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Cognitive Rehabilitation:

C
ognition and perception are primary concerns
in occupational therapy, A disturbance of

A Model for cognitive and perceptual skills, which fre-


quently occurs after brain damage, has a detrimental

Occupational Therapy 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,
Beatriz Colon Abreu, However, visual perception problems cannot be in-
Joan Pascale Toglia terpreted in isolation, Cognitive skills such as orienta-
tion, insight, attention, memory, problem solVing, and
organization also need to be considered, Several tests
Key Words: brain damage, chronic. standardized on adults are available to assess visual
cognition. perception. rehabilitation 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,
A theoretical mOdel that provides a foundation for Hamsher, Varney, & Spreen, 1983), In general, the
understanding function and dysfunction in cogni- objective evaluation methods for evaluating cognitive
tion and perception is needed as a prerequisite for skills in the brain-damaged adult are not well docu-
the development of effective assessment and treat- mented in the occupational therapy literature,
ment tools to be used with the brain-injured adult,
The American Journal of Occupational Therapy
Such a model and clear definitions are absent in
the occupational therapy literature on adult brain and related publications have identified cognition as
function and dysfunction. an area of practice since 1940 (Allen, 1985; Ayres,
This paper represents a cognitive rehabilitation 1958; Baum, 1981; Fidler, 1948; Goldstein, Gershaw,
model adapted for occupational therapy from the & Sprafkin, 1979; Lundgren & Persechino, 1986;
fields of neuropsychology and cognitive psychology, Lyons, 1984; McDaniel, 1954; Mosey, 1968; Panikoff,
Differentiation of terms, an overview of the model's 1983; Schwartz, Shipkin, & Cermak, 1979); yet
theory, and evaluation principles are discussed Ottenbacher (1980) found that the majority of clini-
Cognitive rehabilitation is presented from an infor- cians who tested cognition did so by clinical observa-
mation processing perspective, Three other treat- tions, He found that 54% of the evaluation forms used
ment approaches identified in the literature are dis- with CVA patients did not include a section on cogni-
cussed and compared with cognitive rehabilitation. 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),
Beatriz Colon Abreu, MA, OTR, FAOTA, is Program Super- Visual perception and cognition are both sub-
visor for the Advanced Master's Degree in Developmental components of perception, Visual perception is de-
Disabilities, Department of Occupational Therapy, New fined as the ability to process and interpret visual in-
York University, New York 10003, formation, Cognition is defined as the method that
the central nervous system uses to process informa-
Joan Pascale TogJia, OTR, is Chief Occupational Therapist
at New York Hospital, Cornell Medical Center, New York, tion, Cognition involves a number of interrelated
processes, which occur during the acquisition and

The American journal of Occupational Therapy 439

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manipulation of information. These processes in- tem processes information in three stages. First, the
clude the ability to attend to, organize, and assimilate nervous system registers the stimulus event. Sec-
information (examples of cognitive subskills are flex- ondly, at the analysis level, the system interprets and
ibility, memory, and abstraction). Cognition is not ex- organizes the raw sensory information. Finally, at the
clusively localized in the cortex, some processing hypothesis formation level, the system compares the
occurs at subcortical levels as well (Trexler, 1982). stimulus with experiences in long-term memory and
Theoretically, visual perception and cognition are relates the stimulus to the overall purpose and goal
difficult to separate. Perceiving visual information in- (Klatzy, 1980). Failure in processing can occur at any
valves cognitive processes such as attention and pOint of these three stages of information processing.
memory (Trexler). However, clinically, one can dif- The process of perception elicits two different
ferentiate between "visual perceptual dysfunction" styles of responses: a data-driven response and a con-
and "cognitive dysfunction_" For example, in visual ceptually driven response (Norman, 1969, 1979). The
perceptual dysfunction, the patient may have diffi- data-driven response, also known as bottom-up analy-
culty in tasks requiring attention, memory organiza- sis, is dependent on the external stimulus. It repre-
tion, or problem solVing involVing visual information_ sents the processing of information based on incom-
The patient may not demonstrate problems in audi- ing data through detailed analysis such as pattern rec-
tory reception, attention, or memory. In contrast, ognition_ The conceptually driven response, also
cognitive dysfunction is exemplified by difficulty in known as top-down analysis, proceeds from the inter-
processing information regardless of the sensory mo- nal expectation of the incoming data (Norman, 1969,
dality. 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)-
Theoretical Foundation for Cognitive The ability to process information cannot be ex-
Rehabilitation plained by either response alone_ Perceptual pro-
For the purposes of this study, we combined the anal- cesses elicit both types of responses. The processes'
ysis of the perceptual process from an information frequency depend on the person's characteristics in
processing perspective with Luria's (1970) functional cerebral lateralization, cerebral damage, and the cog-
classification of the brain to form the theoretical nitive task.
foundation for a cognitive rehabilitation model. This view of perceptual processing is compatible
Figure 1 illustrates that the central nervous sys- 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,
Figure 1
Perceptual Process
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·
DECISION gether in any given task (Luria, 1970, 1980).
RESPONSE The continuum provided by the three stages of
"It's a lily" the perceptual process and Luria's brain blocks classi-
fication prOVide the foundation for identifying the six
DATA DRIVEN RESPONSE
critical evaluation areas in the adult population with
CONCEPTUAL DRIVEN RESPONSE
Hypothesis 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
Analysis
(Abreu, 1985)_
The emphasis of the evaluation depends upon
factors such as the pre morbid status, the expected
discharge environment, the perceptual dysfunction,
Sensory and the location or nature of the brain damage.
Detection
The model of cognitive rehabilitation proposed
in this paper uses teaching/learning tools which are
based on information processing theory. The empha-
Note From Cognitive Rehabilitation Manual Cp. 12) by B. C. Abreu
and J P. Toglia, 1984, New York: authors. Copyright 1984 byau- sis is on broadening a person's ability to handle in-
thors. Reprinted by permission. creasing amounts of information by incorporating ef.

