of
knowledge based on prior experience, which is
stored in long-term memory. This fund of knowledge
inevitably affects thinking and perception. Tech-
niques that were designed for a young developing
brain and emphasize acquiring new skills may not be
easily applied to a brain that has already acquired such
skills.
Summary
This paper describes a cognitive rehabilitation model
based on information-processing theory and learning
concepts as a foundation for occupational therapy
evaluation and treatment of the brain-damaged adult.
Using this model will help occupational therapists
include in evaluation and treatment the total percep-
tual processing system for all three brain blocks iden-
tified by Luria (1970). This evaluation helps identify
the essential skills to be screened: orientation, in-
sight, attention, visual processing, motor planning,
and cognition. The evaluation of these skills is en-
hanced by a nontraditional approach to assessment
that uses standard cues to facilitate performance.
The purpose of treatment using the cognitive re-
habilitation model is to maximize existing potential
by prOViding strategies to enhance the patient's ability
to process and organize information efficiently. Thus
treatment involves teaching brain-injured adults how
to facilitate their own performance or learning.
The three treatment tools identified in this model
are (a) the teaching learning process, (b) the environ-
ment, and (c) the patient's body alignment, position-
ing, and active movement patterns. All three are ana-
lyzed from an information-processing perspective.
Because the client's response to a cognitive activity
changes depending on the environment, body align-
ment, body position, and movement patterns, the in-
tegration of movement and environment with cogni-
tive task promotes the ability to use strategies under
various conditions.
The theoretical foundation of cognitive rehabili-
tation is based on models of normal brain function.
More research is needed on abnormal brain function
before generalizations can be made from the normal
to the brain-damaged population. In addition, more
evidence is needed to document the effects of cogni-
tive rehabilitation on functional behaviors. Different
446
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techniques used in cognitive rehabilitation should be
compared to determine which methods are most ef-
fective in promoting learning and generaliZing infor-
mation in the brain-injured adult.
Occupational therapy is both an an and a science.
The goal of science is to produce an accumulating
body of reliable knowledge. More knowledge about
abnormal brain function and deficits in essential skills
would enable us to explain, understand, and predict
the cognitive rehabilitation process from an occupa-
tional therapy perspective. This model will permit us
to use such knowledge to evaluate and treat patients
to promote maximal function.
Acknowledgments
We thank Deborah Labovitz, PhD, Rosalie Miller, PhD, Joy
Cordery, and Connie Martin for editorial assistance and
members of the Occupational Therapy and Audio Visual
departments at Helen Hayes Hospital (operated by New
York State) for their support. We also extend our apprecia-
tion to Anne C. Mosey, PhD, for her frame of reference ideas
that inspired portions of this paper.
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