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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 Because it is not the role of the occupational
Evaluation Model (Six Essential Areas to Test) therapist to diagnose the disabling condition but to
evaluate function and dysfunction as a foundation for
4.
5. Cognition treatment, a portion of the occupational therapy
memory Motor cognitive-perceptual evaluation should emphasize
Planning
quality more than quantity and function more than
dysfunction.
3. In developing such an occupational therapy test,
Visual the following should be considered:
Processing

'-_.... t
2.
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
Attention that require minimal processing effort.
2. Tests should not be terminated when the
6. Occupational client fails to perform the task after standard instruc-
1.
Behavior tions are given. It is not enough to know that the
ADL work
leisure play
Orientation client cannot perform a task.
3. Test scores with yes/no data alone reveal little
about the person's function and should be eliminated.
Note. From Cognitive Rehabililation Manual (p. 15) by B. C. Abreu
The therapist needs to know how the person solved a
and J. P Toglia, 1984, New York: authors. Copyright 1984 byau· problem or approached the task. It is necessary to
thors. Reprinted by permission. identify (a) conditions that improve the processing of
information and facilitate performance and (b) con-
Cognitive remediation and training use table top ditions under which skills deteriorate.
activities, constant environments, and similar activi- 4. Strategies that the client uses should be evalu-
ties for testing and training purposes (Carter et aI., ated to determine if and when they are effective or
1980; Carter et aI., 1983). The cognitive rehabilitation maladaptive (Lezak, 1983; Luria, 1980).
model uses tasks with a variety of environments, body Such an evaluation can be accomplished by giv-
positions, and active movement patterns. ing the client additional specific standardized cues to
see if they affect performance. The overall score is
Assessment reduced when the client cannot perform the test task
with standardized instruction, but the client's ability
Traditionally, occupational therapists have assessed
to reach the correct solution when gUided by the ther-
cognitive-perceptual processes in adults using a
apist is noted This method can help in predicting
"skill-specific approach." A test battery typically con-
how much a person will profit from instructions and
sists of separate categories such as figure ground, po-
cues (Brown & French, 1979; Lezak, 1983; Lyons,
sition in space, spatial relations, body scheme, or
1984; Meichenbaum & Asarnow, 1979). Cues can be
constructional praxis. The patient who fails on a fig-
used to (a) provide feedback, (b) direct attention to
ure ground task is considered to have a figure ground
relevant features, (c) pace the speed of performance,
problem. The person who fails on a constructional
and (d) direct attention toward relevant features
praxis test, is considered to have constructional
(Diller, 1985) Test modifications made and reasons
apraxia (Siev, Freishtat, & Zoltan, 1986). This ap-
for using cues need to be identified and standardized.
proach fails to emphasize quality of performance. For
An information-processing approach to evalua-
example, a person can do poorly on both a figure
tion consists of a series of tasks that are graded in
ground task and a constructional task for the same
accordance with information-processing demands.
reason, namely, because he or she has a tendency to
The follOWing are characteristics that can be manipu-
focus on details irrespective of the whole.
lated to increase or decrease processing demands in
There are many standardized cognitive percep-
both evaluation and treatment (Barth & Boll, 1981;
tual assessment tools available in psychology. These
Hagen, 1982).
tests emphasize normative comparison, for example,
the brain-damaged individual is compared with non- 1. Rate-Increase, decrease, or speed main-
brain-damaged peers on a selected cognitive-percep- tenance of item(s) presented and client's
tual dimension. This approach is useful in determin- response
ing the presence and severity of dysfunction, but test 2 . Amount-The number of items in the
scores alone reveal little about the patient'S function- presentation
ing (Lezak, 1983). 3. Duration-The time during which an attitude

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exists (e.g., attention span, concentration, ration, and amount of information presented prior to
persistence) increasing the compleXity and amount of integration
4. Sensory Modality-The demands, quality, required from sensory modalities. Activities are also
and/or integration required from different av- graded by increasing the amount of sensory integra-
enues of sensations (e.g., selection of differ- tion reqUired from another sensory modality such as
ent sensations based on client's dysfunction) auditory, kinesthetic, and visual modalities.
5. CompleXity-The degree of difficulty at- Three treatment tools are advocated in this
tributed to the task (familiarity, abstractness) model. These are the teaching/learning process, the
environment, and the use of the self (refers to body
The thorough investigation of all areas provides a
alignment, positioning, and active movement pat-
clearer understanding of the patient's strengths as
tern). These tools are matched, graded, and varied to
well as weaknesses and delineates the conditions that
meet the individual client's needs.
facilitate task performance. A treatment program can
be more efficiently designed on the basis of the com-
prehensive evaluation's results. Teaching/Learning
The teaching/learning process is an interaction be-
Treatment tween the client and the therapist designed to help
Treatment is designed to ameliorate deficiencies the client acquire new and more adaptive knowledge,
along the continuum of the perceptual system. Activi- strategies, skills, and attitudes (Mosey, 1986).
ties that gradually increase demands on the informa- Webster's New Collegiate Dictionary (1980) de-
tion processing system are systematically presented. fines teaching as the process of instructing by precept,
The treatment program offers gradations from simple example, or experience. It facilitates the acqUisition
to complex, automatic to effortful, and from the abil- of knowledge, skills, and attitudes. Learning is the
ity to respond to the external environment to the abil- process whereby the individual person modifies his
ity to manipulate the internal environment (Ben- or her response to stimuli or acquires new patterns of
Yishay & Diller, 1983). Three treatment phases are behavior as a result of previous interaction with the
identified in the model. Phase 1 emphasizes the abil- environment (Schwartz, 1985). These changes are re-
ity to detect and respond appropriately to the environ- corded in the nervous system and are not attributable
ment. Clients at this level typically demonstrate con- to maturation or medications. Learning is reduced in
fusion and only gross attention to the environment. the brain-injured adult because the capacity to pro-
Treatment tasks are automatic and require only mini- cess and organize new information is diminished.
mal processing capaCity. Phase 2 addresses the ability Because teaching facilitates learning, modifications
to discriminate, organize, and manipulate information that are made in the teaching process to account for
in the external environment. Clients at this level dem- the new learning impediments can enhance the
onstrate the ability to detect and respond to relevant brain-injured client's learning process.
information; however, they have difficulty discrimi- A therapist as a teacher can only design a situation
nating information in the external environment. believed to enhance learning for that particular client;
Treatment tasks reqUire moderate processing capac- the client does the actual learning. The therapist can
ity. Phase 3 emphasizes the ability to manipulate and only help a client to want to learn through the design
organize internal information, for example, thoughts, of appropriate learning techniques (Mosey, 1986).
emotions, and ideas. Clients at this level have diffi- The emphasis in treatment is not on individual
culty in planning, organizing, and problem solving. tasks but on the cognitive strategies which underlie
Treatment tasks reqUire maximum effort, concentra- task performance. Strategies are organized sets of
tion, and analysis (Ben-Yishay & Diller, 1983; Luria, rules that operate to select and gUide the ability to
1980). process information (Gagne & Briggs, 1974). Strate-
Treatment may begin at any of the phases de- gies that may be emphasized in treatment include
pending on the client'S level of processing capacity. planning ahead, choosing a starting point, controlling
Although the phases represent an information-pro- the speed of response, checking work, searching for
cessing continuum, they do not constitute a fixed more information before verbaliZing a plan prior to
hierarchy. performing an activity, generating alternatives, and
Treatment activities begin at the breakdown scanning from left to right (Adamovich et aI., 1985;
point in performance and are matched with the Craine & Gudeman, 1981; Diller & Gordon, 1981a).
client's information processing capacity (Hagen, These strategies are not specific to any particular task;
1982). An activity that requires cues 50% of the time therefore, they can be emphasized in a variety of dif-
or more is considered to be well above the client's ferent tasks and environments. Computer actiVities,
level. Activities are graded by increasing the rate, du- gross motor tasks, group activities, games and crafts

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can all be used (Lundgren & Persechino, 1986; Toglia, to him or her are important factors in the intervention
1985). Training attempts to ensure that a generaliza- process. The social environment is the matrix of peo-
tion of strategies occurs. The client is given the oppor- ple whom an individual is relating to or will need to
tunity to use learned strategies in different situations relate to in the future (Mosey, 1986) The cultural
that involve similar skills. The client is not moved to environment involves the client's integrated pattern
the next step until there is some evidence of general- of human behavior: the social structures, values,
ization. mores, and expectations that are accepted by his
A major thrust in treatment is helping the client group (Mosey, 1986).
learn how to monitor and control his or her own per- Activities and tasks should use all three types of
formance. This involves teaching the client to recog- environments to facilitate the client's ability to adapt
nize and correct errors in performance. Error detec- to a variety of situations. The demands of each envi-
tion can be facilitated by the therapist through the use ronment can be increased or decreased depending on
of feedback. Feedback can be general or specific the client's cognitive perceptual deficits.
(Craine, 1985; Diller & Gordon, 1981 b; Diller & For example, a person who can perform an activ-
Johnston, 1983). An example of general feedback is a ity in a quiet one-to-one session with the therapist
therapist telling a client who displays poor visual pro- may have difficulty with the same activity when it is
cessing in picture recognition that the error was due presented in a group situation. The social environ-
to his or her poor eye movements in scanning the ment can place more demands on the individual. The
important features of the object in the picture. An demands of the task need to be balanced with the
example of specific feedback is a therapist telling demands of the environment. Games designed to
such a client to direct his or her eye to the critical emphasize cultural differences can also be used to
aspect of the picture and pointing out what was enhance the client's awareness and motivation.
missed.
Error detection can also be facilitated by self-
Body Alignment, Positioning, and Active
monitoring techniques such as activity prediction. In
Movement Patterns
activity prediction the client identifies and quantifies
anticipated results. The prediction will include ex- Normal body alignment is the balanced orientation of
pected errors in timing and accuracy. A comparison of the head, upper and lower trunk, and upper and lower
prediction and actual performance helps the client extremities. This balanced orientation establishes a
gain awareness of his or her errors and facilitates per- secure, symmetrical, and nonstereotypic or fixed pos-
formance (Brown & French, 1979; Diller & Johnston, ture in any particular direction, plane, or axis. The
1983; Lyons, 1984). ability to shift and assume various orientations in a
Error correction is facilitated by helping the rapid fashion is disturbed in brain-damaged clients.
client generate alternate methods for approaching the Their body alignment suffers a biomechanical disar-
task. A client who is aware of his or her errors but rangement of varying degrees depending on the ex-
persists in making the same error benefits from being tent and severity of the muscle tone abnormalities
shown that there is more than one way to solve or caused by the brain damage (Ryerson, 1984). Tech-
correct a problem (Diller &Johnston, 1983; Konow & niques such as those developed by Bobath as well as
Pribram, 1970). This can be done by proViding several proprioceptive neuromuscular facilitation involve
alternatives to the client or by encouraging the client maneuvers to assist the client to paSSively or actively
to generate alternative responses. assume a better body alignment by using specific key
points of control. Cognitive rehabilitation interlaces
these neurodevelopmental concepts and suggests that
Environment the client be realigned before engaging him or her in
Teaching/learning strategies are emphasized in a va- cognitive remediation to facilitate higher cortical
riety of different environments, including cultural, function. Many brain-damaged clients have typically
social, and physical environments. Different environ- poor body alignment, a factor which affects visual pro-
ments elicit different information-processing de- cessing and other higher cortical functions.
mands. It is of critical importance for this treatment Positioning or the bearing of the body in various
approach to mix, match, and vary the demands of the positions, supine, prone, side-lying, sitting, or stand-
environment. ing, is an attribute of a mature and well-integrated
The material surroundings in which the individ- nervous system. Positioning has traditionally been
uallives or is likely to live in the future constitute the used in rehabilitation for assessment and intervention
physical environment. The complexity of the environ- of motor performance dysfunction (Ryerson, 1984).
ment, the degree of safety, and the opportunity for the We have used positioning for cognitive rehabilitation
client to be surrounded by objects that are meaningful purposes. A position that has a wide base of support

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and low center of gravity is more secure and enables cdic task. However, because splinter skills cannot
the brain-injured client to attend to other variables possibly be taught for all areas, techniques that in-
such as cognitive training activities. We have noted volve cognitive remediation with an emphasis on gen-
that when the client's position is varied either by eralization are more effective strategies for improving
changing the support base or by shifting the weight overall function.
on different extremities, the quality of the processing The focus of perceptual motor training is on the
of visual and cognitive information is influenced. For direct remediation of observed perceptual deficits
example, when shifted to a less stable position, (Price, 1977). These areas of the deficits include fig-
clients have been noted to suffer a breakdown in vi· ure ground, form constancy, spatial relationships, po·
sual processing or cognitive tasks they mastered in a sition in space, right-left discrimination, body
more secure position. Therefore, it is suggested that scheme, unilateral neglect, and constructional praxis.
the therapist use the same cognitive remediation ac· This approach was adapted from the work of
tivities, starting with various positions in good body Frostig in treating perceptual motor deficits in chilo
alignment and subsequently changing the activity to dren. Many of the deficit areas mentioned were iden-
reflect increasing perceptual demands. This will en· tified from research with children. Other areas were
courage information processing under various condi· identified through studies on brain·damaged individ-
tions and increase the fleXibility and competencies of uals (e.g., constructional praXis, unilateral neglect).
the client. Intervention involves training in specific areas
Cognitive remediation activities can be upgraded through table top actiVities. The emphasis is on corti·
or downgraded through the types of active movement cal skills, namely, visual perception and visual motor
patterns one demands from the activity. The total skills. Improvement in specific skills is expected to
movement patterns can be performed with bilateral, go from general to functional tasks (Scardina, 1981;
unilateral, distal, and prOXimal, or symmetrical, asym- Siev et aI., 1986).
metrical, and reciprocal movements. Each of these The limitation of this approach is that cognitive
movement patterns has different processing demands skills such as attention, memory, and problem solVing
(Wells & Luttgens, 1976). are not addressed. Moreover, deficits are perceived as
For example, a person's speed of response in isolated issues with no references as to how brain
cognitive perceptual activities may vary depending on damage affects the cognitive perceptual system.
the compleXity of the movement pattern reqUired. A Subskills are not analyzed and the relationship be-
simple movement pattern such as a bilateral symmet- tween the disturbances is not examined.
rical movement reqUired in catching a ball may elicit a Sensory integration therapy is an approach de-
fast response. When the movement is upgraded to signed for learning· disabled children. The literature,
involve an asymmetrical pattern such as in batting a however, links sensory integration therapy with other
ball, the response may be slower because the de· diagnoses such as autism, mental retardation, and psy-
mands of motOr planning are greater. chiatric disorders (Price, 1977; AOTA, 1982) Sensory
integration emphasizes the organization of sensory
processing as the foundation for cognitive and visual
Other Treatment Approaches perceptual skills.
The three other approaches identified in the occupa· Price (1980) states that "sensory integration has a
tional therapy literature for the training of clients who firm base and wide application in acqUired brain dys-
have perceptual deficits are the functional approach, function" (p. 287).
perceptual motor training, and sensory integration The effectiveness of the sensory integration ap-
therapy. Each of these approaches has limitations. proach with the brain-injured adult has not been doc-
The emphasis of the junctional approach is on umented or researched. Ottenbacher (1982) cautions
the task rather than on the subskills involved in the that although sensory integration techniques are
task. Cognitive-perceptual dysfunction is identified Widely used, additional studies are needed to show
by assessing activities in daily living performance. In· that these techniques are successful with populations
tervention involves adapting the client's environ- other than learning-disabled children. He refers to the
ment, for example, using color·coded clothes for the professional and personal risk in applying any treat-
repetitive practice of activities in daily living tasks. ment procedure that has not been demonstrated to be
Splinter skills are fragmented abilities that are learned therapeutically effective by traditional standards.
by repetition without generalization, for example, One must also caution against applying any
learning by rote (Siev et aI., 1986). theory or technique that was designed for children to
A limitation of this approach is a lack of general- an adult population without extensive modification.
ization. Splinter skills, in conjunction with adapting The recovery of cognitive-perceptual function after
the environment, can enhance performance in a spe· brain damage cannot simply be described as a recapit-

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ulation of an ontogenetic sequence. The neurological techniques used in cognitive rehabilitation should be
organization, activation, and inhibition of the brain compared to determine which methods are most ef-
varies according to age. Luria (973) implies that the fective in promoting learning and generaliZing infor-
adult is less dependent on the function of lower brain mation in the brain-injured adult.
centers than the child. This is exemplified by the dif- Occupational therapy is both an an and a science.
ferent effects of lesions in identical areas in the The goal of science is to produce an accumulating
child's brain versus the adult's brain (Luria, 1980; body of reliable knowledge. More knowledge about
Moore, 1986). abnormal brain function and deficits in essential skills
In addition, an adult has acquired a fund of would enable us to explain, understand, and predict
knowledge based on prior experience, which is the cognitive rehabilitation process from an occupa-
stored in long-term memory. This fund of knowledge tional therapy perspective. This model will permit us
inevitably affects thinking and perception. Tech- to use such knowledge to evaluate and treat patients
niques that were designed for a young developing to promote maximal function.
brain and emphasize acquiring new skills may not be
easily applied to a brain that has already acquired such
Acknowledgments
skills.
We thank Deborah Labovitz, PhD, Rosalie Miller, PhD, Joy
Cordery, and Connie Martin for editorial assistance and
Summary members of the Occupational Therapy and Audio Visual
departments at Helen Hayes Hospital (operated by New
This paper describes a cognitive rehabilitation model York State) for their support. We also extend our apprecia-
based on information-processing theory and learning tion to Anne C. Mosey, PhD, for her frame of reference ideas
concepts as a foundation for occupational therapy that inspired portions of this paper.
evaluation and treatment of the brain-damaged adult.
Using this model will help occupational therapists
include in evaluation and treatment the total percep- References
tual processing system for all three brain blocks iden- Abreu, B C. (1981) InterdiSCiplinary approach to the
tified by Luria (1970). This evaluation helps identify adult visual perceptual function-dysfunction continuum. In
the essential skills to be screened: orientation, in- B. Abreu (Ed). Physical Disabilities Manual (pp. 151-182)
New York: Raven Press.
sight, attention, visual processing, motor planning, Abreu, B (1985, March) Perceptual-cognitive rehabil-
and cognition. The evaluation of these skills is en- itation: An occupational therapy model. Physical Disabili-
hanced by a nontraditional approach to assessment ties Special Interest Newsletter [AOTA], pp.1-3.
that uses standard cues to facilitate performance. Adamovich, B., Henderson, J, & Averbach, S. (1985).
The purpose of treatment using the cognitive re- Rehabilitation of closed head injured patients. California:
College Hill Press.
habilitation model is to maximize existing potential Allen, C. K. (1985). Occupational therapYforpsychiat-
by prOViding strategies to enhance the patient's ability ric diseases: Measurements and management of cognitive
to process and organize information efficiently. Thus disabilities. Boston: Little, Brown.
treatment involves teaching brain-injured adults how American Occupational Therapy Association. (1982).
to facilitate their own performance or learning. Occupational therapy for sensory integrative dysfunction.
Official position paper. American Journal of Occupational
The three treatment tools identified in this model Therapy, 36, 831-834.
are (a) the teaching learning process, (b) the environ- Ayres, J (1958). Basic concepts of clinical practice in
ment, and (c) the patient's body alignment, position- physical disabilities. American Journal of Occupational
ing, and active movement patterns. All three are ana- Therapy, 8(6), 300-302.
lyzed from an information-processing perspective. Barth, ]., & Boll, F (1981). Rehabilitation and treat-
ment of central nervous system dysfunction: A behavioral
Because the client's response to a cognitive activity medicine perspective. In C. Prokop & L Bradley (Eds.),
changes depending on the environment, body align- Medical psychology: Contributions to behavioral medicine,
ment, body position, and movement patterns, the in- pp.241-265 New York: Academic Press.
tegration of movement and environment with cogni- Baum, B. (1981). Relationship between constructional
tive task promotes the ability to use strategies under praxis and dressing in the head-injured adult. American
Journal of Occupational Therapy, 35, 438-442.
various conditions. Ben-Yishay, Y, & Diller, L (1983). Cognitive remedia-
The theoretical foundation of cognitive rehabili- tion. In M Rosenthal, E. Griffith, M. R Bond, & J D. Miller
tation is based on models of normal brain function. (Eds), Rehabilitation of rhe head injured adult (pp.
More research is needed on abnormal brain function 167-183) Philadelphia, PA Davis.
before generalizations can be made from the normal Benton, A, Hamsher, K., Varney, N. & Spreen, O.
(1983). Contributions to neuropsychological assessment: A
to the brain-damaged population. In addition, more clinical manual New York: Oxford University Press.
evidence is needed to document the effects of cogni- Bolger, J P (1982). Cognitive retraining: A develop-
tive rehabilitation on functional behaviors. Different mental approach Clinical Neuropsychology, 4, 66-70.

446 july 1987, Volume 41, Number 7

Downloaded from http://ajot.aota.org on 05/09/2019 Terms of use: http://AOTA.org/terms


Boll, T., O'Leary, D., & Barth, J (1981). A quantitative living. Archives of Physical Medicine and Rehabilitation,
and qualitative approach to neuropsychological evaluation. 43,514-517
In C. Prokop & L. Bradley (Eds), Medical psychology. Con- Lundgren, C. c., & Persechino, E. L. (1986) Cognitive
tributions to behavioral medicine, pp. 67-80. New York: group: A treatment for head-injured adults. Americanjour-
Academic Press. nal of Occupational Therapy, 40, 397-401.
Bouska, M. J, Kwatny, E. (1980) Manualfor applica- Luria, A. R. (1970), The functional organization of the
tion of the motor free visual perception test to the adult brain. SCientific American, 222(3), 66-78.
population. (Available from Manual, PO Box 12246, Phila- Luria, A. R (973) The working brain. New York:
delphia, PA) Basic Books.
Brown, A. L., & French, L. A. (1979). The zone of po- Luria, A. R. (1980), Higher corticalfunctions in man.
tential development: Implications for intelligence testing in New York: Basic Books.
the year 2000. In R. J. Sternberg & D. K. Detterman (Eds.), Lyons, B G (1984) Defining a child's zone of proxi-
Human Intelligence (pp. 217-235). New York: Ablex. mal development: Evaluation process for treatment plan-
Carter, L. T., Caruso, J L., Languirand, M. A., & Berard, ning. American journal of Occupational Therapy, 38,
M. A. (1980). Cognitive skill remediation in stroke and 446-451
non-stroke elderly Clinical Neuropsychology, 2, 109-113. McDaniel, M. (1954) The role of occupational thera-
Carter, L. T, Howard, BE., & O'Neil, W. A. (1983) pists in the re-education of aphasic patients. Part I, Ameri-
Effectiveness of cognitive skill remediation in acute stroke can journal of Occupational Therapy Vlrr, 6,235-237
patients. American journal of Occupational Therapy, 37, Meichenbaum, D. H, & Asarnow,J (1979) Cognitive-
320-326, behavioral modification and metacognitive development:
Craine, J (1985) The retraining of frontal lobe dys- Implications for the classroom_ In P C. Kendall & S. D.
function. In L. Trexler (Ed.), Cognitive rehabilitation con- Hollon (Eds), Cognitive-behavioral interventions: Theory,
ceptualization and intervention (pp. 239-261). New York: researcb & procedures. New York: Academic Press.
Plenum Press. Moore, J (1986). Recovery potentials follOWing CNS
Craine,]., & Gudeman, H, (1981). The rehabilitation lesions: A brief historical perspective in relation to modern
in brain functions: Principles, procedures and techniques research data on neuroplasticity. American Journal of Oc-
of neurotraining Springfield, I L Charles C Thomas. cupational Therapy, 40, 459-469
Diller, L. (1985, March). Results of cognitive rehabili- Mosey, A. C. (1968) Recapitulation of ontogenesis: A
tation. Physical Disabilities Special Interest Section News- theory of practice of occupational therapy. American!our-
letter [AOTA], pp 1,4-5 nal of Occupational Therapy, 40,432-436.
Diller, L., & Gordon, W 0981a). Interventions for Mosey, A. C. (1986) Psychosocial comprments ofoccu-
cognitive deficits in brain injured adults. journal of Con- pational tberapy New York: Raven Press
sulting and Clinical Psychology, 49, 822-834 Najenson, T., Rahmani, L., Elazar, B., & Averbach, S.
Diller, L., & Gordon, W (1981b) Rehabilitation and (1984) An elementary cognitive assessment and treatment
clinical neuropsychology In S. Filksov & T Boll (Eds.), of the cranio cerebrally injured patient. In E. Edelstein & E.
Handbook of clinical neuropsychology. New York: Wiley & Couture (Eds.), Behavioral assessment and rehabilitation
Sons. of tbe traumatically brain-damaged (pp. 313-338) New
Diller, L., &Johnston, C. (1983) Error evaluation abil- York: Plenum Press.
ity of right hemisphere brain-lesioned patients. journal of Norman, 0 A. (1969). Memory and attention. An in-
Consulting and Clinical Psychology, 5, 401-402 troduction to buman information processing New York:
Fidler, G. S. P (1948). Psychological evaluation of oc- John Wiley & Sons
cupational therapy activities. Americanjournal ofOccupa- Norman, D. (1979) Perception, memory and mental
tional Therapy II, 5, 284-287 processes. In L. Nilsson (Ed.), Perspectives on memory re-
Frostig, M. (966) Developmental Test of Visual Per- search (pp. 121-144) NJ Lawrence Erbaum.
ception (rev. ed) Palo Alto, CA Consulting Psychologists Otten bacher, K. (1980) Cerebral vJscular accidents:
Press. Some characteristics of occupational therapy evaluation
Gagne, R, & Briggs, L. (1974). Principles of instruc- forms. American journal of Occupational Therapy, 34,
tional deSIgn. New York: Rinehart & Winston. 268-271
Goldstein, A. P., Gershaw, J "'i, SprafKin, R P. (1979) Ottenbacher, K. (1982) Sensory integration therapy:
Structured learning therapy. American joumal of Occupa- Affect or effect. American journal of Occupational Ther-
tional Therapy, 33, 635-639 apy, 36, 571-578
Hagen, C. (1982) Language cognitive disorientation Panikoff, L B. (1983) Recovery trends of functional
follOWing closed head injury: A conceptualization In L. skills in the head-injured adults. American/ournal ofOccu-
Trexler (Ed.), Cognitive Rehabilitation Conceptualization pational Tberapy, 37, 735-743
and Intervention (pp. 131-151) New York: Plenum Press. Price, A, (1977). Nationally Speaking-Sensory inte-
Kaplan,]., & Hier, 0 B. (982) Visuospatial deficits gration in occupational therapy. Americanjournal ofOccu-
after right hemisphere stroke. Americanjournal ofOccupa- pational Therapy, 31, 287-289
tional Therapy, 36, 314-321 Price, A. (1980). Neurotherapy A speci,dization. Amer-
Klatzy, R. (1980). Human memory: Structure and ican journal of Occupational Therapy, 34, 809-815
processes. San Francisco, CA: W H. Freeman. Rahmani, L (1982) The intellectual rehabilitation of
Konow, A., & Pribram, K. (970). Error recognition and brain damaged patients. Clinical Neuropsychology, 4,
utilization produced by injUry to the frontal cortex. Neuro- 44-45
psychologia, 8, 489 Ryerson, Sj (1984) Hemiplegia resulting from vascu
Lezak, M. 0, (1983) Neuropsychological assessment lar insult or disease. In 0 A. Umphred (Ed), Neurological
(rev. ed.), New York: Oxford University Press. rehabilitation (pp. 474-514) St. Louis, MO: Mosby
Lorenze, E., & Cancro, R. (1962) Dysfunction in visual Scardina, V (1981) From pegboards to integration.
perception with hemiplegia: Its relation to activities of daily Americanjournal of Occupational Therapy, 34, 809-815.

The American Journal of Occupational Therapy 447


Downloaded from http://ajot.aota.org on 05/09/2019 Terms of use: http://AOTA.org/terms
Schwartz, R. K. (1985) Tberapyaslearning. Dubuque, In L. Trexler (Ed.), Cognitive rehabilitation conceptual-
IA Kendall/Hunt. ization and intervention (pp. 173-197). New York: Ple-
Schwanz, R., Shipkin, E., & Cermak, L. S. (1979) Ver- num Press.
bal and non-verbal memory abilities of adult brain-damaged Van Zomeren, A. H. (1981) Reaction time and atten-
patients. American journal of Occupational Therapy, 33, tion after closed injury. Service-Lisse: Swete and Zeitlinger
79-83. Publishing Company.
Warren, M. (1981). Relationship of constructional
Siev, E., Freishtat, B., & Zoltan, B. (1986). Perceptual
apraXia and body scheme disorders to dressing performance
and cognitive dysfunction in tbe adult stroke patient (rev. in adult CVA. American journal of Occupational Therapy,
ed.) New Jersey: Charles B. Slack.
35,431-437
Toglia, J. P. (1985, March). Use of games in cognitive Webster's new collegiate dictionary. (1980). New
retraining. Physical Disabilities Special Interest Newsletter York: Merriam.
[AOTA], pp. 3-8. Wells, K. F., & Luttgens, K. (1976). Kinesiology scien-
Trexler, L. (1982) Cognitive and neuropsychological tifiC basis of human motion (rev. ed.). Philadelphia:
aspects of affective change follOWing traumatic brain injury. Saunders.

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